Year : 2003 | Volume
: 13 | Issue : 4 | Page : 423--426
Subpial lipoma of the spinal cord
MF Huda, S Mohanty, V Sharma, Y Tiwari, AK Sinha, A Choudhary, VP Singh
Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221005
|How to cite this article:|
Huda M F, Mohanty S, Sharma V, Tiwari Y, Sinha A K, Choudhary A, Singh V P. Subpial lipoma of the spinal cord.Indian J Radiol Imaging 2003;13:423-426
|How to cite this URL:|
Huda M F, Mohanty S, Sharma V, Tiwari Y, Sinha A K, Choudhary A, Singh V P. Subpial lipoma of the spinal cord. Indian J Radiol Imaging [serial online] 2003 [cited 2020 Jun 1 ];13:423-426
Available from: http://www.ijri.org/text.asp?2003/13/4/423/28726
Gowers published the first report of an intradural lipoma in 1897 . These tumours have subsequently been described in the entire spinal axis. Caram et al reported 3 cases of intradural lipoma extending the entire distance of the spinal canal , but the most frequent site is the conus medullaris as a component of the dysraphic state. Among the spinal lipomas, subpial lipomas are very rare and only a few cases are reported in the literature till now ,,. The cases which are presented here demonstrate the lower cervical and upper thoracic spinal and intradural subpial lipoma with myelopathy without dysraphism. We present the clinico-morphological finding of the cases with review of literature for management of these cases.
A 16 year old male admitted with history of back ache (lower thoracic region) for last two months. tingling both lower limb 1 month and weakness right lower limb for 20 days with no history of bowel and bladder involvement.
Patient had Grade 4/5 power in both lower limb at all joints with hyper reflexia at knee.and ankle with right patellar and ankle clonus present. 70-80% hypoesthesia below D6 bilaterally with impaired joint position sense in both lower limb. There was no spinal tenderness, deformity, or neurocutaneous marker or spinal dysrhaphism. The MRI (T1 and T2 weighted and fat suppression) showed hyperintense fat suppressing right postero lateral intradural lesion from D4 to D9 with cord compression. [Figure 1],[Figure 2],[Figure 3]
Dorsal laminectomy from D3 to D9 was done. A yellowish smooth surface uniform intradural intramedullary mass bulging posteriorly was present . Intratumoural decompression with help of CUSA and operating microscope was done and about 60-70% tumour was removed. There was no clear plane between the lipoma and spinal cord.
Large dural patch graft from fascia lata was applied to create the space.
Post operatively patient improved neurologically. Followup after one year showed that patient can walk freely with mild spasticity.
A 45 years old women admitted with Tingling and progressive weakness of both lower limbs since last 4 years. Difficulty in walking - 4 months with no history of bowel or bladder involvement.
Patient had bilateral increased tone in lower limbs (left > right) with grade 4 / 5 power in all group of muscle with bilateral ankle and knee jerk hyperreflexia and left side ankle clonus with bilateral extensor planter. There was 40-50% hypoesthesia below D8 level with impaired joint position sense in both lower limbs.
T1 and T2 weighted MRI showed hyper intense fate suppressing intradural intramedullary lesion from C6 to D4 level.[Figure 4],[Figure 5],[Figure 6] C5 to D4 laminectomy with subtotal decompression (60-70%) with biopsy done using CUSA knife. The lipoma was soft yellowish ill defined subpial growth diffusely infiltrating into the medulla and nerve roots with no clear line of cleavage.[Figure 7]. After decompression duraplasty using fascia lata graft was done to create more space.
Post operatively patient developed mild CSF leak and wound dehiscence which was resutured and leak was controlled. Neurologically patient improved inform of decrease stiffness of both lower limb and mild improvement in hypoesthesia after six month of follwup patient can walk with support.
A 38 year old house wife had a H/o eczematous skin lesion for last 25 years treated with topical and systemic steroids off and on. She was admitted with history of neck and upper thoracic back pain for last 8 years. Tingling and numbness of all four limbs (lower limb more than upper limbs) since last 2 years. Stiffness and heaviness of both lower limb for last 2 years, and weakness of both lower limb since 1-1/ 2 years and since last 1 year patient is bed ridden due to inability of walking. No history of bowel and bladder involvement.
Patient had atrophy of hand muscle with weak grip (Rt > Lt.) In lower limb tone is increased with weak dorsi and planter flexion (03 / 05). There was hyperreflexia at triceps, knee and ankle jerk with planter extensor. 50% hypoesthesia below D6 level and impaired joint position sense was present. The above feature was bilaterally present. There was no spinal tenderness, deformity, neurocutaneous markers or spinal dysraphism. The T1 and T2 weighted MRI showed hyperintense lesion from C4 to D3 which was fat suppressing [Figure 8],[Figure 9].
The Patient underwent C3 to D4 laminectomy and exploration of intradural lipoma. The lipoma enclosed in a fine pial membrane and was situated right posterolateral aspect of cord. The nerve roots were completely enmeshed by the lipoma. There was no clear plane of dissection between the lipoma and the spinal cord. Normal spinal cord was identified above and below the yellow fatty tumour. About 25% of lipoma was resected as it was suckable and a large dural patch graft from fascia lata was left in place. Post operatively the patient is still admitted and improving in form of decrease spasticity in both limbs and decrease pain at back of neck and upper thoracic region with mild improvement in paraesthesia.
Lipoma are benign tumour and histologically idelntical to normal body fat. Intraspinal lipoma can be broadly divided into Intradural tumour which is intimately associated with the structure of the spinal cord and Epidural lipoma. The two entities are separate phenomenon and should be considered separately. Intradural lipoma with spinal dysraphism is quite common and more likely to present at lumbar region but pial lipoma without spinal dysraphism is rare entity and could be found at all levels of the spinal cord and like epidural lipoma. Bony changes are found in upto 50% of cases 
Several hypothesis regarding the genesis of intradural spinal cord lipomas have been proposed; non, however is entirely satisfactory. Some authors have postulated that these leisions are due to developmental error with resultant inclusions of embryonic rests of fat cell during the formation of the neural tube whereas others feel that connective tissue metaplasia may lead to deposition of fat within the dura . Although the true etiology has yet to be elucidated, many characteristics of these tumour suggest that they are of a hamartomatous origin. Although the hamartomatous anlage is presumably present at birth, the slow growth potential of such lesion often results in formation of a symptomatic mass lesions much later in life, as noted in this series; similar late onset of symptoms is also associated with other hamartomatous lesions of the central nervous system.
MRI is the investigation of choice T1 T2 and fat suppression sequence image clearly show the longitudinal dimension as well as their infiltrative extension into the spinal cord. A dermoid cyst with a high lipid content of mixed triglycerides and unsaturated fatty acids without cholesterol may present the same appearance as an intra dural lipoma.
Subpial lipomas are adherent to the cord and nerve roots tightly and difficult to dissect and hence the most effective treatment in still unclear. Some have suggested that since the fat of the lipoma is metabolically identical with normal body and the patient should undergo aggressive weight loss and scrupulous control of diet.. This clinical approach to controlling the growth of the intradural lipoma is questioned by those who have observed rapid growth despite strict weight control . We feel that subtotal removal of the tumour using microscope and CUSA with dural patch grafting to enlarge the space for the slow growing residual tumour is a prudent and safe approach. Similar approach is adopted by the other author also. Some neurological improvement can be obtained with decompressive laminectomy, subtotal decompression and duraplasty or atleast further deterioration can be prolonged , , , . Intraoperative recording of somatosensory evoked potential can be used to achieve decompression without adding neurological deficit.,,
|1||Gowers WR. Myo-lipoma of the spinal cord. Trans Soc Path Soc Lond 1897; 27: 19-22.|
|2||Caram PC, Scarcella G, Carton CA. Intradural lipomas of the spinal cord with particular emphasis on the intramedullary lipomas. J. Neurosurg 1957; 42:14-28.|
|3||Klekamp J, Fusco M, Samii M. Thoracic intradural extramedullary lipomas. Report of three cases and review of the literature. Acta Neurochir (Wien) 2001 Aug; 143 (8): 767-73; discussion 773-4.|
|4||David J. Gower, Charles F, Engles and Eric S. Friedman. thoracic Intraspinal Lipoma. Br. J. Neurosurg. (1994) 8, 761-764./|
|5||Giudicelli Y, Pierre Kahn A. Bourdeaux AM de Mazancort P. Lacasa D, Hirsch JF. Are the metabolic characteristics of congenital intraspinal lipoma cells, identical to, at different from normal adipocytes. Childs Nerv. Syst. 1986; 2: 290-6.|
|6||Van Dellen JR, Van Den Heever CM. Intraspinal Lipoma. A case report S Afr Med J 1976; 50-49-50.|
|7||Ehni G, Love JG: Intraspinal lipomas. Report of cases, review of the literature and clinical and pathologic study. Arch Neurol Psychiatry 53: 1-28, 1945.|
|8||Ammerman BJ, Henry JM, De Girolami U, Earle KM. Intradural lipomas of the spinal cord. A clinicopathological correlation. J Neurosurg 1976, Mar, 44 (3): 331-6.|
|9||Behari s, Banerji D, Gupta RK Agarwal P, Chhabra DK. Problems in differentiating intradural lipoma from dermoid on magnetic resonance imaging. Australas Radiol 1997 May; 41 (2): 196-8.|
|10||Aoki N. Rapid growth of intraspinal lipoma demonstrated by magnetic resonance imaging. Surg. Neurol 1990; 34: 107-10.|
|11||Mai J, Liang Y, Li M. Clinical analysis of diagnosis and treatment of 44 cases with intraspinal lipoma. Zhonghua Wai Ke Za Zhi (Chineese Journal). 1996 Dec; 34 (12): 735-6.|
|12||McGillicuddy GT, Shucart W, Kwan ES. Intradural spinal lipomas. Neurosurgery 1987 Sep; 21 (3): 343-6.|
|13||Fujiwara F, Tamaki N, Nagashima T, Nakamura M. Intradural Spinal Lipomas not associated with spinal dysrhaphism : a report of four cases. Neurosurgery, 1995 Dec; 37 (6): 1212-5.|
|14||Yamashita K, Yonekawa Y, Kawano T, Tsukahara T. High Cervical Intradural lipoma. Case Report. Neurol Med Chir (Tokyo). 1992 May 32 (5): 285-8.|