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  • Spinal Epidural Lipomatosis

    A member recently sent me a private message of an MRI that shows the presence of epidural fat at L5/S1 that "completely narrows the thecal sac". I thought that I would give my answer here so that other members can see and perhaps comment.

    Some epidural fat is normally present in the spinal canal, particularly in the sacral spinal canal where there is space, as suggested in the following diagram:

    MIDLINE SAGITTAL VIEW OF THE LUMBAR SPINE
    The posterior epidural space (shown in orange) is segmented by areas where the dura contacts bone. The posterior epidural space compartments have their greatest anteroposterior dimension at their superior end. The anterior dura is fused with the posterior longitudinal ligament and the annular ligament at the level of each intervertebral disc, which divide the anterior epidural space into vertical segments. The posterior longitudinal ligament separates from the anterior dura at the lumbosacral junction and the anterior epidural space becomes filled with fat more inferiorly.

    http://depts.washington.edu/anesth/r...aceframes.html

    Some epidural fat is normal. In fact, the epidural fat is typically soft and cushions the spinal cord in the canal. Epidural fat is typically absent from the cervical spine but may appear in the lower thoracic spine and usually is present in the lumbar and sacral spinal canal, usually in front of or in back of the spinal cord and in the sleeves of the spinal roots [source]http://www.biomedexperts.com/Abstract.bme/19459550/Clinical_implications_of_epidural_fat_in_the_spina l_canal_A_scanning_electron_microscopic_study[/source]. However, to have the spinal thecal sac enclosed by fat is abnormal. Lumbar stenosis (a narrowing of the spinal canal in the lumbosacral spine) is a common cause of back pain and neurological symptoms. Most of the time, it is due to narrowed bony canal and requires surgical decompression. However, in some cases, as in the one described above, epidural fat is the cause. It is interesting that in many cases of spinal stenosis, there is usually a loss of epidural fat [source]http://www.aafp.org/afp/980415ap/alvarez.html[/source].

    Spinal epidural lipomatosis is sometimes associated with steroid long term steroid use or endocrinopathies such as Cushing's disease. There have been suggestions that it is associated with obesity. The attached is a paper from Hong Kong published in 2002, describing a 24-year old man who was diagnosed with spinal epidural lipomatosis around L4/5 level. He was put on a diet and lost 3 kg to 91.5 kg with no change in his symptoms. Although he had spondylosis of his spine at L4/5, injection of local anesthetics into the L4/5 joints did not reduce pain. The patient refused surgery and so was continued on a weight reduction program. The paper described a "Y-shaped sign" that is supposedly indicative of compression of the thecal sac.

    The choices of therapy are relatively straight forward. If the condition is associated with symptoms such as pain or neurological loss, particularly related to the position of the fat, the following course of action is reasonable. First, investigate for the possibility of endocrinopathy (such as Cushing's disease that can lead to accumulations of fat in various parts of the body), hypothyroidism [source]http://content.nejm.org/cgi/content/extract/341/18/1399[/source] or steroid use (which should be tapered). If obesity is present, efforts should be made to reduce weight. Second, if the above do not reduce symptoms, the only other option is surgery. The surgery is relatively simple. Epidural fat is relatively easy to remove and can even be done without unroofing the entire lumbosacral canal. Please remember that the spinal cord ends at just below the L1 vertebra and the thecal sac is filled with spinal roots at L5/S1 level.

    Wise.
    Last edited by Wise Young; 07-15-2009, 07:12 PM.

  • #2
    Thanks, Dr. Young. I just recently ran into my first referral for a patient with this as the cause of the SCI. His was at T6 though, and unfortunately the surgery for decompression only made his deficit worse.

    (KLD)
    The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

    Comment


    • #3
      I am happy I have found this site and even more so to find this thread. My husband has been recently diagnosed with SEL while receiving pain management from an auto accident while at work a few months ago. MRI and Myelogram revealed entire lumar area is involved to include 3 bulging discs. He has experienced intermit. loss of bladder & bowel. He is to have surery to correct the lipomatosis. The surgeon said his situation is severe. The limited info I am able to find about SEL indicates it is a relatively rare condition. Can you direct me to specific literature about SEL? After the Myelogram his legs went numb for about 15 minutes,.scared us pretty bad. His pain levels are pretty high with activity so he is taking it very easy. Frequently changes positions as no position is of comfort. I am worried. We are stunned and confused. Prior to the auto accident he has never experienced pain like this before. Thanks in advance for your reply.

      Comment


      • #4
        My husband has just been diagnosed with several spinal issues, large hemangioma, spondylolisthesis, epidural lipomatosis, etc. which reading your replies makes it seems like we have it easy in comparison to many in this community. Our family doctor gave us a list of several neurosurgeons. How does one go about finding/selecting a "good" neurosurgeon in the St Louis area?

        Comment


        • #5
          You can probably depend on the referral of your husband's primary care physician, but I would lean towards those neurosurgeons who also work at trauma hospitals in your area, and have university/teaching affiliations or appointments at the medical schools in your area.

          (KLD)
          The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

          Comment


          • #6
            Lower back MRI results: L3-L4 mild generalized disc bulge. ///////no central canal stenosis or foraminal narrowing is noted. There is prominent epidural fat posterior to L3 and L4 verteebral body causing some narrowing of the thecal sac. This is suggestive of epidural lipomatosis.
            L4-L5 there is generalized disc bulge and mild bilateral facet hypertrophey. there is mild central canal stenosis and mild bilateral foraminal narrowing. There is prominent epidural fat posetrior to the L5 vertebral body causing some narrowing of the thecal sac.
            L5-S1 there is generalized disc bulge, eccentric to the left. mild bilateral facet hypertrophy is note3d. Severe left and mild right foraminal narrowing is noted. There is mild central cananl stenosos. there is prominent epidural fat surrounding the thecal sac causing some narrowing. suggestive of epidural lipomatosis.

            CAN someone translate this to laymans terms

            Comment


            • #7
              I was researching epidural lipomatosis for my employer's auto accident client and found a link that states that a patient my become symptomatic after an accident, as the patient had no symptoms prior to the accident even though the lipomatosis existed. The link is:

              http://www.hkcr.org/publ/Journal/vol..._p.105-108.pdf

              If you google Reference No. 8, you can purchase that reference.

              Comment


              • #8
                Conservative therapy, including weaning of patients from steroids and weight loss, has been successful in a number of cases.Nevertheless, many patients receive steroid medications for other chronic illnesses and may not tolerate weaning from the therapy. Weight loss has been reported to be very successful in patients with SEL in whom obesity is thought to be the cause of the adipose hypertrophy.

                Comment


                • #9
                  Greetings all!

                  I wanted to put this out for opinions as I am wondering if I should be concerned or not? My MRI for the lumbar a week ago (just the area of concern)

                  "L5-S1. Demonstrates early termination of thecal sac with prominence of epidural fat attenuating the thecal sac"
                  Part of the Impression concerning this: "There is early termination of the thecal sac at L5-S1"
                  Apparently it is suppose to extend through to S2-S3. Anyone? Thanks in advance!!

                  Here is a link to the images:

                  http://i783.photobucket.com/albums/y...x36440/SEL.jpg
                  http://i783.photobucket.com/albums/y...36440/SELY.jpg

                  This is new. Have had (still have) intermittent incontinence, constant mid and low back pain (hernias at L2/3 and L3/4), weakness in both legs, neuropathy both legs peripheral.

                  Again, thanks in advance for any advice or words of wisdom. I see my Neurologist next Friday.

                  Additionally: Not obese, no steroids, no cushings, no hyperthyroidism - idiopathic.

                  Brenda

                  Comment


                  • #10
                    I will ask Dr. Young to comment on this.
                    CKF
                    The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

                    Comment


                    • #11
                      Originally posted by SCI-Nurse View Post
                      I will ask Dr. Young to comment on this.
                      CKF
                      CKF,

                      Thanks very much, appreciate!

                      Brenda

                      Comment


                      • #12
                        Originally posted by nadolap View Post
                        Lower back MRI results: L3-L4 mild generalized disc bulge. ///////no central canal stenosis or foraminal narrowing is noted. There is prominent epidural fat posterior to L3 and L4 verteebral body causing some narrowing of the thecal sac. This is suggestive of epidural lipomatosis.
                        L4-L5 there is generalized disc bulge and mild bilateral facet hypertrophey. there is mild central canal stenosis and mild bilateral foraminal narrowing. There is prominent epidural fat posetrior to the L5 vertebral body causing some narrowing of the thecal sac.
                        L5-S1 there is generalized disc bulge, eccentric to the left. mild bilateral facet hypertrophy is note3d. Severe left and mild right foraminal narrowing is noted. There is mild central cananl stenosos. there is prominent epidural fat surrounding the thecal sac causing some narrowing. suggestive of epidural lipomatosis.

                        CAN someone translate this to laymans terms
                        Your spinal cord ends in the L2 vertebral body. Spinal roots fill most of the thecal sac below L1. Most of the changes that are described in the MRI report here involve L4/5 and L5/S1 where the spine joins the pelvis. These two are the most commonly affected spinal segments for disc herniations. You have some disc degeneration so that the disc is bulging at L5/S1. The foramina refers to openings through which roots exit the spinal column. So,you have some narrowing of your spinal canal and mild narrowing of the foramina at these segments. You have fat around the thecal sac, which is contributing to narrowing of the spinal canal.

                        In general, none of these are anything to worry about, because there is no evidence that your spinal cord or spinal roots are compressed. However, the fact that your spinal canal and foramina are narrow may contrbute to back pain. As I pointed out below, one conservative approach is physical therapy and attempt to lose weight. I am not sure that any of the findings require surgery. If the pain or other symptoms continue, removal of the epidural fat may be warranted.

                        Wise.

                        Comment


                        • #13
                          Dr. Young,

                          Thanks very much for your reply. I have herniations at the L2/3/4 levels that affect the L2&3 nerve roots presently. As for your observation of the L4/5, yes my MRI report did state stenosis of the cord at that level.

                          Weight... I am 5'3" and weigh 150, and my BMI is 24, so under what they say you have to worry about with this solid fat stuff in the epidermis. My leg weakness came on slowly. I will admit that most of that is in the front of my thighs. I walk with a cane presently. I can't stand for more than a few minutes (brushing my teeth by example, I have to break down into 3 brushing issues - the pain almost drops me to me knees). Sitting use to be my 'safe haven', but even that isn't anymore. If I lay down with my head and legs elevated, I do get some relief (C5/6 and a year later C6/7 fused with partial corpectomies).

                          I see my Neurologist this Friday along with a full extremities NCS/EMG to see where I am at. Prior - Moderate Neuropathy both legs and severe right arm. Personally, I still think my L2/3/4 is my major pain and weak leg generator?

                          Neck wise, crack in the C6 vertebral body, C7 nerve issues now to the left - calcified, stenosis etc., now to the left (prior to the right). Lost my ring and pinky again - ulnar transposition was a success - prior EMG showed that surgery did NOT fail as Ulnar was clera at the elbow. Now affecting left hand as well. Sigh...

                          By the way.... you didn't reply to *my* post on this reply!!! Please see mine? Thanks!!

                          Brenda

                          Comment


                          • #14
                            Brenda,

                            Unfortunately, I am in Italy with less than ideal internet access.

                            It is generally accepted that the conus medullaris (the tip of the spinal cord ends in the lower third of L1). Soleiman, et al. [1] studied MRI of 635 patients, including 297 women and 338 men, mean age of about 50 years old. They found that the mean conus medullaris termination is indeed in the middle third of L1. The range extends from T11 to the upper third of L3. The mean thecal sac termination (TST) is in the upper third of S2 but ranges from the lower third of L3 to the upper third of S5. Gender did not affect TST but age affected TST.

                            As you can see, the normal range from L3 through S5. Epidural fat may be present and associated with more proximal TST. I am not sure that I would characterize TST at L5-S1 to be “early termination”. It falls within the range of normal.

                            References
                            1. http://www.ncbi.nlm.nih.gov/pubmed/16103859

                            Comment


                            • #15
                              Originally posted by Aviatrix36440 View Post
                              Dr. Young,

                              Thanks very much for your reply. I have herniations at the L2/3/4 levels that affect the L2&3 nerve roots presently. As for your observation of the L4/5, yes my MRI report did state stenosis of the cord at that level.

                              Weight... I am 5'3" and weigh 150, and my BMI is 24, so under what they say you have to worry about with this solid fat stuff in the epidermis. My leg weakness came on slowly. I will admit that most of that is in the front of my thighs. I walk with a cane presently. I can't stand for more than a few minutes (brushing my teeth by example, I have to break down into 3 brushing issues - the pain almost drops me to me knees). Sitting use to be my 'safe haven', but even that isn't anymore. If I lay down with my head and legs elevated, I do get some relief (C5/6 and a year later C6/7 fused with partial corpectomies).

                              I see my Neurologist this Friday along with a full extremities NCS/EMG to see where I am at. Prior - Moderate Neuropathy both legs and severe right arm. Personally, I still think my L2/3/4 is my major pain and weak leg generator?

                              Neck wise, crack in the C6 vertebral body, C7 nerve issues now to the left - calcified, stenosis etc., now to the left (prior to the right). Lost my ring and pinky again - ulnar transposition was a success - prior EMG showed that surgery did NOT fail as Ulnar was clera at the elbow. Now affecting left hand as well. Sigh...

                              By the way.... you didn't reply to *my* post on this reply!!! Please see mine? Thanks!!

                              Brenda
                              I had written the previous reply to you before seeing your second post describing your neurological changes. Based on your description, you have weakness of your quadriceps and that is innervated by your L3-4. It is consistent with a L3/4 compression of your spinal roots. Likewise, the ulnar distribution of your sensory loss in your hand is consistent with a C6 root compression, although there might be peripheral nerve involvement as well of your ulnar nerve at the wrist and elbow. You seem to have a good neurosurgeon/neurologist team that is looking at your problems. As I pointed out already, don’t worry about the high termination of your thecal sac. Focus on whether there is compression of your L3-4 roots.

                              Wise.

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