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Arachnoiditis

nitin goyal on March 14, 2018 at 11:00 am
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    • Nitin Goyalnitin goyal
      Member
      Joined: Mar 13, 2018
      Posts: 0
      #44275

      A 35 y/o female, with L4-L5 discopathy. Severe PDPH after accidental dura punture for doing tfesi at some centre. Two blood patches at 2-3 weeks later, the last one with a mixture of pack cell, cryo and calcium gluconate which immediately led to severe and protracted tonic-clonic seizure. Then emergency laminectomy and evacuation of extensive adhesive clots from T12 to L5 with calcium deposits. Seizures continued for 48 hours. She regained consciousness after three days and extubated. This was 5 months back. She was paraplegic for two weeks, then slowly recovered and now after several months is able to walk with aid.

      Now the problem is a very severe and disabling lumbosacral pain with tinglings of lower extremities. Normal NCV and EMG. Arachnoiditis was a diagnosis by MRI.

      This pain started about two months ago (three months after the event). and is very disabling in nature. Poor response to most analgesics and anti-inflammatories. Now the patient has come to us for treatment. Kindly advice for the same. What is the role of SCS in the same? Thank you.

       

      • Brian RichardsonBrian Richardson
        Member
        Joined: Apr 20, 2017
        Posts: 0
        #44281

        This patient will likely respond extremely well to a trial of SCS. I have found it be very helpful for conditions like this. I wouldn’t hesitate to start the process.

        • Mohd Shahir AnuarMohd Shahir Anuar
          Member
          Joined: Feb 23, 2017
          Posts: 1
          #44282

          Sacral PRF before SCS… perhaps it might help

            • Nitin Goyalnitin goyal
              Member
              Joined: Mar 13, 2018
              Posts: 0
              #44286

              Thank you for kind comments. Sacral PRF? kindly elaborate

            • Anonymous UserAnonymous User
              Member
              Joined: Jan 5, 2018
              Posts: 0
              #44295

              Trial of intrathecal injection with the medicine used for caudal lysis of adhesions we had a case of Arachinoditis patient was almost paraplegic secondary to pain and started off label use of the enzyme but high dose 1200 mg usually we use 150 mg and he started walking and he only takes Tramadol at the moment .the patient actually a physician who had multiple lower back surgeries and end up with similar complications

              • Michael UmanoffMichael Umanoff
                Participant
                Joined: Aug 12, 2017
                Posts: 0
                #44297

                Why was it not an autologous patch? Why in the world inject packed cells, cryo and calcium gluconate?

                  • Nitin Goyalnitin goyal
                    Member
                    Joined: Mar 13, 2018
                    Posts: 0
                    #44303

                    True sir, I also asked the same. but didn’t get that answer.. somehow it was done by someone at some center. Patient is a pediatrician, in too much pain and depression. high depression scores making the matter worse. Also i want to know is that there could be good amount of adhesion present in the epidural space also, which may complicate the matter. Should i do something for that before placing SCS. thank you.

                  • Harold CordnerHarold Cordner
                    Participant
                    Joined: Apr 16, 2016
                    Posts: 0
                    #44335

                    I would not attempt a lysis procedure in this patient given the circumstances and arachnoiditis. SCS has been very successful in these patients.

                    • Raad AlkhafajiRaad Alkhafaji
                      Participant
                      Joined: May 7, 2015
                      Posts: 0
                      #44343

                      SCS or intrathecal pumps ONLY

                      • Gabor B RaczGabor B Racz
                        Participant
                        Joined: Mar 28, 2016
                        Posts: 30
                        #44392

                        Sorry to hear, but this is a tricky case and seems to be missing some information. I do not read any reference of bladder function? A patient with Arachnoiditis, I would expect some bladder function issues. I would suggest you do a ‘Dural Tug’ on the patient, to see if there are adhesions between the dura and the posterior longitudinal ligament. If the patient experiences pain from the tug, it most likely will be localized and highlight the site of the painful condition. Please look at the 2nd edition of Techniques of Neurolysis, GB Racz, MD and Carl Noe, MD. Dr. Hitchcock has described that subarachnoid hypertonic saline injection in Cancer Pain caused great results and I have done the same in one patient under general endotracheal anesthesia. Usually there is improvement in motor function. The patient may also have improved bladder function. My patient did very well by having no pain post-procedure after the previous metastatic pelvic pain.
                        Was the Arachnoiditis present with this patient before the procedure? After subarachnoid hypertonic saline, usually there is twitching for a few days followed by improved bladder function. At this stage, consider scarring triangle if the Dural tug is positive, through S1 or repeat hyaluronidase subarachnoid into the Caudal and Transforaminal Neuroplasty with ziconotide pump as motor function and pain relief are important. SCS? Please check for foot drop or weakness. Best Wishes!

                        Warning: I do not advocate Lysis of Adhesions on patients with Arachnoiditis. The above case, I was going for a loose catheter fragment in the subarachnoid space. Injection under pressure into the arachnoiditis can cause ischemic loculation and injury to the cauda equina.

                        ADDENDUM:
                        I had one patient who had failed back surgery syndrome, secondary to arachnoiditis. The patient was wheelchair bound and paralyzed for several years from progressive arachnoiditis. Attempt was made to remove the loose catheter segment using epiduroscopy with normal saline injections to help with the visualization, after 2 hours, unsuccessful – terminated procedure. Later replaced the morphine sylastic line and patient recovered with full motor and bladder function. Hydro dissection with normal saline of the scarred -nerve root through the L5-S1 epidurascope (plus 1500 units of hyaluronidase was used.) the patient is walking, voiding normally.
                        To this day the patient is under the care of my formal fellow TTUHSC Pain Program Director & Friend Miles Day, MD FIPP, Trawick-Racz Professor.

                          • Jamal AhmedJamal Ahmed
                            Participant
                            Joined: Oct 25, 2017
                            Posts: 4
                            #44407

                            Thank you Dr. Racz for your explanation.
                            I want to ask how do you perform the rural tug sir?

                            • Gabor B RaczGabor B Racz
                              Participant
                              Joined: Mar 28, 2016
                              Posts: 30
                              #44433

                              To appreciate the dural movement, I suggest you review the Cervical Neuroplasty video on Paincast in a patient that had three electrode placed at the C2 Level for Nucleus Caudalis stimulation. Electrodes adhere to the dura and indicate dural mobility. The dura is inserted to the foramen magnum and during the flexion rotation of the patients head and neck, the dura moves from 1 – 1.5 vertebral body lengths. The most richly innovated structure is the posterior longitudinal ligament. Therefore the Dural Tug is performed with the patient sitting up and then bending forward as much as possible and you flex and push the head down. This movement of the dura causes the patient to identify the exact location where the pain is coming from which is were the dura is adhered to the posterior longitudinal ligament. The picture of the lady pointing was taken the day before her procedure and the skin is marked with a pen. The next day the right picture has the patient were the Dural Tug is initiated and she points to the left side at the L2 Neural Foramen which is where the pain spiked during the TUG. This was confirmed by flouroscopy with a pointer to the left L2 Neural Foramen. Inter-laminar catheter mapping and Neuroplasty was performed on this patient and she had 3 years of complete pain relief I hope this helps and I will attach a video where I have one of my patient’s doing a Dural Tug” soon.

                              • Nitin Goyalnitin goyal
                                Member
                                Joined: Mar 13, 2018
                                Posts: 0
                                #44448

                                Thank you Dr. Racz sir, the patient indeed has bladder bowel involvement too.. Thank you sir for the guidance provided in this case. Really grateful.

                                • Jamal AhmedJamal Ahmed
                                  Participant
                                  Joined: Oct 25, 2017
                                  Posts: 4
                                  #44449

                                  thank you sir for your explanation

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