Spinal Epidural Lipomatosis Causing Lumbar Canal Stenosis: A Pictorial Essay on Radiological Grading and the Role of Bariatric Surgery Versus Laminectomy

Spinal epidural lipomatosis (SEL) is a rare condition characterized by an excessive accumulation of adipose tissue in the spinal canal that can have a compressive effect on intraspinal neuroanatomical structures, leading to clinical symptoms. Several different conservative and surgical treatment strategies have been proposed but the treatment and outcomes remain controversial. There is a lack of severity-based evidence documenting the success of decompressive laminectomy in SEL and there are only anecdotal reports of clinico-radiological success with weight loss from bariatric surgery. This article demonstrates the resolution of SEL in two patients with bariatric surgery with the help of pre and postoperative MR imaging. The authors also highlight the classic "types" of spinal epidural lipomatosis with a surgically relevant grading system and elucidate the existence of concurrent extraspinal lipomatosis (i.e. mediastinal and intra-abdominal lipomatosis), drawing parallels with the natural history of SEL. The controversial question remains whether a symptomatic SEL patient needs a multilevel laminectomy for spinal decompression or bariatric surgery that can indirectly help the spinal condition. We propose that bariatric intervention could be better frontline management in patients with multifocal/multisystem lipomatosis (i.e., combined spinal and extraspinal) and spinal decompression would be ideal for those SEL patients with coexisting bony and/or ligamentous spinal canal or foraminal stenosis. This manuscript serves as a comprehensive and contemporary update on the radiological profile and two plausible treatment paths and will look toward further verification by a randomized clinical trial.