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== Clinically Relevant Anatomy<br>  ==


Arachnoid mater: the membranous layer between the pia mater and the dura mater that surround the brain and the nerves of the spinal cord<ref>MOORE, K.L., DALLEY, A.F., AGUR, A.M.R., Clinically oriented anatomy, Wolters Kluwer, Lippincott Williams and Wilkins, 2010</ref>.<br>
== Clinically Relevant Anatomy ==
The central nervous system (CNS) which is made up of the brain and the spinal cord is covered and protected by [[meninges]]. Meninges are generally three membrane layers, the Dura Mater which is the outer layer, Arachnoid Mater which is the middle layer, and the Pia Mater which is the inner layer. There are 31 pairs of spinal nerves that exit the vertebral column, one on the right side and the other on the left, through vertebral foramina<ref>Moore KL, Dalley AF, Agur AM. Clinically oriented anatomy. 7th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health; 2014. </ref>. [[File:Arachnoiditis_Image.png|alt=Arachnoiditis|320x320px|Arachnoiditis|right]]
== Pathological Process ==


Spinal nerves: 31 pairs of nerves that exit the vertebral column through intervertebral foramina as 2 rootlets. One anterior nerve root and one posterior nerve root.  
Arachnoiditis is a progressive disorder that involves the brain and/or the spinal cord caused by inflammation of the arachnoid membrane. There are several types of Arachnoiditis including Adhesive Arachnoiditis which is the most severe type and occurs when spinal nerves stick together, Arachnoiditis ossificans which occurs when arachnoid turns to bone, Cerebral arachnoiditis which affects the membranes surrounding the brain, Hereditary arachnoiditis which is congenital and rare and occurs due to defects affecting the meninges, Neoplastic arachnoiditis which occurs due to cancer and Optochiasmatic arachnoiditis which involves optic nerve<ref name=":0">Peng H, Conermann T. Arachnoiditis. InStatPearls. 2021 Nov 8. StatPearls Publishing.</ref>. <br>There are 3 main stages of Arachnoiditis.  


== Mechanism of Injury / Pathological Process<br>  ==
* The first stage involves the inflammation of the spinal nerves, hyperemia, the disappearance of the subarachnoid space and the scar tissue begins to form. 
* The second stage involves the scar tissue formation process increasing and the nerves further adhere to each other and to the dura. 
* The third stage involves the complete encapsulation of the nerve roots, compression causes atrophy of the nerve roots and the scarring tissues prevent the production of spinal fluid in that area. In some cases, the scar tissue calcifies and is then termed Arachnoiditis Ossificans<ref>Deshmukh, V.R. Encyclopedia of the Neurological Sciences (Second Edition). Brain and Spine Institute, Portland, OR, USA. 2014. </ref>.  


==== Definition/description<br>  ====
== Etiologies ==


Arachnoiditis is a rare condtion of chronic inflammation of the arachnoid. It can involve the brain and/or the spinal cord.<br>It develops in 3 stages, namely<ref name="Arachnoiditis">WRIGHT, M.H., DENNEY, L.C.,’ A comprehensive review of spinal arachnoiditis’, Orthop Nurs., may-jun 2003, vol: 22(3), p.215-9</ref>:<br>1) inflammation of the spinal nerves, distension of the adjacent blood vessels, subarachnoid space disappears and the scare tissue begins<br>2) the scar tissue increases, the nerves adhere to each other and the dura<br>3) complete encapsulation of the nerve roots, compression causes atrophy of the nerve roots and the scarring tissues prevent the production of spinal fluid in that area. It is terrmed Arachnoiditis Ossificans if the scar tissue calcifies.  
* '''Trauma/Surgery-induced''': Arachnoiditis is considered a rare complication of spinal surgery specifically after multiple complex surgeries or trauma to the spine. Multiple lumbar punctures, advanced stages of spinal stenosis and chronic degenerative disc disease may also lead to arachnoiditis. This may result in blood penetration in the subarachnoid space causing inflammation<ref>Arachnoiditis: What it is, causes, symptoms & treatment. Cleveland Clinic. Available at: <nowiki>https://my.clevelandclinic.org/health/diseases/12062-arachnoiditis</nowiki> (accessed 17/2/2023)</ref>.
* '''Chemical-induced''': Myelograms have been considered recently to cause this condition. A myelogram which is a diagnostic test that contains a dye is usually injected in the area surrounding the spinal cord and nerves and is visible on various diagnostic imaging such as X-ray, MRI and CT scan. The repetitive exposure to oil-based radiographic contrast agents used in myelograms causes Arachnoiditis. In addition to that, medications found in epidural steroid injections can cause Arachnoiditis especially if they enter the cerebral spinal fluid (CSF). It's also important to note that, Arachnoiditis due to surgery is precisely localized, meanwhile the one due to epidural injections is more diffuse<ref>Long DM. Chronic adhesive spinal arachnoiditis: pathogenesis, prognosis, and treatment. Neurosurgery Quarterly. 1992 Dec 1;2(4):296-320.</ref>.
* '''Infection-induced''': Arachnoiditis can also be caused by viral or bacterial meningitis, tuberculosis and syphilis affect the spine<ref name=":1">Waldman, S.D. Pain review. Philadelphia, PA: Elsevier.2009.</ref>.<br>Arachnoiditis is also the third most common cause of Failed Back Surgery Syndrome (FBSS)<ref>Burgest S. Simopoulos TC. FAILED BACK SURGERY SYNDROME. Current Therapy in Pain. Elsevier. 2009.</ref>.  


==== Epidemiology/Etiology ====
== Clinical Presentation ==
 
The most prominent symptom of Arachnoiditis would be persistent pain in the lower back and limbs<ref>Tennant F. (228) Which chronic back pain patients have arachnoiditis?. The Journal of Pain. 2016 Apr 1;17(4):S32.</ref>. Other symptoms which are experienced by 90% of patients include:
The inflammation has 3 main causes:<br>1) Trauma–surgery: complications after multiple back surgery may result in blood penetration in the subarachnoid space, causing inflammation.<br>2) Chemical: exposure to oil based radiographic contrast agents used in myelograms, or drugs used for epidural injections.<br>3) Infection: viral or bacterial meningitis, tuberculosis and syphilis affect the spine.<br>This disorder is the third most common cause of Failed Back Surgery Syndrome (FBSS).<br>Arachnoiditis due to surgery is precisely localised, meanwhile the arachnoiditis due to epidural injections is more diffuse.[2]<br>


== Clinical Presentation  ==
* tingling sensation and paresthesia
* weakness in the lower limbs
* cramps and spasms
* bladder and sexual dysfunctions<ref name="Arachnoiditis PT">MATLOCK, C.L. Physiotherapy and spinal nerve root adhesions: a caution. Physiotherapy research international. Vol: 9(4), p.164-173,2004.</ref>
* hyporeflexia


Most patients have symptoms in the lower back, hip, legs, feet, perineum, abdomen or ,in the most severe cases, throughout the body. These symptoms are: chronic, burning pain; tingling; weakness in the legs; sensory loss; muscle cramps; spasms; uncontrolled twitching; bladder and sexual dysfunctions<ref name="Arachnoiditis PT">MATLOCK, C.L., ‘Physiotherapy and spinal nerve root adhesions: a caution’, Physiotherapy research international, vol: 9(4), p. 164-173,2004.</ref>.<br>
The pain tends to be worse at night and normally evoked by non-painful stimuli or no stimulus at all. This pain also tends to increase with activity where pain tends to be delayed at the onset of activity and persist after the cessation of physical activity<ref>Mehta, N. Arachnoiditis. Spine Universe. Available at: <nowiki>https://www.spineuniverse.com/conditions/spinal-disorders/arachnoiditis</nowiki> (accessed 14/2/2023)</ref>. In addition to that, pain can also be caused by other factors besides nerve damage involving the musculoskeletal system due to what this disorder causes from spine dynamic alteration. Patients with this disorder may experience muscle tension, an increase in muscle tone due to nerve damage and severe joint pain<ref>Smith S. Adhesive Arachnoiditis: A Continuing Challenge. Practical Pain Management. 2004;4(2)</ref>.  


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==
Arachnoiditis is usually present in the subarachnoid space but can be clearly seen in the lumbar region where we find the cauda equina. There are various radiographic modalities that can help with the diagnostic procedure but an MRI is the most favorable and most sensitive modality<ref>Malani AN, Vandenberg DM, Singal B, Kasotakis M, Koch S, Moudgal V, et al. Magnetic resonance imaging screening to identify spinal and paraspinal infections associated with injections of contaminated methylprednisolone acetate. JAMA. Jun 19 2013;309(23):2465-72.</ref>. The diagnosis of Arachnoiditis is usually based on 3 main findings which are the inflammation and enlargement of nerve roots on an axial view, their displacement from their normal position, and them appearing clumped together<ref>Cohen MS, Wall EJ, Kerber CW, Abitbol JJ, Garfin SR. The anatomy of the cauda equina on CT scans and MRI. The Journal of bone and joint surgery. British volume. 1991 May;73(3):381-4.</ref>. For patients where an MRI is contraindicated, computed tomography (CT) myelography is an acceptable alternative as a radiographic modality<ref>Patel DM, Weinberg BD, Hoch MJ. CT myelography: clinical indications and imaging findings. Radiographics. 2020 Mar;40(2):470-84.</ref>. Other forms of diagnosis would be finding that C-reactive protein (CRP) or Erythrocyte Sedimentation Rate (ESR), inflammatory markers, levels being exceedingly high<ref>Tennant F. Erythrocyte sedimentation rate and C-reactive protein: old but useful biomarkers for pain treatment. Pract Pain Manage. 2013 Mar 1;13(2):61-5.</ref> in addition to other less known inflammatory markers like interleukins and myeloperoxidase having high levels as well. It's important to note that the presence of high levels of ESR and CRP indicate that Arachnoiditis is active and in need of immediate treatment<ref>Tennant F. Search for inflammatory markers in centralized, intractable pain. American Academy of Pain Management. 2013. </ref>.


Magnetic resonance imaging (MRI) is the study of choice for the diagnostic evaluation of arachnoiditis<ref>Malani AN, Vandenberg DM, Singal B, Kasotakis M, Koch S, Moudgal V, et al. Magnetic resonance imaging screening to identify spinal and paraspinal infections associated with injections of contaminated methylprednisolone acetate. JAMA. Jun 19 2013;309(23):2465-72.</ref>. For patients in whom MRI is contraindicated, computed tomography (CT) myelography is an acceptable alternative.<br>
== Management ==
 
Arachnoiditis is a very difficult condition to treat and the treatment protocols for patients suffering from this condition mainly focus on relieving pain and improving symptoms that affect the patient's daily function.  
== Outcome Measures  ==
 
add links to outcome measures here (see [[Outcome Measures|Outcome Measures Database]])
 
== Management / Interventions<br>  ==
 
There is no cure, only treatment of the chronic symptoms<ref name="arachnoiditis" />.<br>-Oral medication or medication through an intrathecal pump such as: non-steroidal anti-inflammatory drugs (NSAIDs), methadon, morphine, can be used to release neuropathic pain. Antidepressants may reduce burning neuropathic pain, but in much lower doses than for depression. Diazepam is used for muscle relaxation. <br>-Invasive treatment such as intraspinal narcotic analgesia (INA), epidural steroid and local anaesthetic injections are not indicated because there is a risk of exacerbating the inflammation and worsening the patient’s condition.<br>-Spinal cord Electrostimulation (SCS) stand for electrical stimulation by implanted electrodes around the spinal cord in the area that is most involved in causing pain. Some studies indicate a 50% success rate when all types of chronic pain are considered<ref>FREY, M.E., MANCHIKANTI, L., BENYAMIN, R.M., SCHULTZ, D.M.,SMITH, H.S.,COHEN, S.P., ‘Spinal Cord Stimulation for Patients with Failed Back Surgery Syndrome: A Systematic Review’, Pain Physician, vol: 12:379-397, 2009</ref>.<br>-Surgery is not recommended because it causes more scar tissue and more trauma to the already irritated spinal cord.[4]<br><br>
 
== Differential Diagnosis<br>  ==
 
add text here relating to the differential diagnosis of this condition<br>
 
== Key Evidence  ==
 
add text here relating to key evidence with regards to any of the above headings<br>
 
== Resources <br>  ==
 
add appropriate resources here
 
== Case Studies  ==
 
add links to case studies here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
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== References  ==
 
References will automatically be added here, see [[Adding References|adding references tutorial]].
 
<references /> &nbsp;Physiopedia&nbsp;: Arachnoiditis
 
<br>1. Search Strategy<br>To get some information about this topic, following databases were used: Pubmed, Web of Knowledge, Pedro, Amarican journal of roentgenology and books in the library of the Vrije Universiteit Brussel (VUB). The following keywords were entered: (adhesive/spinal) arachnoiditis, arachnitis (synonym), low back pain, physiotherapy, treatment. <br>
 
2. Clinically relevant anatomy<br>[10-11]
 
[10-11]
 
<br>3.&nbsp;<br><br>
 
<br>4.&nbsp;<br>
 
5. Clinical presentation<br>The pain can increase with activity, it can vary in intensity and it can be due to other factors besides nerve damage.[2]
 
<br>6. Differential diagnosis<br>The differential diagnosis is drawn by excluding other causes of FBSS, namely: disc fragments, recurrent disc herniation, stenosis, spondylosis, epidural fibrosis and other causes of polyneuropathy such as multiple sclerosis.[2]
 
<br>7. Diagnostic procedures<br>The diagnosis is based on the evaluation of the symptoms discussed at 5)clinical presentation, excluding other causes of FBSS, magnetic resonance imagining(MRI) and computed tomographic(CT) scan.[1-2-3-4-6-7] It’s important to exclude treatable causes of the present symptoms. Arachnoiditis is a disease that isn’t easily to diagnose. Some patients have to go a long way before they are correctly diagnosed. This involves distrust, anger and sometimes psychological problems seen in the patient.[2-3]
 
<br>8. Examination<br>- conventional measurement of muscle strength:[2-8-9]<br>Muscle with an average of grade 4 allow a person to move normally. But this test seem to be insufficiently sensitive in detecting weakness and fatigability in patients with arachnoiditis. It has to be used in combination with other tests.<br>- MRI and CT-scan:[1-2-4-6-7]<br>The current choice is a T2 weighted, fat suppressed, gadolinium enhanced, high resolution MRI scan. The scan should be read by a neuroradiologist experienced in arachnoiditis diagnosis.<br>-electromyography(EMG) and nerve conduction studies(NCS) are needed to demonstrate nerve damage.[2]<br>-tests for bladder and urodynamic dysfunction are required[2]
 
<br>9. Medical management (current best evidence)<br>There is no cure, only treatment of the chronic symptoms.[1-2]<br>-Oral medication or medication through an intrathecal pump such as: non-steroidal anti-inflammatory drugs (NSAIDs), methadon, morphine, MS continus,… are used to release neuropathic pain. You should take account of the fact that there is a risk of physical dependence and an element of tolerance that can develop in long-term use. Antidepressants are used for the burning neuropathic pain, but in much lower doses than for depression. Diazepam is used for muscle relaxation. <br>-Invasive treatment such as intraspinal narcotic analgesia (INA), epidural steroid and local anaesthetic injections are not indicated because there is a risk of exacerbating the inflammation and worsening the patient’s condition. But it must be a question of weighing up possible benefits against possible risks and individual needs.<br>-Spinal cord Electrostimulation (SCS) stand for electrical stimulation by implanted electrodes around the spinal cord in the area that is most involved in causing pain. Some studies indicate a 50% success rate when all types of chronic pain are considered.[5]<br>-Surgery is not recommended because it causes more scar tissue and more trauma to the already irritated spinal cord.[4]


<br>10. Physical therapy management (current best evidence)<br>The physiotherapy consist mainly of techniques that try to relax the patient, that decrease the pain, the stiffness and the inflammation. Physiotherapy that provokes pain is not beneficial.[2-3]<br>-transcutanous electrical nerve stimulation (TENS) is used to send a painless electrical current to a specific nerve trough electrode patches that are placed on the skin in the area of the pain. This technique has the goal to release the pain, relive stiffness and improve the mobility.<br>-hydrotherapy: is used as relaxation technique, but the water mustn’t be too warm because arachnoiditis patient have heat intolerance<br>-relaxation/meditation/massage: are used as contribution to medication, the patients can’t manage on these techniques only<br>-exercises and stretching: a non-fatigue program to improve and maintain the tone of paravertebral muscles is the most beneficial for the patient. The exercises have to be gentle for the low back and to be slowly executed. The activity should be just under the pain barrier. If not it can increase the pain, irritation and inflammation. Muscle-strengthening exercise are given to help maintain muscle tone rather than increase strength. Stretching is given to maintain the mobility. The patient doesn’t have to feel pain during and after the exercise program.[3]<br>example of muscle-strengthening exercise(for the M. multifundi):[12]<br>patient lies on his back with knees bent, the physiotherapist puts his hand under the patients low back and asks the patients to contract the muscle<br>example of stretching exercise:[3]<br>patient lies on his stomach, he lifts very gentle the head and feet to strengthen the back, hold this position for 10”-15”
=== '''Medical Management''' ===
In order to prevent arachnoiditis from progressing and worsening, the medical treatment protocol should focus on controlling and suppressing neuroinflammation. To treat inflammation, the use of non-steroidal anti-inflammatory drugs (NSAIDs) and pulse therapy is common, especially methylprednisolone<ref>Wright MH, Denney LC. A comprehensive review of spinal arachnoiditis. Orthopaedic Nursing. 2003 May 1;22(3):215-9.</ref>. However, there are only a few studies demonstrating its effectiveness in preventing scar tissue formation<ref>Kara T, Davulcu Ö, Ateş F, Arslan FZ, Sara HI, Akin A. What happened to cauda equina fibers? Adhesive arachnoiditis. Anaesthesia, Pain & Intensive Care. 2020 Jun 10;24(5):555-7.</ref>. Other pharmacologic treatments include naltrexone, tricyclic antidepressants and muscle relaxants such as baclofen which are used to release neuropathic pain<ref>Jurga S, Szymańska-Adamcewicz O, Wierzchołowski W, Pilchowska-Ujma E, Urbaniak Ł. Spinal adhesive arachnoiditis: three case reports and review of literature. Acta Neurologica Belgica. 2021 Feb;121:47-53.</ref>. Invasive treatment such as intra-spinal narcotic analgesia (INA), epidural steroid and local anesthetic injections are not indicated even though they relieve pain because there is a risk of exacerbating the inflammation and worsening the patient’s condition<ref name=":0" />.


<br>11. Key research
=== '''Physiotherapy Management''' ===
Spinal Cord Electrostimulation (SCS) stands for electrical stimulation by implanted electrodes around the spinal cord in the area that is most involved in causing pain. Some studies indicate a 50% success rate when all types of chronic pain are considered<ref>FREY, M.E., MANCHIKANTI, L., BENYAMIN, R.M., SCHULTZ, D.M.,SMITH, H.S.,COHEN, S.P., ‘Spinal Cord Stimulation for Patients with Failed Back Surgery Syndrome: A Systematic Review’, Pain Physician, vol: 12:379-397, 2009</ref>. There are several physical therapy modalities that can be used for patients suffering from Arachnoiditis including heat therapy to relieve muscle spasms and LASER therapy which aids in reducing inflammation and breaking adhesions as well as relieving nerve irritation<ref>Swain AR. Arachnoiditis: The Evidence Revealed. Anesthesiology. 2012 May;116(5):1167.</ref>. The treatment of patients diagnosed with Arachnoiditis requires special consideration specifically gentle, individually-prescribed exercises. The main focus should be restoring motion, preserving function and remaining active. It is particularly important that patients improve and maintain the range of motion of their spine and extremities as much as possible to avoid limitation through daily stretching so that eventually the patient can attain full range of motion specifically in their arms and legs and for that reason, patients are advised to walk outside their home daily<ref>Lewis C. Physiotherapy and spinal nerve root adhesion: a caution. Physiotherapy Research International. 2004 Nov;9(4):164-73.</ref>.


<br>12. Resources<br>[1*][E]http://www.ninds.nih.gov/disorders/arachnoiditis/arachnoiditis.htm<br>[2*][E]http://www.spineuniverse.com/conditions/arachnoiditis<br>[3*][C]OHRY, A., AZARIA, M., ZEILIG, G., ‘Long term follow up of patients with cauda equine syndrome due to intraspinal lipoma.’ Paraplegia., vol:30(5):366-9, may 1992.<br>[4*][C]SHARMA, A., GOYAL, M., MISHRA, N.K., GUPTA, V., GAIKWAD, S.B., ‘MR imaging of tubercular spinal arachnoiditis.’, AJR Am J Roentgenol.&nbsp;;vol:168(3):807-12, Mar 1997. <br> AJR Am J Roentgenol.&nbsp;;vol:143(4):845-55, Oct 1984.<br> AJR Am J Roentgenol., vol:155(4):873-80, Oct 1990.Clinical bottom line
=== '''Surgical Management''' ===
The surgical treatment mainly focuses on releasing the cicatricial adhesions and repair the CSF flow. Its effects are short-term relieving the symptoms experienced by patients suffering from this condition and it's often not recommended because it causes more scar tissue and more trauma to the already irritated spinal cord<ref>Morisako H, Takami T, Yamagata T, Chokyu I, Tsuyuguchi N, Ohata K. Focal adhesive arachnoiditis of the spinal cord: imaging diagnosis and surgical resolution. Journal of Craniovertebral Junction and Spine. 2010 Jul;1(2):100.</ref>.


<br>14. Recent related research (from pubmed)
== Differential Diagnosis ==
The clinical diagnosis of Arachnoiditis mainly focuses on the previous medical history of the patient, physical examinations and radiographic testing. There are various syndromes including tumors and infections to the spinal cord, its roots and its plexus that mimic the clinical features of Arachnoiditis. In order to rule out the possibility of other disorders, an MRI of the lumbar spine should be done in addition to screening lab tests to check the complete blood count, Erythrocyte Sedimentation Rate and anti-nuclear antibody testing. These tests should always be performed if the diagnosis of arachnoiditis is in question<ref name=":1" />.  


<br>15. References<br>[1][A2]WRIGHT, M.H., DENNEY, L.C.,’ A comprehensive review of spinal arachnoiditis’, Orthop Nurs., may-jun 2003, vol: 22(3), p.215-9.<br>[2][A2]SMITH, S., ‘ The syndromic nature of symptoms in adhesive arachnoiditis’, Patron of the ArachoiditisTrust UK, may 2000.<br>http://www.arachnoiditis.info/content/the_adhesive_arachnoiditis_syndrome/the_adhesive_arachnoiditis_syndrome_12.html<br>[3][C]MATLOCK, C.L., ‘Physiotherapy and spinal nerve root adhesions: a caution’, Physiotherapy research international, vol: 9(4), p. 164-173,2004.<br>[4][C]CHAN, C.C., LAU, P.Y., SUN, L.K., LO, S.S., ‘Arachnoiditis ossificans’, Case report, vol: 15(2), apr 2009.<br>[5][A2]FREY, M.E., MANCHIKANTI, L., BENYAMIN, R.M., SCHULTZ, D.M.,SMITH, H.S.,COHEN, S.P., ‘Spinal Cord Stimulation for Patients with Failed Back Surgery Syndrome: A Systematic Review’, Pain Physician, vol: 12:379-397, 2009.<br>[6][C]FRIZZELLI, B., KAPLN, P., DUSSAULT, R., SEVICK, R., ‘Arachnoiditis Ossificans: MR Imaging Features in Five Patients’, AJR, vol: 177, aug. 2001.<br>[7][A2]ROSS, J.S., MASARYK,T.J., MODIC, M.T., DELAMATER, R., BOHLMAN, H., WILBUR, G., KAUFMAN, B., ‘ MR imagining of lumbar arachnoiditis’, AJNR, sep-oct 1987.<br>[8][C]PERRY, J., BARNES, G., GRONLEY, J.K., ‘The postpolio syndrome. An overuse phenomenon.’, Clin Orthop Relat Res, vol: 233:145-62, Aug 1988.<br>[9][C]PERRY, J., FONTAINE, J.D., MULROY, S., ‘Findings in post-poliomyelitis syndrome. Weakness of muscles of the calf as a source of late pain and fatigue of muscles of the thigh after poliomyelitis.’, J Bone Joint Surg Am., vol: 77(8):1148-53, aug 1995.<br>[10][D]SCHUNKE, M., SCHULTE, E., SCHUMACHER, U., VOLL, M., WESKER, K., Prometheus, Bohn Stafleu van Loghum, Houten, 2005.<br>[11][D].<br>[12][D]MEEUSEN, R., Rug- en nekletsels deel 2, Kluwer, 2001, p83.<br>  
== References ==
<references />


[[Category:Neurology]]
[[Category:Neurological - Conditions]]

Latest revision as of 13:15, 17 February 2023

Original Editor - Boris Alexandra Top Contributors - Reem Ramadan, Wendy Walker, Kim Jackson, Vidya Acharya, Boris Alexandra, Naomi O'Reilly, George Prudden and WikiSysop

Clinically Relevant Anatomy[edit | edit source]

The central nervous system (CNS) which is made up of the brain and the spinal cord is covered and protected by meninges. Meninges are generally three membrane layers, the Dura Mater which is the outer layer, Arachnoid Mater which is the middle layer, and the Pia Mater which is the inner layer. There are 31 pairs of spinal nerves that exit the vertebral column, one on the right side and the other on the left, through vertebral foramina[1].

Arachnoiditis

Pathological Process[edit | edit source]

Arachnoiditis is a progressive disorder that involves the brain and/or the spinal cord caused by inflammation of the arachnoid membrane. There are several types of Arachnoiditis including Adhesive Arachnoiditis which is the most severe type and occurs when spinal nerves stick together, Arachnoiditis ossificans which occurs when arachnoid turns to bone, Cerebral arachnoiditis which affects the membranes surrounding the brain, Hereditary arachnoiditis which is congenital and rare and occurs due to defects affecting the meninges, Neoplastic arachnoiditis which occurs due to cancer and Optochiasmatic arachnoiditis which involves optic nerve[2].
There are 3 main stages of Arachnoiditis.

  • The first stage involves the inflammation of the spinal nerves, hyperemia, the disappearance of the subarachnoid space and the scar tissue begins to form.
  • The second stage involves the scar tissue formation process increasing and the nerves further adhere to each other and to the dura.
  • The third stage involves the complete encapsulation of the nerve roots, compression causes atrophy of the nerve roots and the scarring tissues prevent the production of spinal fluid in that area. In some cases, the scar tissue calcifies and is then termed Arachnoiditis Ossificans[3].

Etiologies[edit | edit source]

  • Trauma/Surgery-induced: Arachnoiditis is considered a rare complication of spinal surgery specifically after multiple complex surgeries or trauma to the spine. Multiple lumbar punctures, advanced stages of spinal stenosis and chronic degenerative disc disease may also lead to arachnoiditis. This may result in blood penetration in the subarachnoid space causing inflammation[4].
  • Chemical-induced: Myelograms have been considered recently to cause this condition. A myelogram which is a diagnostic test that contains a dye is usually injected in the area surrounding the spinal cord and nerves and is visible on various diagnostic imaging such as X-ray, MRI and CT scan. The repetitive exposure to oil-based radiographic contrast agents used in myelograms causes Arachnoiditis. In addition to that, medications found in epidural steroid injections can cause Arachnoiditis especially if they enter the cerebral spinal fluid (CSF). It's also important to note that, Arachnoiditis due to surgery is precisely localized, meanwhile the one due to epidural injections is more diffuse[5].
  • Infection-induced: Arachnoiditis can also be caused by viral or bacterial meningitis, tuberculosis and syphilis affect the spine[6].
    Arachnoiditis is also the third most common cause of Failed Back Surgery Syndrome (FBSS)[7].

Clinical Presentation[edit | edit source]

The most prominent symptom of Arachnoiditis would be persistent pain in the lower back and limbs[8]. Other symptoms which are experienced by 90% of patients include:

  • tingling sensation and paresthesia
  • weakness in the lower limbs
  • cramps and spasms
  • bladder and sexual dysfunctions[9]
  • hyporeflexia

The pain tends to be worse at night and normally evoked by non-painful stimuli or no stimulus at all. This pain also tends to increase with activity where pain tends to be delayed at the onset of activity and persist after the cessation of physical activity[10]. In addition to that, pain can also be caused by other factors besides nerve damage involving the musculoskeletal system due to what this disorder causes from spine dynamic alteration. Patients with this disorder may experience muscle tension, an increase in muscle tone due to nerve damage and severe joint pain[11].

Diagnostic Procedures[edit | edit source]

Arachnoiditis is usually present in the subarachnoid space but can be clearly seen in the lumbar region where we find the cauda equina. There are various radiographic modalities that can help with the diagnostic procedure but an MRI is the most favorable and most sensitive modality[12]. The diagnosis of Arachnoiditis is usually based on 3 main findings which are the inflammation and enlargement of nerve roots on an axial view, their displacement from their normal position, and them appearing clumped together[13]. For patients where an MRI is contraindicated, computed tomography (CT) myelography is an acceptable alternative as a radiographic modality[14]. Other forms of diagnosis would be finding that C-reactive protein (CRP) or Erythrocyte Sedimentation Rate (ESR), inflammatory markers, levels being exceedingly high[15] in addition to other less known inflammatory markers like interleukins and myeloperoxidase having high levels as well. It's important to note that the presence of high levels of ESR and CRP indicate that Arachnoiditis is active and in need of immediate treatment[16].

Management[edit | edit source]

Arachnoiditis is a very difficult condition to treat and the treatment protocols for patients suffering from this condition mainly focus on relieving pain and improving symptoms that affect the patient's daily function.

Medical Management[edit | edit source]

In order to prevent arachnoiditis from progressing and worsening, the medical treatment protocol should focus on controlling and suppressing neuroinflammation. To treat inflammation, the use of non-steroidal anti-inflammatory drugs (NSAIDs) and pulse therapy is common, especially methylprednisolone[17]. However, there are only a few studies demonstrating its effectiveness in preventing scar tissue formation[18]. Other pharmacologic treatments include naltrexone, tricyclic antidepressants and muscle relaxants such as baclofen which are used to release neuropathic pain[19]. Invasive treatment such as intra-spinal narcotic analgesia (INA), epidural steroid and local anesthetic injections are not indicated even though they relieve pain because there is a risk of exacerbating the inflammation and worsening the patient’s condition[2].

Physiotherapy Management[edit | edit source]

Spinal Cord Electrostimulation (SCS) stands for electrical stimulation by implanted electrodes around the spinal cord in the area that is most involved in causing pain. Some studies indicate a 50% success rate when all types of chronic pain are considered[20]. There are several physical therapy modalities that can be used for patients suffering from Arachnoiditis including heat therapy to relieve muscle spasms and LASER therapy which aids in reducing inflammation and breaking adhesions as well as relieving nerve irritation[21]. The treatment of patients diagnosed with Arachnoiditis requires special consideration specifically gentle, individually-prescribed exercises. The main focus should be restoring motion, preserving function and remaining active. It is particularly important that patients improve and maintain the range of motion of their spine and extremities as much as possible to avoid limitation through daily stretching so that eventually the patient can attain full range of motion specifically in their arms and legs and for that reason, patients are advised to walk outside their home daily[22].

Surgical Management[edit | edit source]

The surgical treatment mainly focuses on releasing the cicatricial adhesions and repair the CSF flow. Its effects are short-term relieving the symptoms experienced by patients suffering from this condition and it's often not recommended because it causes more scar tissue and more trauma to the already irritated spinal cord[23].

Differential Diagnosis[edit | edit source]

The clinical diagnosis of Arachnoiditis mainly focuses on the previous medical history of the patient, physical examinations and radiographic testing. There are various syndromes including tumors and infections to the spinal cord, its roots and its plexus that mimic the clinical features of Arachnoiditis. In order to rule out the possibility of other disorders, an MRI of the lumbar spine should be done in addition to screening lab tests to check the complete blood count, Erythrocyte Sedimentation Rate and anti-nuclear antibody testing. These tests should always be performed if the diagnosis of arachnoiditis is in question[6].

References[edit | edit source]

  1. ↑ Moore KL, Dalley AF, Agur AM. Clinically oriented anatomy. 7th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health; 2014.
  2. ↑ 2.0 2.1 Peng H, Conermann T. Arachnoiditis. InStatPearls. 2021 Nov 8. StatPearls Publishing.
  3. ↑ Deshmukh, V.R. Encyclopedia of the Neurological Sciences (Second Edition). Brain and Spine Institute, Portland, OR, USA. 2014.
  4. ↑ Arachnoiditis: What it is, causes, symptoms & treatment. Cleveland Clinic. Available at: https://my.clevelandclinic.org/health/diseases/12062-arachnoiditis (accessed 17/2/2023)
  5. ↑ Long DM. Chronic adhesive spinal arachnoiditis: pathogenesis, prognosis, and treatment. Neurosurgery Quarterly. 1992 Dec 1;2(4):296-320.
  6. ↑ 6.0 6.1 Waldman, S.D. Pain review. Philadelphia, PA: Elsevier.2009.
  7. ↑ Burgest S. Simopoulos TC. FAILED BACK SURGERY SYNDROME. Current Therapy in Pain. Elsevier. 2009.
  8. ↑ Tennant F. (228) Which chronic back pain patients have arachnoiditis?. The Journal of Pain. 2016 Apr 1;17(4):S32.
  9. ↑ MATLOCK, C.L. Physiotherapy and spinal nerve root adhesions: a caution. Physiotherapy research international. Vol: 9(4), p.164-173,2004.
  10. ↑ Mehta, N. Arachnoiditis. Spine Universe. Available at: https://www.spineuniverse.com/conditions/spinal-disorders/arachnoiditis (accessed 14/2/2023)
  11. ↑ Smith S. Adhesive Arachnoiditis: A Continuing Challenge. Practical Pain Management. 2004;4(2)
  12. ↑ Malani AN, Vandenberg DM, Singal B, Kasotakis M, Koch S, Moudgal V, et al. Magnetic resonance imaging screening to identify spinal and paraspinal infections associated with injections of contaminated methylprednisolone acetate. JAMA. Jun 19 2013;309(23):2465-72.
  13. ↑ Cohen MS, Wall EJ, Kerber CW, Abitbol JJ, Garfin SR. The anatomy of the cauda equina on CT scans and MRI. The Journal of bone and joint surgery. British volume. 1991 May;73(3):381-4.
  14. ↑ Patel DM, Weinberg BD, Hoch MJ. CT myelography: clinical indications and imaging findings. Radiographics. 2020 Mar;40(2):470-84.
  15. ↑ Tennant F. Erythrocyte sedimentation rate and C-reactive protein: old but useful biomarkers for pain treatment. Pract Pain Manage. 2013 Mar 1;13(2):61-5.
  16. ↑ Tennant F. Search for inflammatory markers in centralized, intractable pain. American Academy of Pain Management. 2013.
  17. ↑ Wright MH, Denney LC. A comprehensive review of spinal arachnoiditis. Orthopaedic Nursing. 2003 May 1;22(3):215-9.
  18. ↑ Kara T, Davulcu Ö, Ateş F, Arslan FZ, Sara HI, Akin A. What happened to cauda equina fibers? Adhesive arachnoiditis. Anaesthesia, Pain & Intensive Care. 2020 Jun 10;24(5):555-7.
  19. ↑ Jurga S, Szymańska-Adamcewicz O, Wierzchołowski W, Pilchowska-Ujma E, Urbaniak Ł. Spinal adhesive arachnoiditis: three case reports and review of literature. Acta Neurologica Belgica. 2021 Feb;121:47-53.
  20. ↑ FREY, M.E., MANCHIKANTI, L., BENYAMIN, R.M., SCHULTZ, D.M.,SMITH, H.S.,COHEN, S.P., ‘Spinal Cord Stimulation for Patients with Failed Back Surgery Syndrome: A Systematic Review’, Pain Physician, vol: 12:379-397, 2009
  21. ↑ Swain AR. Arachnoiditis: The Evidence Revealed. Anesthesiology. 2012 May;116(5):1167.
  22. ↑ Lewis C. Physiotherapy and spinal nerve root adhesion: a caution. Physiotherapy Research International. 2004 Nov;9(4):164-73.
  23. ↑ Morisako H, Takami T, Yamagata T, Chokyu I, Tsuyuguchi N, Ohata K. Focal adhesive arachnoiditis of the spinal cord: imaging diagnosis and surgical resolution. Journal of Craniovertebral Junction and Spine. 2010 Jul;1(2):100.
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