Spinal arachnoiditis: disease or coincidence?

The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis)

BACKGROUND & IMPORTANCE

This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward.

METHODS

The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions.

RESULTS

Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic.

DISCUSSION & CONCLUSION

DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.

Idiopathic Arachnoiditis of the Cauda Equina: A Case Report from Tanzania

Arachnoiditis is a rare clinical entity that usually presents with severe debilitating radiating pain that can pose a challenge in diagnosis especially in areas without appropriate imaging modalities. We present a 26-year-old male with progressive lower back pain with radiation to the lower extremities, aggravated by movement and touch. We diagnosed idiopathic arachnoiditis based on cerebrospinal fluid analysis and magnetic resonance imaging. He was managed with a 5-day course of methylprednisolone and analgesics with a good outcome. Severe back pain without a specific cause in a young patient should be investigated with proper imaging modalities and lumbar puncture if warranted to evaluate the cause.

Spinal arachnoiditis followed by intrathecal tigecycline therapy for central nervous system infection by extremely drug-resistant Acinetobacter baumannii

In prior research, intrathecal tigecycline was successfully used to treat central nervous system infection by extensively drug-resistant Acinetobacter baumannii. However, little is known about its safe dose and adverse reactions. This study reports the case of a 28-year-old male patient who was diagnosed with central nervous system infection by extensively drug-resistant A. baumannii after the removal of a ventriculoperitoneal shunt. Intravenous and intrathecal tigecycline were administrated simultaneously. Spinal arachnoiditis was discovered after nine doses of intrathecal tigecycline. Spinal arachnoiditis was resolved after discontinuation of the antibiotic. This is the first report of an adverse reaction to intrathecal tigecycline. The case was complicated by spinal arachnoiditis, which obstructed the assessment of cerebrospinal fluid. The appropriate dose and administration schedule of intrathecal tigecycline remain to be determined.

An evaluation of the effectiveness of hyaluronidase in the selective nerve root block of radiculopathy: a double blind, controlled clinical trial

Study Design

Prospective, double-blind, randomized controlled trial.

Purpose

To determine the ability of hyaluronidase to provide longer lasting pain relief and functional improvement in patients with lumbar radiculopathy.

Overview of Literature

Selective nerve root block (SNRB) is a good treatment option in lumbar radiculopathy. We studied the effectiveness of hyaluronidase when added to the traditional SNRB regimen.

Methods

A sample size of 126 patients per group was necessary. A sample of 252 patients who underwent an injection procedure with or without hyaluronidase due to radiculopathy was included in this study. The patients were randomly divided into two groups: the control (C) group and the hyaluronidase (H) group. After SNRB due to radiculopathy, the visual analog scale (VAS) was compared at 2, 4, 6, 8, and 12 weeks between the two groups, and the Oswestry disability index (ODI) was compared at 12 weeks between the two groups.

Results

Both groups seemed to have general improvement in VAS, but in C group, the VAS was higher than the H group 2 and 4 weeks after the surgery, and the difference in time-group change between 2 groups was statistically significant (p <0.05). ODI improved in both groups, and the difference in time-group change between 2 groups was not statistically significant (p >0.05).

Conclusions

The rebound pain (the re-occurrence of pain within 2-4 weeks after injection) that occurs within 2-4 weeks after the injection of the routine regimen can be reduced when hyaluronidase is added to the routine SNRB regimen.

Familial adhesive arachnoiditis associated with syringomyelia

Adhesive arachnoiditis is a rare condition, often complicated by syringomyelia. This pathologic entity is usually associated with prior spinal surgery, spinal inflammation or infection, and hemorrhage. The usual symptoms of arachnoiditis are pain, paresthesia, and weakness of the low extremities due to the nerve entrapment. A few cases have had no obvious etiology. Previous studies have reported one family with multiple cases of adhesive arachnoiditis. We report a second family of Belgian origin with multiple cases of arachnoiditis and secondary syringomyelia in the affected individuals.

The effect of hyaluronidase in interlaminar lumbar epidural injection for failed back surgery syndrome

Objective

To evaluate the effect of hyaluronidase in patients with failed back surgery syndrome (FBSS) treated with interlaminar lumbar epidural injection (ILEI).

Method

Sixty patients suffering from severe low back pain and sciatica were randomly allocated into three groups. Group T received ILEI with 2 ml triamcinolone 40 mg/ml and 5 ml bupivacaine 0.25%. Group H received ILEI with 1500 IU hyaluronidase and 5 ml bupivacaine 0.25%. Group TH received interlaminar lumbar epidural injection (ILEI) with 1500 IU hyaluronidase, 2 ml triamcinolone 40 mg/ml and 5 ml bupivacaine 0.25%. The effect was evaluated using Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) at pre-injection, 2 weeks, 6 weeks and 12 weeks after ILEI.

Results

After 2 weeks and after 6 weeks, patients in both Group T and Group TH had significant effectiveness more than Group H in decrease of VAS and ODI. After 12 weeks, only patients in Group TH had significant effectiveness in decrease of VAS and ODI (p<0.05). In every period, Group TH had the most effectivess in decrease of VAS and ODI after ILEI.

Conclusion

ILEI for FBSS with triamcinolone and hyaluronidase is considered to have more long term effectiveness to reduce pain and improve function after ILEI than injection with triamcinolone alone or hyaluronidase alone.

Postoperative spinal adhesive arachnoiditis presenting with hydrocephalus and cauda equina syndrome

To our knowledge, the association between hydrocephalus and postoperative spinal adhesive arachnoiditis (SAA) has never been reported. Herein we describe an unusual case of a 45-year-old man with spinal adhesive arachnoiditis (SAA) who developed delayed-onset hypertensive hydrocephalus and cauda equina syndrome (CES) after multiple low-back surgeries. The patient's clinical presentation, imaging findings, surgical management, and the possible mechanisms are discussed in the light of the present literature.

Symptomatic lumbar spinal arachnoiditis: fact or fallacy?

It is generally accepted that chronic adhesive lumbar arachnoiditis is a cause of symptoms, notably back pain and/or pain (of almost any type, not necessarily 'anatomical') in the lower limbs, although there is no clearly defined clinical pattern which is clearly associated with this syndrome. There is no doubt that arachnoiditis occurs as a pathological and radiological entity due to a number of causes. In the view of the present authors, the nexus between the pathology and radiology on the one hand, and the patients' symptoms on the other hand, has not been demonstrated with any degree of scientific rigor.

Nerve root sleeve injections in patients with failed back surgery syndrome: a comparison of three solutions

OBJECTIVE

To evaluate outcome in patients with failed back surgery syndrome treated with nerve root sleeve injections.

DESIGN AND PATIENTS

An open, nonblinded, randomized study on 60 patients with documented fibrosis in fewer than three nerve roots.

INTERVENTIONS

After random selection, 20 patients were injected with 1 ml bupivacaine 0.5% combined with 1500 units hyaluronidase and 1 ml saline per nerve root sleeve (group A), another 20 were treated with 1 ml bupivacaine 0.5% combined with 40 mg methylprednisolone solution (Depo Medrol) per nerve root (group B), and a third group was treated with bupivacaine 0.5% combined with 1500 units hyaluronidase and 40 mg methylprednisolone solution (group C). The volume of each injection was 2 ml. The injections were given twice at an interval of 1 week.

OUTCOME MEASURES

The patients were evaluated on a verbal pain rating scale 1, 3, and 6 months after the second injection. The Kruskal-Wallis test was used to detect statistically significant differences among the three groups, and the analysis was refined with the Friedman test.

RESULTS AND CONCLUSIONS

Overall, although injections induced analgesia at 1 month, these effects were reduced at 3- and 6-month follow-ups. No statistical differences were found between the three treatment groups (after 1 month, p = 0.71; after 3 months, p = 0.69; after 6 months, p = 0.66. The Friedman test showed a significant decrease in treatment score as a function of time in groups B and C (p = 0.015) but not in group A (p = 0.074). Corticosteroids seem responsible for the last phenomenon.

Tuberculous radiculomyelitis (arachnoiditis): myelographic (and CT myelographic) appearances

Tuberculous radiculomyelitis (arachnoiditis) remains one of the important causes of paraplegia in India. The diagnosis usually rests on clinical history and examination, and on laboratory findings in the cerebro-spinal fluid (CSF). Few descriptive reports are available of the myelographic appearance, with water-soluble contrast media, in tuberculous radioculomyelitis (arachnoiditis). A retrospective review of 21 myelograms and 10 computed tomographic (CT) myelograms, in 14 patients with tuberculous radiculomyelitis, was carried out, with a view to describing, in detail, the radiographic features. An attempt was made to assess the use of the radiologic procedures in diagnosis and follow up in these patients. Conventional myelographic findings included block (8/14), irregular subarachnoid space (9/14), filling defects (8/14), sluggish contrast flow (2/14), root thickening (3/14) and atrophic cord (2/14). Computed tomographic myelography showed reduced contrast density in portions of the opacified CSF ring around the cord in affected region (6/7) and, in addition, demonstrated septa and adhesions. Intravenous contrast CT was not found to be useful (2/2). Follow-up studies showed partial resolution (3/6), deterioration (1/6) and status quo of radiological findings (2/6). Although these changes can be seen in chronic radiculomyelitis (arachnoiditis) from other causes, such as leukaemic infiltration/lymphoma, other chronic central nervous system infections and iatrogenic causes, including repeated intrathecal injections, conventional myelography appeared to be useful for diagnosis and follow up in tuberculous radiculomyelitis (arachnoiditis).

Peroperative prednisolone fails to improve the clinical outcome following surgery for prolapsed lumbar intervertebral disc. A randomized controlled trial

Ninety three patients undergoing their first conventional hemilaminectomy for lumbar disc protusion were randomized to a double blind clinical trial. Half of the patients were treated immediately following surgery with prednisolone; 50 mg per day for fourteen days and then 25 mg per day for another 14 days. The other patients were treated for the same time period with placebo tablets. Assessments using subjective and objective outcome criteria at 26 weeks, 52 weeks and 156 weeks of follow-up, demonstrated no statistically significant differences between the randomized groups. It is concluded that systemic prednisolone administration in the pre- and postoperative period does not in this study improve the clinical outcome after first time lumbar discectomy.

Depo-Medrol and myelographic arachnoiditis

OBJECTIVE

This study was undertaken to see if patients who had a radiological diagnosis of arachnoiditis attributed to methylprednisolone acetate (Depo-Medrol, Upjohn Pty Limited) had the clinical syndrome of arachnoiditis.

DESIGN

An attempt was made to review all patients, reported by Roche in 1984 with a radiological diagnosis of corticosteroid-induced arachnoiditis, by taking a detailed history and performing a physical examination.

SETTING

The Department of Orthopaedics and Traumatic Surgery, The University of Sydney, The Royal North Shore Hospital, Sydney.

RESULTS

Of the 18 patients reported by Roche 15 were located and participated in this study. The clinical syndrome of arachnoiditis was defined as a constant burning pain in the back and legs, impotence, marked limitation of spinal motion, alteration of sensation and power in the legs, and a need for regular analgesia. Three of the 15 patients had the clinical syndrome of arachnoiditis. The grade of radiological change was unrelated to the severity of symptoms. The details of doses and precise sites of administration were unavailable for the severely affected individuals.

CONCLUSIONS

The absence of any other apparent cause for their symptoms implies that Depo-Medrol should not be used in or about the thecal sac.

Steroid-induced arachnoiditis

Eighteen cases are reported in which the myelographic appearances of adhesive arachnoiditis were found. These patients have had intrathecal steroid injections as either the only procedure or the most likely procedure that could have induced such changes. Adhesive arachnoiditis has not been found at this hospital in the absence of some type of intervention. Other possible iatrogenic causes of arachnoiditis have been excluded in this group. The literature on the aetiology and symptomatology of steroid-induced arachnoiditis is reviewed.