Arachnoiditis: what is it, causes, symptoms, treatment, prevention

What is arachnoiditis?

Arachnoiditis is an inflammation of the middle layer (arachnoid) of the meninges (meninges), which is the protective covering that surrounds the brain and spinal cord and the nerve roots of the cauda equina.

The meninges (the lining of the spinal canal) are connective tissue composed primarily of collagen and elastin. Damage, trauma, swelling, or infection can cause inflammation of the arachnoid layer anywhere.

Arachnoiditis has been known since the 19th century, when infections were the main cause, mainly tuberculosis and syphilis. It has now become known that the dissolution and degeneration of the arachnoid layer cause genetic and autoimmune disorders.

Signs and symptoms of arachnoiditis

— The natural course of the disorder.

Without treatment, arachnoiditis has a somewhat unpredictable natural course. Some cases can resolve naturally and do so completely without any evidence that they existed. However, once a diagnosis is made, the illness can be classified as a mild, modest, severe, or catastrophic event.

Easy casefor example, one in which pain is intermittent and there is no dysfunction of the bladder or range of motion of the limbs.

Moderate case Is one with persistent but easily controlled pain accompanied by some dysfunction of the bladder and weakness of the lower extremities.

Hard case will require daily pain medication as the pain is severe, persistent and intractable. There is a dysfunction of the bladder, the inability to sit or stand in one position for more than a few minutes, as well as weakness and paraparesis (partial paralysis) of the lower extremities.

Catastrophic case will have all the elements of a severe case plus paraparesis (partial paralysis) of the lower limbs, cognitive impairment, severe fatigue, largely related to being attached to a bed or sofa and the need for help with daily routines activities. If untreated, catastrophic cases of arachnoiditis leave the patient with a shortened life expectancy, autoimmunity, and terminal events, usually associated with overwhelming infections or heart failure.

The main goal of modern treatment is to prevent the progression of the disease from mild to moderate severity to a catastrophic condition.

The severity of arachnoiditis is directly related to the intensity of glial cell activation and neuroinflammation in the nerve roots of the cauda equina. Serum testing for neuroinflammatory markers shows that neuroinflammation ranges from high intensity to relatively harmless or inactive. Thus, the natural, raw course of events is unpredictable. In addition to spontaneous resolution, some cases, for unknown reasons, have an active neuroinflammation, which stops or "dies", but leaves behind permanent neurological disturbances and pain. Most of the cases that come to the attention of modern doctors, as a rule, progress with intermittent periods of remission and activity.

The catastrophic stage of arachnoiditis may disappear, probably due to medical and physical measures that do not treat or correct disorder, but seems to prevent its most catastrophic and devastating complications, such as paralysis of the lower limbs, adrenal insufficiency, severe autoimmunity, immunodeficiency and early life-ending infections and sepsis.

— Symptoms

A typical symptom complex of arachnoiditis is constant pain with various neurological manifestations. The intensity of the pain may change when moving between seated, recumbent, or standing positions. People with arachnoiditis can achieve comfort by standing or lying down, or the situation can be the exact opposite, either sitting or lying down can increase pain. In addition to positional pain relief, other symptomsexperienced by most patients include sensations of dripping water and / or insects crawling down the legs. Burning sensations in the lower legs are also common. Some symptoms of difficulty urinating are present. These may include hesitation at the start or difficulty stopping urination (neurogenic bladder).

Many patients complain of blurred vision, headache, and dizziness, which are believed to be caused by obstruction of the cerebrospinal fluid flow. The narrowing of the spinal canal, as well as the clots and scar tissue present in the spinal canal, act as a “dam” that prevents the constant flow of fluid. Cerebrospinal fluid can leak or, more appropriately, "leak" through the arachnoid and hard layers of the lining of the spinal canal into the soft tissue surrounding the spinal canal. Cerebral cerebrospinal fluid is extremely toxic to soft tissues, so significant pain can develop and soft tissues, including muscles, nerves, and fascia, can degenerate, scar, and contract after contact with leaking liquid.

Arachnoiditis, like other diseases of the brain and spinal cord, can create a systemic or generalized autoimmune disorder with immunodeficiency. This is thought to occur when inflammatory byproducts and / or tissues of the brain or spinal cord reach the general circulation. Autoimmune manifestations include arthritis of the joints, muscle pain, thyroiditis, and small fiber neuropathy. Some patients with arachnoiditis are first diagnosed with autoimmune diseases, such as systemic lupus erythematosus or Hashimoto's disease. Some are diagnosed fibromyalgia.

Since the nerve roots of the cauda equina have multiple connections with various internal organs, in depending on the anatomical location of the inflamed and trapped nerve roots, various symptoms. They can affect the stomach and intestines, including the rectum and anus. Food sensitivity, nausea, vomiting, constipation, diarrhea, urinary and fecal incontinence can all occur in different patients. The genitals, bladder and bowel function can be negatively affected. In severe cases, urinary incontinence and impotence (erectile disfunction). May occur respiratory symptoms, including dyspnea. Dysfunctions of the legs and feet are extremely common, including unsteady gait and weakness in the legs and feet. Paraparesis is relatively common, and in some cases there is even complete paralysis from the waist down.

— Physical signs.

The main physical signs in a patient with arachnoiditis are in the lower limbs and back. Physical signs in the legs include weakness, fatigue, poor balance, and abnormal reflexes. Pain can occur when the legs are extended or stretched. Paraparesis of the lower extremities may occur. Patients usually have more pain on one side of the body than the other. Consequently, the patient will often lean in favor of one side, continually leaning into a position that relieves their pain. Over time, this attempt to find comfort and relief leads to the formation of asymmetric muscle groups in the back with visible areas of muscle hypertrophy and atrophy.

If the paraspinal muscles and soft tissues are bathed by chronic oozing cerebrospinal fluid from the brain, they can scar and contract. Consequently, patients may not be able to fully extend their arms and legs. Chronic leakage of cerebrospinal fluid can also cause significant soft tissue contraction between skin and spine, resulting in a deepening of the midline, tissue along the lower spine and sometimes discoloration.

Causes of arachnoiditis

In the 21st century, there are 4 main causes of arachnoiditis:

1. anatomical disorders of the structure of the spine;
2. genetic diseases of the connective tissue;
3. bruises, injuries;
4. autoimmune disorders.

Arachnoiditis can begin with damage to the arachnoid membrane or nerve roots of the cauda equina. Regardless of where the damage begins, eventually the adhesions will stick or glue the nerve roots and the arachnoid together, causing severe pain and disruption.

The spinal cord ends at the top of the lumbar spine and grows into a dozen nerve roots. They float freely in the spinal canal ("tube") and are collectively known as the cauda equina. At some point along the lumbar and sacral spine, the nerve roots are individually branch off to connect and activate the feet, legs, bladder, genitals, intestines and stomach..

Any anatomical change that causes the spinal canal to narrow, bend, or otherwise distort the spinal canal in the lumbosacral spine, may eventually cause arachnoiditis.

The spinal canal containing cerebrospinal fluid must always remain open and free of obstruction. Spinal fluid is produced in the brain and is replenished about 4 times a day. It leaves the brain to enter the spinal canal. The function of the cerebrospinal fluid is to carry nutrients, remove impurities such as products of inflammation, as well as lubrication and constant washing of the nerve roots of the cauda equina so that they do not rub against each other friend. This can cause irritation, neuroinflammation, scarring, and adhesion.

The spinal canal, which carries the cerebrospinal fluid, must be kept open and clean at all times so that there are no obstructions to the flow of fluid or compression of the nerve roots. It is for this reason that the human body must stand and walk every few minutes and turn over frequently during sleep.

Exist multiple states (diseases) of the spine, which can disrupt the flow of cerebrospinal fluid and cause compression, irritating the nerve roots in the cauda equina. Vertebral arthritis osteoporosis, vertebral collapse and herniated discs can occur with age or accident. Kyphoscoliosis, spondylolisthesis, and rheumatoid spondylitis are genetically determined conditions.

The most common anatomical structural condition that causes arachnoiditis is chronic disc protrusion (hernia). The protruding discs constrict the spinal canal ("stenosis") and cause the nerve roots in the cauda equina to shrink into clumps. These lumps subsequently cause irritation and neuroinflammation, which eventually develops into adhesions that adhere or adhere to the arachnoid membrane. Any injury, including medical interventions, that can irritate the arachnoid membrane, nerve roots, or toxic substances, including drugs, can enter the spinal canal and accelerate the main neuroinflammatory process caused by protrusions of the intervertebral disc or any other anatomical abnormalities spine.

Affected populations

Persons who have had spinal surgery, intrathecal injections of toxic fluids (for example, hyaluronidase, blood, dyes, steroids, and topical anesthetics with preservatives) in the spinal sac or with injuries to the spine and head may be at greater risk of developing this disorder.

However, the exact prevalence and incidence of arachnoiditis is unknown. According to one estimate, approximately 11,000 new cases occur every year; however, the cause can vary from back surgery, pain relief procedures, and diagnostic interventions carried out mainly in the Americas, Europe and Asia, with an unspecified number of Africa.

Obviously, the greater number of surgical and anesthetic spinal procedures significantly increased the number of cases. For various reasons, in some cases, arachnoiditis may be misdiagnosed or misdiagnosed, which makes it difficult to determine its real frequency in the general population.

Related disorders

There are numerous conditions characterized by signs and symptoms that are similar to those found in arachnoiditis, however, only a few of them will be listed. These include failed back surgery syndrome, multiple sclerosis, fibromyalgia, reflex sympathetic dystrophy, chronic pain syndrome, cauda equina syndrome, syringomyelia, and some spinal cord tumors.

In many cases, certain conditions can arise as complications of arachnoiditis, making diagnosis more difficult. Sometimes the symptoms seen in some people with arachnoiditis can be dismissed as psychosomaticand these patients may be labeled as "pain in your head" cases.

Diagnostics

— Laboratory tests.

Currently, there are no specific laboratory tests that would identify a patient with arachnoiditis. Because the condition is a neuroinflammatory disease, certain by-products of inflammation known as "markers" are often elevated. These include sedimentation rate of erythrocytes (ESR); Myeloperoxidase C-reactive protein (CRP) and cytokines.

If any of these markers are elevated, treatment goals should include suppressing neuroinflammation and lowering the affected marker (s) to normal serum levels. It is emphasized that the absence of elevated inflammatory markers does not necessarily mean that neuroinflammation is either controlled or absent.

Certain hormones of the adrenal and gonads, such as cortisol, testosterone and pregnenolone, can be reduced in serum due to severe stress and pain from arachnoiditis. Low serum hormone levels are seen as indicators that the disease process is poorly controlled.

— Diagnosis of adhesive arachnoiditis.

Diagnostics requires 4 elements:

1. a history of the triggering event or illness;
2. typical symptoms;
3. abnormal physical signs;
4. MRI results.

Specific signs of arachnoiditis are usually recognized by contrast MRI that uses injected dye or imaging High-resolution Tesla (3) for contrasting cerebrospinal fluid from the spinal cord, nerve roots and arachnoid cover.

The necessary evidence for a diagnosis is the presence of nerve root lumps and adhesions that attach the lumps to the arachnoid layer of the spinal cord covering. While other images, such as nerve root displacement, enlargement and asymmetry, may be present on MRI imaging, these results alone are not sufficient to establish diagnosis.

The main problem is that the classic appearance of nerve root adhesion and adhesion formation may not be visible for several months after the provoking event. In addition, patients may have symptoms, physical signs, and laboratory test abnormalities that indicate disease, but an MRI may not show this. In these cases, therapeutic trials of drugs used to treat arachnoiditis are warranted.

Treatment of arachnoiditis

Until recently, arachnoiditis was often referred to as a "refractory" and "hopeless" condition. However, two major scientific discoveries have led to the development of a "first generation" medical process or protocol for treating it.

First discovery is that neuroinflammation is caused by the activation of cells in the brain and spinal cord called "glia". Pain, injury, infection, or exposure to foreign chemicals or metals (such as those that can enter the spinal cord) fluid by medical interventions and surgical procedures) can activate glial cells that cause neuroinflammation. Following these discoveries, several drugs and hormones have been identified that will suppress glial cell activation and neuroinflammation.

Second discovery is that the brain and spinal cord secrete certain hormones called neurohormones, whose main functions are to suppress neuroinflammation and / or regenerate damaged nerve cells. Some of these are called "neurosteroids" because they contain a steroidal chemical structure. They include:

• pregnenolone;
• allopregnanolone;
• progesterone;
• dehydroepiandrosterone;
• estradiol.

It has been demonstrated that the external administration of some of these internal hormones controls neuroinflammation and promotes neuroregeneration in laboratory animals. The administration of some of these hormones and their chemical analogs is currently used to treat arachnoiditis.

The treatment process consists of two main elements:

1. drug treatment;
2. physical measures.

Medicines are divided into 3 therapeutic classes: (1) suppressors of neuroinflammation (examples: ketorolac, methylprednisolone); (2) neuroregenerating agents (examples: pregnenolone, nandrolone); and (3) pain relievers (examples: low dose naltrexone, gabapentin, opioids).

Physical measures are aimed at maximizing cerebrospinal fluid flow and preventing scarring and nerve contraction roots, muscles and other potentially damaged cells that can cause neurological damage and pain. Basic physical measures include daily walks, gentle stretching of the limbs, water soak, deep breathing, and athletics.

Pain control in arachnoiditis is symptomatic and generally consistent with standard pain relief. Unfortunately, pain in this condition can compete with or exceed the pain in metastatic bone cancer, and, if necessary, require extreme, symptomatic measures, such as implanted electrical stimulants and high-dose opioids, including those given by injection, suppositories and implanted intrathecal pumps.

Many new pain treatments for severe intractable pain similar to that caused by arachnoiditis are being investigated today. Some, such as intravenous infusions of lidocaine, vitamin C, and ketamine, have been reported to provide long periods of pain relief. While pain control is purely symptomatic, physical and medical measures to suppress neuroinflammation and stimulation of neuroregeneration is applied to permanently achieve some resolution of the disease and reduce symptoms and disorders.

Prophylaxis

The finding that many cases are preceded by degenerative or structural abnormalities of the spine suggests that primary prevention of arachnoiditis is possible. It is well known that chronic degenerative conditions of the spine are associated with a sedentary lifestyle, obese and lack of exercise.

People with developing low back pain with leg and bladder dysfunction, immediately after medical procedures, including lumbar puncture, epidural anesthesia, or surgery, are at high risk of developing arachnoiditis. In suspicious cases and to prevent illness, it is recommended that the most powerful antiviral anti-inflammatories such as ketorolac and methylprednisolone were given on an emergency basis to prevent the occurrence of arachnoiditis.