Adhesive Arachnoiditis

Adhesive Arachnoiditis – Treatment Options

Introduction
Adhesive arachnoiditis is a rare, chronic pain disorder caused by inflammation and subsequent fibrosis of the arachnoid mater, one of the membranes surrounding the spinal cord. This leads to scar tissue formation, nerve root clumping, and impaired cerebrospinal fluid (CSF) flow. Causes include spinal surgery, trauma, infections (tuberculosis, syphilis), spinal hemorrhage, intrathecal injections, or chronic mechanical irritation. Symptoms may include severe burning pain, paresthesias, weakness, neurogenic bladder/bowel dysfunction, and progressive disability. There is currently no cure; treatment focuses on symptom management and preserving quality of life.

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1. Medical Management (Symptom-Oriented)

• Analgesics:

  • NSAIDs or acetaminophen for mild pain.

  • Opioids in refractory, severe pain (with careful monitoring).

• Neuropathic pain agents:

  • Gabapentin, pregabalin, duloxetine, amitriptyline for nerve pain.

• Muscle relaxants:

  • Baclofen or tizanidine for spasticity.

• Anti-inflammatory drugs:

  • Corticosteroids (oral or epidural) sometimes used early, though limited benefit in chronic disease.

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2. Interventional Pain Management

• Epidural adhesiolysis (Racz procedure): Catheter-based mechanical and chemical disruption of scar tissue to reduce pain.

• Spinal cord stimulation (SCS): Implanted device delivering electrical impulses to modulate pain perception.

• Intrathecal drug delivery systems: Pumps delivering opioids or baclofen directly into CSF for refractory cases.

• Epidural injections: Local anesthetics or corticosteroids may provide temporary relief, though long-term benefit is limited.

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3. Surgical Approaches

• Surgical adhesiolysis: Attempt to free nerve roots from adhesions, though outcomes are variable and surgery may worsen scarring.

• CSF diversion procedures (shunting): In rare cases, to improve CSF flow and relieve hydrocephalus-like symptoms.

• Surgery is generally reserved for progressive neurological deficits rather than pain control alone.

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4. Rehabilitation and Supportive Care

• Physical therapy: Gentle exercises to maintain mobility, muscle strength, and posture.

• Occupational therapy: Adaptation to daily living activities, assistive devices.

• Psychological support: Cognitive-behavioral therapy (CBT), mindfulness, and chronic pain counseling.

• Lifestyle strategies:

  • Heat therapy, hydrotherapy, or transcutaneous electrical nerve stimulation (TENS) for pain relief.

  • Avoidance of repeated invasive spinal procedures that may worsen adhesions.

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5. Monitoring and Long-Term Care

• Regular neurological exams to assess progression.

• Monitoring for bladder and bowel dysfunction.

• Pain management plan reviewed frequently to balance efficacy and safety.

• Addressing depression, anxiety, and reduced quality of life associated with chronic pain.

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6. Multidisciplinary Care

• Neurologists and neurosurgeons: For diagnosis, surgical consideration, and follow-up.

• Pain specialists: For interventional pain therapies and opioid-sparing regimens.

• Rehabilitation teams: For physical and occupational therapy.

• Psychologists/psychiatrists: For chronic pain coping and mental health support.

• Primary care physicians: For long-term coordination and monitoring comorbidities.