Multiple epidural steroid injections and body mass index linked with occurrence of epidural lipomatosis: a case series

BMC Anesthesiology

Rafael Jaimes²  Angelo G Rocco¹ 

[1] Department of Orthopedics, Harvard Vanguard Medical Associates, 133 Brookline Ave, Boston, MA 02215, USA

[2] The George Washington University, 2300 I St NW Ross Hall Room 456, Washington D.C 20037, USA

关键词: Sciatica;    Cortisol;    Obesity;    Epidural steroid injection;    Epidural lipomatosis;   

Others  :  1084478
DOI  :  10.1186/1471-2253-14-70

 received in 2013-11-17, accepted in 2014-08-05,  发布年份 2014

【 摘 要 】

Background

Epidural lipomatosis (EL) is an increase of adipose tissue, normally occurring in the epidural space, sufficient to distort the thecal sac and compress neural elements. There is a lack of knowledge of risk factors, impact on patient’s symptoms, and its possible association with epidural steroid injections.

Methods

History, physical examination, patient chart, and MRI were analyzed from 856 outpatients referred for epidural steroid injections. Seventy patients with signs of EL on MRI comprised the study group. Thirty-four randomly selected patients comprised the control group. The severity of EL was determined by the MRI assessment. The impact of EL was determined by the patient’s history and physical examination. Logistic regression was used to correlate the probability of developing EL with BMI and epidural steroid injections.

Results

EL was centered at L5 and S1 segments. The average BMI for patients with EL was significantly greater than that of control group (36.0 ± 0.9 vs. 29.2 ± 0.9, p <0.01). The probability of developing EL with increasing BMI was linear up to the BMI of 35 after which it plateaued. Triglycerides were significantly higher for the EL group as compared to controls (250 ± 30 vs. 186 ± 21 mg/dL p < 0.01). The odds of having EL were 60% after two epidural steroid injections, 90% after three epidural steroid injections and approached 100% with further injections, independent of BMI. Other risk factors considered included alcohol abuse, use of protease inhibitors, levels of stress, hypothyroidism and genetic predisposition. However there were insufficient quantities to determine statistical significance with a degree of confidence. The impact of EL on patient’s symptoms correlated with EL severity with Spearman correlation coefficient of 0.73 at p < 0.01 significance level.

Conclusions

The BMI and triglycerides levels were found to be significantly elevated for the EL group, pointing to an increased risk of EL occurrence in progressively more obese US population. The data also revealed a strong correlation between the number of subsequent epidural steroid injections and EL occurrence calling for caution with the use of corticosteroids.

【 授权许可】

   
2014 Jaimes and Rocco; licensee BioMed Central Ltd.

【 图 表 】

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【 参考文献 】

• [1]Lee M, Lekias J, Gubbay SS, Hurst PE: Spinal cord compression by extradural fat after renal transplantation. Med J Aust 1975, 1(7):201-203.
• [2]Fogel GR, Cunningham PY 3rd, Esses SI: Spinal epidural lipomatosis: case reports, literature review and meta-analysis. Spine J 2005, 5(2):202-211.
• [3]Al-Khawaja D, Seex K, Eslick GD: Spinal epidural lipomatosis–a brief review. J Clin Neurosci 2008, 15(12):1323-1326.
• [4]Borre DG, Borre GE, Aude F, Palmieri GN: Lumbosacral epidural lipomatosis: MRI grading. Eur Radiol 2003, 13(7):1709-1721.
• [5]Flores A, VKH S, Dickman CA: Idiopathic spinal epidural lipomatosis: report of two cases and review of literature. BNI Quarterly 1995, 11:22-25.
• [6]Quint DJ, Boulos RS, Sanders WP, Mehta BA, Patel SC, Tiel RL: Epidural lipomatosis. Radiology 1988, 169(2):485-490.
• [7]Fan CY, Wang ST, Liu CL, Chang MC, Chen TH: Idiopathic spinal epidural lipomatosis. J Chin Med Assoc 2004, 67(5):258-261.
• [8]Rocco AG, Reisman RM, Lief PA, Ferrante FM: A two-person technique for epidural needle placement and medication infusion. Reg Anesth 1989, 14(2):85-87.
• [9]Kuhn MJ, Youssef HT, Swan TL, Swenson LC: Lumbar epidural lipomatosis: the “Y” sign of thecal sac compression. Comput Med Imaging Graph 1994, 18(5):367-372.
• [10]Pouchot J, Si-Hassen C, Damade R, Bayeux MC, Mathieu A, Vinceneux P: Cauda equina compression by epidural lipomatosis in obesity. Effectiveness of weight reduction. J Rheumatol 1995, 22(9):1771-1775.
• [11]Pinkhardt EH, Sperfeld AD, Bretschneider V, Unrath A, Ludolph AC, Kassubek J: Is spinal epidural lipomatosis an MRI-based diagnosis with clinical implications? A retrospective analysis. Acta Neurol Scand 2008, 117(6):409-414.
• [12]Kumar K, Nath RK, Nair CP, Tchang SP: Symptomatic epidural lipomatosis secondary to obesity. Case report. J Neurosurg 1996, 85(2):348-350.
• [13]Robertson SC, Traynelis VC, Follett KA, Menezes AH: Idiopathic spinal epidural lipomatosis. Neurosurgery 1997, 41(1):68-74. discussion 74–5
• [14]Unger RH: The physiology of cellular liporegulation. Annu Rev Physiol 2003, 65:333-347.
• [15]Haddad SF, Hitchon PW, Godersky JC: Idiopathic and glucocorticoid-induced spinal epidural lipomatosis. J Neurosurg 1991, 74(1):38-42.
• [16]Fessler RG, Johnson DL, Brown FD, Erickson RK, Reid SA, Kranzler L: Epidural lipomatosis in steroid-treated patients. Spine (Phila Pa 1976) 1992, 17(2):183-188.
• [17]Koch CA, Doppman JL, Patronas NJ, Nieman LK, Chrousos GP: Do glucocorticoids cause spinal epidural lipomatosis? When endocrinology and spinal surgery meet. Trends Endocrinol Meta 2000, 11(3):86-90.
• [18]Bodelier AG, Groeneveld W, van der Linden AN, Haak HR: Symptomatic epidural lipomatosis in ectopic Cushing's syndrome. Eur J Endocrinol 2004, 151(6):765-769.
• [19]Lipson SJ, Naheedy MH, Kaplan MM, Bienfang DC: Spinal stenosis caused by epidural lipomatosis in cushing’s syndrome. N Engl J Med 1980, 302(1):36.
• [20]Ogawa A, Johnson JH, Ohneda M, McAllister CT, Inman L, Alam T, Unger RH: Roles of insulin resistance and beta-cell dysfunction in dexamethasone-induced diabetes. J Clin Invest 1992, 90(2):497-504.
• [21]Madiehe AM, Lin L, White C, Braymer HD, Bray GA, York DA: Constitutive activation of STAT-3 and downregulation of SOCS-3 expression induced by adrenalectomy. Am J Physiol Regul Integr Comp Physiol 2001, 281(6):R2048-R2058.
• [22]Rosenstock J, Banarer S, Fonseca VA, Inzucchi SE, Sun W, Yao W, Hollis G, Flores R, Levy R, Williams WV, Seckl JR, Huber R: The 11-beta-hydroxysteroid dehydrogenase type 1 inhibitor INCB13739 improves hyperglycemia in patients with type 2 diabetes inadequately controlled by metformin monotherapy. Diabetes Care 2010, 33(7):1516-1522.
• [23]Pejic RN, Lee DT: Hypertriglyceridemia. J Am Board Fam Med 2006, 19(3):310-316.
• [24]Beard CM, Barnard RJ, Robbins DC, Ordovas JM, Schaefer EJ: Effects of diet and exercise on qualitative and quantitative measures of LDL and its susceptibility to oxidation. Arterioscler Thromb Vasc Biol 1996, 16(2):201-207.
• [25]Grun F, Blumberg B: Minireview: the case for obesogens. Mol Endocrinol 2009, 23(8):1127-1134.
• [26]Tomlinson JW, Sherlock M, Hughes B, Hughes SV, Kilvington F, Bartlett W, Courtney R, Rejto P, Carley W, Stewart PM: Inhibition of 11beta-hydroxysteroid dehydrogenase type 1 activity in vivo limits glucocorticoid exposure to human adipose tissue and decreases lipolysis. J Clin Endocrinol Metab 2007, 92(3):857-864.
• [27]Tok CH, Kaur S, Gangi A: Symptomatic spinal epidural lipomatosis after a single local epidural steroid injection. Cardiovasc Intervent Radiol 2011, 34(Suppl 2):S250-S255.
• [28]McCullen GM, Spurling GR, Webster JS: Epidural lipomatosis complicating lumbar steroid injections. J Spinal Disord 1999, 12(6):526-529.
• [29]Sandberg DI, Lavyne MH: Symptomatic spinal epidural lipomatosis after local epidural corticosteroid injections: case report. Neurosurgery 1999, 45(1):162-165.
• [30]Roy-Camille R, Mazel C, Husson JL, Saillant G: Symptomatic spinal epidural lipomatosis induced by a long-term steroid treatment. Review of the literature and report of two additional cases. Spine (Phila Pa 1976) 1991, 16(12):1365-1371.
• [31]Selye H: Forty years of stress research: principal remaining problems and misconceptions. Can Med Assoc J 1976, 115(1):53-56.
• [32]Masuzaki H, Paterson J, Shinyama H, Morton NM, Mullins JJ, Seckl JR, Flier JS: A transgenic model of visceral obesity and the metabolic syndrome. Science 2001, 294(5549):2166-2170.
• [33]Tsigos C, Chrousos GP: Hypothalamic-pituitary-adrenal axis, neuroendocrine factors and stress. J Psychosom Res 2002, 53(4):865-871.
• [34]Pasquali R, Vicennati V, Cacciari M, Pagotto U: The hypothalamic-pituitary-adrenal axis activity in obesity and the metabolic syndrome. Ann N Y Acad Sci 2006, 1083:111-128.
• [35]Brunner EJ, Hemingway H, Walker BR, Page M, Clarke P, Juneja M, Shipley MJ, Kumari M, Andrew R, Seckl JR, Papadopoulos A, Checkley S, Rumley A, Lowe GD, Stansfeld SA, Marmot MG: Adrenocortical, autonomic, and inflammatory causes of the metabolic syndrome: nested case–control study. Circulation 2002, 106(21):2659-2665.
• [36]Baik I, Shin C: Prospective study of alcohol consumption and metabolic syndrome. Am J Clin Nutr 2008, 87(5):1455-1463.
• [37]Crouse JR, Grundy SM: Effects of alcohol on plasma lipoproteins and cholesterol and triglyceride metabolism in man. J Lipid Res 1984, 25(5):486-496.
• [38]Sturm R: Increases in morbid obesity in the USA: 2000–2005. Public Health 2007, 121(7):492-496.
• [39]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(8):670-673.
• [40]van Rooij WJ, Borstlap AC, Canta LR, Tijssen CC: Lumbar epidural lipomatosis causing neurogenic claudication in two obese patients. Clin Neurol Neurosurg 1994, 96(2):181-184.
• [41]Qasho R, Ramundo OE, Maraglino C, Lunardi P, Ricci G: Epidural lipomatosis with lumbar radiculopathy in one obese patient. Case report and review of the literature. Neurosurg Rev 1997, 20(3):206-209.
• [42]Maillot F, Mulleman D, Mammou S, Goupille P, Valat JP: Is epidural lipomatosis associated with abnormality of body fat distribution? A case report. Eur Spine J 2006, 15(1):105-108.
• [43]Boutsen Y, Donckier J: Epidural lipomatosis. Postgrad Med J 2000, 76(891):60-61.