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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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As shown in Table 2, pain is a common denominator in every case, but to better understand this pain (usually derived from either a direct or an indirect injury to the intraspinal nervous system), it may be recognized that it is not uncommon that this neuropathic pain is also accompanied by some sensory loss phenomenon1,25 as occurs with needle-produced paraesthesia. In brief, this painful dysesthesia,42 caused by either isolated or repeated nerve root trauma, such as when the clumped nerve roots rub against each other or when pain is elicited as the patients extend their legs or flex their spine, and in so doing, essentially stretch the nerve roots. Portions of the these nerve roots—which are normally free floating in the CSF—are fixed as they adhere to each other or to the wall of the dural sac thus eliciting what amounts to ectopic nerve impulse activity with single or multiple burst charges.55 This mechanism has some similarity to the paraesthesia provoked by stretching or tapping on a nerve trunk and somewhat similar to the perceptions that cause allodynia and/or hyperalgesia, indicating an increased mechanosensitivity.56,57

Contrary to the pain seen in a classic radiculopathy—that usually projects along a nerve trunk or follows a nerve dermatome and of which the most typical is sciatica—pain in patients with ARC does not extend along a continuous path, but is present in regions or patches either at the medial upper section of the thigh, or at the posterolateral aspect of the distal thigh or may appear irregularly on the lateral distant portion of the leg. When it does extend to the toes, it is accompanied by fasciculations in the early stages and by frank muscle spasms later on.58,59 This unusual mapping may represent irritation of nociceptor afferent fibers transmitted to muscle fibers in the form of desynchronized reflex responses to random ectopic firing.55 In some cases, certain plasticity has been shown when pharmacological manipulations have been performed on recovering fibers, axons or neurons after a variety of injuries.70,71 In some instances, segmental numbness may be due to the predominant effect of descending impulses upon the dorsal horn, supposedly followed by the projection of neurons of the spinothalamic tract and possibly connecting with inhibitory interneurons located next to the dorsal root ganglion entry’s zone. This may control the extent of the sensory deficit manifested on the skin distribution.72 If followed in detail, some of these representations can be traced back to the location, the side, and the level where the clumping of the nerve roots is present.

The extent and severity of sexual dysfunction are alarming as reported by many patients that experienced pain during and after intercourse, which resulted in overt fear and hesitation for sexual activity, mainly because most physicians do not inquire about them and do not document this important aspect of the patient’s disease. The prevalent symptoms were different among the genders; in the males, partial (60%) or total (40%) impotence was the most common and feared; loss of libido and difficulty in arousing where also common. In some cases, if erection was obtained, pain and burning sensation would occur at ejaculation. Sexual dysfunction in the female group consisted mostly of loss of libido and severe pain (pelvic, lumbar or in the lower extremities) during or after intercourse, resulting in worries and concern for their lack of active participation in marital sex. Frequently, in both groups, low back and/or lower extremity pain during or after intercourse was stoically tolerated by patients in an effort to please their partners (see Table 3).

Moreover, the partners’ desire not uncommonly was tempered by the concern for causing pain and injury to the patient. Needless to say, this scenario lead to disappointment and friction that were prelude to intermarriage conflict. Though advice on trying different positions was at times helpful, counseling with the patient and or his/her partner did little to improve their actual sexual performance although it did help them to understand it and accept it as part of the disease. Since sexual dysfunction was a major contributor to the loss of self-esteem, depression, and relative isolation seen in many of these cases, physicians are encouraged to ask patients about it, document it in their records, follow it, and refer patients to sex therapists when deemed necessary.

Smoking cigarettes is considered a prevailing factor in postoperative morbidity73 since it contributes to respiratory complications,74 delays healing, and probably increases the incidence of pseudoarthrosis and pseudomeningoceles45 from frequent coughing and resultant increase in intradural pressure. This appears to be an ominous habit; in order to have the optimal chances of success, practitioners most insist that smoking cessation is achieved, especially if spinal surgical intervention is contemplated.75,76 Of interest was the finding that excessive alcoholic beverage ingestion was reported in patients in whom the prescription of analgesics and other adjuvant medications had been considered inadequate and inappropriate.

Urinary hesitation and dysuria were found more frequently in males, however, this symptom is not unusual in middle-aged men with early benign prostatic hypertrophy. It emphasizes the need for a complete work-up in order to arrive at a precise diagnosis. In women, urinary incontinence was the most frequent sign of bladder dysfunction. Urinary retention was commonly seen as one of the alarming signs of cauda equina involvement in the immediate postoperative period. Bladder dysfunction included a variety of symptoms that may or may not be included within the label of “neurogenic bladder." These may include “dripping or leaking” as a result of a dysfunctional sphincter. Incomplete emptying produces persistent residual urine which may become easily infected. A combination of storage and emptying dysfunction is secondary to sympathetic receptors malfunction and afferent nerve dysfunction having a myriad of symptoms such as frequency, urgency, incontinence, and hesitancy. The symptoms were noted to be more frequent and more severe in females than in males for patients having ARC after spinal surgical interventions.

Conclusions

This review of the symptoms noted in a group of patients with ARC—with or without failed back syndrome—represents an analysis of the author’s clinical observations of these diseases. The author’s interpretations are aimed to inform those who care for these patients that the intensity, frequency, and characteristics of these manifestations are real. In brief, this article has attempted to identify the possible path of transmission and perception, while recognizing that much is still in the unknown category.

Last updated on: April 13, 2017
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