Spinal Lipomas

Jeffrey P. Blount, MD, and Scott Elton, MD, Division of Neurosurgery, University of Alabama at Birmingham, Children's Hospital of Alabama, Birmingham, Alabama

Neurosurg Focus. 2001;10(1) 

In This Article

Complications

Lipomas of the Conus Medullaris

Wound-Related Complications. Despite careful attention, the authors of several large series have reported significant rates of postoperative wound complications (infections, CSF leaks, and wound breakdown) that range from 10 to 20%.[17,30,46,54,56] Careful attention to closure is therefore imperative. Some surgeons favor several days of flat bedrest in the immediate postoperative period as a measure to decrease the likelihood of CSF leaks.

Acute Neurological Decline. The risk of surgery-related neurological deterioration was at one time thought prohibitively high; as such, only a limited debulking of the subcutaneous mass was undertaken. With greater understanding of the anatomy and natural history of lipomyelomeningoceles a more aggressive surgical approach has become widely supported.[15] In addition to conceptual advances, technical developments including improved operating microscopes, better illumination, improved microsurgical instruments, refined lasers, and advances in intraoperative monitoring have all contributed to surgery-related advances. In using these adjuncts the authors of most contemporary series report a 1 to 2% surgery-related risk of neurological deterioration.

Retethering of the cord and late-onset deterioration remains the greatest risk for patients undergoing resection of a lipomyelomeningocele.[5,73] Although reduction of the fatty mass and placement of dural substitute grafts has been used to prevent dural constriction and subsequent risk of retethering, it is apparent that in a significant percentage of patients late retethering is demonstrated which is clinically manifested as delayed neurological deterioration.[19] Colak, et al.,[19] reported that 19 of 94 patients who underwent surgery for lipomyelomeningocele required 28 subsequent operations for symptomatic retethering. Pierre-Kahn and colleagues 56 reported that only 53% of patients who underwent surgery for lipomyelomeningocele were symptom free at an average of more than 5 years of follow up. Of the 6% of these patients who underwent reoperation, further improvement was demonstrated in 31%, arrested progression in 44%, and continued deterioration in 19%. The rate of late-onset neurological deterioration in this report is higher than other recently reported series.[56] This observation has been taken by some authors to suggest that initial surgery before the lesion becomes symptomatic does not alter the natural history of the disease and to support a conservative approach to the treatment of spinal lipomas.[28]

Wu, et al.,[72] have recently reported that in 84% of patients undergoing repair of a lipomyelomeningocele before age 1.5 years stable clinical and urodynamic functions were maintained. Late-onset neurological deterioration was observed in 16%, and this occurred between 9 months and 8 years postoperatively. In their series the best predictor of long-term bladder function was preoperative urodynamic status.

Wu, et al., concluded that early diagnosis and surgical intervention is warranted, but follow-up study must continue for years because retethering was seen up to 8 years following surgery. In other recent series the authors have documented rates of delayed-onset deterioration of 3.3 to 5% over follow-up periods ranging from 6 months to over 20 years.[59]

Lipoma of the Terminal

Filum Wound-Related Complications. As the overlying planes of tissue are normal in lipomas of the terminal filum the closure of the wound is simplified and wound-related problems are less common. Incidences of wound-related complications of less than 3% have been reported in large series.[38]

Neurological Complications. New deficits are exceedingly uncommon following release of a fatty filum. La Marca, et al.,[38] have recently reported that of 55 pediatric patients who presented with a lipoma of the terminal filum, 28 were asymptomatic at the initial operation and 27 presented with symptoms. Of the asymptomatic children, none worsened after surgery, and all remained asymptomatic throughout more than mean of follow-up period of 3 years.[38] Pierre-Zahn and colleagues 55 reported no worsening of functioning at more than 5 years postoperatively in a group of patients who underwent division of a filum lipoma. Although the risk of retethering appears very low Souweidane and Drake [66] have reported on two patients in whom retethering was demonstrated following division of a lipoma of the terminal filum.

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