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Epidural Spinal Injections in Spinal Stenosis due to Lipomatosis: With or without Steroids?

Epidural Spinal Injections in Spinal Stenosis due to Lipomatosis: With or without Steroids? LETTERS Epidural Spinal Injections in Spinal Stenosis due to Lipomatosis: With or without Steroids? pinal epidural lipomatosis (SEL) is characterized by the over- In a recent meta-analysis, no significant difference between Sgrowth of epidural adipose tissue inside the spinal canal and epidural injections with steroids and local anesthetics or local an- may present with symptoms of spinal stenosis or nerve root com- esthetics alone has been found —that is, an epidural injection pression. In a recent study, it has been reported that 6.26% of with local anesthetics only is also an evidence-based approach. patients presenting with clinical signs of spinal stenosis showed This sequential use of an injection with steroids followed by infil- symptomatic SEL. Spinal epidural infiltrations under imaging trations without steroids may limit the risk of worsening SEL. In guidance are a safe treatment for symptomatic spinal stenosis and the treatment of patients with symptomatic SEL, the underlying are frequently performed by interventional radiologists. Usually, etiology should also be considered. For example, in patients with a mixture of local anesthetics and corticosteroids is used. Botwin SEL due to obesity, weight reduction has been shown to reduce and Sakalkale reported a good clinical response (pain relief of SEL. 80%–85%) after epidural injections with steroids in 2 patients In conclusion, evidence in the treatment of spinal stenosis due with SEL and symptoms of spinal stenosis. On the other hand, to SEL with epidural infiltrations is very limited. We propose a repeat epidural infiltrations with corticosteroids have been dis- sequential approach using an epidural infiltration with steroids cussed as an etiologic factor in the development of SEL. The study for the first injection followed, if needed, by further epidural in- by Jaimes and Rocco reported that1 epidural steroid injection filtrations with local anesthetics only. This procedure may reduce was linked to the occurrence of SEL in a logistic regression model. deleterious effects on the progression of SEL. Further studies on Because larger studies and prospective investigations are miss- this topic are needed. ing, the interventional radiologist is in a dilemma whether ste- roids should be used in symptomatic SEL. In these cases, we sug- gest a pragmatic approach. According to the data of Jaimes and REFERENCES Rocco, the first epidural injection can be performed with the use 1. Kim K, Mendelis J, Cho W. Spinal epidural lipomatosis: a review of of steroids. In their study, a single epidural steroid injection was pathogenesis, characteristics, clinical presentation, and manage- not associated with SEL; it seems that a single dose of epidurally ment. Global Spine Journal 2018 Aug 13. [Epub ahead of print] administered steroids is not enough to aggravate epidural fat CrossRef 2. Malone JB, Bevan PJ, Levis TJ, et al. Incidence of spinal epidural lipo- accumulation. matosis in patients with spinal stenosis. J Orthop 2018;15:36–39 In the case of a symptomatic spinal stenosis, we usually per- CrossRef Medline form a single epidural injection using CT guidance and an inter- 3. Botwin KP, Sakalkale DP. Epidural steroid injections in the treatment laminar approach with the use of steroids and local anesthetics (4 of symptomatic lumbar spinal stenosis associated with epidural li- mL of mepivacaine/1 mL of dexamethasone). If there is a marked pomatosis. Am J Phys Med Rehabil 2004;83:926–30 CrossRef Medline improvement after this first injection, other treatment compo- 4. Jaimes R 3rd, Rocco AG. Multiple epidural steroid injections and body mass index linked with occurrence of epidural lipomatosis: a nents such as physiotherapy and medication are adjusted to main- case series. BMC Anestehsiol 2014;14:70 CrossRef Medline tain the improvement. Only in the case of persistent or immedi- 5. Meng H, Fei Q, Wang B, et al. Epidural injections with or without ately relapsing pain is treatment with epidural injection repeated. steroids in managing chronic low back pain secondary to lumbar The safe time interval between 2 epidural injections with steroids spinal stenosis: a meta-analysis of 13 randomized controlled trials. in patients with good clinical SEL is unknown. If there is no Drug Des Devel Ther 2015;9:4657–67 CrossRef Medline significant improvement after the first injection with steroids in 6. Borstlap AC, van Rooij WJ, Sluzewski M, et al. Reversibility of lumbar epidural lipomatosis in obese patients after weight-reduction diet. symptomatic SEL, we think further injections in the short term Neuroradiology 1995;37:670–73 CrossRef Medline should be performed with local anesthetics only. X J. Gossner Department of Diagnostic and Interventional Radiology Evangelisches Krankenhaus Go¨ttingen-Weende http://dx.doi.org/10.3174/ajnr.A6128 Go¨ttingen, Germany E40 Letters Aug 2019 www.ajnr.org http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png American Journal of Neuroradiology American Journal of Neuroradiology

Epidural Spinal Injections in Spinal Stenosis due to Lipomatosis: With or without Steroids?

Gossner, J.
American Journal of Neuroradiology , Volume 40 (8) – Aug 1, 2019
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References (6)

Publisher
American Journal of Neuroradiology
ISSN
0195-6108
eISSN
1936-959X
DOI
10.3174/ajnr.A6128
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Abstract

LETTERS Epidural Spinal Injections in Spinal Stenosis due to Lipomatosis: With or without Steroids? pinal epidural lipomatosis (SEL) is characterized by the over- In a recent meta-analysis, no significant difference between Sgrowth of epidural adipose tissue inside the spinal canal and epidural injections with steroids and local anesthetics or local an- may present with symptoms of spinal stenosis or nerve root com- esthetics alone has been found —that is, an epidural injection pression. In a recent study, it has been reported that 6.26% of with local anesthetics only is also an evidence-based approach. patients presenting with clinical signs of spinal stenosis showed This sequential use of an injection with steroids followed by infil- symptomatic SEL. Spinal epidural infiltrations under imaging trations without steroids may limit the risk of worsening SEL. In guidance are a safe treatment for symptomatic spinal stenosis and the treatment of patients with symptomatic SEL, the underlying are frequently performed by interventional radiologists. Usually, etiology should also be considered. For example, in patients with a mixture of local anesthetics and corticosteroids is used. Botwin SEL due to obesity, weight reduction has been shown to reduce and Sakalkale reported a good clinical response (pain relief of SEL. 80%–85%) after epidural injections with steroids in 2 patients In conclusion, evidence in the treatment of spinal stenosis due with SEL and symptoms of spinal stenosis. On the other hand, to SEL with epidural infiltrations is very limited. We propose a repeat epidural infiltrations with corticosteroids have been dis- sequential approach using an epidural infiltration with steroids cussed as an etiologic factor in the development of SEL. The study for the first injection followed, if needed, by further epidural in- by Jaimes and Rocco reported that1 epidural steroid injection filtrations with local anesthetics only. This procedure may reduce was linked to the occurrence of SEL in a logistic regression model. deleterious effects on the progression of SEL. Further studies on Because larger studies and prospective investigations are miss- this topic are needed. ing, the interventional radiologist is in a dilemma whether ste- roids should be used in symptomatic SEL. In these cases, we sug- gest a pragmatic approach. According to the data of Jaimes and REFERENCES Rocco, the first epidural injection can be performed with the use 1. Kim K, Mendelis J, Cho W. Spinal epidural lipomatosis: a review of of steroids. In their study, a single epidural steroid injection was pathogenesis, characteristics, clinical presentation, and manage- not associated with SEL; it seems that a single dose of epidurally ment. Global Spine Journal 2018 Aug 13. [Epub ahead of print] administered steroids is not enough to aggravate epidural fat CrossRef 2. Malone JB, Bevan PJ, Levis TJ, et al. Incidence of spinal epidural lipo- accumulation. matosis in patients with spinal stenosis. J Orthop 2018;15:36–39 In the case of a symptomatic spinal stenosis, we usually per- CrossRef Medline form a single epidural injection using CT guidance and an inter- 3. Botwin KP, Sakalkale DP. Epidural steroid injections in the treatment laminar approach with the use of steroids and local anesthetics (4 of symptomatic lumbar spinal stenosis associated with epidural li- mL of mepivacaine/1 mL of dexamethasone). If there is a marked pomatosis. Am J Phys Med Rehabil 2004;83:926–30 CrossRef Medline improvement after this first injection, other treatment compo- 4. Jaimes R 3rd, Rocco AG. Multiple epidural steroid injections and body mass index linked with occurrence of epidural lipomatosis: a nents such as physiotherapy and medication are adjusted to main- case series. BMC Anestehsiol 2014;14:70 CrossRef Medline tain the improvement. Only in the case of persistent or immedi- 5. Meng H, Fei Q, Wang B, et al. Epidural injections with or without ately relapsing pain is treatment with epidural injection repeated. steroids in managing chronic low back pain secondary to lumbar The safe time interval between 2 epidural injections with steroids spinal stenosis: a meta-analysis of 13 randomized controlled trials. in patients with good clinical SEL is unknown. If there is no Drug Des Devel Ther 2015;9:4657–67 CrossRef Medline significant improvement after the first injection with steroids in 6. Borstlap AC, van Rooij WJ, Sluzewski M, et al. Reversibility of lumbar epidural lipomatosis in obese patients after weight-reduction diet. symptomatic SEL, we think further injections in the short term Neuroradiology 1995;37:670–73 CrossRef Medline should be performed with local anesthetics only. X J. Gossner Department of Diagnostic and Interventional Radiology Evangelisches Krankenhaus Go¨ttingen-Weende http://dx.doi.org/10.3174/ajnr.A6128 Go¨ttingen, Germany E40 Letters Aug 2019 www.ajnr.org

Journal

American Journal of Neuroradiology – American Journal of Neuroradiology

Published: Aug 1, 2019

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