CASE 10328 Published on 21.09.2012

Intradural Spinal Lipoma Without Spinal Dysraphism With Subcutaneous Extension

Section

Neuroradiology

Case Type

Clinical Cases

Authors

¹Nitesh Shekhrajka, Krishnakumari A. Modi, Ajay Mehta, Vishesh Agarwal, Karam Chand Sharma

1) Regionhospital Horsens, Biilleddiagnostisk Afdeling; Sundvej 30 8700 Horsens, Denmark; Email:nitesh1703@gmail.com
Regionhospital Horsens, Medicinsk Afdeling; Sundvej 30 8700 Horsens, Denmark;
Aarhus University Hospital, Radiologisk Afdeling, Tage-Hansens Gade 2, 8000 Aarhus C, Denmark
Department of Psychiatry, Einstein Medical Center, Philadelphia, USA
Department of Neurosurgery, Safdarjung Hospital, New Delhi, India

Patient

65 years, male

Categories

Area of Interest Musculoskeletal soft tissue, Musculoskeletal spine, Neuroradiology spine, Management, Musculoskeletal system ; Imaging Technique CT, CT-High Resolution, MR

Procedure Comparative studies, Staging, Complications, Imaging sequences, Intraoperative ; Special Focus Pathology, Obstruction / Occlusion, Hyperplasia / Hypertrophy, Neoplasia ;

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Clinical History

20 year history of gradually progressive swelling on the back in the inter-scapular region. Associated progressive para paresis in lower torso and lower limbs and urinary retention for past 6 months.

Imaging Findings

Large, multilobulated, soft tissue mass lesion measuring 28 cm x 20 cm (approx.) Located subcutaneously in the back in the midline with right paraspinal predominance from Th7 to L1. Mass involving the musculature and thoracic cage.
Erosion of the right sided pedicles from Th9 to Th12. Expansion of the intervertebral foraminae from Th9 to Th12 with extension via the enlarged foramina into the extramedullary intradural compartment of spinal canal.
Pressure erosion of the adjacent lower right ribs to extend in the posterior mediastinum.
The mass is hypodense on CT. No calcification.
On MRI, the mass is relatively well defined and is hyperintense on T1 and T2 –weighted images with thin linear streaks of low signal intensity. The lesion shows suppression on fat saturated images on MR - represents Lipoma.

Discussion

BACKGROUND-

Spinal lipomas are congenital tumours usually presenting as slow growing benign tumours. 60% are localised intradurally and 40% extradurally.[1]

Intradural spinal lipomas are slightly more common in men than in women (2, 6, 7)
Lipomas are benign tumours that are histologically identical to normal body fat (4).

Intradural spinal lipomas are rarely diagnosed in patients who do not have neural tube defects. These congenital, histologically benign neoplasms account for less than 1% of all spinal cord tumours[2, 3] and are most often found in cervical and thoracic regions.
It is rare to diagnose intradural spinal lipoma in patients who do not exhibit dysraphism (5)
Most spinal lipomas originate in the dorsal juxtamedullary region of the spinal cord (10);
however, the embryologic defect that leads to the development of these tumours is unknown. Several hypotheses have been proposed to explain how spinal cord lipomas arise. The most widely accepted theory is that a developmental malformation occurs during the formation of the neural tube and leads to inclusion of embryonic crests of fat cells (6, 11). Although the aetiology is unclear, many characteristics of these tumours indicate that they are growing hamartomas. Specifically, they are relatively often associated with other spinal malformations such as spina bifida, and histological evidence also points to a hamartomatous origin (2, 6, 8, 12).
Guifffre's 1966 review stressed that most spinal lipomas are subpial, and are never completely enclosed by neural tissue.(2)

CLINICAL PERSPECTIVE-

The typical neurological manifestation of this condition is a slowly progressive course of spastic para- or tetraparesis and pain (2, 8, 9, 10). Most of these tumours extend over multiple spinal levels and reach a significant volume before they are detected.The typical extent is at least four or five vertebral body segments. The characteristic finding on myelography is widening of the spinal cord in the area of the tumour (13)

IMAGING PERSPECTIVE-
The intimate association of spinal lipomas with adjacent neural structures is best delineated with MRI (14), and high signal intensity on T1-weighted images is characteristic of lipomas. T2-weighted images of these lesions tend to be variable, and the mass may appear hyper-, iso- or hypointense compared to normal neural parenchyma (3, 5, 15).

MANAGEMENT IN THIS PARTICULAR CASE-

D8-L1 laminectomy and subtotal resection of tumour were performed.
Spinal adhesions were relieved under microscope.
The diagnosis of lipoma was confirmed on histopathology.
The patient showed good neurological improvement post-operatively.

Differential Diagnosis List

Intradural Spinal Lipoma Without Spinal Dysraphism With Subcutaneous Extension

Meningioma

Myelomeningocele

Metastatic tumour

Neurofibroma

Lipoma

Final Diagnosis

Intradural Spinal Lipoma Without Spinal Dysraphism With Subcutaneous Extension

References

[1] Erdogan B, Bavbek M, Altinors N et al (2002) Cervical intramedullary lipoma not associated with spinal dysraphism. Turkish Neurosurgery 12:46-49, 2002

[2] Giuffre R (1996) Intradural spinal lipomas. Review of the literature: 99 cases and report of an additional case. Acta Neurochir (Wien) 14:69-95, 1996

[3] Wilson JT, Shapiro RH, Wald SL (1996) Multiple intradural spinal lipomata with intracranial extension. Pediatr Neurosurg 24: 5- 7, 1996

[4] Guidicelli Y, Pierre-Kahn A, Bourdeaux AM, de Mazancourt P, Lacasa D, Hirsch JF (1986) Are the metabolic characteristics of congenital intraspinal lipoma cells identical to, or different from normal adipocytes?. Childs Nerv Syst 2:290-6, 1986

[5] Kodama T, Numaguchi Y, Gellad FE, Sadato N (1991) Magnetic resonance imaging of a high cervical intradural lipoma. Comp Med Imaging Graph 15:93-5, 1991

[6] Ammerman BJ, Henry JM, Girolami UD: Earle KM (1976) Intradural lipomas of the spinal cord: A clinicopathological correlation. J Neurosurg 44:331-6, 1976

[7] La Marca F, Grant JA, Tomita T, McLone DG (1997) Spinal lipomas in children: outcome of 270 procedures. Pediatr Neurosurg 26(1):8-16, 1997

[8] Klekamp J, Fusco M, Samii M (2001) Thoracic Intradural Extramedullary Lipoma: Report Of Three Cases and Review of the Literature. Acta Neurochir (Wien) 143:767-774, 2001

[9] Pierre-Kahn A, Zerah M, Renier D, et al (1997) Congenital lumbosacral lipomas. Childs Nerv Syst 13(6): 298-335, 1997

[10] Wood BP, Harwood-Nash DC, Berger P, Goske M Intradural spinal lipoma of the cervical cord. AJR 145:174-6, 1985

[11] Lunardi P, Missori P, Ferrante L, Fortuna A (1990) Long-term results of surgical treatment of spinal lipomas: report of 18 cases. Acta Neurochir (Wien) 104:64-8, 1990

[12] Mori K, Kamimura Y, Uchida Y, Kurisaka M, Eguchi S (1986) Large intramedullary lipoma of the cervical cord and posterior fossa. J Neurosurg 64:974-6, 1986

[13] Giuffre R Spinal lipoma, in Vinken PJ, Bruyn GW, Handbook of Clinical Neurology, New York. Elsevier, 1975: 20; 389-414

[14] Lantos G, Epstein F, Kory LA (1987) Magnetic resonance imaging of intradural spinal lipoma. Neurosurgery 20:469-472, 1987

[15] Aoki N (1990) Rapid growth of intraspinal lipoma demonstrated by magnetic resonance imaging. Surg Neurol 34:107-110, 1990

Case information

URL:	https://www.eurorad.org/case/10328
DOI:	10.1594/EURORAD/CASE.10328
ISSN:	1563-4086

Figure 1

Sagittal recounstruction on CT

Large, multilobulated, soft tissue mass lesion measuring 28 cms X 20 cms (approx.) Located subcutaneously in back in the midline with right paraspinal predominance from D7 to L1.

Figure 2

Sagittal recounstruction on CT

Large, multilobulated, soft tissue mass lesion measuring 28 cms X 20 cms (approx.) Located subcutaneously in back in the midline with right paraspinal predominance from D7 to L1.

Figure 3

Axial CT