[Gabor B Racz]

#72854

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I was recently contacted by a patient in Ohio who was referred to me suffering from a diagnosed case of Arachnoiditis. The patient’s pain doctor recommended that she have an Epidural Lysis procedure to help manage the pain, he did not feel comfortable doing the procedure as he heard about Lysis but had not trained on doing the procedure at his clinic. The patient eventually found my contact information and asked if I would recommend one of my ex-fellows in her area to perform an Adhesiolysis. Here lies the problem; after lecturing around the world for many years, I have always preached to the audience about being leery of doing a Lysis of Adhesions case on a patient with Arachnoiditis.

Arachnoiditis is known for its uncontrollable spreading of scar tissue within the subarachnoid space. It used to be more common when oil-based contrasts were used which induced an inflammatory process, that led to fibrocytes which caused an extensive invasion of the perineural spaces. Scar tissue spreads and contracts, which leads to interference of the blood supply to all structures including nerves.
Epidural Lysis (Neuroplasty) usually refers to the peri or epidural space and is less likely to lead to disasters. Any time there is pressure build up without decompressive transforaminal run-off you are skirting with disasters. If transforaminal run-off is assured, transforaminal epidural Neuroplasty is indicated. The danger of Neuroplasty in the presence of arachnoiditis is there may be a partial tear of the dura which will cause spreading of any injectate into the subdural or subarachnoid space. This spread will increase pressure build up in the lumbar sacral area causing interference with the blood supply to the bowel/bladder and other nerves.

In the early 80’s, I visited Dr. John Lloyd in Oxford, England, I was shown 2 papers from India, one on tuberculous arachnoiditis and the other one on non-tuberculous arachnoiditis Infections that lead to the development of arachnoiditis. The lesson I learned was the favorable response following subarachnoid injections of hyaluronidase, which inhibits neutrophil infiltration, therefore causing initiation of the inflammatory process.
In patients with arachnoiditis hyaluronidase may lead to less pain and recovery of motor function in bladder and extremities. However, this procedure needs to be repeated dependent on the patient’s response.
Subarachnoid injection of contrast should only be done with myelogram quality contrast, use only non-ionized to avoid paralysis and/or death.

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