Abstract
Spinal angiolipomas are rare benign tumors composed of mature adipose tissue and vascular elements, most commonly located in the thoracic epidural space. Lumbar involvement is considerably less frequent, and variable proportions of adipose and vascular tissue may result in atypical magnetic resonance imaging (MRI) characteristics and diagnostic uncertainty. We report the case of a 36-year-old woman with an approximately one-year history of persistent low back pain associated with subjective bilateral lower-extremity weakness despite a preserved neurological examination. An initial non-contrast lumbar MRI was interpreted as showing no significant abnormality other than minimal degenerative changes; however, retrospective review revealed a subtle posterior epidural lesion. Because of persistent symptoms, further investigation with contrast-enhanced MRI was performed, demonstrating an elongated epidural lesion extending from L1 to L3, predominantly involving the posterior and right posterolateral epidural space with associated foraminal extension. The lesion demonstrated areas of low T1 signal intensity and intense homogeneous contrast enhancement. The patient underwent L1-L3 laminoplasty and gross-total resection. Intraoperatively, the lesion had a macroscopically adipose appearance and was moderately vascular. Histopathological examination demonstrated mature adipose tissue admixed with numerous vascular channels, confirming the diagnosis of spinal angiolipoma. Postoperatively, pain and subjective lower-extremity weakness improved without new neurological deficits, and early postoperative MRI showed no evidence of residual or recurrent tumor. This case highlights the variable imaging appearance of lumbar spinal angiolipomas and the value of correlating MRI characteristics with intraoperative and histopathological findings, particularly in enhancing epidural lesions without a predominantly fatty appearance.