allows for prompt and precise diagnosis of the characteristic lesions
of ARC; specifically, MRI defines the location and the extent
of intraspinal (intra and extradural) pathology. Thickened and swollen
nerve roots and cauda equina can be identified as early as one or two
days after the injurious event. Clumped nerve roots may not be seen
until months later, indicating a maldistribution of the usually orderly
mapping of the roots located at the most dependent portion of the dural
sac, surrounded by and floating in CSF at the lumbar region. In worse
cases, deformities of the dural sac, adherence of the roots to the
sac wall, fibrosis and scarring may appear. CAT scans may show
skeletal, ligament and muscle abnormalities, and extradural intraspinal
lesions, but only when it is preceded by myelography would intradural
structures be recognized (except calcifications). The author is against
the risk of unnecessary myelograms, but when metal hardware is present,
since the diagnosis is crucial, this method may have to be used, as
long as water-based dyes are injected. It is acknowledged that this
type of contrast media may also produce ARC. The expertise of the radiologist
interpreting the films is imperative to achieve a precise diagnosis
of ARC, and adequate hydration of the patients will ensure reduced
concentration of the dye used.
is no cure for arachnoiditis. In the acute inflammatory phase of ARC,
the administration of systemic and intraspinal corticosteroids may
prevent the evolution into the chronic phase. Pain may be treated with
indomethacin, dipyrone or ibuprofen; in addition, d-penicillamine and
colchicine are helpful. Oxybutynin
usually improves urinary incontinence, and sildenafil citrate has been
shown to correct most cases of impotence; however, the alterations
of sexual function are much more complicated, with loss of libido and
especially low back and lower extremity pain during and after intercourse.
Muscle relaxants are indicated if muscle spasms are severe and not
susceptible to treatment with physical therapy and reconditioning.
Once the proliferative phase starts, any intervention may exacerbate the pain path mechanisms; therefore, invasive procedures have to be selected if the risk/benefit ratio is favorable. Epidural steroids are helpful in producing temporary pain relief and reducing the extradural formation of fibrosis; so is the epidural and intrathecal infusion of analgesics. SC stimulation reduces pain temporarily in localized (mononeuronal) cases. Neuroplasty is contraindicated because it requires the injection of 10% hypertonic saline and hyaluronidase that produces arachnoiditis.
surgical breakdown of adhesions, even when performed meticulously under
the microscope carries a great risk because SC dysfunction may be aggravated;
laminectomies, foraminotomies and spinal fusions would need to be absolutely
indicated because of the potential danger of recurrent dural sac injury
and entry of blood. Long-term opioid therapy is not to be taken lightly,
especially with Schedule II “slow-release” preparations; the consequences
of drug dependency are intangible, but very real, with serious behavioral
in Schedule III are preferred.
A variety of new therapeutic agents and interventional modalities are being proposed mostly for the symptomatic treatment of ARC; however, the most important therapy is prevention, since most of these cases are iatrogenically caused. Education of physicians, nurses, and technicians regarding the numerous causes of this disease is an essential initial step, followed by the information to the public in general, and to patients with spinal disease in particular, so as to warn them against accepting questionably effective procedures in desperation to have their pain relieved and to procure competent and responsible physicians in their care. Once an injurious event takes place, prompt action to define the precise diagnosis and to institute treatment is primordial. There is no place for hesitation since there is only a short window of opportunity during which chances to reverse the process are feasible. Once the proliferative phase begins, there is only symptomatic treatment.