What Is Arachnoiditis Symptoms, Causes and More

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What is arachnoiditis?

Arachnoiditis is a pain disorder caused by the inflammation of the arachnoid, one of the membranes that surrounds and protects the nerves of the spinal cord. It is characterized by severe stinging, burning pain, and neurological problems.

Arachnoiditis is an inflammatory condition of the arachnoid mater or ‘arachnoid’, one of the membranes known as meninges that surround and protect the nerves of the central nervous system, including the brain and spinal cord.

The arachnoid can become inflamed because of adverse reactions to chemicals, infection from bacteria or viruses, as the result of direct injury to the spine, chronic compression of spinal nerves, complications from spinal surgery or other invasive spinal procedures, or the accidental intrathecal injection of steroids intended for the epidural space.

Inflammation can sometimes 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. The condition is extremely painful, especially when progressing to adhesive arachnoiditis. Another form of the condition is arachnoiditis ossificans, in which the arachnoid becomes ossified, or turns to bone, and is thought to be a late-stage complication of the adhesive form of arachnoiditis.

Arachnoiditis is a debilitating condition characterized by severe stinging and burning pain and neurologic problems. It is caused by an inflammation of the arachnoid lining—one of the 3 linings that surround the brain and spinal cord. This inflammation causes constant irritation, scarring, and binding of nerve roots and blood vessels.

Illustrated below—in the intradural space—are the 3 meninges (protective membranes) that surround the brain and spinal cord.

Arachnoiditis is a progressive neuroinflammatory disease.1-3 Although recognized many years ago, heretofore it has been considered a rare disease and is listed in the “Rare Disease Registry.”2,3 I first introduced readers to the term adhesive arachnoiditis (AA) in the August 2014 issue of Practical Pain Management.3 Today, we expand our coverage of the condition, which is, for many reasons, increasing in incidence and prevalence.

Although the term arachnoiditis simply implies inflammation of the arachnoid lining of the meninges or thecal sac, the major pathologic abnormality in the majority of cases is neuroinflammation of the nerve roots in the cauda equina.4-8 Once glia cells in nerve roots produce neuroinflammation, they may form adhesions and scars that may cause nerve roots to stick together or clump and adhere to the arachnoid lining.9-13

Arachnoiditis occurs when the arachnoid is damaged.

The arachnoid is part of a group of membranes that cushion the brain and spinal cord nerves. When this cushioning is damaged, nerves may not function correctly.

The nerves in the spinal cord are surrounded by several thin tissues, called meninges, which provide cushioning and protection. The arachnoid mater is the middle tissue of the meninges.

Damage to the arachnoid mater can cause swelling and inflammation. This swelling can cause nerves in the spine to stick together, altering nerve function and triggering intense pain. Arachnoiditis is almost always caused by an injury. There are some reports of hereditary arachnoiditis, but most people with arachnoiditis develop the condition because of an injury to the spine.

Arachnoiditis is a progressive disorder, which means that it tends to get worse over time if not treated. In some people, it can be debilitating.

Arachnoiditis is a pain disorder caused by the inflammation of the arachnoid, one of the membranes that surround and protect the nerves of the spinal cord. Severe stinging, a “burning” pain, and neurological problems characterize the condition. Inflammation of the arachnoid can lead to the formation of scar tissue and can cause the spinal nerves to stick together and malfunction.

Symptoms

Arachnoiditis has no consistent pattern of symptoms, but in many people it affects the nerves connecting to the lower back and legs. The most common symptom is pain, but arachnoiditis can also cause:

  • Tingling, numbness, or weakness in the legs
  • Sensations that may feel like insects crawling on the skin or water trickling down the leg
  • Severe shooting pain that can be similar to an electric shock sensation
  • Muscle cramps, spasms and uncontrollable twitching
  • Bladder, bowel and sexual problems

As the disease progresses, symptoms may become more severe or even permanent. Many people with arachnoiditis are unable to work and suffer significant disability because they are in constant pain.

Arachnoid inflammation can lead to many painful and debilitating symptoms which can vary greatly in each case, and not all people experience all symptoms. 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. While arachnoiditis has no consistent pattern of symptoms, it frequently affects the nerves that supply the legs and lower back.

Many patients experience difficulty sitting for long (or even short) periods of time due to discomfort or pain, or because of efferent neurological or other motor symptoms, such as difficulties controlling limbs. Difficulty sitting can be problematic for patients who have trouble standing or walking for long periods, as wheelchairs are not always helpful in such cases.

The predominant symptom of arachnoiditis is chronic and persistent pain in the lower back, lower limbs or, in severe cases, throughout the entire body. Other symptoms may include:

  • Tingling, numbness, or weakness in the legs
  • Bizarre sensations such as insects crawling on the skin or water trickling down the leg
  • Severe shooting pain (which some liken to an electric shock sensation)
  • Muscle cramps, spasms, and uncontrollable twitching
  • Bladder, bowel, and/or sexual dysfunction

If the disease progresses, symptoms may become more severe or even permanent. This disorder can be very debilitating, as the pain is constant and intractable. Most people with arachnoiditis are unable to work and have significant disability.

The symptoms of arachnoiditis vary from person to person and can change over time. In the early stages of the disease, some people with arachnoiditis mistakenly believe they have a muscle or joint injury.

While muscles and joints might hurt, the source of the pain is neurological, so massage and similar strategies will not relieve the symptoms.

The most common symptoms of arachnoiditis include:

  • changes in vision
  • joint or muscle pain
  • nerve pain
  • unusual sensations, such as burning or tingling
  • ringing in the ears
  • muscle weakness
  • changes in hearing
  • meningitis, or swelling of the meninges

Less frequently, people with arachnoiditis may experience these symptoms:

  • swelling of the brain (hydrocephalus)
  • inability to sweat
  • unusual or uncontrollable body movements
  • urinary problems
  • chronic fatigue
  • migraines

Arachnoiditis has no consistent pattern of symptoms, but in many people it affects the nerves connecting to the lower back and legs and its most common symptom is pain. Arachnoiditis can cause many symptoms including the following:

  • Tingling, numbness, or weakness in the legs
  • Sensations that may feel like insects crawling on the skin or water trickling down the leg
  • Severe shooting pain that can be similar to an electric shock sensation
  • Muscle cramps, spasms, and uncontrollable twitching
  • Bladder, bowel, and/or sexual dysfunction

Symptoms may become more severe or even permanent if the disease progresses. Many people with arachnoiditis are unable to work and have a significant disability because of constant pain.

Causes

Inflammation of the arachnoid can lead to the formation of scar tissue and can cause the spinal nerves to stick together and malfunction. The arachnoid can become inflamed because of an irritation from one of the following sources:

 Direct injury to the spine.

  • Chemicals: Dye used in myelograms (diagnostic tests in which a dye called radiographic contrast media is injected into the area surrounding the spinal cord and nerves) have been blamed for some cases of arachnoiditis. The radiographic contrast media responsible for this is no longer used, however. Also, there is concern that the preservatives found in epidural steroid injections may cause arachnoiditis.
  • Infection from bacteria or viruses: Infections such as viral and fungal meningitis or tuberculosis can affect the spine.
  • Chronic compression of spinal nerves: Causes for this compression include chronic degenerative disc disease or advanced spinal stenosis (narrowing of spinal column).
  • Complications from spinal surgery or other invasive spinal procedures: Similar causes include multiple lumbar (lower back) punctures.

The root cause of the condition is not entirely clear, and it appears to have multiple causes, including iatrogenic cause from misplaced epidural steroid injection therapy when accidentally administered intrathecally (inside the dura mater, the sac enveloping the arachnoid mater), or from contrast media used in myelography prior to the introduction of Metrizamide.Other noninfectious inflammatory processes include surgery, intrathecal hemorrhage, and the administration of anesthetics (e.g. chloroprocaine), and steroids (e.g. prednisolone, triamcinolone acetonide).

A variety of other causes exist, including infectious, inflammatory, and neoplastic processes. Infectious causes include bacterial, viral, fungal, and parasitic agents. Prior spinal surgery has been documented as a cause of arachnoiditis ossificans, as well as for the adhesive form. It can also be caused by long term pressure from either a severe disc herniation or spinal stenosis.

Trauma/surgery-induced

Arachnoiditis has long been recognized as a rare complication of spinal surgery (particularly after multiple or complex surgeries) or trauma to the spine. Other similar causes include multiple lumbar punctures (especially if there is a “bloody tap” with bleeding into the spinal fluid), advanced spinal stenosis, or chronic degenerative disc disease.

Chemically-induced

In recent years, myelograms have come under scrutiny as being a possible cause of this condition. A myelogram is a diagnostic test in which a radiographic contrast media (dye) is injected into the area surrounding the spinal cord and nerves. This dye is then visible on x-rays, CT, or MRI scans and used by physicians to diagnose spinal conditions. There is now a concern that exposure (especially repeated exposure) to some of the dyes used in myelograms may cause arachnoiditis. Similarly, there is concern that the preservatives found in epidural steroid injections may cause arachnoiditis, especially if the medication accidentally enters the cerebral spinal fluid.

Infection-induced

Arachnoiditis can also be caused by certain infections that affect the spine such as viral and fungal meningitis or tuberculosis.

The cause of arachnoiditis may influence the type a person develops, as well as the outlook and treatment plan. The most common causes include:

  • an injury during spinal surgery, which accounts for about 60 percent of cases
  • myelography, when a dye is injected into the spinal column
  • exposure to chemicals that damage the meninges
  • injections into the spine, such as following an epidural
  • lumbar puncture
  • viral and bacterial infections of the spine
  • physical trauma to the spine, such as from a car accident
  • cancer in or around the spine

A very small number of arachnoiditis cases are genetic.

Diagnosing 

Diagnosing arachnoiditis can be difficult, but tests such as the CAT scan (computerized axial tomography) or MRI (magnetic resonance imaging) have helped with diagnosis. A test called an electromyogram (EMG) can assess the severity of the ongoing damage to affected nerve roots by using electrical impulses to check nerve function.

Note: Myelograms with the radiographic contrast currently in use, combined with CAT scanning, are not considered to be responsible for causing arachnoiditis or causing it to worsen.

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.

Treating Arachnoiditis

There is no cure for arachnoiditis. Treatment options for arachnoiditis are similar to those for other chronic pain conditions. Most treatments focus on relieving pain and improving symptoms that impair daily activities. Often, health care professionals recommend a program of pain management, physiotherapy, exercise, and psychotherapy. Surgery for arachnoiditis is controversial, because outcomes can be poor and provide only short-term relief. Clinical trials of steroid injections and electrical stimulation are needed to determine whether those treatments are effective.

Arachnoiditis is difficult to treat and treatment is generally limited to alleviation of pain and other symptoms. While arachnoiditis may not yet be curable and can be significantly life-altering, management of the condition, including with medication, physical therapy, and if appropriate, psychotherapy, can help patients cope with the difficulties it presents. Surgical intervention generally has a poor outcome and may only provide temporary relief, but some cases of surgical success have been reported.

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. Some patients benefit from motorized assistance devices such as the Segway or standing wheelchairs, although these types of devices may be beyond the reach of those with limited means. Standing endurance and vibration tolerance are considered before considering such devices in any case.

There is no cure for arachnoiditis. Treatment options are geared toward pain relief and are similar to treatments for other chronic pain conditions. Some examples include the following:

  • Pain medications such as NSAIDs, corticosteroids (orally or injected), anti-spasm drugs, anti-convulsants (to help with the burning pain), and in some cases, narcotic pain relievers. Some of these medications may be administered through an intrathecal pump which, when implanted under the skin, can administer medication directly to the spinal cord.
  • Physical therapy such as hydrotherapy, massage, and hot/cold therapy.
  • Transcutaneous Electrical Nerve Stimulation (TENS) is a treatment in which a painless electrical current is sent to specific nerves through electrode patches that are placed on the skin. The mild electrical current generates heat that serves to relieve stiffness, improve mobility, and relieve pain.
  • Spinal cord stimulator is a device that transmits an electrical signal to the spinal cord for pain relief.

Surgery is not recommended for arachnoiditis because it only causes more scar tissue to develop and exposes the already irritated spinal cord to more trauma.

Arachnoiditis is rare, so it may require many tests and take some time to diagnose. There is no standard test for arachnoiditis, but imaging tests may be used. These include:

  • magnetic resonance imaging (MRI)
  • computerized axial tomography (CAT) scan

An electromyogram (EMG) may also be used to determine the severity of the damage. This test uses electrical impulses to check how well the nerves are functioning.

Treating arachnoiditis can be difficult. The area around the spinal cord is delicate, and even minor damage can have severe consequences. Surgery is possible but not always recommended. Surgery is not always effective and exposes the spine to potential further damage. Even when surgery is effective, the benefits are usually temporary.

Arachnoiditis is difficult to treat. Management aims to relieve pain and improve symptoms that impair fuction. Treatment may involve pain management, physical therapy, and psychotherapy. Surgical intervention is controversial because it generally provides only short-term relief and may increase the formation of scar tissue, making the condition worse

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