Acute management of arachnoiditis

There is a huge difference between arachnoiditis and adhesive arachnoiditis.  In the Burton report ,  Charles V. Burton, M.D. writes about difference these two stages:

 “The difference between arachnoiditis and adhesive arachnoiditis is the same as that between a candle and a conflagration.”

They are both fire but other  similes exist.  They differ in degree and intensity and the difference is quite substantial.   A candlelit dinner represents fire as a friend.  A conflagration represents fire as a foe.

Adhesive arachnoiditis is the end of the arachnoiditis spectrum.  Adhesive arachnoiditis can carry the possibility of a lifetime of agony while arachnoiditis typically does not.

The cruel nature of adhesive arachnoiditis makes preventing it the most important issue. The early diagnosis and the treatment of the acute stage is important to prevent further damage and save patients from the life long suffering. The fast and early diagnosis is needed to do within the 3 months time window, as soon the better. “Eventually, the nerve roots undergo an inflammatory stage in the affected areas and after three months, they begin to adhere to each other and to the inner layer of the arachnoid initiating the adhesive phase of arachnoiditis

There is two main points in the acute treatment:
1. to calm down inflammation and…
2. to treat pain and other symptoms.
All further invasive spinal operations should be avoided. Prof. Antonio Aldrete has published an article about this issue in the Acta Anaesthesiologica Scandinavica , Neurologic deficits and arachnoiditis following neuroaxial anesthesia. The abstract tells to us:

” Of late, regional anesthesia has enjoyed unprecedented popularity; this increase in cases has brought a higher frequency of instances of neurological deficit and arachnoiditis that may appear as transient nerve root irritation, cauda equina, and conus medullaris syndromes, and later as radiculitis, clumped nerve roots, fibrosis, scarring dural sac deformities, pachymeningitis, pseudomeningocele, and syringomyelia, etc., all associated with arachnoiditis. Arachnoiditis may be caused by infections, myelograms (mostly from oil-based dyes), blood in the intrathecal space, neuroirritant, neurotoxic and/or neurolytic substances, surgical interventions in the spine, intrathecal corticosteroids, and trauma.

Regarding regional anesthesia in the neuroaxis, arachnoiditis has resulted from epidural abscesses, traumatic punctures (blood), local anesthetics, detergents, antiseptics or other substances unintentionally injected into the spinal canal.

Direct trauma to nerve roots or the spinal cord may be manifested as paraesthesia that has not been considered an injurious event; however, it usually implies dural penetration, as there are no nerve roots in the epidural space posteriorly. Sudden severe headache while or shortly after an epidural block using the loss of resistance to air approach usually suggests pneumocephalus from an intradural injection of air. Burning severe pain in the lower back and lower extremities, dysesthesia and numbness not following the usual dermatome distribution, along with bladder, bowel and/or sexual dysfunction, are the most common symptoms of direct trauma to the spinal cord. Such patients should be subjected to a neurological examination followed by an MRI of the effected area. Further spinal procedures are best avoided and the prompt administration of IV corticosteroids and NSAIDs need to be considered in the hope of preventing the inflammatory response from evolving into the proliferative phase of arachnoiditis. “

Prof. Antonio Aldrete has published results of his treatment trials: Aldrete JA, Ghaly RF  2008: Timing of Early Treatment of Neurological Deficits Post Intervention and Operative Spinal Procedures  Commonly the treatment is individual for every patient.