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
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.
Includes a description of the normal meninges
and the pathological lesions (gross and microscopic) seen in
the various forms of arachnoiditis (ARC).
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.
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.
IN THE INTRATHECAL SPACE: Under certain circumstances, blood
in the subarachnoid space acts as a chemically-irritant factor
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.
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
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
Forms of Arachnoiditis
ARACHNOIDITIS: Obliterating forms include Arachnoiditis
Ossificans and Pachymeningitis, which are extreme presentations
B. SYRINGOMYELIA usually
consists of cavitary intramedullary lesions located in the spine,
which may interfere with the normal circulation of the CSF.
ARACHNOIDITIS includes visual field alterations with endocrine
disturbances since it affects the chiasma and the pituitary
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.
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.
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.
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.
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.
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.
TREATMENTS are mostly symptomatic including analgesics,
antidepressants, muscle relaxants, anti-inflammatories and
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.
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
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.
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
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