Spinal arachnoiditis

spinal arachnoiditis condition

1. SPINAL ARACHNOIDITIS

2. ANATOMY Arachnoid mater: the membranous layer between the pia mater and the dura mater that surround the brain and the nerves of the spinal cord. 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.

3. Arachnoiditis of the spinal cord is a non specific inflammatory disease of the arachonoid membrane which is characterized pathologically by thickening of the arachnoid membrane with adhesion or adherence to the dura matter and manifested clinically through roots or radiclar signs and symptoms.  

4. Arachnoiditis is a rare condtion of chronic inflammation of the arachnoid . It can involve the brain and/or the spinal cord . It develops in 3 stages, namely: 1) inflammation of the spinal nerves, distension of the adjacent blood vessels, subarachnoid space disappears and the scare tissue begins 2) the scar 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 scarring tissues prevent the production of spinal fluid in that area. It is terrmed Arachnoiditis Ossificans if the scar tissue calcifies.

5. Etiology The inflammation has 3 main causes: 1) Trauma–surgery: complications after multiple back surgery may result in blood penetration in the subarachnoid space, causing inflammation. 2) Chemical: 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.

6. 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.

7. CLINICAL FEATURES Arachnoiditis is usually seen in 40 to 60 years of age but rarely below 20years. Onset : it can be acute or sometimes it may take months.Pain : pain is usually localized type with a burning character. Later the painstarts radiating down the lower limb due to nerve root irritation. Paresthesia :  this also takes place due to irritation of the sensory nerve  roots. Sensory loss:  this occurs when the sensory nerve roots get completely blocked. Muscle weakness with atrophy:  although the anatomy of the motor nerve roots make them less prone to get compressed, it can happen in the later stage which will then give rise to weakness and wasting of the corresponding muscles. 

8. Diagnostic Procedures Magnetic resonance imaging (MRI) is the study of choice for the diagnostic evaluation of arachnoiditis . For patients in whom MRI is contraindicated, computed tomography (CT) myelography is an acceptable alternative.

9. MANAGEMENT   The medical management  usually consists of corticosteroids in acute stage of inflammation. NSAID for pain relief and inflammation. Surgical management  consists of Rhizotomy in cases of unbearable pain.Surgical decompression for removal of cyst.

10. Oral medication or medication through an intrathecal pump such as: non-steroidal anti-inflammatory drugs (NSAIDs), methadon , morphine, can be used to release neuropathic pain. Antidepressants may reduce burning neuropathic pain, but in much lower doses than for depression. Diazepam is used for muscle relaxation.

11. -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. -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. -Surgery is not recommended because it causes more scar tissue and more trauma to the already irritated spinal cord.

12. PHYSIOTHERAPY MANAGEMENT Moist heat  mainly for reducing the muscle     spasm.  In case of radiating pain due to     involvement of nerve roots the patient may be treated with TENS. Even in     cases of paresthesia TENS is usually used.  Laser  has been found to reduce the     inflammation and also break the adhesion in the deep seated structures     which helps in setting free the irritation on the nerve roots thereby     relieving the discomforts of the patient. 

13. Active exercises  like static exercises for   the abdominus , back extensor, gluteus and quadriceps helps in reducing     pain in the initial stages and also maintains the tone in the muscles.  Dynamic exercises  may be started once the     pain level comes within the patient’s tolerance level. These exercises may   be continued by the patient throughout the life for preventing any chances     of recurrence.  SLR:  Active and passive SLR is given to     lengthen the neural structures and relieve the tension in them. This is a     type of neural mobilization that helps in relieving the signs of   radiculopathy .  Gait  training in cases of     muscular weakness.

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