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  • Epidural Lipomatosis

    Hi,
    I have MS and have been on a lot of steroids. Two years ago, I began losing sensation in my legs, began to experience leg weakness and my gait slowed considerably. I recently consulted with a neurologist and he ordered MRIs of all levels of my spine. I have not done the C-spine MRI yet. My recent T-Spine and L-spine MRIs show mild cord atrophy, multilevel Foraminal Stenosis, mild decreased signal through all levels of T-spine, some central Stenosis at multiple levels of the T-spine and L-spine, encroachment of the origin of the S1 root and Epidural Lipomatosis at T-2-T-3 and L2-L3. I am wondering if it makes sense to consult with a spinal Orthopedics Specialist. I don't know if there is anything I can do about the Epidural Lipomatosis. I have never been over weight and don't have Cushings. I have been on a lot of steroids though and I do eat a low carb, high fat and high protein diet. Is anyone familiar with Epidural Lipomatosis?
    Thanks,
    Christine

  • #2
    Dr Wise Young posted a comment on Spinal Epidural Lipomatosis 7/15/2009

    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). 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).

    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) 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.
    Attached Images [IMG]/forum/images/attach/pdf.gif[/IMG] Vol.5%20No.%202_p.105-108.pdf (228.9 KB, 328 views)


    pbr
    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.

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    • #3
      Welcome to CareCure, S354. I encourage you to go ahead and have the c-spine MRI, as the symptoms you describe can be caused by lesions or other problems in the cervical cord. After your neurologist has seen the MRIs of your total spine, be guided by his/her recommendations as to what (if anything) should be done next. Best wishes to you.
      MS with cervical and thoracic cord lesions

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      • #4
        Spinal Epidural Lipomatosis and Spinal Epidural Hematoma - Teenage Girl, Ideopathic

        Searching the net for relevant experiences of others with ideopathic spinal epidural hematoma and spinal epidural lipomatosis in a teenage girl...

        Six months ago, our 17 yo daughter (previously very active, no history of steroid treatment, not overweight) had onset of extreme thoracic back pain. We have engaged a team of excellent and very caring doctors, several specialties including neurosurgeon (who does not advise surgery but for now trying to wait it out and hope to see it resolve on its own...). However, none of our doctors have first-hand patient experience with a case like this one... From my own research I know it is atypical. She is first of all a teenager and a girl, no steroid use, no trauma event, not obese, etc. She has no neurological impacts that we know of, other than the pain when most extreme has of late sent her into "episodes" where her eyes roll, she gets somewhat unable to move, lasts 2+ minutes. EEG however, in which she invoked this same pain and eye movement, was normal.

        Most frustrating to her is most of the doctors do not see why she is having the pain such as she is. No meds seem to touch it - currently on Cymbalta, Mobic, Ultram. My daughter's pain is severe, always at least a 5 but often for days an 8/9 level - - she misses more than half of school due to pain, accommodates the pain by use of a wheelchair and crutches, has found specific but rather unavoidable physical positions that further spike the pain. She has various braces and supports that she also uses at will. A TLSO helps keep her from making the movements that spike the pain and gives her weakening back (from lack of activity?) support. She does not use any of these aids continuously, at advice of the doctors to assure her muscles do not atrophy. She had prior been very active - - marching band, horse riding, bike riding - - now she spends most of her time on the couch.

        She described the pain - - even before we had the first MRI or knew what was the cause - - as like a sword slitting her back right along the spine from neck to waist. It does not radiate.

        She has 29-degree double curve scoliosis - - no treatment advised and has been monitored since discovered around age 13. She has neurologic issues history, having been a cyclic vomiting syndrome baby. She had vomiting episodes that lasted 8 hours occurring every 5 weeks from age months to around 2 years. Tegretol helped avert these episodes. She was left following that with mild migraines and extreme GERD for which she has taken meds every since. (Gantrissan - spelling? til off market, then since then Prevacid, now more recently Nexxium).

        Can anyone offer first-hand experience dealing with this especially in teenagers? Know of any medical centers or physicians who have case histories with ideopathic spinal epidural lipomatosis and concurrent hemorrhage (hematoma suspected)...?

        Here are results from one of the recent MRIs (she has now had several, along with bone scan, arteriogram, hematology...): "...epidural space expanded C7 extending to T12, posterior and to right of thecal sac. This fat measures nearly 8mm. Mixed signal abnormality with prominent T2 hypointensity indicates likely presence of hemorrhage byproduct. Evidence of significant pre-existing epidural lipomatosis. It also confirmed known scoliosis - thoracic dextroscoliosis with apex at T10-11. No evidence of the fat or hemorrage compressing the spinal cord."

        Thank you for any ideas, or even just for letting me know how you or your patients may have worked through a similar tough situation...

        - Mom
        Last edited by bdehmason; 12-31-2012, 10:28 AM.

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