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  • Radiographic predictors of early and late clinical deterioration in patients with lumbosacral lipomas

    Final Number:
    1344

    Authors:
    Albert Tu MD; Ross Hengel BSc; Douglas Cochrane MD, FRCSC

    Study Design:
    Other

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2014 Annual Meeting

    Introduction: Lumbosacral lipomas are congenital lesions of development and the most common spinal dysraphism treated at the BC Children’s Hospital (BCCH). Although patients may present asymptomatic, most will develop neurologic symptoms. Previous management has included prophylactic detethering; however, recent studies have found deterioration rates following surgery similar to non-operated patients. Given that these patients are often difficult to examine, the use of radiographic imaging may be helpful in identifying which individuals are likely to deteriorate earlier and hence benefit from pre emptive surgery rather than observation.

    Methods: A retrospective review of all lumbosacral lipomas seen at BC Children’s Hospital in a modern era (ie. Last 20 years) was carried out. Patients undergoing prophylactic surgery were excluded. Patients with filum lipomas were also excluded.

    Results: 23 patients with lumbosacral lipomas were identified. 11 patients worsened within 16 months of life (early deterioration), while 9 deteriorated after 30 months (late deterioration). 3 patients have been followed for over 60 months and remain asymptomatic. Patients who deteriorated early were much more likely to have large, intradural lipomas that filled out the canal and compressed neurologic structures. Furthermore, syrinxes were more common and these were much larger than in other patients. Early deteriorating patients also more frequently presented with motor deficits whereas late deteriorating patients developed urologic/bowel symptoms.

    Conclusions: Given the potential for incomplete recovery after prolonged neurologic deterioration, families of patients at risk of early deterioration may be counselled to consider prophylactic surgery, while those with risk factors for late deterioration may be followed clinically. This data would also suggest that a compressive effect of the intradural lipoma may contribute to early deterioration and strategies centred on decompressing the lipoma may be considered in addition to traditional detethering surgeries.

    Patient Care: By identifying subgroups of patients, individual management paradigms can be created to better suit different projected clinical courses. Early deteriorating patients may benefit more from prophylactic surgery whereas late deteriorating patients may avoid a potentially riskier surgery during infancy or an unnecessary surgery altogether.

    Learning Objectives: By the end of the session, participants should be able to: 1) identify radiographic predictors for early and late deterioration; 2) consider patient centred management paradigms that account for predicted clinical course; 3) Discuss the role for prophylactic and delayed surgery as determined by the predicted clinical course

    References: 1.Kulkarni A V, Pierre-Kahn A, Zerah M: Conservative management of asymptomatic spinal lipomas of the conus. Neurosurgery 54:868–73 2. Pang D, Zovickian J, Oviedo A: Long-term outcome of total and near-total resection of spinal cord lipomas and radical reconstruction of the neural placode, part II: outcome analysis and preoperative profiling. Neurosurgery 66:253–72; discussion 272–3, 2010 3. Sarris CE, Tomei KL, Carmel PW, Gandhi CD: Lipomyelomeningocele: pathology, treatment, and outcomes. Neurosurg Focus 33:E3, 2012 4. Wykes V, Desai D, Thompson DNP: Asymptomatic lumbosacral lipomas--a natural history study. Childs Nerv Syst 28:1731–9, 2012

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