CASE 14

By: Dr. Sattam Lingawi and Dr. Alaa Al-Turkustani

HISTORY: 22-year-old female patient postbariatric surgery complaining of bilateral lower limbweakness and pain.

What are your findings?

What is the differential diagnosis?

FINDINGS:

Fig 1 & 2: Sagittal T1 & T2 SE of the cervico-thoracic spine demonstrating posterior epidural lesion at the thoracic and upper lumbar level. The signal intensity is matching that of fat on both sequences.

Fig 3: Non-enhanced axial CT scan of the thoracic spine at T7 level demonstrating low density of the epidural mass with HU measurment of -120.

Fig 4, 5 & 6: Axial T2, T1& enhanced T1SE with Fat saturation MRI sequences of the thoracic spine at T7 level demonstrateing that the posterior epidural lesion follows fat signal intensity with no evidence of fluid collection or hematoma. No evidence of abnormal enhancement detected.

DIFFERENTIAL DIAGNOSIS:

• Epidural lipomatosis.

• Epidural Hematoma.

DIAGNOSIS:

Epidural lipomatosis.

PEARLS AND DISCUSSION:

Epidural lipomatosis refers to an excessive accumulation of fat within the spinal epidural space, typically in the lumbar region, such that the thecal sac is compressed, and in some instances results in compressive symptoms.

Epidemiology

• Glucocorticoid:

  • Excesslong term steroid administration (e.g. for asthma): 55% - most common.

  • Endogenous Cushing syndrome: 3%.

• Obesity: 25%.

• Idiopathic: 17%.

Treatment and prognosis

In most instances, no specific treatment is required, although review of need for steroid and weight loss are sensible interventions.

In some patient’s symptoms are severe and operative decompression is required and is usually successful.

FURTHER READING:

1. Caroline Geers, Fre´de´ric E. Lecouvet. Polygonal Deformation of the Dural Sac in Lumbar Epidural Lipomatosis: Anatomic Explanation by the Presence of Meningovertebral Ligaments, AJNR Am J Neuroradiol 24:1276–1282, August 2003

2. DANIEL R. Fassett, M.D., M.B.A., and Meic h. Schmidt, M.D. Spinal epidural lipomatosis: a review of its causes and recommendations for treatment, Neurosurg Focus 16 (4): Article 11, 2004