Epidural Lipomatosis

[painfre]

I have a pt with axial LBP with radiating pain to b/l knees and MRI showing Epidural lipomatosis from L5 through the sacral canal. and mild to moderate disc protrusions at L3 and L4 levels.
Glucocorticoids may cause lipomatosis. I am wondering if can do LESI with celestone in this pt.

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[lobelsteve]

I have a pt with axial LBP with radiating pain to b/l knees and MRI showing Epidural lipomatosis from L5 through the sacral canal. and mild to moderate disc protrusions at L3 and L4 levels.
Glucocorticoids may cause lipomatosis. I am wondering if can do LESI with celestone in this pt.

I've done it with good success (but only lasting 3 months)

Search the forum as this topic has been discussed with lots of info.

 

[Tenesma]

i do it all the time - most get some degree of relief....

 

[SSdoc33]

agreed. i find that these patients actually do better with interlaminars, as the lipomatosis is usually central

 

[clubdeac]

agreed. i find that these patients actually do better with interlaminars, as the lipomatosis is usually central

If the lipomatosis is central and you go midline would there be a less pronounced loss of resistance increasing the risk of a wet tap??

 

[SSdoc33]

If the lipomatosis is central and you go midline would there be a less pronounced loss of resistance increasing the risk of a wet tap??

you get the LOR b/c of the ligamentum flavum, not the epidural fat. should not have any effect. the epidural fat should not have anywhere near the resistance as a ligament.

btw, im not a huge fan of the purely midline approach, as you need to go thru the thick interspinous ligaments. starting out slightly paramedian works a bit better for me, but that is a different thread, i guess.

 

[Tenesma]

actually when i spoke to the surgeons who did the debulking of the lipomatosis they both told me that the fat gets quite hard and isn't soft and squishy... so LOR may be affected...

bilateral TFESI.

 

[lobelsteve]

actually when i spoke to the surgeons who did the debulking of the lipomatosis they both told me that the fat gets quite hard and isn't soft and squishy... so LOR may be affected...

bilateral TFESI.

Yup. Or unilateral of pain is one side biased.

 

[clubdeac]

actually when i spoke to the surgeons who did the debulking of the lipomatosis they both told me that the fat gets quite hard and isn't soft and squishy... so LOR may be affected...

bilateral TFESI.

Yeah the reason I ask is b/c I tried a midline on a guy with severe lipomatosis and not once but twice went right through the canal and didn't stop until I hit the posterior vertebral body. Both times there was no loss and I couldn't even aspirate CSF after pulling the needle back into where the intrathecal space should've been. I was completely dumbfounded. I reviewed the MRI with the neuroradiologist and I believe the canal was so small at L5-S1 from the surrounding lipomatosis that I completely missed it. Crazy

 

[Tenesma]

YUP --- identical experiences... that's why i don't do interlaminars on those patients at those levels...

 

[painfre]

Coming back to my pt, I am planning to do LESI around L3-4 and not @ L5 because of lipomatosis.

 

[lobelsteve]

Coming back to my pt, I am planning to do LESI around L3-4 and not @ L5 because of lipomatosis.

If you inject above the level where the pain is coming from, you could just put in NSS. Go lower. S1 TFESI is reasonable, and will be more effective than at L3-4, especially if you suspect L5-S1 pathology.

 

[Tenesma]

i don't like going ABOVE the level as the cortisone will typically not spread the way i want....

i would do a Bilateral L5 TFESI or Bil S1 TFESI... if that is what correlates w/ sx and imaging.

 

[SSdoc33]

i don't like going ABOVE the level as the cortisone will typically not spread the way i want....

i would do a Bilateral L5 TFESI or Bil S1 TFESI... if that is what correlates w/ sx and imaging.

i disagree. you are looking not only for an anti-inflammatory effect, but ideally some fat necrosis from the cortisone. you want to put the most medication at the level of the pathology. i think the "i dont get a good LOR with epidural lipomatosis" is a myth. looking at maybe 50 interlams adn there has never been an issue with these patients. let us know your results 🙂

 

[lobelsteve]

i disagree. you are looking not only for an anti-inflammatory effect, but ideally some fat necrosis from the cortisone. you want to put the most medication at the level of the pathology. i think the "i dont get a good LOR with epidural lipomatosis" is a myth. looking at maybe 50 interlams adn there has never been an issue with these patients. let us know your results 🙂

Are we performing the procedure for pain relief or fat necrosis?
If you say for fat necrosis, do not pass go and do not collect $200.
Incidence of fat necrosis with steroids is too low to consider this a legit possibility.

 

[SSdoc33]

Are we performing the procedure for pain relief or fat necrosis?
If you say for fat necrosis, do not pass go and do not collect $200.
Incidence of fat necrosis with steroids is too low to consider this a legit possibility.

both. agreed incidence is low and nothing to "count on". the thought process that a TFESI is a better injection for a HNP because the medication gets delivered closer to the area of pathology can be extrapolated to using a ILESI for epidural lipomatosis.

 

[olafa]

Anyone doing caudal approach for these patients? Like Steve said, targeting the lower levels...

i don't like going ABOVE the level as the cortisone will typically not spread the way i want....

i would do a Bilateral L5 TFESI or Bil S1 TFESI... if that is what correlates w/ sx and imaging.

 

[painfre]

I am doing between L3 and L4 bcos of mild to moderate disc protrusions at L3 and L4 levels and not lipomatosis at L5-S1.

 

[lobelsteve]

I am doing between L3 and L4 bcos of mild to moderate disc protrusions at L3 and L4 levels and not lipomatosis at L5-S1.

Do you mean the L3-4 and L4-5 discs? If you go at L3-4, little to nothing will get to L4-5. Any recess, foraminal, or canal stensosis- pain pattern is where? Is this for axial pain?

So much time so little to do.