Treatment

Adhesive arachnoiditis represents the most severe form of an inflammatory disease process involving the pia-arachnoid membranes of the brain and spinal canal. It is a most cruel disease because, when symptomatic, the pain and associated incapacitation are typically constant and can be functionally devastating to the sufferer. No cure presently exists for adhesive arachnoiditis. Reasonable treatment is, however, possible.

We now know that the scarring of adhesive arachnoiditis "is forever". In the 1960s and 1970s a number of neurosurgeons, including the author, attempted to treat the condition, in totally disabled, and therapy resistant, patients with microsurgical removal of scar tissue from nerves. These were major operative procedures using local enzymes to loosen the scar tissue and microsurgical instruments to remove it. The common experience was similar; patients very often improved for a short time and then worsened. Following this experience treatment has focused on symptomatic and supportive care falling into the following catagories:

• Physical modalities, exercise and stretching
• Drugs, Medications, Injections, Blocks
• Biofeedback, Meditation, Self-enhancement programs
• Chronic Pain Rehabilitation Programs
• Implanted Electronic Pain Relief Devices

Implanted Electronic Pain Relief Devices

In 1974 this author established the Department of Neuroaugmentive Surgery at the Sister Kenny Rehabilitation Institute to work of the development of implanted electronic devices designed to augment function of the nervous system. This effort was initiated as a means of getting away from the many nerve destroying procedures (i.e. neurectomy, cordotomy, cerebral lobotomy and topectomy) which were then in vogue. Sadly, the destructive procedures often created more problems then they solved. It became apparent that the individual's most precious possession was their intact nervous system. Neuroaugmentive devices are designed to augment (or potentiate) the normal function of the intact nervous system. The most successful over-all application of neuroaugmentive devices has been in the area of spinal stimulators used for the relief of intractable pain.

The first spinal electronic implanted pain relief device was introduced by neurosurgeon C. Norman Shealy in 1968 to treat the intractable pain from cancer. It really wasn't until a decade later that many of the many technical and instrumentation problems were solved and these devices became "standard". The neurosurgical staff of ILBNC have been active in developing implanted electronic devices as worthwhile alternatives to nerve destruction since 1974. At this time the author's experience in implanting electronic spinal pain relief devices is close to 1,000 cases. The long-term good results have averaged about 65%.  In 1999 three patients who have continued to use their neurostimulators for over 20 years required  system component replacement. 

Who Is A Good Candidate For Neurostimulation For Pain Relief?

Fortunately spinal neurostimulators are most effective in controlling the constant, dull, aching pain typical of adhesive arachnoiditis. They are poor in controlling sharp, lancinating well-defined pain. The best patients are those who have continued to exercise and who have avoided the use of narcotic medications. Neurostimulators are better at relieving extremity pain, rather than back pain. Sacral area pain is very resistant to treatment. Medicare/ Social Security and professional guidelines (in the U.S.) require that potential neurostimulator candidates be "last resort" patients. This means that all other types of less invasive therapy must have been tried first (and failed).

How Are Spinal Neurostimulators Used?

In order to determine if someone is going to obtain reasonable pain relief from neurostimulation advance testing must be carried out. Many nervous systems differ and some have been previously injured by trauma, chemicals or disease. Test electrodes can be inserted through percutaneous needles or by electrodes placed under local anesthesia. Today there are totally implanted systems (with batteries included much like cardiac pacemakers) or radio-frequency (RF) coupled systems where the controls and batteries are external. This author has found that placing the electrodes under local anesthesia and use of the RF coupled systems have been the most successful and have the highest level of patient satisfaction. After a period of ambulatory testing the system is internalized inside the body. The implanted components are not visible to someone else. Typically patients use the neurostimulation for only a few hours a day. In most patients having the unit on for an hour or so provides additional hours of pain relief. The mechanism for this is thought to be the electrical enhancement of the brain endorphin production (the normal pain relief substances). Component or lead wire failure is now uncommon and typically happens when the patient experiences trauma, such as a motor vehicle accident.

Anything New For The Arachnoiditis Pain Sufferer?

Why some patients who have the severe scar of adhesive arachnoiditis have serve pain while others have none, and why some patients improve over time has not yet been determined. Anecdotal evidence suggests that an important factor has to do with the blood flow and nutrient supply to the scarred nerves. We know that anoxic nerves are hyperirritable and may discharge pain signals to the brain because of simple movement or even breathing. With this in mind a number of new surgical techniques are now being explored to revascularize the impaired spinal nerves. Early results of this have been encouraging but it is clear that this procedure is something to be considered for highly selected patients. 

Charles V. Burton, M.D.
Senior Medical Director
The Institute for Low Back and Neck Care
Minneapolis, Minnesota, U.S.A.
June 22, 1999