Intrathecal steroids were successful in the few patients treated. Otherwise, intractable pain was improved for at least 6 months. One patient developed loss of bowel and bladder control following one injection of Depo-Medrol, which was the only steroid used. Recovery was satisfactory, but residuals remained. There were no other side effects and all patients were able to discontinue therapy while maintaining satisfactory pain control.

Spinal cord stimulation (SCS) was most effective treatment and now is our (Long et al) standard therapy used. An immediate success rate of <70% was achieved; intermediate success was <50%; long term success was <30% and has been reported in detail elsewhere. None of the patients worsened. When pain is a major problem, SCS is favored

Direct operation with microlysis of the adhesions was used for the complaint of pain alone in the first series of patients and had a 55% success rate at 5 years. However, 13% had developed significant increases in bowel and bladder dysfunction. Major motor or sensory deficits following surgery was rare.

In the second series of patients, the criteria for surgical microlysis of the adhesions was changed. Surgery was reserved for those with a clearly progressive neurological syndrome. During this period, only three patients had progressed to paraplegia, but a small number off additional patients had evidence of progression of neurological syndrome. Twelve patients were operated on. Of the 12, five had satisfactory pain control, but none achieved lasting pain relief and all have received additional therapy for pain. One patient had complete resolution of a rapidly progressive cauda equina syndrome. The patient remained without neurological complaints for 5 years. In nine of the patients, the neurological deficit either stabilized or improved; in four patients, the progression stopped; in five, substantial improvement in strength occurred.

Sensory complaints did not improve and none of these nine patients had substantial change in bowel and bladder function. One patient initially stabilized and remained so for less than a year. The patient subsequently complained of progressive loss of function, but no change in neurological examination has occurred. In the final patient, stabilization occurred for 3 years and then demonstrable loss of neurological function resumed. That patient has become more severely paraparetic and now uses a wheelchair or transport vehicle for the disabled.

Based upon experience, Long feels that the majority of patients with arachnoiditis are not candidates for direct operation. He based this upon 35 patients evaluated for more than 20 years. Long-term success of lysis of adhesions for pain control is not high. Satisfactory pain control occurs in less than 50% initially and this percentage reduces with time. When the problem is loss of neurological function, which is progressive, re-operation has an excellent chance of stopping the progression and occasionally improving function. A fixed neurological deficit is unlikely to improve. When bowel and bladder deficiencies are the major problem, improvement is even more unlikely. Spinal stenosis should be corrected since the diagnosis of arachnoiditis is uncertain in the face of stenosis. Other extradural abnormalities can be corrected if appropriate indications exist. The presence of [Continued on Next Page]

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