Although intradural lipomas of the cauda equina with extradural extension have been recognized for over a century, their importance is not widely known. The subcutaneous swelling is easily mistaken for a meningocele and sincqthere is normal skin cover and no neurological involvement in the early stageDs a conservative approach is usually advised. It is not generally appreciated that tlhe subcutaneous lipoma is in fact a mushroom-like structure with a stalk which passes intradurally and is firmly adherent to the cauda equina, the filum terminale, and the conus medullaris)1n due course most of these lipomas cause neurological symptoms. The onset of neurological involvement may be early or late. It may be sudden and severe and for this reason we now recommend early exploration, even in the absence of any neurological abnormality. Review of the LiteratureJohnson (1857a, b) gave the first accurate description of this condition. A subcutaneous swelling in the sacral region, first noted at 3 weeks, gradually increased in size, but the child was symptom-free until 9 months of age when he developed twitching and convulsive movements of the right leg. At operation a month later there was a subcutaneous fatty tumour the size of a small orange, with a stalk protruding through a small opening in the sacral canal. It was continuous above with the membranes of the spinal cord from which it was dissected free without opening the membranes. The child improved after operation, the abnormal movements of the leg disappeared, and he was able to stand and to take a few steps. Six weeks later he died of peritonitis. At necropsy a fatty mass was found within the dura extending upwards and pressing on the spinal cord and involving the roots of origin of the lowest spinal nerves, which seemed to be embedded in its substance. There was an associated malformation of the lower sacral vertebrae.

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