Arachnoiditis Part 2—Case Reports
Adhesive arachnoiditis (AA) is a progressive, inflammatory disease that causes painful scarring of the spinal cord and impedes nerve conduction and the flow of spinal fluid. Its increasing prevalence demands that pain practitioners recognize the condition and properly treat it. Without prompt management, AA causes severe debility and suffering among patients. The first part of this 2-part series reviewed the clinical description of AA.1
Part 2 will present 4 patients with magnetic resonance image (MRI)-documented cases of AA. These cases were selected because they have slightly different initiating causes and treatments. All have been able to improve pain relief, function, and quality of life with treatment. AA patients will almost always demand an aggressive multi-faceted treatment approach with standard measures, as well as some off-label and non-standard measures. In many ways, AA patients are the prototype of the most severe, intractable pain patients, as they will inevitably require a multiplicity of treatment measures including opioids.
If a clinician reads any publication about AA, they will find that there is no known cure and that the aim of treatment is to alleviate pain and other symptoms such as urinary retention, impotence, and hypertension.2 The National Institute of Neurological Disorders and Stroke recommend “a regimen of pain management, physiotherapy, exercise, and psychotherapy.” AA patients can be harmed if a practitioner is not aware of some hazards.
Case 1: Post-Lumbar Surgery
A man in his 40’s developed chronic back pain after lifting boxes. In 1999 at the age 46, he underwent a microdiscectomy at L4/L5. The attending surgeon placed 80 mg of methylprednisolone in the surgical area prior to completion of the surgical procedure. Shortly after the surgery, the patient developed severe pain and was diagnosed with AA by MRI. The cause of the AA was likely the placement of a corticosteroid directly into the surgical site.
To relieve the patient’s pain, he was started on a regimen of opioid drugs. Over the ensuing years, the patient saw numerous physicians and underwent a number of procedures, including nerve blocks and electromagnetic measures, as well as trials of numerous medications. Despite these interventions, he progressively worsened over time and was referred to our intractable pain program in March 2007.
When he presented to our clinic, the patient’s pain was grossly uncontrolled. The patient’s pain management regimen included: (1) fentanyl transdermal patch, 100 mcg every other day; (2) transmucosal fentanyl, 800 mcg 8 times per day; and (3) duloxetine (Cymbalta) 60 mg per day.
At the time of referral, the patient was in agony and could not stand for more than 5 to 10 minutes. He spent most of his initial evaluation lying on the clinic floor. He described his pain as being from the waist down and that it was an intense, burning sensation. Walking, standing, or movement made it worse. Most of each day he was bed-bound.
Our initial clinical treatment consisted of adding the following to his analgesic regimen: (1) acetazolamide (Diamox) 500 mg daily, which is approved to treat glaucoma, to lower pressure within the spinal cord; (2) hydromorphone 8 mg every 4-6 hours for breakthrough pain; and (3) topical morphine massaged over the site of his adhesions. He was taught gentle stretching exercises of both extremities and lumbar spine.
Since his first visit in 2007, he has progressively improved and does not need to lie down to find pain relief. Beginning in 2010, he progressively began to lower his opioid dosage to the point that he is now on the following opioids: oxycodone immediate release, 60 mg per day; and hydromorphone, 48 mg per day. He believes he can eventually be taken off his opioids as he now has some pain free hours.
In 2013, the patient’s serum testosterone level was tested for the first time and was found to be low. He was placed on human chorionic gonadotropin (HCG) 250 units per day. Today, his testosterone level is normal. He routinely uses inversion stretching by hanging upside down. A repeat MRI showed only epidural fibrosis. He has returned, part-time, to his business of selling auto parts, and he credits most of his current steady improvement to HCG and inversion stretching.
Case 2: Trauma and Electrocution
In 1998, a then 28-year-old man fell 30 feet from an overhead crane and became entangled in electric wires, where he was electrocuted with 440 watts of electricity. An MRI performed shortly after the fall showed clumping of the nerve rootlets of the cauda equina at the L-3 level. The diagnostic imaging also showed degenerative changes in the cervical and lumbar spines. The patient was diagnosed with AA and was begun on opioid medications for pain relief. He has been on opioids for more than 15 years.
The patient was referred to our clinic in 2011, when he was 51. At the time of referral his medication regimen included oxycodone extended release, 80 mg 9 times per day—total daily dose: 720 mg; hydromorphone immediate release, 80 mg per day; and fentanyl transmucosal, 1600 mcg twice daily. Despite this regimen, the patient was bed-bound most days and experienced increased pain with walking, lifting, sex, bending over, and lying down for more than 2 hours.
The patient was taught gentle stretching exercises of the extremities and spine, and was started on morphine extended release, 100 mg 3 times per day, and his fentanyl transmucosal dose was increased to 3 times per day. This regimen has remained stable since 2011, and he is no longer confined to bed, can drive a car, and is able to carry on all activities of daily living.
Today, at age 54, the patient’s opioid regimen consists of: (1) oxycodone extended release, 80 mg 9 time a day; (2) transmucosal fentanyl, 1600 mcg 3 times per day; (3) morphine extended release, 100 mg 3 times per day; and (4) hydromorphone immediate release, 8 mg, taken 3 to 4 times a day for breakthrough pain.
The patient describes his pain as severe and constant. Without his current opioid regimen, the patient is unable to function or get out of bed. A possible contributor to his need for a high-dose opioid regimen is that he has 2 cytochrome P450 defects (2C9 and 2C19) and ulcerative colitis. Ulcerative colitis is, itself, a painful, autoimmune disorder that may require analgesic relief. Opioid serum levels were obtained to determine if his opioids were therapeutically effective: (1) oxycodone 270 ng/mL; (2) hydromorphone 9.2 ng/mL; and (3) fentanyl 1.0 ng/mL. He has remained on essentially the same opioid regimen for more than 5 years.
The patient attends the clinic in an ambulatory, alert state. His vital signs are always within the normal range, with a normal size, reactive pupil. His most recent blood pressure was 136/91 mm/Hg and pulse rate was 92 beats per minute. His ancillary medications include: (1) temazepam (Restoril), 30 mg for insomnia; and (2) topical carisoprodol at a dosage of 350 mg and prednisone 10 mg in one ounce of cold cream base, which is massaged over his adhesive site.