Teaching NeuroImages: Severe myelopathy due to epidural lipomatosis

A 45-year-old woman presented with 2 years of progressive bilateral leg weakness and stiffness. She had a history of severe asthma and had been on high-dose steroids for 13 years. On examination, she had a Cushingoid appearance and spastic paraparesis. Sequential MRIs of her thoracic spine demonstrated increased T1 signal in the epidural space consistent with epidural lipomatosis, eventually causing severe cord compression (figures 1 and 2). The epidural space normally contains adipose tissue, but in patients who are obese or on long-term steroids, this can become pathologically enlarged.1 The treatment consists of weight loss, steroid weaning, and in severe cases, decompressive surgery.2