Arachnoiditis

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 Physiopedia : Arachnoiditis

1. Search Strategy
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.

2. Clinically relevant anatomy
Arachnoid mater: it’s the membranous layer between the pia mater and the dura mater that surround the brain and the nerves of the spinal cord.[10-11]

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.[10-11]

3. Definition/description
Arachnoiditis is a chronic inflammation of the arachnoid. It can involve the brain and/or the spinal cord.[1-2-3-4]
It develops in 3 stages, namely:[2]
1) inflammation of the spinal nerves, distension of the adjacent blood vessels, subarachnoid space disappears and the scare tissue begins
2) the scare tissue increases, the nerves adhere to each other and the dura
3) complete encapsulation of the nerve roots, compression causes atrophy of the nerve roots and the scaring tissues prevent the production of spinal fluid in that area. We speak of arachnoiditis ossificans if the scar tissue calcifies, it’s a very rare condition.

4. Epidemiology/Etiology
The inflammation can be caused by 3 main causes, namely:[1-2-3-4]
1) trauma–surgery: complications after multiple back surgery may cause bloodpenetration in the subarachnoid space and cause inflammation.
2) chemically: exposure to oil based radiographic contrast agents used in myelograms or drugs used for epidural injections.
3) infection: viral or bacterial meningitis, tuberculosis and syphilis affect the spine.

This disorder is the third most common cause of Failed Back Surgery Syndrome (FBSS).
Arachnoiditis due to surgery is precisely localised, meanwhile the arachnoiditis due to epidural injections is more diffuse.[2]

5. Clinical presentation
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.[3]The pain can increase with activity, it can vary in intensity and it can be due to other factors besides nerve damage.[2]

6. Differential diagnosis
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]

7. Diagnostic procedures
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]

8. Examination
- conventional measurement of muscle strength:[2-8-9]
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.
- MRI and CT-scan:[1-2-4-6-7]
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.
-electromyography(EMG) and nerve conduction studies(NCS) are needed to demonstrate nerve damage.[2]
-tests for bladder and urodynamic dysfunction are required[2]

9. Medical management (current best evidence)
There is no cure, only treatment of the chronic symptoms.[1-2]
-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.
-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.
-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]
-Surgery is not recommended because it causes more scar tissue and more trauma to the already irritated spinal cord.[4]

10. Physical therapy management (current best evidence)
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]
-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.
-hydrotherapy: is used as relaxation technique, but the water mustn’t be too warm because arachnoiditis patient have heat intolerance
-relaxation/meditation/massage: are used as contribution to medication, the patients can’t manage on these techniques only
-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]
example of muscle-strengthening exercise(for the M. multifundi):[12]
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
example of stretching exercise:[3]
patient lies on his stomach, he lifts very gentle the head and feet to strengthen the back, hold this position for 10”-15”

11. Key research

12. Resources
[1*][E]http://www.ninds.nih.gov/disorders/arachnoiditis/arachnoiditis.htm
[2*][E]http://www.spineuniverse.com/conditions/arachnoiditis
[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.
[4*][C]SHARMA, A., GOYAL, M., MISHRA, N.K., GUPTA, V., GAIKWAD, S.B., ‘MR imaging of tubercular spinal arachnoiditis.’, AJR Am J Roentgenol. ;vol:168(3):807-12, Mar 1997.
AJR Am J Roentgenol. ;vol:143(4):845-55, Oct 1984.
AJR Am J Roentgenol., vol:155(4):873-80, Oct 1990.Clinical bottom line

14. Recent related research (from pubmed)

15. References
[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.
[2][A2]SMITH, S., ‘ The syndromic nature of symptoms in adhesive arachnoiditis’, Patron of the ArachoiditisTrust UK, may 2000.
http://www.arachnoiditis.info/content/the_adhesive_arachnoiditis_syndrome/the_adhesive_arachnoiditis_syndrome_12.html
[3][C]MATLOCK, C.L., ‘Physiotherapy and spinal nerve root adhesions: a caution’, Physiotherapy research international, vol: 9(4), p. 164-173,2004.
[4][C]CHAN, C.C., LAU, P.Y., SUN, L.K., LO, S.S., ‘Arachnoiditis ossificans’, Case report, vol: 15(2), apr 2009.
[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.
[6][C]FRIZZELLI, B., KAPLN, P., DUSSAULT, R., SEVICK, R., ‘Arachnoiditis Ossificans: MR Imaging Features in Five Patients’, AJR, vol: 177, aug. 2001.
[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.
[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.
[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.
[10][D]SCHUNKE, M., SCHULTE, E., SCHUMACHER, U., VOLL, M., WESKER, K., Prometheus, Bohn Stafleu van Loghum, Houten, 2005.
[11][D]MOORE, K.L., DALLEY, A.F., AGUR, A.M.R., Clinically oriented anatomy, Wolters Kluwer, Lippincott Williams and Wilkins, 2010.
[12][D]MEEUSEN, R., Rug- en nekletsels deel 2, Kluwer, 2001, p83.