Arachnoiditis: Difference between revisions
| Line 164: | Line 164: | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
Treatment of arachnoiditis is palliative, and mostly medications are used for this purpose. Antidepressant and anticonvulsant analgesics are the mainstays of treatment. However, other classes of medications can also be beneficial. The U.S. Food and Drug Administration has approved several medications for neuropathic pain syndromes: pregabalin and duloxetine for diabetic neuropathy and gabapentin and pregabalin for postherpetic neuralgia. These medications are often used for the treatment of arachnoiditis with variable efficacy. These medications are often started at a low dosage and titrated upward as tolerated. Most of these medications take a few weeks to take analgesic effects to be reached. Some examples of these medications dosage are given in the table. | Treatment of arachnoiditis is palliative, and mostly medications are used for this purpose. Antidepressant and anticonvulsant analgesics are the mainstays of treatment. However, other classes of medications can also be beneficial. The U.S. Food and Drug Administration has approved several medications for neuropathic pain syndromes: pregabalin and duloxetine for diabetic neuropathy and gabapentin and pregabalin for postherpetic neuralgia. These medications are often used for the treatment of arachnoiditis with variable efficacy. These medications are often started at a low dosage and titrated upward as tolerated. Most of these medications take a few weeks to take analgesic effects to be reached. Some examples of these medications dosage are given in the table. | ||
<br /> | |||
{| class="wikitable" | |||
|+Examples of dosing regimens for Anticolvusant and antidepresasant medications | |||
!Medication | |||
!Starting dose | |||
!Dose increase and interval | |||
!Maximal dose | |||
|- | |||
|Tricyclic anti depressant | |||
|10-25mg at night | |||
|10-25 mg per week | |||
|150 mg /day | |||
|- | |||
|Duloxetine | |||
|20-30mg per day | |||
|20-30 mg per week | |||
|60mg /day | |||
|- | |||
|Pregabalin | |||
|50-75mg BID | |||
|50-75 mg per week | |||
|600mg /day | |||
|- | |||
|Gabapentine | |||
|100-300mg BID | |||
|100-300 mg per week | |||
|1800-3600mg /day | |||
|} | |||
===Surgery=== | ===Surgery=== | ||
Revision as of 00:44, 9 July 2020
|
WikiDoc Resources for Arachnoiditis |
|
Articles |
|---|
|
Most recent articles on Arachnoiditis Most cited articles on Arachnoiditis |
|
Media |
|
Powerpoint slides on Arachnoiditis |
|
Evidence Based Medicine |
|
Clinical Trials |
|
Ongoing Trials on Arachnoiditis at Clinical Trials.gov Trial results on Arachnoiditis Clinical Trials on Arachnoiditis at Google
|
|
Guidelines / Policies / Govt |
|
US National Guidelines Clearinghouse on Arachnoiditis NICE Guidance on Arachnoiditis
|
|
Books |
|
News |
|
Commentary |
|
Definitions |
|
Patient Resources / Community |
|
Patient resources on Arachnoiditis Discussion groups on Arachnoiditis Patient Handouts on Arachnoiditis Directions to Hospitals Treating Arachnoiditis Risk calculators and risk factors for Arachnoiditis
|
|
Healthcare Provider Resources |
|
Causes & Risk Factors for Arachnoiditis |
|
Continuing Medical Education (CME) |
|
International |
|
|
|
Business |
|
Experimental / Informatics |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Please help WikiDoc by adding content here. It's easy! Click here to learn about editing.
Overview
Arachnoiditis is a term used to describe thickening, inflammation, and scaring of the arachnoid membrane, which is the middle layer surrounding the central nervous system. These abnormalities may be self-limited or may cause compression of the nerve roots and spinal cord. Patients may report a variety of clinical symptoms, including severe back pain that persists at rest, perineal/saddle numbness, neurological deficits, skin rashes, and sympathetic or vascular changes. The cause of arachnoiditis is unknown but may occur as a result of invasion (surgery), neuraxial injections, certain myelograms, infections, blood, a herniated disc, or tumors. Diagnosis is based on symptoms, and magnetic resonance imaging. Unfortunately, the treatment of arachnoiditis is difficult and limited and should focus on symptomatic management.
Historical Perspective
The phenomenon of adhesive arachnoiditis was first described by Quinke in 1893 in a case report. In 1897, Schwarz wrote about signs and symptoms of arachnoiditis caused by syphilis. Elkington wrote about the classic description of arachnoiditis in 1936 and termed it as meningitis serosa circumscripta spinalis. He also described various presentations of arachnoiditis in 1951. Foix and Alajouanine described a noninfectious spinal arachnoid scar reaction in 1926 and termed it as hypertrophic vascular ascending myelitis. Ransome and Monterio mentioned that tuberculous meningitis might present as extensive spinal arachnoiditis. The first case of arachnoiditis was associated with syphilis.[1][2][3]
Classification
National Organization for Rare Disorders (NORD) divides arachnoiditis into the following types.
- Adhesive Arachnoiditis
- Arachnoiditis Ossificans
- Cerebral Arachnoiditis
- Hereditary Arachnoiditis
- Neoplastic Arachnoiditis
- Optochiasmatic Arachnoiditis
- Postmyelographic Arachnoiditis
- Rhinosinusogenic Cerebral Arachnoiditis
The radiologists classify arachnoiditis, according to Delamarter's MRI classification.
• Type I—appears as an adhesive mass of adherent roots centrally in the thecal sac, considered mild arachnoiditis.
• Type II—the empty sac, the roots adhere peripherally to the meninges.
• Type III—a soft-tissue mass replaces the subarachnoid space.
Wilkinson developed another classification system that divided the myelographic appearances into four groups.
• Type I: A unilateral focal defect centered on the nerve root exit pouch adjacent to the intervertebral disc space.
• Type II: An annular or a circumferential defect with a bilateral notch and only filiform passage of the medium.
• Type III: Complete transverse obstruction with the picture of stalagmites, candle-guttering, or paintbrush defects.
• Type IV: An infundibuliform cul-de-sac with loss of radicular striation, a vitreous appearance, and cutting-off of the root sleeves.
Pathophysiology
{{#ev:youtube|XEBaA9LBZug}}
Causes
Common causes of arachnoiditis include the following.[4]
- Mechanical injury during spinal surgery ( about 60% cases)
- Spinal trauma
- neuroaxial (spinal and epidural) anesthesia ( about 22% cases)
- one or more spinal tabs (7% cases)
- myelography
- bacterial and viral spinal infections (7%)
- Spinal tumors
- Repeated subarachnoid injections of anticancer drugs or antimetabolites
- Spinal cord contamination
Differentiating arachnoiditis from other Diseases
Arachnoiditis is a clinical diagnosis that is supported by a combination of clinical history, physical examination, and radiography. Following pain syndromes may mimic arachnoiditis and should be considered in the differential diagnosis.[5][6][7]
- spinal cord tumors
- cauda equina syndrome
- arachnoiditis ossificans,
- failed back syndrome
- syringomyelia
- Spinal cord infections
Epidemiology and Demographics
Arachnoiditis is a rare disorder. Its exact incidence is hard to determine as its difficult-to-diagnose condition with a wide range of clinical presentations. Some cases of arachnoiditis may go undiagnosed or misdiagnosed. Therefore the exact incidence of arachnoiditis remains not only unknown but also likely significantly underestimated. However, recently the number of lumbar arachnoiditis cases are increasing due to lumbar supine surgeries and spinal anesthesia.[8] [9]
Arachnoiditis affects more females than males because two-thirds of pregnant females receive spinal or epidural anesthesia during child delivery.
Risk Factors
The major risk-factors of arachnoiditis are briefly highlighted below:
- Bacterial, viral or fungal infections that spread to the brain and spinal cord
- Diseases that weaknen the immune system e.g AIDS, diabetes or organ transplantation
- Surgical or needle neural trauma
- Intrathecal corticosteroids
- Unintentional injection of subarachnoid blood
- Injection of neurotoxic or neuroirritant substances into the subarachnoid space
- Cancers such as melanoma, non-Hodgkin’s lymphoma, breast cancer, lung cancer as well as other cancers specific to the brain
Screening
There is insufficient evidence to recommend routine screening for arachnoiditis.
Natural History, Complications, and Prognosis
Symptoms of arachnoiditis often start after many years of the suspected inciting event. Chronic arachnoiditis can vary in severity from mild to moderate or may progress to severe and catastrophic, disrupting quality of life. There may be remissions and relapses; however: symptoms may resolve with treatment. The course of chronic arachnoiditis is typically irregular, but it is progressive in up to 33% of patients and non-progressive in 50-59%.
Aside from the chronic pain and various possible neurologic deficits, common complications of arachnoiditis may include hydrocephalus, syringomyelia, and arachnoid cysts. A rare complication is internal malabsorptive hydrocephalus.[10][11]
Supportive care and symptomatic management is the mainstay of treatment. Although this is not a life-threatening condition, the quality of life can be significantly compromised due to pain and neurological deficits. The course of the disease is very unpredictable. The majority of the patients have a stable neurological disability that does not progress over time.
Diagnosis
Diagnostic Study of Choice
There is no single best test for the definitive diagnosis of arachnoiditis. Diagnosis is based on clinical presentation, signs, and the supporting MRI or CT or myelography.
History and Symptoms
Patients suggestive of arachnoiditis should be asked about any history of spinal trauma, spinal cord infections, spinal surgery, or spinal anesthesia. Sometimes an inciting event can not be identified. Arachnoiditis symptoms vary from subclinical to advance and serve. Symptoms of arachnoiditis are challenging to distinguish from other types of compressive neurological diseases because many of the symptoms are similar, and the disease onset can be months to years from the initial injury. Patients will complain about pain, numbness, paraesthesia, and tingling in affected nerve root or roots.
- Chronic and persistent pain in the lower back that may radiate down the legs
- Bowel/bladder, sexual dysfunction
- Muscle cramps, spasms, and uncontrolled twitching
- Burning in the ankles and feet
- Unexplained skin rashes and itching
- Loss of sensation below the area afflicted
- Partial or complete paralysis of the lower extremities
- Neurologic deficits
Physical Examination
The findings of the physical examination depend on which nerves are affected by the disease. A physical examination can reveal changes in reflexes, sensation, proprioception, or weakness.
Abnormal findings on the physical exam may include the following.
- Reduced reflexes in extremities which are often asymmetrical
- Loss of touch or vibration sensation
- Pain on arms extension
- Weakness of the extremities which is often asymmetrical
- Restriction of range of extremities
- Asymmetry of paraspinal muscle groups
- Indentation of lower supine
Laboratory Findings
While the definitive diagnosis of arachnoiditis requires imaging, other tests contribute to understanding the risks of disease and may provide clues to the selection of treatment options. These tests include those that access the underlying inflammation and other hormonal levels that may be altered in chronic pain conditions. Addressing these conditions may improve the quality of life.
- CBC
- VDRL
- Inflammatory makers
- C-Reactive Protein-High Sensitivity (CRP-HS)
- Erythrocyte Sedimentation Rate (ESR)
- Interleukins (IL-6)
- Tumor Necrosis Factor (TNF)
- Hormone Assessments
- Pregnenolone
- DHEA
- Cortisol
- Progesterone
- Estradiol
- Testosterone
Radiography
Routine plain radiographs can not be used to evaluate spinal cord and nerve roots. However, the contents of the thecal sac can be evaluated with myelography with intrathecal administration of iodinated contrast. Conus medullaris usually terminates between T12-L1 and L1-L2 levels in adults. Below the level of conus medullaris termination, nerve roots float freely within the thecal sac. Meningeal inflammation can lead to thickened verve roots, the formation of CSF loculations, and blockage of CSF flow. Radiographic findings can aid in the diagnosis.
Computed Tomography
MRI is superior to CT scanning for the diagnosis of arachnoiditis because of poor contrast resolution in CT scans. However, CT myelography is useful in demonstrating the classic imaging findings of arachnoiditis. The classic image findings include narrowing or blockage of the subarachnoid space, thickened or matted nerve roots, soft tissue mass within the arachnoid space, as well as intrathecal calcification, irregular collections of contrast material, and absent filling of nerve root sleeves. The degree of confidence is high with myelography as compared to conventional CT. [12]
MRI
Imaging Findings
Other Diagnostic Studies
Treatment
Arachnoiditis is a difficult condition to treat. Treatment is limited to alleviation of pain and other symptoms. Surgical intervention generally has a poor outcome and only provides temporary relief. Steroid injection is generally discouraged and may worsen the condition.
Medical Therapy
Treatment of arachnoiditis is palliative, and mostly medications are used for this purpose. Antidepressant and anticonvulsant analgesics are the mainstays of treatment. However, other classes of medications can also be beneficial. The U.S. Food and Drug Administration has approved several medications for neuropathic pain syndromes: pregabalin and duloxetine for diabetic neuropathy and gabapentin and pregabalin for postherpetic neuralgia. These medications are often used for the treatment of arachnoiditis with variable efficacy. These medications are often started at a low dosage and titrated upward as tolerated. Most of these medications take a few weeks to take analgesic effects to be reached. Some examples of these medications dosage are given in the table.
| Medication | Starting dose | Dose increase and interval | Maximal dose |
|---|---|---|---|
| Tricyclic anti depressant | 10-25mg at night | 10-25 mg per week | 150 mg /day |
| Duloxetine | 20-30mg per day | 20-30 mg per week | 60mg /day |
| Pregabalin | 50-75mg BID | 50-75 mg per week | 600mg /day |
| Gabapentine | 100-300mg BID | 100-300 mg per week | 1800-3600mg /day |
Surgery
Prevention
Future or Investigational Therapies
Recent research has indicated that a group of chemicals called cytokines that are produced by various cells in the body may be responsible for generating the pain response. Medications that affect the release of cytokines or block the action of cytokines may reduce the pain response. Various anti-cytokine medications are now being used to treat painful disease states such as Rheumatoid Arthritis and Crohn's Disease. In a recent study the anti-cytokine medication, Thalidomide, is being evaluated for its effect in treating pain associated with Arachnoiditis.
External links
- Circle Of Friends With Arachnoiditis (COFWA)
- American Chronic Pain Association (ACPA)
- National Chronic Pain Outreach Association (NCPOA)
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
- National Institute of Dental and Craniofacial Research (NIDCR)
- Arachnoiditis
- Arachnoiditis, if you have ever suffered from back pain or know anyone who has then this is where to find help and information.
- Support for those with disorders of the Arachnoid Membrane
- http://www.burtonreport.com/InfSpine/AdhesArachAnatomy.htm
References
- ↑ Elkington, J. St. C. (1951). Arachnoiditis. In Modern Trends in Neurology, ed. Anthony Feiling, ch. 5, pp. 149-161. Butterworths, London.
- ↑ ELKINGTON, J. St. C. (1936). Meningitis serosa circumscripta spinalis (spinal arachnoiditis). Brain, 59, 181-203
- ↑ Foix C, Alajouanine T . La myélite nécrotique subaigue. Rev Neurol (Paris) 1926; 2: 1–42.
- ↑ "Antonio Aldrete. Arachnoiditis. Orphanet. March, 2010".
- ↑ Vloeberghs M, Herregodts P, Stadnik T, Goossens A, D'Haens J. Spinal arachnoiditis mimicking a spinal cord tumor: a case report and review of the literature. Surg Neurol. 1992;37(3):211-215. doi:10.1016/0090-3019(92)90233-d
- ↑ Wright MH, Denney LC. A comprehensive review of spinal arachnoiditis. Orthop Nurs. 2003;22(3):215-221. doi:10.1097/00006416-200305000-00010
- ↑ Martin RJ, Yuan HA. Neurosurgical care of spinal epidural, subdural, and intramedullary abscesses and arachnoiditis. Orthop Clin North Am. 1996;27(1):125-136.
- ↑ Anderson TL, Morris JM, Wald JT, Kotsenas AL. Imaging Appearance of Advanced Chronic Adhesive Arachnoiditis: A Retrospective Review. AJR Am J Roentgenol. 2017;209(3):648-655. doi:10.2214/AJR.16.16704
- ↑ Todeschi J, Chibbaro S, Gubian A, Pop R, Proust F, Cebula H. Spinal adhesive arachnoiditis following the rupture of an Adamkiewicz aneurysm: Literature review and a case illustration. Neurochirurgie. 2018;64(3):177-182. doi:10.1016/j.neuchi.2017.11.003
- ↑ Di Ieva A, Barolat G, Tschabitscher M, et al. Lumbar arachnoiditis and thecaloscopy: brief review and proposed treatment algorithm. Cent Eur Neurosurg. 2010;71(4):207-212. doi:10.1055/s-0029-1243201
- ↑ Anderson TL, Morris JM, Wald JT, Kotsenas AL. Imaging Appearance of Advanced Chronic Adhesive Arachnoiditis: A Retrospective Review. AJR Am J Roentgenol. 2017;209(3):648-655. doi:10.2214/AJR.16.16704
- ↑ APA Dong, Aisheng, MD*; Zuo, Changjing, MD*; Zhang, Ping, MSc†; Lu, Jianping, MD‡; Bai, Yushu, MD§ MRI and FDG PET/CT Findings in 3 Cases of Spinal Infectious Arachnoiditis, Clinical Nuclear Medicine: October 2014 - Volume 39 - Issue 10 - p 900-903