Arachnoiditis
Arachnoiditis
Definition
Arachnoiditis literally means "inflammation of the arachnoid," which is the middle of the three membranes (meninges ) surrounding the brain and spinal cord. The term more generally refers to several rare neurologic disorders caused by inflammation of a portion of the arachnoid and subarachnoid space, affecting the neural tissue that lies beneath. Symptoms of arachnoiditis are quite variable, and may include anything from a skin rash to moderate or severe pain , to paralysis. The condition is often progressive, can only rarely be cured, and existing treatments vary in their effectiveness.
Description
Three membranes, including the dura mater, arachnoid, and pia mater, and a layer of cerebrospinal fluid (CSF) surround, protect, and cushion the brain and spinal cord. The pia mater adheres to the brain and spinal cord, and is separated from the arachnoid membrane by the subarachnoid space, which contains the circulating CSF. Arachnoiditis always involves inflammation in one or several restricted areas, but the entire membrane is never affected. Fibrous (scar) tissue growth along the affected section of the membrane usually occurs, projecting down through the subarachnoid space and encompassing neural tissue of the brain (cerebral arachnoiditis) and/or nerve roots of the spinal cord (spinal arachnoiditis). Nerve damage occurs through restricted blood flow (ischemia), compression from accumulated fluids (edema), and secondary effects of the inflammatory process itself.
Other terms used less frequently for arachnoiditis include arachnitis, chronic adhesive arachnoiditis (CAA), and spinal fibrosis. Other conditions that may be associated with or mimic arachnoiditis include syringomyelia (cyst near the spinal cord), cauda equina (lower spinal cord) syndrome, and spinal tumor. Several different types of arachnoiditis have been described, including adhesive (fibrous attachments), ossifying (bony tissue growth), neo-plastic (tumor growth), optochiasmatic (optic nerve and chiasm), and rhinosinusogenic (olfactory nerve and area above the sinuses).
Demographics
The true incidence of arachnoiditis is not known, but it is rare. It affects males and females equally, and seems to be less frequent in children than in adults. Rare cases of familial arachnoiditis have been documented, but no particular ethnic groups seem to be at higher risk.
Causes and symptoms
The causes of arachnoiditis are varied, but fall into the following four categories:
- trauma to the membrane due to spinal surgery (often multiple procedures), cranial or spinal injury, or needle insertion to remove CSF for testing
- external agents such as anesthesia, corticosteroids, medications, or medical dyes/chemicals injected near the spinal cord (epidural) or directly into the CSF
- infection of the arachnoid/CSF (meningitis)
- blood in the CSF caused by trauma, spontaneous bleeding, or infection
For reasons that are not entirely clear, different areas of the arachnoid have differing sensitivities to the causative agents. Spinal arachnoiditis due to infection most often occurs in the cervicothoracic (neck and upper back) region, while cases due to external agents most often occur in the lumbosacral (lower back) area. Likewise, spinal arachnoiditis of any type is more common than the cerebral/cranial variety.
Symptoms of cerebral arachnoiditis may include severe headaches, vision disturbances, dizziness , and nausea/vomiting. Vision disturbances are especially pronounced in optochiasmatic arachnoiditis. If inflammation and tissue growth in specific areas of the cranial arachnoid membrane divert or obstruct normal flow of the CSF, the result is hydrocephalus (increased fluid pressure within the brain).
Typical symptoms of spinal arachnoiditis include back pain that increases with activity, pain in one or both legs or feet, and sensory abnormalities of some type, usually involving decreased reflexes. Patients may also exhibit decreased range of motion of the trunk or legs, and urinary sphincter dysfunction (urgency, frequency, or incontinence). In more severe cases, partial or complete paralysis of the lower extremities may occur.
Diagnosis
The most reliable method of establishing the diagnosis of arachnoiditis is a positive computed tomography (CT) or magnetic resonance imaging (MRI) scan, combined with one or more of the symptoms. Testing for certain cell types and proteins in the CSF may prove helpful only in the early stages of the inflammation. On the other hand, imaging studies may be negative or equivocal early on, and only later be more definitive as inflammation and tissue growth becomes more pronounced. In some cases, a definitive diagnosis may not be possible.
Treatment team
A neurologist is the primary specialist involved in monitoring and treating arachnoiditis. Occupational/physical therapy (OT/PT) might also be suggested to assist with treatment for pain and adaptation to sensory deficits and/or muscular weakness in the back and lower limbs. A neurosurgeon performs any elected surgeries to address the various effects of the inflammation. Many individuals with chronic pain attend pain clinics staffed by physicians (usually anesthesiologists) and nurses who specialize in pain management. Neuropsychiatrists and neuropsychologists specialize in treating the psychological problems specific to individuals who have an underlying neurologic condition.
Treatment
Treatment for arachnoiditis is mostly done with medications, and is geared toward reducing the inflammation and alleviating pain. Medications may include both nonsteroidal and steroidal anti-inflammatory drugs, along with non-narcotic and narcotic pain medications. Other possible treatments include epidural steroid injections, transcutaneous electrical nerve stimulation (TENS), topical analgesics, and alternative medical therapies.
Direct spinal cord stimulation is a newer pain management method that involves placement of tiny electrodes under the skin, directly on the affected nerve roots near the spine. Mild current application inhibits pain signals, and is provided by a small, battery-powered unit that is placed under the skin by a surgeon.
Surgery to remove fibrous or ossified tissue at the site of the inflammation is used only if more conservative methods do not provide sufficient relief. Surgical removal of a small portion of one or more vertebrae at the area of the nerve root is called a laminectomy . A neurosurgeon treats hydrocephalus by placing a shunt (plastic tube) from the brain to the abdominal cavity to relieve increased pressure. Microsurgical techniques to remove scar tissue from around the nerve roots themselves are a more recent development.
Prognosis
Given the lack of effective treatments for arachnoiditis, the prognosis in most instances is poor, with the neurologic symptoms remaining static or worsening over time. It is not uncommon for people who undergo surgery for the condition to improve at first, but eventually regress within several years.
Resources
BOOKS
Bradley, Walter G., et al., eds. Neurology in Clinical Practice, 3rd ed. Boston: Butterworth-Heinemann, 2000.
Victor, Maurice, and Allan H. Ropper. Adam's and Victor's Principles of Neurology, 7th ed. New York: The McGraw-Hill Companies, Inc., 2001.
Wiederholt, Wigbert C. Neurology for Non-Neurologists, 4th ed. Philadelphia: W.B. Saunders Company, 2000.
PERIODICALS
Chin, Cynthia T. "Spine Imaging." Seminars in Neurology 22 (June 2002): 205–220.
Faure, Alexis, et al. "Arachnoiditis Ossificans of the Cauda Equina: Case Report and Review of the Literature." Journal of Neurosurgey/Spine 97 (September 2002): 239–243.
Rice, M. Y. K., et al. "Obstetric Epidurals and Chronic Adhesive Arachnoiditis." British Journal of Anaesthesia 92 (2004): 109–120.
Wright, Michael H., and Leann C. Denney "A Comprehensive Review of Spinal Arachnoiditis." Orthopaedic Nursing 22 (May/June 2003): 215–219.
ORGANIZATIONS
American Paraplegia Society. 75-20 Astoria Boulevard, Jackson Heights, NY 11370-1177. (718) 803-3782. <http://www.apssci.org>.
American Syringomyelia Alliance Project, Inc. P.O. Box 1586, Longview, TX 75606-1586. 800-272-7282. <http://www.asap.org>.
NIH/NINDS Brain Resources and Information Network. PO Box 5801, Bethesda, MD 20824. (800) 352-9424. <http://www.ninds.nih.gov/>.
National Organization for Rare Disorders (NORD). 55 Kenosia Ave, PO Box 1968, Danbury, CT 06813-1968. (800) 999-6673; Fax: (203) 798-2291. <http://www.rarediseases.org>.
National Spinal Cord Injury Association. 6701 Democracy, Bethesda, MD 20817. (800) 962-9629. <http://www.spinalcord.org>.
Spinal Cord Society. 19051 County Hwy 1, Fergus Falls, MN 56537. (218) 739-5252.
Scott J. Polzin, MS, CGC