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"Arachnoiditis: The Silent Epidemic"

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I.       PREFACE

A brief introduction on the humane aspects of arachnoiditis, the personal involvement with patients affected by it, and the aims as well as the objectives for writing this book.

II.      Historical perspective

A perspective of the disease with its predominant symptom—unrelenting, severe pain—is formed as brief information, followed by a sequence of the earliest medical descriptions (since 1863), and the medical trends that made it into an iatrogenic disease are discussed.

III.    Anatomopathology

Includes a description of the normal meninges and the pathological lesions (gross and microscopic) seen in the various forms of arachnoiditis (ARC).

IV.   Pain Transmission &  

        modulation

In this chapter, an attempt to define the pain pathways and spinal cord receptors involved in the various types as well as other symptoms found in patients with ARC.        

V.   Etiology

       A.     INFECTIONS:  At first, the earlier cases of ARC were caused by syphilis, tuberculosis, meningitis, influenza, etc.  Lately, echinoccocus, cryptococcus, and the AIDS virus have been the most frequent origin of it. 

     B.     MYELOGRAPHY:  Reviews how oil-based and also some water-based dyes used for myelography caused innumerable cases of ARC from the 1940’s to the 1990’s.

     C.     BLOOD IN THE INTRATHECAL SPACE:  Under certain circumstances, blood in the subarachnoid space acts as a chemically-irritant factor producing ARC.

     D.     ANESTHETIC SUBSTANCES IN THE SPINE:  High concentrations of anesthetic substances or prolonged exposure of neural tissue to lower concentrations, as well as direct trauma to spinal cord or nerve roots during injection produce a variety of lesions varying from cauda equina, radiculitis, transient nerve root irritation, etc., some of which end up in ARC.

     E.      SPINAL SURGICAL INTERVENTIONS:  Surgical interventions of the spine appear to leave a higher than expected incidence of ARC (between 15 and 20%) due to the entry of blood into the subarachnoid space through inadvertent rents or recognized tears of the dural sac.  Pseudomeningoceles, leaks of CSF, epidural abscesses or postoperative hemorrhage are surgical complications that frequently ensue in ARC.

V.   EtiologY (cont)

     F.      CORTICOSTEROIDS:  Corticosteroids have been the subject of great debate as to causative agents of ARC, while at the same time being the optimal anti-inflammatory medication.  The controversy going on for nearly 30 years is put to rest in this chapter, as it defines the concentration of the preservatives contained in the various preparations of steroids as the culprits, and emphasizes the indications for  corticosteroids in the inflammatory and the proliferative phases of ARC.

     G.     TRAUMA:  Trauma of the spine is identified as a possible cause of ARC, especially when there is considerable hemorrhage in the subarachnoid space as well as spinal cord and/or nerve root injury.  Emphasis is placed on the opportune early use of corticosteroids in reducing subsequent neurologic deficit.

VI.  Other Forms of Arachnoiditis
     A.     OBLITERATIVE ARACHNOIDITIS:  Obliterating forms include Arachnoiditis Ossificans and Pachymeningitis, which are extreme presentations of ARC.

     B.     SYRINGOMYELIA usually consists of cavitary intramedullary lesions located in the spine, which may interfere with the normal circulation of the CSF.

     C.     OPTOCHIASMATIC ARACHNOIDITIS includes visual field alterations with endocrine disturbances since it affects the chiasma and the pituitary gland.

     D.     CEREBRAL ARACHNOIDITIS is frequently caused by chronic, uncontrollable infection of the cranial frontal, maxillary, or sphenoid sinuses, or the mastoid cells in severe chronic otitis media.  In addition to neurologic deficits, cranial nerve disturbance, atypical facial pain, and headaches can be found with common psychogenic manifestations.

VII.  Questionable Causes of  

         Arachnoiditis

     A.     SPINAL STENOSIS:  Spinal stenosis has been suggested as a form of ARC because there appears to be apparent nerve root clumping in neuroimaging studies; the concept is refuted, however, since there is no acute inflammatory phase, and the pseudo-clumping of the nerve roots frequently disappears after decompressive procedures of the spine.

     B.     FOREIGN BODY REACTION:  Foreign Body Reaction has been proposed as a cause of ARC when gauze, suture materials, talcum powder, glues and other materials have been inadvertently or purposefully left in the intrathecal space.

     C.     HERNIATED NUCLEUS PULPOSUS:  Constrictive or cystic lesions of ARC have given the clinical and radiological impression of intraspinal tumors.  On the other hand, some tumors of the spinal structures may appear to be ARC.  Occasionally, primary or metastatic lesions invade the meninges, resembling ARC.

VIII.  Diagnosis of Arachnoiditis

     A.  CLINICAL DIAGNOSIS:  The clinical signs and symptoms of ARC are described, including the localized and systemic manifestations as they appeared in 162 patients with radiologically confirmed ARC.  Their possible mechanisms and paths through the posterior horn of the spinal cord and the ascending spinal tracts are discussed.

     B.     LABORATORY AND RADIOLOGICAL DIAGNOSIS:  Few laboratory studies have been shown to be of any use in diagnosing or confirming the presence of ARC, nor have the electrophysiological tests proven to be reliable for this purpose.  The precise diagnosis of ARC has been shown mostly by carefully-performed and interpreted MR imaging, especially with contrast media.  The indication for plain radiographs and CAT scan after myelography is discussed.  The possible role of myeloscopy as a diagnostic tool is mentioned.  Contains 33 images representing this disease.

IX.  Prognosis

Being incurable, ARC has a poor prognosis since patients are usually affected for life, with considerable pain, physical and sexual dysfunction, and common emotional disturbances (especially depression).  Discusses patient groups as means of improving outcomes.  The advantages of the Internet as well as the disadvantages of transmitting incorrect information are also addressed.   

X.  THERAPEUTIC OPTIONS

     A.     MEDICAL TREATMENTS are mostly symptomatic including analgesics, antidepressants, muscle relaxants, anti-inflammatories and anticonvulsants.  However, there is a definite strategy in the indications for each of these agents at the various phases and stages of ARC.  The role of physical therapy and holistic approaches are discussed.  The interventions of psychotherapy, when needed, are emphasized.

     B.     INTERVENTIONAL PAIN RELIEF PROCEDURES:  Epidural and intrathecal injections and long-term infusions are discussed, as well as specific indications and possible benefits.  The pros and cons of adhesiolysis and neuroplasty procedures are debated.

     C.     ELECTRICAL STIMULATION OF THE NERVOUS SYSTEM:  Dorsal column stimulation in its various forms is discussed defining its specific indications as well as deciphering the results in the series already published.  Acupuncture and TENS unit therapy are addressed.  The possible role of cerebral electrical stimulation is noted.

     D.     SURGICAL TREATMENT:  Advocated off and on for nearly 100 years, the reports usually consists of a few poorly-selected and not consistently treated cases. However, the new combined approach, including selective medical treatment, preemptive analgesia, microscopic lysis of adhesions and the use of adhesion-preventing materials appears to be more promising.

XI.  Future Prospectives

The understanding of the various phases of ARC, its pathophysiology, and the need for prompt diagnosis constitute the basic triad that would lead to the education of physicians and other health care providers aiming at preventing this disease, which is acquiring epidemic proportions.  The many prospective research avenues are noted as possible means of preventing and treating arachnoiditis are mentioned as well as means of how to improve the patients’ quality of life.