Spinal epidural lipomatosis presenting to a U.S. Veterans Affairs pain and rehabilitation department: a report of two cases

Abstract

BackgroundSpinal epidural lipomatosis is an uncommon source of neurogenic claudication. We present two cases of spinal epidural lipomatosis as it relates to diagnosis, management, and a possible association with common medical intervention.Case presentationCase 1: 63-year old male patient presented with neurogenic claudication symptoms, but without evidence of bony central canal stenosis on lumbar computed tomography. He entered a trial of spinal manipulation with transient beneficial gains after seven appointments, but no durable change in neurogenic claudication. An MRI was recommended at this point which revealed grade III spinal epidural lipomatosis at the L5/S1 level.Case 2: 51-year old male patient presented to a pain management physician with radicular symptoms for a series of lumbar epidural steroid injections. He completed a series of three lumbar epidural steroid injections with only short-term benefit. A repeat MRI demonstrated the presence of grade I (borderline grade II) spinal epidural lipomatosis.ConclusionsThe first case illustrates a limitation of ruling out central canal stenosis with computed tomography for patients unable to undergo an MRI. The second case demonstrates a possible association between steroid injections and spinal epidural lipomatosis. An association of this kind has not been established; further research is needed to determine the significance.

Is there an association between lumbosacral epidural lipomatosis and lumbosacral epidural steroid injections? A comprehensive narrative literature review

“…The search yielded a total of 321 articles. After assessing titles, abstracts, and bibliographies and after removal of duplicates, 14 publications that met inclusion criteria remained ( Table 1 , Table 2 , Table 3 ) [ 2 , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] ]. Ten publications were either case reports or small patient cohort case series; two were retrospective case control series, and two articles were cross-sectional retrospective chart reviews.…”

“…grade 31 % of Grade 2 LEL pts had ESI 35% of Grade 3 LEL pts had ESI “ESI(s) maybe another associated risk factor for SEL, but further research is needed.” Level IV Silcox et al. (2018) [19] Case Series 2 patients 1 patient: 51 yo M Approach: Interlaminar #of ESIs: 3 ND 3 injections over a 5 week period. Obesity (BMI-34 kg/m2), Male Sex, No history of anabolic or corticosteroid use Borré et al.…”

“…Twelve of the 14 articles investigate and/or suggest LESI exposure as a potential cause of LEL [ 2 , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] ]. Two of the 14 articles describe LESI as a potential treatment modality for symptomatic relief of lumbosacral radicular pain and associated disability in the setting of LEL [ 20 , 21 ].…”

“…Lumbosacral epidural lipomatosis (LEL) may occur concomitantly with or independently of osteoligamentous degenerative lumbar spinal stenosis. LEL may present as an incidental finding or can result in symptoms [2] , [3] , [4] , [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] . When substantial, LEL may result in non-specific back pain with or without radicular symptoms, neurogenic claudication, or in severe cases, cauda equina syndrome due to direct mechanical compression resulting in indirect vascular compromise, leading to venous engorgement and ischemia [ 2 , 3 , 11 ].…”

“…Prior to and since this study, literature reports have described the use of LESI(s) as a treatment for LEL-related radicular symptomatology [ 20 , 21 ]. Alternatively, several publications have attributed the development or progression of LEL to LESI(s) [ 2 , 9 , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] ]. Anecdotally, there is significant heterogeneity in interventional spine practice patterns and associated variance in willingness to perform LESI(s) in patients presenting with radicular pain syndromes in the setting of LEL.…”