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The Changing Pattern of Spinal Arachnoiditis J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.2.97 on 1 February 1978. Downloaded from Journal ofNeurology, Neurosurgery, andPsychiatry, 1978, 41, 97-107 The changing pattern of spinal arachnoiditis M. D. M. SHAW, J. A. RUSSELL, AND K. W. GROSSART From the Institute of Neurological Sciences, Southern General Hospital, Glasgow SUMMARY Spinal arachnoiditis is a rare condition. Eighty cases, diagnosed during a period when 7600 spinal contrast investigations were undertaken, have been reviewed. The majority had suffered a previous spinal condition, the most common being lumbar disc disease. There has been a change in the distribution of arachnoiditis with the lumbar region now most frequently involved. This accounts for the persistence of radicular symptoms and the relatively low incidence of paraplegia when compared with earlier series. Surgery does not appear to have any role in the treatment. It was not until Horsley's (1909) description under Case material the title "chronic spinal meningitis" that spinal arachnoiditis became the first type of arachnoiditis INCIDENCE guest. Protected by copyright. to be recognised as a separate disease entity, al- During the period January 1955 to September though both Spiller et al. (1903) and Mendel and 1976 spinal arachnoiditis was diagnosed in 80 Adler in 1908 (quoted by Elkington, 1936) re- patients, 18 of whom presented in the first 10 year ported localised cystic lesions deep to the pia period. The male: female ratio was 2: 1. The mater, and Schwarz (1897) had described it during histogram (Fig. 1) shows the sex distribution his description of syphilitic meningomyelitis according to age in decades, the range being 8 associated with cavitation of the cord. Since then to 73 years. the condition has been described as "adhesive spinal arachnoiditis" (Stookey, 1927), "meningitis 30 serosa circumscripta spinalis" (Elkington, 1936), and "spinal adhesive arachnoiditis" (Mackay, 2 1939). Male Patients 54 Elkington (1951) stated that the natural history Female Patients 26 is for the condition to progress to paraplegia, but he and other authors (Kulowski and Scott, 1934; 18 Elsberg, 1942; Rocovich, 1947) agreed that surgi- 14- cal decompression is the only, if limited, prospect 0. of relief, or of achieving a static state. However, French (1946) and Lombardi et al. (1962) felt Z 8- http://jnnp.bmj.com/ that this was not justifiable as at best the patients gained only a very transient degree of relief. 6- In view of the changing patterns in this con- dition and the continuing dichotomy as to whether 2- direct surgery has any place in the treatment (Ransford and Harries, 1972), we felt that it would 0 10 20 30 40 50 60 70 80 be worthwhile reviewing the experience gained in Aqe (Years) the Institute of Neurological Sciences, Glasgow, Fig. 1 Spinal arachnoiditis: age and sex distribution. on September 25, 2021 by over the past 21 years. Statistical significance was determined by using the chi-square test. Values SITES of 0.05 were accepted as being significant. The lumbosacral region was the sole site affected in 71% of the cases. In a further 20% the Address for reprint requests: Mr J. A. Russell. Division of Ncuro- suirgery, Institute of Neurological Sciences, Southern General Hospitli, thoracic region was al'so involved, and the whole .Glasgow G51 4TF. Scotland. spinal canal in 5%. In only 4% was the thoracic Accepted 21 July 1977 region alone affected, and there were no cases in 97 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.2.97 on 1 February 1978. Downloaded from 98 M. D. M. Shaw, J. A. Russell, and K. W. Grossart whom the condition was restricted to the cervical after the onset of symptoms attributable to spinal region. arachnoiditis. The myelographic criteria used to make the diagnosis were: DIAGNOSTIC METHODS 1. Partial or complete block (Fig. 2). All but one of the patients underwent positive 2. Narrowing of the subarachnoid space (Fig. 3). contrast myelography (meglumine iothalamate 3. Obliteration of the nerve root sleeves and 60% w/v (Conray 280: May and Baker) in 15 thickening of the nerve roots (Figs. 3 and 4). patients, and iophendylate (Myodil: Glaxo) in 64) 4. Irregular distribution and loculation of the at the time of diagnosis of the arachnoiditis. The contrast medium (Fig. 4). remaining patient was diagnosed post mortem (the 5. Fixity of previously inserted contrast medium cause of death was found to be an occlusion of (Fig. 5). the left common carotid artery) some 17 years 6. Pseudo-cyst formation. guest. Protected by copyright. http://jnnp.bmj.com/ on September 25, 2021 by Fig. 3 Water-soluble myelogram showing narrowing of subarachnoid space, adherence of nerve roots to Fig. 2 Myelogram showing block at upper border of arachnoid mater, and obliteration of nerve root first thoracic vertebra. sleeves. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.2.97 on 1 February 1978. Downloaded from The changing pattern of spinal arachnoiditis 99 guest. Protected by copyright. Fig. 5 Plain radiograph showing fixity of previously Fig. 4 Water-soluble myelogram showing irregular inserted contrast medium. distribution of contrast medium and thickened nerve http://jnnp.bmj.com/ roots. films were lost) were submitted to surgery which allowed confirmation of the diagnosis. At the time of the study the myelograms of 77 patients were reviewed. Two patients' films had PREVIOUS SPINAL CONDITIONS been mislaid but each had been diagnosed as spinal Ninety-four per cent of the patients had under- arachnoiditis at the time of the original reporting gone a previous illness or treatment involving the of the myelogram. Of the 77 patients, two of the spinal column or its contents. The most common above myelographic features were found in all condition was intervertebral disc disease which on September 25, 2021 by the patients except one in whom the diagnosis was had been diagnosed in 64% of all the patients, radiologically uncertain. The frequency with and of these, all but one suffered from lumbar which the radiographic criteria was found is disc disease. Of the latter, 10% also developed a shown in Table 1. second spinal disease (Table 2). Primary in- Thirty-one of the patients (including the one fections, which had all required multiple lumbar in whom, on review of the radiology, the diagnosis punctures for the administration of intrathecal was felt to be uncertain, and one of those whose antibiotics had been diagnosed in 15% of the J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.2.97 on 1 February 1978. Downloaded from 100 M. D. M. Shaw, J. A. Russell, and K. W. Grossart Table 1 Spinal arachnoiditis-radiographic findings Of the 36 patients with arachnoiditis who underwent myelography during assessment of Arachnoiditis treatment groups their lumbar disc disease, 24 were demonstrated to have a lesion at one level, eight at multiple levels, Radiographic finidings No. Operation No operation and four were negative. Only one of these patients Block 41 21 20 was investigated using meglumine iothalamate Globulation 59 25 34 60% w/v. Nerve thickening 25 9 16 Fixed contrast 56 20 36 Fifty-one patients had previously undergone Narrow subarachnoid space 65 23 42 spinal surgery: two for tumours (both dermoid No radiographs 1 - 1 Lost radiographs 2 1 1 tumours in the lumbar canal), one for spinal Uncertain diagnosis 1 1 0 subarachnoid haemorrhage in whom the only Total number of patients 80 31 49 finding was of a swollen cervical cord, and one for an anterolateral cordotomy undertaken for pain after a traumatic amputation of the right Table 2 Spinal arachnoiditis-diseases occurring arm. Forty-seven patients underwent surgery for together with lumbar disc disease lumbar disc disease: 77% were submitted to a fenestration procedure, 11% to a laminectomy Second disease Nutmber of patients (60% of which were hemilaminectomies), and in Injury 2 the remainder the approach was unknown. Postoperative infection I Spinal angioma I Multiple level exploration was undertaken in 62% Multiple sclerosis I of the 47 patients (79% of which were at two Total 5 levels, 14% at more than two levels and in the guest. Protected by copyright. others, though multiple, the actual number is unknown) and 26% were bilateral explorations. patients. Seventy-five per cent of these infections In order to compare this incidence with that were tuberculous and the remainder pyogenic. occurring in a general population undergoing Injury accounted for a further 9% of the patients, lumbar disc surgery, the cases operated upon dur- while tumours (3%), subarachnoid haemorrhage ing six years selected at random from the period (1%), spinal anaesthetic (1%), and previous under study, were analysed. Exploration at more cordotomy (1%) were all uncommon. than one level was carried out in 50% of these Sixty-four patients had undergone a previous patients, and 3% were explored bilaterally. lumbar puncture either for diagnostic or thera- Of the seven patients who ultimately became peutic reasons. Twelve of these patients had no paraplegic, two had sustained injuries, two had record of whether blood was present in the cere- had tuberculous meningitis, two dermoid tumours, brospinal fluid either macroscopically or micro- and one a prolapsed lumbar intervertebral disc scopically. In the remaining 52 patients, blood removed. was present in 8% (75% of which was only detected on microscopy). TIME INTERVAL During the course of investigation of their The time intervals, between investigation and/or initial complaint 43 patients had been submitted treatment of the initial spinal condition and the to myelography, but in only one case was a water- onset of symptoms which were attributable to the http://jnnp.bmj.com/ soluble contrast medium used. The myelograms arachnoiditis varied from immediately to 27 were examined for evidence of technical diffi- years (Table 3).
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