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Table of Contents    
LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 3  |  Page : 318-320

Y-sign and other diagnostic findings in idiopathic spinal epidural lipomatosis


1 Department of Neurology, New York Medical College, Valhalla, New York, USA
2 Department of Neurosurgery, New York Medical College, Valhalla, New York, USA

Date of Submission17-May-2013
Date of Decision19-May-2013
Date of Acceptance13-Jun-2013
Date of Web Publication16-Jul-2013

Correspondence Address:
Robert Fekete
Department of Neurology, New York Medical College, Valhalla, New York
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.115084

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How to cite this article:
Patil KA, Hillard VH, Fekete R. Y-sign and other diagnostic findings in idiopathic spinal epidural lipomatosis. Neurol India 2013;61:318-20

How to cite this URL:
Patil KA, Hillard VH, Fekete R. Y-sign and other diagnostic findings in idiopathic spinal epidural lipomatosis. Neurol India [serial online] 2013 [cited 2019 Sep 16];61:318-20. Available from: http://www.neurologyindia.com/text.asp?2013/61/3/318/115084


Sir,

Spinal epidural lipomatosis (SEL) describes abnormal accumulation of fatty tissue in epidural space, with predilection for thoracic spine but also possible in lumbar spine. The condition may be idiopathic but it has been linked to endogenous hypercortisolemia and exogenous glucocorticoid use. [1]

A 61-year-old right handed Caucasian male complained of right lower extremity paresthesia and sensory loss of one week duration and 6 days of mild right lower extremity weakness leading to a sensation of "buckling" during ambulation. He has a history of arthritis, chronic obstructive pulmonary disease (COPD), dyslipidemia, gastro-esophageal reflux disease, and right total knee arthroplasty. He smoked for at least 20 pack years, but quit 2 years ago. For treatment of COPD, he took tiotropium 18 μg daily, fluticasone 220 μg twice daily, and albuterol 90 μg as needed. On general examination, he was 193 cm tall and weighed 112 kg, with a body mass index (BMI) of 30.1 kg/m 2 . Neurologic examination revealed significant impairment for light touch and pinprick sensation on the dorsum of the right foot and impaired proprioception of right toes. Reflexes were 1+ in the biceps and triceps bilaterally. Knee and ankle reflexes were absent bilaterally. Plantar response was mute bilaterally.

Computed tomography (CT) scan of abdomen/pelvis was performed given prior history of right psoas abscess, which was completely resolved at this time. Two new abscesses in the left iliopsoas muscle measuring 2.4 × 2.2 cm and 1.7 × 2.2 cm were found. Magnetic resonance imaging (MRI) of thoracic spine was normal and lumbar spine, at L4/L5 and L5/S1 levels, there was deformation of the thecal sac secondary to epidural lipomatosis [Figure 1] and [Figure 2]. In addition, disc bulges at L2/L3 and L3/L4 caused mild spinal stenosis without foraminal impingement. There was also an incidental L3/L4 synovial cyst. Nearly 7-8 mm areas of dorsal lipomatosis were seen in the thoracic spine [Figure 3]. The left psoas abscesses were successfully drained under CT guidance with significant improvement of pain and gait difficulty.
Figure 1: Lumbar epidural lipomatosis (arrows) seen as hyperintense on T1 (a) nearly isointense to CSF on T2 (b) and hypointense on short T1 inversion recovery (STIR) sequence (c) There is an incidental synovial cyst at L3/L4 level

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Figure 2: Classic "Y‑sign" deformation of the thecal sac on axial T1 MRI at L5/S1

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Figure 3: Thoracic epidural lipomatosis (arrows) seen as hyperintense on T1 (a) nearly isointense to CSF on T2 (b) and hypointense on short T1 inversion recovery (STIR) sequence (c)

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SEL is a rare complication of Cushing's syndrome, systemic and local glucocorticoid use [1] and medication side effect of antiandrogens and protease inhibitors, and also occurs in idiopathic cases associated with obesity. [2] There is preference for thoracic spine (60%) versus lumbar spine (40%). Treatment is based on severity of compression and can range from excision and laminectomy to more conservative measures such as treatment of endogenous hypercortisolemia, reduction or elimination of offending exogenous agent (typically glucocorticoid) and weight reduction in cases due to obesity. [3]

Our patient most likely has idiopathic SEL due to obesity with BMI above 30. The likelihood for inhaled fluticasone at 0.44 mg per day to have systemic activity is low, but in a meta-analysis of inhaled corticosteroids, fluticasone had greater dose-related systemic effects including adrenal suppression than other inhaled corticosteroids. [4] Short T1 inversion recovery (STIR) T1 sequence was useful for confirmation of diagnosis as lipid is hypointense on this sequence [Figure 1]c. Classic deformation of the thecal sac into the "Y-sign" was seen in our case, but other shapes including star and triangle are possible in lumbar SEL. [2] In thoracic SEL, dorsal lipomatosis displacing the thecal sac ventrally is typical and should measure more than 7 mm in the anterior-posterior plane, [2] 7-8 mm areas of dorsal epidural lipomatosis were seen in the thoracic spine in our case [Figure 3]. He will be followed on an outpatient basis with weight loss regimen as conservative treatment. His fluticasone will be changed to an inhaled steroid with less systemic activity.

 
  References Top

1.Sandberg DI, Lavyn MH. Symptomatic spinal epidural lipomatosis after local epidural corticosteroid injections: Case report. Neurosurgery 1999;45:162-5.  Back to cited text no. 1
    
2.Butteriss D, Jayakrishnan V. Acute spinal cord compression. Br J Radiol 2007;80:686-9.  Back to cited text no. 2
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3.Borstlap AC, van Rooij WJ, Sluzewski M, Leyten AC, Beute G. Reversibility of lumbar epidural lipomatosis in obese patients after weight-reduction diet. Neuroradiology 1995;37:670-3.  Back to cited text no. 3
[PUBMED]    
4.Lipworth BJ. Systemic adverse effects of inhaled corticosteroid therapy: A Systematic review and meta-analysis. Arch Intern Med 1999;159:941-55.  Back to cited text no. 4
[PUBMED]    


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