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Spinal epidural lipomatosis in myeloma

We describe a case of progressive refractory multiple myeloma presenting with spinal cord compression due to spinal epidural lipomatosis (SEL) and review the literature. A 64-year-old man was diagnosed nine years earlier with multiple myeloma, and baseline skeletal survey showed myelomatous deposits in both humeri, femora, pelvis, and anterior compression fractures of T11, T12, L1, and L3. He was treated with four cycles of infusional vincristine, doxorubicin, and pulse dexamethasone (VAD) chemotherapy followed by high dose melphalan and autologous peripheral blood stem cell transplant in 1998. Following disease progression in 2003, he was started on alpha interferon and 40 mg of dexamethasone weekly. Further progression was treated with daily thalidomide and 40 mg dexamethasone twice weekly. Because of a poor response, bortezomib was initiated in 2006, without concurrent steroids, but the patient failed to respond to this, as well as the combination of cyclophosphamide and dexamethasone 4 mg three times per weekly. From September 2006, the patient was therefore maintained on alternate daily dexamethasone (8 mg) whilst awaiting access to lenalidomide. However, in February 2007, the patient presented with a 7-day history of worsening midthoracic back pain and difficulty in walking, and on admission was in urinary retention, although bowel function was preserved. Clinical examination demonstrated bilateral hip flexion weakness. Reflexes were preserved and there was no clonus. Examination of sensation was complicated due to peripheral neuropathy due to his previous vincristine, thalidomide, and bortezomib treatment, although there was a sensory level at T7/8. The most recent X-ray imaging of his spine in January 2005 had demonstrated compression fractures at T4, T7, and T11 to L2. Magnetic resonance imaging (MRI) demonstrated a marked increase in the quantity of epidural fat, from the level of T2 down to the sacrum, with the largest quantity of epidural fat located at T3 to T9 (Figure 1). The thoracic dural theca was displaced anteriorly with effacement of the subarachnoid space but no spinal cord signal abnormality. In addition, there was extensive myelomatous infiltration of the entire vertebral column with multiple pathological vertebral crush fractures. A bone marrow aspirate and biopsy confirmed a heavy plasma cell infiltrate. His dexamethasone was increased to 40 mg daily, and he underwent urgent thoracic laminectomy of the regions T5 to T8, which confirmed fat infiltration, with only a temporary improvement in strength, and no change to his peripheral paraesthesia. Repeat MRI demonstrated a significant improvement in the degree of thoracic spinal cord displacement, but with worsening thecal compression in the lumbar region. A lumbar laminectomy was therefore performed six days after his thoracic laminectomy. Following this, a trial of dexamethasone cessation was attempted as it was felt that it may have been contributing to his lipomatosis. However, this resulted in immediate deterioration in lower limb strength. Repeat MRI was then suggestive of leptomeningeal disease due to myeloma, and so urgent spinal radiotherapy (16 Gy in 4 fractions) was administered and dexamethasone reinstituted. Lumbar puncture was considered to be contraindicated and so leptomeningeal involvement could not be confirmed on CSF cytology. Nerve conduction studies at that time revealed evidence of