The subject of adhesive arachnoiditis as a disease entity has been, and continues to be a most serious global health care problem. It is evident to me, as a physician and surgeon who has been intimately involved in studying, publishing, lecturing and treating patients with this disease for over 25 years that there has been a serious failure, in the past, by the medical, scientific and governmental professions to focus appropriate attention on this important entity.
The subarachnoid space represents the most fragile, pristine, and sensitive structure in the human body. The introduction of foreign body substances, for any purpose, is not without patient risk.
All foreign bodies are irritating to the arachnoid membranes. Some substances such as oil-based myelographic media and steroid preparations containing ethylene glycols are known to be particularly irritating and toxic and capable of producing disability and incapacitation.Adhesive arachnoiditis is the most severe form of arachnoiditis, an inflammatory condition which can be due to many causes including infection. The degree of arachnoiditis in any given individual depends on a number of factors including the nature of the toxic or infectious agent as well as the individual’s auto-immune response as well as other factors. The arachnoiditis process is potentiated by the presence of blood, and its break-down products in the subarachnoid space.
From my personal observations, over the past 25 years, it is evident that many patients with adhesive arachnoiditis have severe scarring of their nerves without associated clinical signs or symptoms. In fact the great majority of patients with adhesive arachnoiditis due to oil myelography are asymptomatic because of the slow progression of the inflammatory process. The opposite is typically true for those who have adhesive arachnoiditis due to the ill-advised deposition of ethylene glycol steroids into the subarachnoid space typically for the purpose of “epidural” steroid administration. My calculations suggest that although 95% of individuals who have adhesive arachnoiditis causually related to oil myelography are without symptoms, the other 5% (representing about 1 million individuals) are seriously disabled because of this pathologic process.The reason for this discrepancy appears to be directly related to the degree of initial inflammation and whether the nervous system is given adequate time to acclimate to the progressive insult. The human nervous system (as is the human body) legend in its ability to adjust, and maintain function, despite the most amazing gradually applied insults. The opposite is true for sudden or rapidly progressing insults. It is important to also point out that those patients with adhesive arachnoiditis who are without symptoms live with “a sword over their heads” as apparently minor additional insults (i.e. Myelography, injury, surgery, etc.) can tip the clinical balance.For many decades clinicians have argued regarding the role of the technique of administering oil substances in regard to risk of adhesive arachnoiditis. Assuming the supposition that the benefit was higher than the risk and informed consent was obtained prior to oil myelography my observations are as follows:
- The least patient risk was to perform atraumatic entry and subsequent aspiration of the oil media.
- Next best was atraumatic entry and using the least amount of oil
media as possible for the study.
- To avoid multiple taps on entry or aspiration as this adds free
blood to the oil media, thus markedly increasing toxicity.
The failure to appreciate adhesive arachnoiditis as a disease entity has come back to haunt the public through the inordinately common use of ill-advised “epidural” steroid injections with suspensions containing ethylene glycol. Epidural steroid injection is an overused therapy. When performed in the absence of fluoroscopic monitoring with epidurography this procedure the procedure is dangerous. When performed by well-trained procedurist, associated with informed consent, good technique and basically non-toxic steroids it is a reasonable invasive therapy; after quality non-invasive therapy has failed.
Charles V. Burton,
November 29, 2003
M.K., shown above in 2003, has been disabled since she had a pantopaque myelogram in 1977. Following the introduction of the oil media multiple dural punctures were made in an attempt to remove all of the pantopaque. In this process M.S. was tipped head down and oil entered the subarachnoid space at the base of the brain. M.S. developed adhesive arachnoiditis producing back and leg pain as well as headache. The disability experienced was of such a degree that a depth brain neurostimulating system was implanted in 1978 for pain control.
The case presented above is typical of situations where multiple dural punctures added free blood to the oil dye increasing the toxic inflammatory response. The understanding of this is important in the continuing need to prevent clinically significant adhesive arachnoiditis in patients who have placed their trust in their physicians.