October 2017 Edition. Volume XVII

Is Anatomic Arachnoiditis Common? Yes, anatomic arachnoiditis (also termed “arachnoid adhesions or fibrosis”) is something found, in some degree, in almost all adults but typically has no clinical significance.  “Anatomic” arachnoiditis (also termed “arachnoid adhesions”) is simply reflective of  some degree of arachnoid  inflammation having been present.  This may result from minor infections involving the subarachnoid space or result from insult or injury (i.e. trauma, spinal surgery, etc.).


How does Arachnoiditis differ from Adhesive Arachnoiditis?

Candle200GIFFireBoatConf200GIFThe difference between arachnoiditis and adhesive arachnoiditis is the same as that between a candle and a conflagration.

They are both fire but other  similes exist.  They differ in degree and intensity and the difference is quite substantial.   A candlelit dinner represents fire as a friend.  A conflagration represents fire as a foe.

Adhesive arachnoiditis is the end of the arachnoiditis spectrum.  Adhesive arachnoiditis can carry the possibility of a lifetime of agony while arachnoiditis typically does not.

ForestFire200GIFConflagrations are usually disasters in real life.  When the natural accommodative processes of the human nervous system fail and adhesive arachnoiditis becomes symptomatic it can then be a true disaster for the individual.  The reason for this is that the agony (worse than pain) produced is constant and unrelenting.  Sufferers are not even given the blessing of relief  by a shortened life expectancy.  

Today there are many thousands such sufferers who are old and frail.  They need support and care and have only received disrespect from medical and governmental authorities who have implied that there is no such disease and that their problem is really “in their heads.”

Why is it that the great majority of patients with Adhesive Arachnoiditis have no associated pain? It is because of the remarkable ability of the human nervous system to acclimate to insult and injury of all types.  Even though spinal nerves become enmeshed in scar tissue and deprived of vascular blood supply  and cerebrospinal fluid nutrition they appear, in the majority of cases, after an initial period to be often able to reach a delicate equilibrium.  For this to occur the inflammatory process has to be slow enough to allow the nervous system to acclimate.  In LSAA the impaired nerves always have the potential for destabilization if additional insult occurs.  This is a situation similar to the “post-polio syndrome.”


How Fast Does Adhesive Arachnoiditis Develop?

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Shown above are two sets of axial MRI images from the same patient taken over a period of seven months (comparable levels) during which he had a series of epidural steroid injections.  In the first set there is evidence of some arachnoid adhesions.  In the second set the arachnoiditis has progressed to Class III Adhesive Arachnoiditis.


If Patients with Adhesive Arachnoiditis Do Not Experience Associated Pain or Neurologic Deficit Has Harm Been Done?
The best way to answer this question is to provide a case in point: It is horrendous, but true, that because of the dramatic world-wide increase in usage, and in value, human organs have become a commodity.  Their harvesting is sometimes perpetrated on the unsuspecting.  Many examples exist, typically in underdeveloped nations, where a “John” is lured into a House of Ill repute and awakens the next day somewhere else, in a tub of ice water, minus a kidney.  If the individual is able to recover from this experience their kidney function should be normal because most humans can live normal lives with only one kidney.  In the example provided has harm been done?  Of course it has.


Under what circumstances does non-painful Adhesive Arachnoiditis become painful?
The nervous system does a remarkable job of using its great reserve to deal with adversity.  It has been estimated that 97% of neurons serve as “reserve” during an individual’s lifetime.  It is because of this fact that recovery following a stroke (particularly in young people) can be so rapid and complete.  Should this reserve be seriously compromised, in advance, the subsequent course is usually most different.  The “punch drunk” prize fighter represents this situation where, over years, neuronal reserve has been lost and now the “bare bones” remainder is being compromised.  In adhesive arachnoiditis the nervous system appears, in the majority of cases, to be able to maintain reasonable function despite the significant neuronal impairment produced.  The delicate balance can be changed by subsequent events adversely influencing the existing delicate balance.  Clinical experience has shown that the most common factor producing decompensation of the “steady state” leading to clinical symptoms is the introduction of blood into the subarachnoid space.  Science has known since 1926 that blood, and its break-down products, can serve as foreign body substances and actually create, as well as potentiate, adhesive arachnoiditis. A common denominator in causing blood to be present is trauma. Clinical experience supports motor vehicle accidents and additional spinal surgery as being the most frequent  circumstances causing this
situation.


Why is the typical pain of Adhesive Arachnoiditis so disabling?
The pain (or agony) associated with adhesive arachnoiditis is particularly cruel and unrelenting.  This adversity is particularly devastating because this disease, unlike others such as cancer, do not basically limit life expectancy.  Nerves being deprived of nutrition become hyperexcitable and emit constant streams of nociceptive impulses to the brain.  This type of abnormal afferent information is interpreted by the brain as being quite disagreeable in nature.  This type of agony has a similarity to causalgia.  Pain specialists (dolorologists) describe this type of condition as being an example of a “Regional Complex Pain Disorder
.”

What Surgical Procedures Have Helped in Treating the Pain of LSAA?
A really good surgical treatment for the pain of LSAA does not yet exist.  Time has shown that when neurostimulators are implanted in carefully selected patients they can be a long-term blessing in allowing  a return to a normal life.  Direct surgical removal of scar tissue and attempting to revascularize the impaired nerves has not turned out to be worth the effort.


Are Implanted Morphine Pumps of Benefit in Treating the Pain of LSAA?

The basic issue of using chronic opioid therapy in pain patients is controversial, the issue of chronic opioid therapy in LSAA patients with pumps delivering morphine into the subarachnoid space is a very controversial issue.  LSAA patients have true organic nociceptive pain (as opposed to neuropathic pain).  Morphine pumps are expensive, require significant maintenance, and the subarachnoid catheters are prone to create arachnoid adhesions, cysts, etc, causing blockage and then requiring surgical revision.  Patients become resistant to opioids (requiring ever-increasing dosages), they affect mental function, they often require additional drugs to control constipation, itching and somnolence.  Opioids can produce significant alternations in respiratory, liver, endocrine, gastrointestinal, immune, nutritional and motor systems (Fox CD: Chronic Opioid Therapy: Another Reappraisal, Amer. Pain Soc. Bull., Jan/ Feb 2002). While implanted morphine pumps may be reasonable (risk versus benefit) for the patient with terminal cancer there is every evidence to suggest that in the LSAA patient the problems are much greater than the benefits.


Has Adhesive Arachnoiditis been the cause of unnecessary surgery?
Indeed it has.  One of the most appalling aspects of the use of neurotoxic materials such as iophendylate for myelography has been the misinterpretation of the scar from resulting adhesive arachnoiditis as being a “recurrent disc herniation” and leading to additional negative surgery.  The histories of multiply operated-upon adhesive arachnoiditis patients is rife with the tales of negative additional explorations.  All of this has served only to “muddy the water” regarding the basic culpability of the myelographic agent as being etiologic in the entire sad process.


Can Patients with Adhesive Arachnoiditis Develop Spontaneous Weakness or Loss of Bowel and Bladder Function?
Although this is uncommon the answer to the question is yes.  Clinical experience has shown that the most advanced cases (Class III Adhesive Arachnoiditis) are prone develop these problems.  This appears to be due to progressive calcification of the scar tissues as illustrated in 
the cases below.

CalcLsaa200GIFCalLSAAStanke200GIFIn both
CT scans the red dots are on areas of calcified adhesive arachnoiditis.  In the example to the left the radiolucencies are actually nerve roots within the calcified mass.  On the right the nerve roots are between the calcified areas.


 

Can adhesive arachnoiditis cause death?

Cases have been reported where active  lumbar adhesive arachnoiditis has progressed up the spine to the brain where the inflammatory process has caused blockage of the ventricular system, leading to hydrocephalus and death.


Can Adhesive Arachnoiditis Cause Constant and Intractable Headache?
When there is entry of neurotoxic agents into the subarachnoid space at the base of the brain the subsequent local adhesive arachnoiditis is capable of producing constant intractable headache.

PantSkull200This image shows the case of a patient who had a cervical Pantopaque® myelogram.  The oil went into the base of the brain as well as the subarachnoid space over the brain hemispheres (as shown).  This unfortunate individual developed a basilar adhesive arachnoiditis and associated intractable pain which wastotally incapacitating.


 

Can Adhesive Arachnoiditis Cause Other Medical Problems?
Pain, spasm and neurologic abnormalities are the most common clinical problems associated with adhesive arachnoiditis.  There are many other medical problems, such as autoimmune disorders, which have been attributed to this disease entity.  Unfortunately this disease entity has been treated like an orphan by the medical, scientific, and governmental disciplines in the past and few studies have been carried out to clarify these serious problems.

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