0:00

Okay, Dr. Schupeck.

0:01

This is a 53-year-old.

0:03

The patient is referred. I'm going to read this

0:05

history because it's so complicated.

0:08

Referred for subsequent moderate to sharp and severe

0:13

burning, dull pinching, mid-lower back and leg pain,

0:18

difficulty with all movement,

0:20

numbness and tingling in the lower legs.

0:23

History of fusion L4-5.

0:25

Diagnosis: Post-laminectomy syndrome. Sequelae,

0:29

spinal stenosis. So let's have a look at this case.

0:33

I've got a Sagittal T1, non-contrast on the left.

0:38

Make it a little bigger just to match it up nicely.

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And you can see the patient's had some pedicle

0:43

screws placed at multiple levels.

0:45

Let's line them up a little bit better here.

0:48

And then we have a T2.

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It's a little less magnified with

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a little seroma in the back.

0:53

And the nerve roots look a bit strange.

0:56

We never really see a good transition from CONUS.

1:00

To Cauda Equina,

1:02

at least not until we get down really low.

1:05

So the question is, with this complex history,

1:08

what's really going on? Now,

1:10

I would scroll over to the Neural Foramina,

1:12

and they look pretty good on one side.

1:14

And then I'd scroll over to the Neural Foramina and

1:17

they look pretty good on the other side, too.

1:19

We'd obviously take a walk through memory lane and look

1:23

at the axials and make sure that we don't have

1:26

a pedicle screw that is nailing some nerve root,

1:29

which we didn't.

1:30

And I'm going to put up an axial

1:32

c plus T1 on the far left.

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I'm going to put up an axial T2 in the middle

1:38

and a non-contrast T1 on the right.

1:42

Let's scroll these.

1:44

And these two are scrolling together because

1:47

they're part of the same exam series.

1:50

And as we get down lower, we see nice,

1:52

delicate nerve roots. But as we get up higher,

1:55

things start to look really weird.

1:57

Now, let's see where we are when I say higher.

1:59

How? High, are we?

2:01

Let's see if I can get my cursor in here.

2:04

We're only at L2-3, so at L2-3,

2:08

we've got this Agglomerated gray signal intensity.

2:13

And the reason we're showing this case is,

2:15

is this arachnoiditis?

2:18

Is it epidural lipomatosis?

2:20

Is it both, do we care?

2:23

Do we care? Yeah, I think you care.

2:26

Why do we care? Well, the reason is, first of all,

2:31

the history is really important,

2:33

and that history is all over the lot,

2:36

meaning you can't make a root out of that.

2:38

So you're not talking about a localized

2:41

neural compression where you can say,

2:43

look for one frame and one root, something like that.

2:46

So you're talking about a more diffused process.

2:49

Now, epidural lipomatosis is very tough.

2:53

You're going to see it fairly frequently.

2:55

Obesity probably the most common cause,

2:58

but other things would be repeated epidural.

3:00

Injections or Cushing's disease,

3:02

I think would be the most top three, probably, right?

3:04

Yes. You can get it from repeated Epidural injections?

3:07

I think so. Wow. At least I've heard that.

3:10

I mean,

3:10

I don't have any scientific verification on my own,

3:13

but I've talked to people, and I think that is true.

3:15

Have you seen it yourself with the Epidural injections?

3:19

I've had patients that have had multiple epidurals

3:22

and have had this problem.

3:23

I'd say obesity.

3:25

Most of them have overlapped in that regard,

3:27

so it's a little hard to say.

3:29

But the problem with epidural lipomatosis is if

3:33

you go all the way down to L5-S1, I mean,

3:34

the sac is down to nothing.

3:36

So you'd say, wow, that got to do something about that.

3:39

And once again,

3:40

as we talked in a little earlier session,

3:43

you can have the most severe sequelae sac,

3:46

but no neurologic deficit, no progressive deficit.

3:49

You mean epidural lipomatosis?

3:51

Just like with spinal stenosis,

3:53

you can have very severe, but not a deficit.

3:55

So when you start thinking about, okay, well,

3:58

let's say I wanted to do something about this.

4:00

Like, do what? You'd have to do

4:02

a laminectomy from here to here, right?

4:05

From here to here.

4:06

Yeah. I mean, terrible operation, right?

4:08

You'd be there tearing out fat,

4:09

blood all over the place.

4:11

You are as likely to cause a problem as to fix anything.

4:14

There are articles about it,

4:16

so you can't do a little mini.

4:18

I'm going to stop you and go back to

4:19

my original question, which is,

4:21

does it matter whether he's got epidural lipomatosis,

4:25

arachnoiditis, or both? Well, it does,

4:28

because

4:29

if he has any component of arachnoiditis,

4:32

your chances of success just went from small to zero.

4:36

Okay.

4:37

So there's a lot of reasons to be very careful

4:40

about operating on epidural lipomatosis.

4:42

I've done it a couple of times.

4:43

Not very impressive results. You read articles?

4:46

It's great. I'm not sure about that,

4:48

but if they have arachnoiditis on top of it, as I say,

4:52

big operation, couple of problems,

4:55

very diffuse symptoms.

4:56

You're not looking like a surgical candidate to me.

5:00

You know, surgery is a localized therapy,

5:04

meaning you have to have some localization of a symptom

5:07

to a structure to a compression to make it work.

5:11

And in this case, you know,

5:13

we're kind of all over the lot.

5:14

The history is not helping us.

5:15

We've got a couple of problems,

5:17

all of which are very difficult to deal with surgically.

5:20

So our odds of success are kind of trending very far

5:23

down. Yeah. I'll be honest with you and the audience.

5:26

I'm not sure.

5:27

The contribution of each to producing this

5:32

clumping appearance of the nerve roots.

5:35

It's interesting that up higher,

5:37

the epidural lipomatosis is like a wing nut.

5:40

It's off to the side,

5:42

and it's squishing the cord from side to side

5:45

transversely. And then when you get down lower,

5:48

the epidural. This is more AP.

5:51

In fact, it's in the front,

5:52

and you start to see the nerve roots open up.

5:55

So for that reason, that degree of variability,

5:58

I'm highly suspicious.

6:00

That this upper part has a contribution

6:03

of Arachnoiditis, probably.

6:04

The rest of it is massive epidural lipomatosis.

6:08

But I wanted to show this because it often gets

6:11

confused as a potential overlap syndrome.

6:14

Sometimes people with pure epidural lipomatosis

6:17

are called Arachnoiditis and vice versa.

6:20

And the patient's not fused either.

6:21

Right. So is there a mechanical component to it?

6:24

You know, listening to Tree worse with every movement.

6:26

So, I mean, he's never really got a fusion.

6:29

So 20 different reasons to have symptoms.

6:32

Very difficult to deal with without some major

6:36

intervention, with a very questionable outcome.

6:39

So there's a patient we wouldn't operate on.

6:41

We'd probably give a differential and say,

6:43

component of Arachnoiditis and epidural lipomatosis.

6:47

Let's move on from here.