RENEW OR SUBSCRIBE TO PPM
Subscription is FREE for qualified healthcare professionals in the US.
7 Articles in Volume 14, Issue #7
Fibromyalgia: What Clinicians Need to Know
Interactions Between Pain Medications and Illicit Street Drugs
Arachnoiditis Part 1: Clinical Description
Meralgia Paresthetica—A Common Cause of Thigh Pain
Editor's Memo: Real Progress—Non-Opioid Advances in Pain Management
Ask the Expert: Dependence vs. Addiction
Letters to the Editor August 2014

Arachnoiditis Part 1: Clinical Description

Arachnoiditis is a rare, but extremely debilitating, chronic pain condition caused by injury to the arachnoid layer of the spinal cord. The goal of treatment is to improve a patient’s function and quality of life by alleviating (but not eliminating) symptoms, especially pain.
Page 3 of 3

Because the primary lesion in AA causes neuropathic pain due to scarring, a good first-line effort would be to start a patient on an antiepileptic agent such as gabapentin or pregabalin (Lyrica), and/or the serotonin-norepinephrine reuptake inhibitor duloxetine (Cymbalta, others). Attempts should be made to find an antidepressant that is effective. I’ve had good luck with amitriptyline given at bedtime. Anti-inflammatories, prescription and natural, should be added to the mix. Muscle relaxants, including baclofen and carisoprodol (Soma, others), are worth trying in patients without risk of addiction. Opioids usually are essential in AA. High dosages and multiple opioids may be necessary because AA is characterized by severe flares and breakthrough pain.

Since these patients may have severe, debilitating, constant pain, which may respond only partially to standard treatments, AA patients are willing to attempt non-standard measures. Non-standard agents and measures such as ketamine (Ketalar, others), low-dose naltrexone (ReVia, others), minocycline, stimulants, and neurohormones may help selected cases.

A backbone of AA treatment is specific stretching exercises that attempt to pull apart the scarred area of the spinal cord. To identify the site, I have patients assume different stretching or range-of-motion positions with both arms and legs. When the patient finds a position that GENTLY “tugs” or “pulls” at the AA site, I have the patient daily repeat that specific stretch position. Massage therapy has been helpful to many AA patients. The theory is that massage can help the flow of spinal fluid and electrical charges pass through the scarred area.

There are some absolute DON’TS:

  • Do not allow any therapist to perform physical therapies on a patient with AA without your direct supervision. I’ve seen some AA patients worsened and damaged because a well-meaning therapist was not familiar with AA and further damaged the spinal cord by over-
    exuberant spine manipulation.
  • Do not inject anything near the AA site because there may be small fistulae that connect the AA site to tissue outside the spinal column.
  • Attempts to treat AA with an electric current or electromagnetic device should be cautiously done for fear of causing a dramatic pain flare.

A new treatment approach that some patients report to be successful is reclining with head down on an inversion table. I have one patient who hangs upside down. The idea is to pull apart the scarred, adhesive site. Hydrotherapy and trampoline walking also have been excellent, comforting therapies in my hands.

Summary

AA is a profound calamity in pain and suffering. There is no greater pain or misery than that seen in a severe case. Some AA patients have milder forms, and aggressive therapies might prevent the full-blown condition. AA is increasing in incidence.

Pain practitioners need to suspect AA in any patient who complains of severe pain following an epidural injection, spine surgery, spine trauma, or an infectious illness. The spinal insult initially damages the arachnoid lining, causing pain. An adhesive scarring process then ensues. Pain practitioners are encouraged to survey their current spine caseload to, perhaps, identify patients who have AA.

The treatment of AA usually must be aggressive and comprehensive because AA produces a cascade of sequelae: 1) nerve root adhesions, 2) centralization of pain, and 3) an autoimmune, inflammatory disorder. AA is one of the painful conditions that can require opioids in a high dosage because the severity of pain in these patients might not respond to the usual and customary non-opioid measures and standard opioid dosages.

Last updated on: March 27, 2017
Continue Reading:
Arachnoiditis Part 2—Case Reports

Join The Conversation

Register or Log-in to Join the Conversation
SHOW MAIN MENU
SHOW SUB MENU