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Suspecting and Diagnosing Arachnoiditis

A review of the symptoms noted in a group of patients with arachnoiditis presents an analysis of clinical observations of this disease.
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Table 2. Pain Related And Sensory Symptoms Observed In Patients With Arachnoiditis
Burning pain 478 (97.7%)
Gnawing pain in lumbosacral area 341 (69.9%)
Stabbing pain in lumbosacral area 188 (38.40%)
Constricting pain in legs or ankles 197 (40.2%)
Burning sensation in one foot 239 (48.8%)
Burning sensation in both feet 179 (36.6%)
Segmental numbness in the lower extremities 298 (60.9%)
Tingling sensation in one leg 392 (80.1%)
Tingling sensation in both legs 178 (36.4%)
Hypoesthesia 129 (26.3%)
Formication 66 (13.4%)
Dysesthesia 89 (18.2)
Gait abnormalities 198 (40.4)
Paraplegia 13 (2.6%)
Hyporeflexia in one leg 216 (44.1%)
Hyporeflexia in both legs 84 (17.7%)
Hyperreflexia in one leg 17 (3.4%)
Skin rash 58 (11.8%)
Muscle spasms 447 (91.4%)
Pruritus 49 (10%)
Allodynia 106 (21.6%)
Hyperalgesia 112 (22.9%)
Plantar Neuromas 19 (3.8%)
Table 3. Systemic Symptoms Associated With Arachnoiditis
Low-grade fever of unknown origin 357 (73%)
Frequent headaches (>4/week) 265 (54.1%)
Chronic fatigue 231 (47.2%)
Morning back stiffness 402 (82.2%)
Heat intolerance 416 (85%)
Profuse diaphoresis 409 (83.6%)
Nocturnal diaphoresis 304 (62.1%)
Frequent nausea 42 (8.5%)

Figure 1. “Tucked sacrum" noted in a patient with “spina bifida occulta" .

Dilatation or ectasia of the dural sac was common in those patients that had undergone spinal surgery through the posterior approach. Most of these, 126 ( 25.7%), occurred after laminectomy operations, and 84 others after spinal fusion (17.1%). All 210 of these patients (42.9%) also had clinical and radiological manifestations of ARC. Chronic obstructive lung disease was diagnosed in eight patients (1.6%) while five others (0.9%) had the ominous triad of arachnoiditis, pseudomeningocele, and pseudoarthrosis of the lumbar spine.

Clinical Symptoms in Patients with Arachnoiditis

Severe, unrelenting pain was the predominant symptom in patients with confirmed arachnoiditis. Although presentation had various characteristics, the common denominator was consistently burning pain that was present in 478 patients (97.7%). Low back and unilateral lower extremity pain occurred in 169 patients (34.5%) and 279 (57%) had pain in both lower extremities. The pain radiated upwards to the thoracic spine in 141 patients (28.8%) and 68 patients (13.9%) also had upper extremity pain, but these localizations of pain were possibly unrelated to ARC. The pain-related manifestations, the characteristics of the pain, the sensory and motor deficits, as well as the abnormalities found in the reflexes of the lower extremities are presented in Table 2.

Systemic Symptoms

These patients also presented with a variety of systemic symptoms not specifically related to spinal disease manifestations. Most were related to neurovegetative dysfunction that could, in part, be attributed to the intimate anatomical connection between the lumbosacral spinal cord and the corresponding sympathetic chain. Some of these manifestations have also been described in patients with traumatic spinal cord injuries, multiple sclerosis, and transverse myelitis. Among them are the symptoms listed in Table 3.

Genito-Urinary Dysfunction

Other frequently encountered symptoms were those related to bladder dysfunction, chiefly those affecting the complex sphincter function and having greater prevalence in women (256) with arachnoiditis, therefore they were considered separately from the symptoms that occurred in men (233). Most of these can be encompassed in the so called “neurogenic bladder." To substantiate the origin of the symptoms, volumetric studies were performed by a urologist in order to differentiate them from cases in which pelvic floor weakness had resulted from obstetrical injury or any other cause.

Approximately two-thirds of the patients reported the onset of bladder dysfunction occurring after the injurious event (listed in Table 1). Most of these manifestations are typical of the syndrome referred to as “neurogenic bladder." Sixty one women were forced to do self-catheterization—a rather humiliating self-care procedure—in order to empty their bladder.

Gastrointestinal Symptoms

Bowel dysfunction consisted mostly of constipation in 312 (64%) of the patients and it was usually related to opioid oral intake and was generally treated with laxatives and occasional enemas. Intermittent bouts of diarrhea were noted in 132 patients (26.9%) some of which were also suspected to have irritable bowel syndrome. Severe constipation requiring either colostomy or frequent removal of fecal impaction was noted in 8 patients (1.6%) with either thoracic medullary lesions including syringomyelia (3 cases) or severe injuries to the cauda equina in 26 patients (5.3%). Rectal incontinence, noted in 51 women (19.9%) and 18 men (7.7%), was usually the most disturbing and embarrassing manifestation. Upper gastrointestinal disorders were related to the long-term ingestion of anti-inflammatory medications and occasional steroids. Two patients appeared to have developed fulminant liver failure after long term acetaminophen ingestion (3 to 4 gms daily); in both cases viral hepatitis was also present.

Last updated on: April 13, 2017
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