Attending Physician Mayo Clinic Faribault, Minnesota, United States
Case Diagnosis: Epidural lipomatosis as the cause of refractory low-back pain with radiation in a 68-year-old male.
Case Description: A 68-year-old male with significant past medical history of obesity presented to an outpatient musculoskeletal clinic with progressive low back pain that radiated down the right posterolateral thigh. Pain was rated 10/10 and was exacerbated with physical activity. MRI of the lumbar spine revealed epidural lipomatosis contributing to severe neuroforaminal stenosis and multilevel spinal canal stenosis. Patient failed conservative management, including physical therapy, Neurontin, oral steroids, ice, heat, and electrical stimulation. He was referred to neurosurgery and the decision was made to proceed with multi-level decompressive laminectomies and bilateral foraminotomies with epidural lipomatosis resection. Post-operatively, the patient had impairments with activity tolerance, strength, and pain, resulting in functional deficits with activities of daily living. He was subsequently admitted to a comprehensive inpatient rehabilitation program. The patient was able to regain significant function and was discharged home independently.
Discussions: Epidural lipomatosis remains a rare disease that may lead to spinal cord compression. Patients with epidural lipomatosis may be asymptomatic, but often present with low back pain and manifestations of spinal cord compression. Males are affected more than females, and the thoracic spine is the spinal segment most often involved. Common causes include central obesity, exogenous glucocorticoid exposure, and Cushing disorder. MRI is the standard diagnostic imaging modality. Treatment may include conservative management, but surgical intervention is often necessary if more severe neurologic deficits are present.
Conclusions: Epidural lipomatosis is a condition described by excess fat accumulation in the epidural space. Patients with epidural lipomatosis may be asymptomatic, but often experience varying degrees of neurologic deficits secondary to spinal cord compression. While it remains a rare phenomenon, it should not be overlooked, especially in patients with a history of exogenous steroid use, obesity, or other metabolic disorders.