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Journal of Back and Musculoskeletal Rehabilitation 27 (2014) 181–190 DOI 10.3233/BMR-130434 IOS Press

Transforaminal epidural steroid injection in the treatment of lumbosacral radicular pain caused by epidural lipomatosis: A case series and review Zack McCormicka,∗ and Christopher Plastarasb a

b

Department of PM&R, Rehabilitation Institute of Chicago, Northwestern University, Chicago, IL, USA Department of PM&R, University of Pennsylvania, Philadelphia, PA, USA

Abstract. BACKGROUND: Spinal epidural lipomatosis (SEL) can cause radicular pain due to spinal nerve root impingement. While SEL decompression surgery can provide symptom relief, these patients are often poor surgical candidates due to elevated BMI or immunosuppression. Transforaminal epidural steroid injection (TFESI) has been attempted as an alternative treatment for patients with SEL who are unable to tolerate conservative medical treatment. To date, only two such cases have been reported in the literature. OBJECTIVES: We report three additional cases of radicular pain associated with SEL, review the current literature on this condition, and describe the risks and benefits of using TFESI to treat radicular pain due to SEL. METHODS: We measured changes on the pain visual analogue scale (VAS) and pain disability index (PDI) from presentation to 1–5 weeks after treatment with sequential TFESIs. RESULTS: Pain VAS scores improved by 50–75% and PDI scores improved 13–44 points. CONCLUSIONS: This case series suggests that TFESI can provide modest short-term symptom relief of lumbosacral radicular pain and improvement in disability caused by SEL. Further study of non-operative management of SEL is warranted, given the high risk associated with surgery in this population. Keywords: Lipomatosis, epidural injection, radiculopathy

1. Introduction Spinal epidural lipomatosis (SEL) is an uncommon but well described deposition of adipose tissue in the spinal epidural space. SEL can impinge upon the spinal cord or roots, and when occurring in the lumbosacral region, it typically presents with low back and radicular pain. If weakness develops, surgical decompression of epidural fat is necessary to prevent permanent neu∗ Corresponding author: Dr. Zack McCormick, 780 S Federal St., unit 1201, Chicago, IL 60605, USA. Tel.: +1 510 388 7084; E-mail: [email protected].

rologic damage and resulting disability. If no weakness or progressive neurologic change is present, symptomatic SEL is typically treated conservatively with pain medication, physical therapy, and weight loss [1– 4] before resorting to decompression surgery. Recently, transforaminal epidural steroid injection (TFESI) has been attempted as an additional tool for treating lumbosacral radicular pain due to SEL. To date, only two cases have been reported in the literature [5]. We describe three cases of SEL with associated acute, subacute, and chronic lumbosacral radicular pain, treated with TFESI. We review the current literature on the treatment of SEL and discuss the potential benefits and

c 2014 – IOS Press and the authors. All rights reserved ISSN 1053-8127/14/$27.50 

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risks of TFESI as a treatment option in the context of these three cases.

2. Methods 2.1. Transforaminal Epidural Steroid Injection (TFESI) The patient was positioned prone. The skin was prepped in the usual sterile manner with betadine. The fluoroscope was positioned to provide an oblique view to expose the subpedicular space. The skin and soft tissues were anesthetized with approximately 2 mL of 1% lidocaine (preservative free) administered with a sterile 25 gauge 3.8 cm needle. Using fluoroscopic guidance, a sterile 22 gauge 12.7 to 17.8 cm spinal needle was then positioned at the foramen in the superior aspect above the exiting spinal nerve. 1 mL of Omnipaque 300 (iohexol) contrast dye was injected through microbore tubing under live fluoroscopy to ensure no intravascular uptake and to confirm medial and superior epidural flow pattern. The following solution was then injected through microbore tubing: 2 mL of 1% lidocaine (preservative free) as a test dose without adverse effect followed by 1.6 mL of dexamethasone solution (10 mg/mL).

3. Outcome measures The following were recorded: 11-point pain scores upon presentation, percent improvement in pain based on a continuous pain visual analogue scale (VAS), and pain disability index (PDI) at presentation and at follow-up. Validation studies of the PDI, performed by Grönblad and colleagues, have shown strong intrarater reliability with an intraclass correlation coefficient of r = 0.91, and a high correlation with the Oswestry Disability Questionnaire at r = 0.83 [6].

4. Case presentations 4.1. Case 1 A 79 year-old man with a history of hypercholesterolemia (HL), hypertension (HTN), type 2 diabetes mellitus (T2DM), and a body mass index (BMI) 42.1, presented to our clinic with three years of progressive low back pain with radiation to the right anterolateral

thigh. At the time of presentation, he reported his current pain to be 8/10 in intensity and “stabbing” in quality. His pain was relieved by positions of sustained lumbar flexion and worsened with walking or standing. His pain did not respond to acetaminophen, physical therapy, or a right L4-L5 facet joint steroid and local anesthetic injection one year prior. He had not experienced saddle anesthesia, bowel or bladder incontinence. His physical exam was remarkable for moderately restricted and painful lumbar flexion, extension, and rightward rotation, with the most painful direction being lumbar extension. Hip range of motion (ROM), Hip Scour (HS), Hip Flexion Abduction External Rotation (FABER), Seated Slump (SS), and Straight Leg Raise (SLR) tests did not elicit typical pain. Manual motor testing demonstrated 5/5 strength, sensation was intact throughout, and muscle stretch reflexes were 2+ throughout his lower extremities, bilaterally. Because the physical exam did not clearly localize pathology, nerve conduction studies and electromyography (NCS/EMG) were performed, which showed a right L5 radiculopathy. An MRI of the lumbosacral spine was subsequently obtained, demonstrating L2-L3 disc degeneration, a right central L3-L4 disc bulge, and L4L5 central disc bulge, a left lateral L5-S1 disc extrusion, and L2-S1 spinal epidural lipomatosis (SEL) with grade III compression of the thecal sac, most severe from L4-S1 (Figs 1a, 1b, 1c). He was referred to a weight loss program and 8 weeks of physical therapy with mechanical diagnosis and treatment. Due to radicular symptoms implicating the right L4 or L5 nerve root and NCS/EMG indicating the right L5 nerve root, right transforaminal epidural steroid injection (TFESI) at the L5-S1 level was chosen to allow for cephalad flow and resulting treatment of both nerve roots. The patient received two right sided TFESIs at this level, spaced two week apart. Upon follow up three weeks after his second injection, he reported a 75% improvement on the pain visual analogue scale (VAS) in both his low back and anterior thigh, with partial centralization of his thigh pain. His pain disability index (PDI) decreased from 52/70 on presentation to 29/70 after TFESIs. The patient was contacted at 8 weeks and one year after the injections and he reported stable pain and disability levels since after receiving interventional treatment, still with low back pain, but without radicular symptoms. 4.2. Case 2 A 47 year-old man with HL, HTN, a BMI of 32.5, and right fibular fracture with internal fixation

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Table 1 History, physical exam, and diagnostic study results Age Gender

Case 1 79 Male

Case 2 47 Male

Case 3 50 Male

Pain duration Pain location Pain radiation Exacerbating factors

> 3 years Low Back Pain R anterior thigh Standing

6 months Low Back Pain R anterior thigh and posterior leg Standing, Sitting, Walking

2 weeks Low Back Pain L leg Standing, Walking

Comorbidities

HL, HTN, Type 2 DM, Sick Sinus Syndrome s/p Prostatectomy s/p R Total Knee Replacement

HTN, T2DMs/p recent Fibular Open Reduction Internal Fixation of Ankle

HTN, Type 2 DM

Ht (cm), Wt. (kg), BMI

163, 111, 42.1

183, 109, 32.5

198, 188, 48.0

Strength, Reflex, Sensation Deficits

None

None

None

Most Painful direction of Lumbar Range of Motion

Pain with sustained Extension

Ankle cast precluded ROM Testing (loss of balance)

Extension with left rotation

EMG Results

L5 radiculopathy

EMG Not Performed

EMG Not Performed

Level of SEL on MRI

L2-S1, most severe L4-S1

L4-S1

L4-S1

Other abnormalities on MRI

Multilevel spondylitic changes Multilevel degenerative discs Figure 1a, 1b, 1c

L5-S1 ZA joint arthropathy R L5-S1 foraminal stenosis Figure 2a, 2b, 2c

B/l L4-L5 ZA joint arthropathy with R foraminal narrowing Figure 3a, 3b, 3c

Abbreviations: >: Greater than; s/p: Status post; BMI: Body mass index; HL: Hyperlipidemia; ht: Height; ZA: Zygoapophysial; HTN: Hypertension; cm: centimeters; B/l: Bilateral; DM: Diabetes Mellitus; Kg: Kilograms.

8 months ago and revision one month prior, presented to our clinic with 6 months of low back pain with radiation to the right anterolateral thigh and lateralposterior leg. He reported his current pain to be 9/10 in intensity, “burning and tingling” in quality. The pain worsened with sitting, standing, and walking. Ibuprofen and gabapentin did not improve his symptoms and he was unable to tolerate a course of physical therapy due to pain. He had experienced no saddle anesthesia, bowel or bladder incontinence. During physical exam, an ankle cast precluded lumbar range of motion testing due to loss of balance. Hip ROM, HS, FABER, SS, and SLR tests did not provoke typical pain. Manual motor testing demonstrated 5/5 strength, sensation was intact throughout, and muscle stretch reflexes were 2+ throughout his lower extremities, bilaterally. MRI of the lumbosacral spine demonstrated multilevel degenerative disc and facet joint disease, worst at L5-S1 causing severe right neural foraminal narrowing and SEL most prominent at L4-L5 and L5-S1, with grade II compression of the thecal sac at these levels (Figs 2a, 2b, 2c). The patient was referred to a weight loss program and for 8 weeks of physical therapy with mechanical diagnosis and treatment. Based on the L5 nerve root referral pattern and the severe L5-S1 foraminal stenosis on MRI, two right L5-S1 TFESIs were performed two week apart. The patient reported a 50% improvement on the pain VAS for both low back and

radicular symptoms on follow-up two weeks after the second TFESI. His PDI decreased from 62/70 on presentation to 56/70 on follow-up 2 weeks after the second TFESI. He then received one right S1 TFESI three weeks after the second L5-S1 injection due evidence of right S1 nerve root encroachment and displacement due to SEL on MRI. He reported 45% improvement on the pain VAS for both low back and radicular symptoms at 5 day follow up after his third TFESI, and his PDI decreased further to 49/70. Due to return of his pain to baseline prior to injections, 6 months after his third TFESI, the patient underwent L5-S1 laminectomy and foraminotomy. Upon 6 month follow up after decompression surgery, the patient reported nearly complete improvement of symptoms. However, at one year follow up, the patient’s low back and radicular pain had returned to 8/10 in intensity. 4.3. Case 3 A 50 year-old male with a history of HTN, T2DM, and a BMI of 48.0 presented with two weeks of severe, 10/10, low back pain with radiation to “all sides” of the leg, 10/10 in intensity, “achy and numb” in quality. The pain began upon standing from a seated position, at which point, the patient felt a “pop.” The pain worsened with standing, walking, and ascending

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(a)

(b)

(c) Fig. 1. (a) and (b): T1-weighted axial section of the lumbar spine, showing the L4-L5 and L5-S1 intervertebral discs, respectively. A trifid dural sac, the “Y-sign,” is evident at the L4-5 and L5-S1 levels, indicative of severe compression of the thecal sac by epidural adipose tissue. This represents Grade III compression according to the classification defined by Borre et al. [26]. (c): T1-weighted sagittal section of the lumbosacral spine, showing L2-S1 SEL with compression of the thecal sac, most severe from L4-S1.

stairs. It was not relieved by ibuprofen or oxycodoneacetaminophen. His exam was remarkable for pain during lumbar extension with left rotation and decreased sensation to light touch at the left lateral calf. Manual motor testing demonstrated 5/5 strength, sensation was intact to light touch throughout, and muscle stretch reflexes were 1+ throughout his lower extremities, bilaterally. Hip ROM, Hip grind test, Patrick’s, and FABER tests were all normal. MRI of the lumbosacral spine demonstrated degenerative disc disease from the L3L4 to the L5-S1 disc levels, small L3-L4 and L4L5 disc bulges, L4-L5 and L5-S1 bilateral facet joint arthrosis causing severe left neural foraminal stenosis at the L4-L5 level, and SEL with grade II compression of the thecal sac at the L4-L5 level (Figs 3a, 3b, 3c). The patient was referred to a weight loss program and for 8 weeks of physical therapy with mechanical diagnosis and treatment. Due to pain on facet loading

maneuvers including left lumbar rotation with extension, facet arthrosis on MRI, and the vague nature of the distribution of referred pain, the left facet joints at the L4-5 level followed by the L5-S1 level were injected with corticosteroid. Injection of the L5-S1 level provided significant but transient relief. Left L4 and L5 medial branch block failed to confirm the facet joints as pain generators. Due to severe neural foraminal stenosis at the level of the left L4 nerve root, a left L45 TFESI was subsequently performed. The patient reported a 50% improvement on the pain VAS for both low back and leg pain after the TFESI until a slip on ice and fall onto his back, 8 days following the procedure, resulting in a T12 vertebral fracture. His PDI was 63/70 on presentation, 54/70 on follow-up 8 days after the TFESI, one day after his fall and would have been lower if scored prior to his fall. He was subsequently prescribed gabapentin and over the following year, his

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Table 2 Procedure details Case 1

Case 2

Case 3

#1: R L5-S1 TFESI #2: R L5-S1 TFESI, 2 weeks after TFESI #1

#1: R L5-S1 #2: R L5-S1, 2 weeks after #1 #3: R S1 TFESI, 3 weeks after TFESI #2.

#1: L4-L5 TFES Note: Prior to TFESI, had L L4-L5 and L L5-S1 ZA joint injections, as well as L4 and L5 medial branch blocks, all with no or minimal pain relief.

Length of Needle

17.8 cm (for both injections)

17.8 cm for 1st , 12.7 inches for 2nd , 3rd

17.8 cm

Flouroscopy Time (sec)

#1: 36 #2: 42

#1: 30 #2: 18 #3: 12

#1: 30

Complications

#1: None #2: None

#1: Challenging needle placement due to body habitus. Procedure tolerated

#1: Challenging needle placement due to body habitus. Lateral view obscured.

Procedure tolerated poorly due To pain.

#2: Procedure tolerated poorly due to pain. #3: Trouble tolerating the procedure due to pain.

Procedure tolerated poorly due to Pain.

Injection number, Side, Level, Procedure, Type

Abbreviations: #: Injection number; TFESI: Transforaminal epidural steroid injection; sec: Seconds; ZA: Zygoapophysial; cm: centimeters.

(b)

(a)

(c) Fig. 2. (a) and (b): T1-weighted axial section of the lumbar spine, showing the L4-L5 and L5-S1 intervertebral discs, respectively. Epidural adipose tissue has compressed the thecal sac into a triangular cross-section at the L4-L5 and L5-S1 levels. This is indicative of significant compression, representing Grade II compression according to the classification defined by Borre et al. [26]. (c): T1-weighted sagittal section of the lumbosacral spine, showing L4-S1 SEL with compression of the thecal sac.

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(a)

(b)

(c)

Fig. 3. (a) and (b): T1-weighted axial section of the lumbar spine, showing the L4-L5 and L5-S1 discs, respectively. A trifid dural sac, the “Y-sign,” is evident at the L4-L5 level, indicative of severe compression of the thecal sac by epidural adipose tissue. This represents Grade III compression according to the classification defined by Borre et al. [26] Grade III compression is seen at the L5-S1 Level (3a). (c): T1-weighted sagittal section of the lumbosacral spine, showing L4-L5 SEL with compression of the thecal sac.

pain remained stable at a similar level to what he reported after his TFESI but before his fall.

5. Discussion Spinal epidural lipomatosis (SEL) is defined as the excessive deposition of adipose tissue in the spinal epidural space. SEL accumulates in the anterior and posterior aspects of the epidural space as two unconnected structures [7], affecting either the thoracic or lumbosacral spine. No cases of SEL have been reported in the cervical spine [1]. While the prevalence of asymptomatic SEL is unknown, over 100 cases of symptomatic SEL have been reported [1,8]. In descending order or frequency [1], this condition is associated with chronic corticosteroid use [9–16], obesity [9,17,18], excessive endogenous production of cortisol [2,3,19–22], and highly active antiretroviral therapy (HAART) [4,23–25]. It occurs more commonly in men (75%) than women (25%). The mean age of patients with SEL is 43 years [26,27]. SEL induced by corticosteroid excess accumulates in the thoracic region approximately twice as often as in the lumbar region. In contrast, SEL affects the lumbar region

three times more frequently than the thoracic region in obese patients [1]. In the majority of reported cases of SEL due to exogenous corticosteroid use, patients received 5–11 years of doses equivalent to 30–100 mg of prednisone per day [1,28,29]. The longest reported time to development of SEL with corticosteroid use is 33 years where as the shortest was 4 months [1,30,31]. The clinical presentation of lumbosacral SEL may include progressive pain, weakness, numbness, incontinence, abnormal reflexes, and paralysis [32]. In a comprehensive review of all of the cases of SEL reported in the English language literature up to 2008, which included 111 cases, Al-Khawaja et al. reported that thoracic SEL presented with myelopathy (55%) or paraplegia (19%) where as lumbosacral SEL presented with low back and radicular pain (54%), claudication (21%), or leg weakness (25%) [8]. SEL is a diagnosis based on imaging. While CT scan allows for the diagnosis of compressive SEL, at a pathognomonic density of −50 to −100 hounsfield units, MRI is considered a more sensitive and specific modality [27]. The high contrast between adipose tissue and the thecal sac on T1-weighted MRI permits an accurate evaluation of the extent of pathologic epidural tissue overgrowth in the spinal canal. The normal range

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Table 3 Treatment outcomes Pain Score Immediately pre and post-injection

Perceived % Improvement at follow-up

PDI on presentation and at follow-up

Case 1

Case 2

Case 3

#1: 8/10 to 0/10 #2: 8/10 to 6/10

#1: 8/10 to 0/10 #2: 7/10 to 0/10 #3: 8/10 to 7/10

#1: 10/10 pre-injection, postinjection score not filed.

75% at 3 week follow up after TFESI #2.

50% at 2 weeks follow up after TFESI #2 (better sleep, better stairs) 45% at 5 days follow up after TFESI #3

50% at 8 days after TFESI.

Presentation: 52/70 Post-TFESI #1: 37/50 (did not answer 2 questions) Post-TFESI #2: 29/70

Presentation: 62/70 Post-TFESI #2: 56/70 Post-TFESI #3: 49/70

Presentation: 63/70 Post-TFESI: 54/70; note: patient fell the day before this followup appointment affecting his PDI score.

Surgery 6 months after last ESI L5-S1 laminectomy & foraminotomy with initial improvement but then return of symptoms 6 months after surgery. Abbreviations: #: Injection number; /: Out of a total possible score of; %: Percent; TFESI: Transforaminal epidural steroid injection; PDI: Pain disability index.

for sagittal epidural fat thickness is 3 to 6 mm while in symptomatic SEL, the sagittal epidural fat thickness may approach 7 to 15 mm [33]. Borre et al. characterized a grading system using axial MRI images with 4 grades of compression from 0 to III [34]. Grade 0 is characterized by a ratio of the dural sac diameter to the epidural fat diameter > 1.5 or a ratio of the epidural fat diameter to anterior-posterior diameter of the spinal canal of < 40%. Grades I, II, and III are characterized by ratios of 1.0–1.46 or 41–50%, 0.34–0.99 or 51–74%, < 0.33 or > 74%, respectively. In a retrospective study of 2528 patients with SEL, this grading system showed strong intra- and inter-rater reliability with intra- and inter-class correlations coefficients of 0.79–0.82 and 0.76–0.85, respectively [34]. This study showed no symptomatic cases in association with grade I compression. Fourteen and a half percent of patients with grade II compression reported symptoms, where as all patients with grade III stenosis reported symptoms. A trifid dural sac or “Y” sign (seen in Figs 1b and 3a), originally described by Kuhn et al., is consistent with grade III compression [35]. Dural sac compression occurs at a mean of 2 vertebral segments when the lumbosacral region is affected and 4.3 to 5 segments when the thoracic region is affected [8]. Notably, the severity of lumbar symptoms including low back pain, radicular leg pain, weakness, sensory function, bladder function, walking capacity, and restrictions of activities of daily living tends to correlate better with the number of vertebral segments af-

fected compared to the grade of compression, with a greater number of affected segments being associated with more significant symptoms and functional impairment [36]. If no weakness or progressive neurologic change is present, symptomatic SEL is typically treated conservatively with pain medication, physical therapy, and weight loss [1–4]. Data suggest that patients who can tolerate weight loss and/or a steroid taper achieve good outcomes. A meta-analysis of 104 cases by Fogel et al. demonstrated that weight loss, non-invasive symptomatic treatment, and corticosteroid taper when indicated significantly improved symptoms of 77% of patients with SEL secondary to excessive exogenous corticosteroids use and 82% of patients with SEL secondary to obesity [1]. Borstlap et al. found resolution of the “Y” sign to correlate with clinical improvement of symptoms in patients with SEL treated with a weight-reduction program [37]. Decompressive surgery with debulking of compressive epidural fat and possibly laminectomy is undertaken if weakness develops or if pain is severe and refractory to conservative measures [38,39]. Significant symptom relief after decompression has been reported at rates of 60–77% [8,28,29,36,39], though the duration of symptom relief is not well characterized in the surgical outcomes literature. Epidural fat can reaccumulate after surgery [40] and cause symptoms to reoccur. Fessler et al. reviewed 15 cases of SEL that required decompression surgery and found a 27% mor-

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tality rate (4 of 15 patients) associated with this procedure [29]. Fessler’s study represents a sub-population of patients with SEL who are at the highest risk of surgical complications, as the cases reviewed consisted exclusively of individuals on chronic corticosteroids due to organ transplant, or systemic disease requiring significant immunosuppression. Other small studies have reported no complications post-operatively [36]. However, Fessler’s findings highlight the serious potential risk in SEL surgery compared to conservative treatment. Nearly all patients with SEL have co-morbid conditions that increase their risk of post surgical morbidity and mortality given that the population with SEL consists largely of individuals with metabolic syndrome or conditions requiring immunosuppression. Recently, TFESI has been attempted for the treatment of lumbosacral radicular pain due to SEL after failure of non-invasive treatment in hopes of sparing this patient population from decompression surgery. Botwin and Sakalkale reported significant short-term improvement in pain with 80–85% improvement in pain scores two weeks after injection in two cases, without any associated complication [5]. We report three additional cases in which patients with SEL experienced significant short term (1–5 week) improvement in pain and disability scores, with 75%, 78%, and 50% reductions on the pain VAS, or 6, 7, and 5 point improvements, respectively, in which improvement of at least 2 points on the pain VAS is considered the minimal important change for clinical significance [41,42]. Similarly, during short-term follow up of 1–5 weeks, these patient experienced 44%, 19%, and 13% respective improvements in PDI score, in which a 10% improvement is considered the minimal change for clinical significance [43]. In two cases, these pain and functional improvements were sustained at one year follow up, while one patient went on to require SEL decompression surgery due to refractory pain, though without new weakness or neurologic change. Further study is indicated to determine if TFESI reliably provides both short and long-term symptom relief and improvement of disability. Additionally, the three above cases describe treatment of patients with SEL due to obesity, but outcomes have not been studied in patients with SEL due to corticosteroid excess or HAART. TFESI may represent a potential option for the treatment of lumbosacral radicular pain due to SEL when non-invasive measures fail, prior to committing to decompression surgery. However, there is a theoretical risk of worsening SEL with this procedure. Six cases of symptomatic lumbosacral SEL following epidural

injection in patients with minimal to no prior SEL on imaging have been reported [39,44–47]. McCullen et al. describe the development of symptomatic SEL in a patient after 8 epidural steroid injections within two years, including 5 within 3 months for lumbosacral radiculitis. The patient was noted to have Cushingoid features upon presentation with worsening pain after the series of 8 injections. She was treated conservatively with weight loss and discontinuation of ESIs, and her symptoms resolved. Sandberg and Lavyne report a case of symptomatic SEL in a patient three years after receiving two epidural steroid injections (transforaminal and interlaminar approaches, respectively). After receiving additional injections, the patient’s symptoms worsened, necessitating surgical decompression. Tok et al. report a case of new SEL diagnosed three months after two ESIs spaced two weeks apart. The patient underwent surgical decompression, which relieved his symptoms. Danielson and Harrast report a case of symptomatic SEL after a single caudal ESI, though the patient’s symptoms resolved without intervention in the following 5 months. Choi et al. report two cases of symptomatic SEL, though these findings may be confounded by the presence of surgery prior to development of SEL in addition to an ESI. One patient developed symptoms and MRI showed new SEL 6 months after receiving two ESIs and a lumbar fusion procedure, and the second developed symptoms 4 months after receiving a single ESI and 5 months after a lumbar vertebroplasty. Given this theoretical risk of worsening SEL, we recommend restricting the use of TFESI to patients who would otherwise require surgery due to pain refractory to conservative treatment or as bridging shortterm pain relief to scheduled surgery. We suspect that TFESI may prevent a portion of this population at high risk of complication from undergoing surgery. We also recommend TFESI for SEL as a means of increasing mobility and tolerance of a weight loss and physical therapy program, rather than as isolated symptomatic relief, which is likely to be transient without addressing the mechanical compression caused by epidural fat.

6. Conclusion This case series suggests that transforaminal epidural steroid injection can provide modest short-term symptom relief and improvement in disability in patients with lumbosacral radicular pain caused by spinal epidural lipomatosis. This procedure should be used

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with caution due to a theoretical risk of increasing epidural adipose accumulation, and should only be used in patients who would otherwise undergo surgery until the long-term safety of this procedure is better characterized. Further study of non-operative management of symptomatic SEL is warranted, given the risk associated with surgery in patients with this condition.

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Transforaminal epidural steroid injection in the treatment of lumbosacral radicular pain caused by epidural lipomatosis: a case series and review.

Spinal epidural lipomatosis (SEL) can cause radicular pain due to spinal nerve root impingement. While SEL decompression surgery can provide symptom r...
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