Arachnoiditis

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Arachnoiditis
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Specialty scores for Arachnoiditis

Overview

Arachnoiditis is a condition characterized by inflammation of the arachnoid tissue, which is one of the membranes that surround and protect the brain, spinal cord and nerves of the central nervous system. This inflammation can result in the formation of scar tissue and adhesions which leads to the nerves possibly sticking together. This complication is referred to as adhesive arachnoiditis, and it can be severely painful for the affected individual.

Another complication of arachnoiditis is arachnoiditis ossificans where the tissue turns into bone, and this is regarded as a late-stage complication of adhesive arachnoiditis.

Epidemiology

The prevalence of arachnoiditis is not known but around 25,000 cases of the condition occur every year in North and South America as well as Europe and Asia. Around 11,000 of these cases are noted to occur in the United States alone. This number seems to increase in areas where spinal operations are more prevalent and the number of affected people may be more since the condition goes misdiagnosed or undiagnosed which makes it further difficult to know its exact prevalence.

Causes

The main reason why arachnoiditis occurs is not clearly understood, but there are numerous causes which may result in the condition.

These include the following:

  • Direct injury to the spine. This is seen with repetitive spinal injuries performed in the same patient.
  • Trauma to the spinal cord.
  • Infections which may be viral, bacterial, parasitic or fungal in origin.
  • Inflammatory processes which include intrathecal hemorrhage, where epidural medications such as steroids are administered accidentally inside the dura mater (the membrane that covers the arachnoid membrane); and administering anesthetic medications such as chloroprocaine. These are regarded as iatrogenic causes since the medication is administered by a doctor.
  • Chemicals such as dyes used for performing a myelogram, a diagnostic test where the radiographic contrast dye is injected into the area surrounding the spinal cord and the nerves. However, this contrast medium is no longer used.
  • Prior spinal surgery has been noted to be a cause of adhesive arachnoiditis and arachnoiditis ossificans.
  • Chronic pressure from spinal stenosis or a herniated disk on the arachnoid membrane.
  • Neoplastic conditions such as non-Hodgkin’s lymphoma, melanoma, lung cancer, breast cancer, and even possibly medulloblastoma, ependymoma, choroid plexus carcinoma, and glioblastoma multiforme have also been associated with the development of arachnoiditis.

Signs and symptoms

Arachnoiditis can cause severe, debilitating pain including neuralgia (nerve pain). Tingling and numbness (paresthesia) of the extremities can occur if the spinal cord becomes involved and muscle cramps, uncontrollable twitches, and spasms may also present. Severe shooting pains similar to that of an electrical shock have been described by patients as well as the sensation that something is crawling over their skin.

If the autonomic nervous system lower down in the spinal cord becomes involved, then patients may experience loss of bladder and/or bowel control and sexual dysfunction.

Arachnoiditis tends to involve the nerves of the lower back and legs. Therefore, other issues include difficulty in sitting for long periods of time, as well as walking or standing for such periods of time.

Patients with the condition may experience issues with walking or standing for long periods of time and, unfortunately, wheelchairs are not always helpful in such cases.

As the condition progresses, patients with arachnoiditis will experience increasing worsening of their symptoms which may end up becoming permanent. This may lead to permanent disability of the patient and this can result in the inability to work further.

Diagnosis

Arachnoiditis is a diagnosis of exclusion. This means that other more common conditions of the lower back and leg pain are ruled out before diagnosing the correct problem. The patient’s history though would help to narrow down the diagnosis list.

MRI investigations may help to make the diagnosis of the condition, but other regions of calcification or build-up of hemosiderin may cause a false positive result. An unenhanced CT scan of the affected area will be done together with an MRI, where one can better visualize the presence and extent of bone formation due to arachnoiditis.

Electromyograms (EMG) are often used to confirm the presence of arachnoiditis. In this special investigation, assessing nerve functioning and the extent and severity of the nerve damage is performed using electrical impulses.

Management

There is no known cure for arachnoiditis, and it’s a difficult condition to manage as this is limited to pain control.

Medications that can be prescribed for patients include:

  • Acetaminophen
  • Non-steroidal anti-inflammatories such as ibuprofen, diclofenac, and naproxen.
  • Muscle relaxants such as orphenadrine and centrally acting drugs such as the benzodiazepines (diazepam).
  • Opioids or narcotics such as codeine, morphine, hydrocodone, or dihydrocodone.
  • Antidepressants which help for neuralgia such as tricyclic antidepressants (amitriptyline) or serotonin-norepinephrine reuptake inhibitors (duloxetine)
  • Anti-epileptic medications that also help with nerve pain such as gabapentin, pregabalin, and carbamazepine.

Patients can also be helped to cope with the condition through physical therapy, where physical manipulation by an experienced physical therapist is beneficial in reducing pain and improving the functionality of the affected individual, and even psychotherapy can aid in overcoming mood disturbances such as depression associated with the arachnoiditis.

Any further administration of steroid medications or local anesthetic agents into the spinal canal or epidural space will not be effective and will, in fact, aggravate the symptoms experienced by the affected patient.

Surgical intervention has been attempted in cases where the above therapies haven’t been successful. In some cases, there was a success but it was generally a less than favorable outcome as it only provided temporary relief for the patient.

Motorized assistance devices such as Segways and hover-boards have been noted, by those who can afford such objects, as helpful.

Prognosis

Since arachnoiditis has no known cure, and it is a chronic disorder, the prognosis of the condition may be difficult to assess since the beginning of the disease and onset of symptoms is difficult to determine.

Arachnoiditis is a debilitating condition for most people affected by the disease since it causes chronic and sometimes severe pain as well as other neurological deficits. It may lead to other complications such as syringomyelia.

Conclusion

Arachnoiditis is a rare neurological disorder which is caused by inflammation of the arachnoid mater, a membrane that covers and protects the brain and the spinal cord. Any inflammation of this membrane affects nerve roots within the affected area, whether it is directly or indirectly.

The most common clinical presentation of arachnoiditis is discomfort and pain noticed in the lower back and extremities. The condition is not a life-threatening one but it can cause severe enough symptoms as time progresses to cause enough disability to render the patient disabled. The autonomic nervous system may also be affected thereby resulting in bladder, bowel and sexual-related problems.

Since the condition is often misdiagnosed or undiagnosed, it is very important for doctors to consider arachnoiditis as part of their differential diagnosis when patients present with the mentioned clinical features, especially if they have a history of or recently had spinal surgeries performed on them or if they were injected with steroid and or local anesthetic agents in the spinal canal or epidural space.