Chronic Adhesive Arachnoiditis Symptoms, Back Pain and Compounded Pain Management
The scary thing about arachnoiditis isn’t its name—it’s the way it sneaks up on the unsuspecting victim and rapidly progresses from a mild irritation to a potentially severe disability. It may arise from a normal spinal procedure that causes little more than a headache, then within a few months, back pain is constant and other symptoms appear, such as weak legs and bowel dysfunction.
Experts have started to alert the medical community that some cases of back pain may be undiagnosed arachnoiditis.1 In addition to quickly assessing back pain patients for the risk of arachnoiditis, pharmacists can help to improve their quality of life by discussing compounded pain management.
Description of Arachnoiditis
Clinicians specializing in arachnoiditis report a rise in the number of cases, which they attribute to the increase in spinal taps, epidurals and spinal cord manipulations over the last decade. The data collected from their experience highlights some key information that compounding pharmacists should keep in mind as they counsel patients—people with chronic back pain may have undiagnosed adhesive arachnoiditis (AA). The risk of AA is especially high when chronic back pain is accompanied with severe pain from standing and leg tremors, according to researchers presenting at the 2015 meeting of the American Academy of Pain Management. Additionally, patients labeled as “failed back surgery syndrome” have a high prevalence of AA.
The arachnoid, the middle layer of three meninges that cover the brain and spinal cord, connects to the innermost membrane with a delicate web of fibers. The space between the two membranes creates a channel where spinal fluid circulates. When the arachnoid becomes inflamed, it can interfere with spinal fluid flow and lead to increased fluid pressure, but it notably manifests as inflammation of the nerve roots in the cauda equina. This chronic neuroinflammation causes adhesions between nerve roots or between nerve roots and the arachnoid lining. Patients often seek medical help when pain caused by adhesions becomes unbearable. At that time, the diagnosis is confirmed when an MRI shows nerve root displacement, enlargement and clumping.
Rundown of Causes, Symptoms and Complications
You only need to ask patients with back pain a few questions to see if they’re at risk for adhesive arachnoiditis. Just find out if their medical history includes any of these causes:
- Trauma/surgery – About 60 percent of cases are caused by spinal operations, 22 percent by epidural anesthesia, and 7 percent by lumbar puncture.2 Intrathecal steroid injections and repeated subarachnoid injections of anticancer drugs are also risk factors. Other traumatic causes include advanced spinal stenosis, chronic degenerative disc disease and spinal injury.
- Infection – An estimated 7 percent of cases are caused by bacterial and viral spinal infections.
- Chemically induced – Repeated exposure to dyes used in myelograms and preservatives in epidural steroid injections may cause arachnoiditis.
Symptoms could be summarized as chronic pain and neurological symptoms, but that doesn’t even begin to convey the extent of the pain. Think in terms of debilitating and intractable neurogenic back and limb pain and you’re closer to the reality of most patients with AA. You may notice an abnormal gait, as these patients take slow, short steps and tend to lean as they walk. They may complain of leg weakness and limited range of motion. The most common symptoms include:
- Constant back pain
- Bladder and bowel dysfunction
- Pain and weakness when standing – must sit or lie down
- Tremors in legs
- Stabbing pain in legs
- Burning or stinging in legs and feet
- Skin sensations such as tingling or bug-crawling
- Episodes of blurred vision
- Headaches and dizziness
- Impaired attention, memory and cognition
Adhesive arachnoiditis often progresses to include lower extremity paralysis and bladder, bowel or gastrointestinal dysfunction. For example, what began as mild pain with some bladder dysfunction becomes total inability to urinate without catheterization, and lower limb paralysis.
Treatment Protocols and the Role of Compounding Solutions
Lack of well-controlled clinical trials to support AA treatment, overlapping and confounding differential diagnoses, and chronic pain that’s difficult to treat all point to one conclusion—treatment must be highly individualized. Compounding pharmacists who turn medication counseling into a personal connection, and who search for answers and explore tailored compounded treatments, will make a significant difference for AA patients.
The treatment goal is to stop the characteristic progressive deterioration and disability. A multimodal regimen is required to accomplish this. Current treatment protocols come from the clinical experts. Forest Tennant, MD, DrPH, a specialist in the research and treatment of intractable pain, recommends choosing the best regimen from the following options:3
- Oral methylprednisolone, 4 to 8 milligrams, or prednisone, 5 to 10 milligrams, one dose taken three to five days weekly.
- Ketorolac, IM injection
- Combine one or two of these choices – acetazolamide, pentoxifylline, minocycline, indomethacin.
- Topical analgesics – Lidocaine is a safe effective topical anesthetic; Dr. Tennant also recommends prednisone, carisoprodol and topical morphine.
- Neuropathic agents – Gabapentin, pregabalin, baclofen, duloxetine, diazepam and topiramate.
- N-methyl-D-aspartate antagonists – Ketamine, dextromethorphan.
- Adrenergic agents – methylphenidate, phentermine, dextroamphetamine.
- Opioids – When further pain relief is necessary to perform activities of daily living and to enable exercise.
- Hormone replacement for deficiencies in cortisol, DHEA, pregnenolone, progesterone, testosterone, estradiol, thyroid or vitamin D.
- Vitamin B12
- High-protein, anti-inflammatory diet
- Pentoxifylline with vitamin E
Exercises to prevent adhesions:
- Stretch and range of motion in both extremities
- Daily walks
- Foot flexing
- Straight leg raises
- Knee bending
Physicians may consider using any number of pharmaceuticals known to relieve neuropathic pain or recommend behavioral therapy to treat the depression that arises from chronic pain. Pharmacists should reach out to AA patients to assess treatment effectiveness and to explore ways that compounding can make it easier to comply with the regimen. Depending on the patient’s needs, you might combine multiple oral meds, suggest switching to a sublingual form for quicker pain relief or develop an individualized topical treatment.
Intervention Promotes Early Identification and Diagnosis
Identification and treatment of arachnoiditis are undeniably difficult and long-term outcomes are unpredictable, but one thing is certain—early diagnosis and proper pain management offer hope for a better quality of life. Since AA is rare, it may not be on the radar of many physicians. Pharmacists should watch for back pain patients requiring high doses of analgesics or who have difficulty standing, blurred vision, burning feet, or bladder or bowel dysfunction. Provide individuals information about AA, urge them to consult their doctor and be sure to follow-up the next time they’re in the pharmacy. You may be the only health professional positioned to promote appropriate diagnosis and treatment.
Pharmaceutica North America provides the pharmaceuticals used to treat adhesive arachnoiditis. Whether you need bulk APIs, custom compounding kits, prescription drug products or OTC supplements, call us today to talk about how we can support you and your patients.
- “Chronic Back Pain May Be Arachnoiditis,” September 2015, http://www.medscape.com/viewarticle/851427 ↩
- “Arachnoiditis,” March 2010, http://www.orpha.net/consor/cgi-bin/Disease_Search.php?lng=EN&data_id=16721&Disease_Disease_Search_diseaseGroup=Arachnoiditis&Disease_Disease_Search_diseaseType=Pat&Disease(s)/group%20of%20diseases=Arachnoiditis&title=Arachnoiditis&search=Disease_Search_Simple ↩
- “Arachnoiditis: Diagnosis and Treatment,” June 2016, http://www.practicalpainmanagement.com/pain/spine/arachnoiditis-diagnosis-treatment ↩