Illustration of Arachnoiditis

Arachnoiditis is an inflammatory condition of the arachnoid mater or 'arachnoid', one of the membranes known as meninges that surround and protect the central nervous system. The outermost layer of the meninges is the dura mater (Latin for hard) and adheres to inner surface of the skull and vertebrae.[1] The arachnoid is under or "deep" to the dura and is a thin membrane that adheres directly to the surface of the brain and spinal cord.[1]

Etiology

Arachnoiditis has been described as having many different etiologies. As an infectious source, tuberculosis,[2][3] syphilis,[2][3] candida,[3] mycosis,[3] and HIV.[4] As a mechanical source, spinal and cranial surgery,[5] trauma,[6] and disc herniation.[6] Prior disease including ankylosing spondylitis,[2][7] autoimmune vasculitis,[4] and Guillain-Barré syndrome[4] have been known to cause arachnoiditis. Chemical causes include morphine,[8] myelograms with oil-based radiographic contrast agents,[8] phenolic solutions,[9] chlorhexidine,[10] epidural injection of steroids and antibiotics,[2] blood in subarachnoid hemorrhage,[11] epidural blood patches and anesthetics.[12][13]

Oftentimes, the precise cause of arachnoiditis is not known due to the variable latency from cause to symptom onset. With growing incidence of spine surgery, a common cause of arachnoiditis is lumbar spine procedures.[14]

Pathogenesis

The above etiologies can cause inflammation of the arachnoid, leading to arachnoiditis. This inflammation is enough to cause pain and even potentially neurological deficits - symptoms caused by nerves not communicating properly with the body's mechanisms for sensation and movement.[15][16] The inflammation can lead to the formation of scar tissue and adhesion that can make the spinal nerves "stick" together, a condition where such tissue develops in and between the leptomeninges - between dura and arachnoid or pia and arachnoid.[16] This condition can be very painful, especially when progressing to adhesive arachnoiditis. Adhesive arachnoiditis occurs when inflammation leads to recruitment of cells to the area and fibrous exudate, and ensuing deposition of collagen forms bands that could cause ischemia or even atrophy of the spinal cord or nerve roots.[16][17] Chronic inflammation could lead to arachnoiditis ossificans, in which the inflammed arachnoid becomes ossified, or turns to bone, and is thought to be a late-stage complication of the adhesive form of arachnoiditis.[18] More serious complications can occur, including spinal cord swelling, myelomalacia, cauda equina syndrome, and hydrocephalus.[17][19]

Signs and symptoms

Arachnoid inflammation can lead to many painful and debilitating symptoms which can vary greatly in each case, and not all people experience all symptoms.[4][15][20] Chronic pain is common, including neuralgia, while numbness and tingling of the extremities can occur with spinal cord involvement, and bowel, bladder, and sexual functioning can be affected if the lower part of the spinal cord is involved.[4][15][20] While arachnoiditis has no consistent pattern of symptoms, it frequently affects the nerves that supply the legs and lower back.[4][15][20] Many patients experience difficulty sitting for long (or even short) periods of time due to discomfort or pain.[20][4]

Diagnosis

Arachnoiditis
Myelogram showing arachnoiditis in the lumbar spine
SpecialtyNeurosurgery

Diagnosis is based on a combination of clinical findings, patient examination, and imaging evaluation.[21] The most common affected area is the lumbar region of the back, and includes the classic symptomatic triad of back pain, neurological deficits, and MRI with notable adhesions.[22] For the ossificans form of the condition, unenhanced CT may better show the presence and extent of arachnoid ossifications, and is complementary to MRI, as MRI can be less specific and findings can be confused with regions of calcification or hemosiderin.[23][24]

Treatment

Arachnoiditis can be difficult to treat and treatment is generally limited to alleviation of pain and other symptoms.[25] While arachnoiditis may not yet be curable with the potential to be life-altering, management including medication, physical therapy, and if appropriate, psychotherapy, can help patients cope with the difficulties it presents.[25]

Medications that have been used to treat arachnoiditis include nonsteroidal anti-inflammatory drugs,[26] and pulse steroid therapy with methylprednisolone,[26][4][27] and multi-modal pain regimens.[4] Surgical intervention generally has a poor outcome and may only provide temporary relief,[25] but some cases of surgical success have been reported.[28] Epidural steroid injections to treat sciatic pain have been linked as a cause of the disease by the U.S. Food and Drug Administration as well as in other research, and are therefore discouraged as a treatment for arachnoiditis as they will most likely worsen the condition.[29][30][31] Some patients benefit from motorized assistance devices, although these types of devices may be beyond the reach of those with limited means.

Prognosis

Arachnoiditis is a chronic disorder with no known cure,[25] and prognosis may be difficult to determine because of an unclear correlation between the beginning of the disease or source and the appearance of symptoms. For many, arachnoiditis is a disabling disease that causes chronic pain and neurological deficits,[23] and may also lead to other spinal cord conditions, such as syringomyelia.[32][33]

References

  1. 1 2 Ghannam, Jack Y.; Al Kharazi, Khalid A. (2023), "Neuroanatomy, Cranial Meninges", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 30969704, retrieved 2023-11-04
  2. 1 2 3 4 Shah, Jeshil; Patkar, Deepak; Parmar, Hemant; Prasad, Srinivasa; Varma, Ravi (2001-05-17). "Arachnoiditis associated with arachnoid cyst formation and cord tethering following myelography: Magnetic resonance features". Australasian Radiology. 45 (2): 236–239. doi:10.1046/j.1440-1673.2001.00911.x. ISSN 0004-8461. PMID 11380373.
  3. 1 2 3 4 Safi, Saleh; Thabat, Abdelnaser; Arshad, Mohamed; Hanoun, Mohamed (2021-09-01). "Arachnoiditis – A challenge in diagnosis and success in outcome – Case report". Interdisciplinary Neurosurgery. 25: 101219. doi:10.1016/j.inat.2021.101219. ISSN 2214-7519.
  4. 1 2 3 4 5 6 7 8 9 Peng, Huanhuan; Conermann, Till (2023), "Arachnoiditis", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 32310433, retrieved 2023-11-08
  5. ↑ Werner, Cassidy; Mathkour, Mansour; Scullen, Tyler; Dallapiazza, Robert F.; Dumont, Aaron S.; Maulucci, Christopher M. (July 2020). "Recurrent arachnoid cysts secondary to spinal adhesive arachnoiditis successfully treated with a ventriculoperitoneal shunt". Clinical Neurology and Neurosurgery. 194: 105835. doi:10.1016/j.clineuro.2020.105835. PMID 32305826. S2CID 215730361.
  6. 1 2 Wright, Michael H.; Denney, Leann C. (May 2003). "A Comprehensive Review of Spinal Arachnoiditis". Orthopaedic Nursing. 22 (3): 215–219. doi:10.1097/00006416-200305000-00010. ISSN 0744-6020. PMID 12803151.
  7. ↑ Bilgen, I. G.; Yunten, N.; Ustun, E. E.; Oksel, F.; Gumusdis, G. (1999-07-01). "Adhesive arachnoiditis causing cauda equina syndrome in ankylosing spondylitis: CT and MRI demonstration of dural calcification and a dorsal dural diverticulum". Neuroradiology. 41 (7): 508–511. doi:10.1007/s002340050793. ISSN 1432-1920. PMID 10450845. S2CID 44009176.
  8. 1 2 Davies, D. G. (January 1976). "Cerebrospinal fluid sampling technique and Astrup pH and PCO2 values". Journal of Applied Physiology. 40 (1): 123–125. doi:10.1152/jappl.1976.40.1.123. ISSN 0021-8987. PMID 2575.
  9. ↑ Jurga, Szymon; Szymańska-Adamcewicz, Olga; Wierzchołowski, Wojciech; Pilchowska-Ujma, Emilia; Urbaniak, Łukasz (2021-02-01). "Spinal adhesive arachnoiditis: three case reports and review of literature". Acta Neurologica Belgica. 121 (1): 47–53. doi:10.1007/s13760-020-01431-1. ISSN 2240-2993. PMC 7937595. PMID 32833147.
  10. ↑ Iqbal, I. Mohamed; Morris, R.; Hersch, M. (November 2018). "Adhesive Arachnoiditis following Inadvertent Epidural Injection of 2% Chlorhexidine in 70% Alcohol—Partial Recovery over the Ensuing Eight Years". Anaesthesia and Intensive Care. 46 (6): 572–574. doi:10.1177/0310057X1804600606. ISSN 0310-057X. PMID 30447665.
  11. ↑ Tachibana, Toshiya; Moriyama, Tokuhide; Maruo, Keishi; Inoue, Shinichi; Arizumi, Fumihiro; Yoshiya, Shinichi (2014-11-01). "Subarachnoid-subarachnoid bypass for spinal adhesive arachnoiditis: Case report". Journal of Neurosurgery: Spine. 21 (5): 817–820. doi:10.3171/2014.7.SPINE131082. PMID 25170651.
  12. ↑ Tseng, Sheng-Hong; Lin, Swei-Ming (1997-12-01). "Surgical treatment of thoracic arachnoiditis with multiple subarachnoid cysts caused by epidural anesthesia". Clinical Neurology and Neurosurgery. 99 (4): 256–258. doi:10.1016/S0303-8467(97)00086-3. ISSN 0303-8467. PMID 9491300. S2CID 45501339.
  13. ↑ Carlswärd, C.; Darvish, B.; Tunelli, J.; Irestedt, L. (August 2015). "Chronic adhesive arachnoiditis after repeat epidural blood patch". International Journal of Obstetric Anesthesia. 24 (3): 280–283. doi:10.1016/j.ijoa.2015.04.005. ISSN 0959-289X. PMID 26119259.
  14. ↑ Gonzalez M., Claudia E.; Enriquez, Luis E.; Cruz A., Camilo (2012-05-01). "Arachnoiditis Following Spinal Anesthesia for Cesarean Section". Colombian Journal of Anesthesiology. 40 (2): 150–152. doi:10.1016/S2256-2087(12)70031-7. ISSN 2256-2087.
  15. 1 2 3 4 Rice, I; Wee, M.Y.K.; Thomson, K (January 2004). "Obstetric epidurals and chronic adhesive arachnoiditis". British Journal of Anaesthesia. 92 (1): 109–120. doi:10.1093/bja/aeh009. ISSN 0007-0912. PMID 14665562.
  16. 1 2 3 Killeen, T.; Kamat, A.; Walsh, D.; Parker, A.; Aliashkevich, A. (December 2012). "Severe adhesive arachnoiditis resulting in progressive paraplegia following obstetric spinal anaesthesia: a case report and review". Anaesthesia. 67 (12): 1386–1394. doi:10.1111/anae.12017. ISSN 0003-2409. PMID 23061983.
  17. 1 2 Cornelson, Stacey M.; Johnnie, Edward D.; Kettner, Norman W. (2018-12-01). "Neural Mobilization in a 54-Year-Old Woman With Postoperative Spinal Adhesive Arachnoiditis". Journal of Chiropractic Medicine. 17 (4): 283–288. doi:10.1016/j.jcm.2018.07.004. ISSN 1556-3707. PMC 6391232. PMID 30846922.
  18. ↑ Krätzig, Theresa; Dreimann, Marc; Mende, Klaus Christian; Königs, Ingo; Westphal, Manfred; Eicker, Sven Oliver (2018-08-01). "Extensive Spinal Adhesive Arachnoiditis After Extradural Spinal Infection–Spinal Dura Mater Is No Barrier to Inflammation". World Neurosurgery. 116: e1194–e1203. doi:10.1016/j.wneu.2018.05.219. ISSN 1878-8750. PMID 29883820. S2CID 47002240.
  19. ↑ Morisako, Hiroki; Takami, Toshihiro; Yamagata, Toru; Chokyu, Isao; Tsuyuguchi, Naohiro; Ohata, Kenji (2010). "Focal adhesive arachnoiditis of the spinal cord: Imaging diagnosis and surgical resolution". Journal of Craniovertebral Junction and Spine. 1 (2): 100–106. doi:10.4103/0974-8237.77673. ISSN 0974-8237. PMC 3075825. PMID 21572630.
  20. 1 2 3 4 Rice, I; Wee, M.Y.K.; Thomson, K (January 2004). "Obstetric epidurals and chronic adhesive arachnoiditis". British Journal of Anaesthesia. 92 (1): 109–120. doi:10.1093/bja/aeh009. PMID 14665562.
  21. ↑ Kara T, Davulcu Ö, Ateş F, Arslan FZ, Sara HI, Akin A (2020-10-06). "What happened to cauda equina fibers? Adhesive arachnoiditis". Anaesthesia, Pain & Intensive Care. 24 (5). doi:10.35975/apic.v24i5.1364. ISSN 2220-5799. S2CID 226319113.
  22. ↑ Parenti V, Huda F, Richardson PK, Brown D, Aulakh M, Taheri MR (May 2020). "Lumbar arachnoiditis: Does imaging associate with clinical features?". Clinical Neurology and Neurosurgery. 192: 105717. doi:10.1016/j.clineuro.2020.105717. PMID 32062307. S2CID 211019420.
  23. 1 2 Steel CJ, Abrames EL, O'Brien WT (2015). "Arachnoiditis Ossificans - A Rare Cause of Progressive Myelopathy". The Open Neuroimaging Journal. 9 (1): 13–20. doi:10.2174/1874440001509010013. PMC 4578143. PMID 26401174.
  24. ↑ Maulucci CM, Ghobrial GM, Oppenlander ME, Flanders AE, Vaccaro AR, Harrop JS (September 2014). "Arachnoiditis ossificans: clinical series and review of the literature". Clinical Neurology and Neurosurgery. 124: 16–20. doi:10.1016/j.clineuro.2014.06.024. PMID 24999276. S2CID 12593117.
  25. 1 2 3 4 "Arachnoiditis Information Page". National Institute of Neurological Disorders and Stroke, National Institutes of Health. Archived from the original on 2016-12-09. Retrieved 2015-10-23.
  26. 1 2 Gonzalez CE, Enriquez LE, Cruz CA (May 2012). "Arachnoiditis Following Spinal Anesthesia for Cesarean Section". Colombian Journal of Anesthesiology. 40 (2): 150–152. doi:10.1016/S2256-2087(12)70031-7.
  27. ↑ Jurga S, Szymańska-Adamcewicz O, Wierzchołowski W, Pilchowska-Ujma E, Urbaniak Ł (February 2021). "Spinal adhesive arachnoiditis: three case reports and review of literature". Acta Neurologica Belgica. 121 (1): 47–53. doi:10.1007/s13760-020-01431-1. PMC 7937595. PMID 32833147.
  28. ↑ Tachibana T, Moriyama T, Maruo K, Inoue S, Arizumi F, Yoshiya S (November 2014). "Subarachnoid-subarachnoid bypass for spinal adhesive arachnoiditis". Journal of Neurosurgery. Spine. 21 (5): 817–820. doi:10.3171/2014.7.SPINE131082. PMID 25170651.
  29. ↑ Nelson DA, Landau WM (April 2001). "Intraspinal steroids: history, efficacy, accidentality, and controversy with review of United States Food and Drug Administration reports". Journal of Neurology, Neurosurgery, and Psychiatry. 70 (4): 433–443. doi:10.1136/jnnp.70.4.433. PMC 1737322. PMID 11254764.
  30. ↑ Shaw MD, Russell JA, Grossart KW (February 1978). "The changing pattern of spinal arachnoiditis". Journal of Neurology, Neurosurgery, and Psychiatry. 41 (2): 97–107. doi:10.1136/jnnp.41.2.97. PMC 492975. PMID 632824.
  31. ↑ Neal JM, Kopp SL, Pasternak JJ, Lanier WL, Rathmell JP (2015). "Anatomy and Pathophysiology of Spinal Cord Injury Associated With Regional Anesthesia and Pain Medicine: 2015 Update". Regional Anesthesia and Pain Medicine. 40 (5): 506–525. doi:10.1097/AAP.0000000000000297. PMID 26263076. S2CID 10759432.
  32. ↑ Brammah TB, Jayson MI (November 1994). "Syringomyelia as a complication of spinal arachnoiditis". Spine. 19 (22): 2603–2605. doi:10.1097/00007632-199411001-00019. PMID 7855688. S2CID 34679325.
  33. ↑ Ibrahim GM, Kamali-Nejad T, Fehlings MG (August 2010). "Arachnoiditis ossificans associated with syringomyelia: An unusual cause of myelopathy". Evidence-Based Spine-Care Journal. 1 (2): 46–51. doi:10.1055/s-0028-1100914. PMC 3623106. PMID 23637667.

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