CLINICAL ASSESSMENT

It is vital for the assessing physician to take into account that adhesive arachnoiditis does not present with a discrete clinical picture and that there may be symptoms that at first glance appear unrelated to any proven pathology.

Sadly, a significant proportion of patients may have had difficult previous experiences with the medical profession. Many have been labelled as having psychosomatic problems, although as the Mensana study in 1993([57]) found, chronic pain patients do tend to have underlying organic pathology.

There is, moreover, a physician bias against patients involved in litigation and also women with chronic pain conditions (xli).

These factors may cause distrust from the patient. This can be compounded by feelings of anger about iatrogenic causes for the condition (if the patient is aware of this) and thus the patient may be either over-assertive or excessively anxious. It may therefore be unproductive to assess the patient’s personality and coping abilities within the first interview, and this may be best postponed until a good rapport has been established.

Historical information may be convoluted and patients are often poorly able to communicate the sequence of events and the current, usually diverse symptoms.

Examination may or may not reveal significant neurological deficit. However, the possibility of pain of central origin should be borne in mind even if there is no obvious clinically observable abnormality.

One point that may be relevant is that the conventional measurement of muscle strength may be insufficiently sensitive in detecting weakness and fatigability. Perry has published two papers ([58]) about the limitations of manual testing for weakness and also discussing compensatory overuse of muscle groups in Postpolio Syndrome, which shares some of

the features of arachnoiditis. Perry states that “muscles with grade 5,4 or even 3+ strength allow a person to move normally; the greater intensity of effort is unrecognised,” and that studies show that “the mean strength of grade-4 muscles was approximately 40% of normal.” This is likely to also be the case in arachnoiditis patients.

It should also be remembered that occasionally there might be denervation hypertrophy of muscles instead of atrophy.

The Mensana authors stated that “Unfortunately, the psychiatric abnormalities that are the normal response to chronic pains tend to bias many physicians, resulting in less than extensive evaluations”. They go on to recommend a multidisciplinary approach, which they believe leads to improved diagnostic accuracy. Although the study does not refer specifically to arachnoiditis, as it is a chronic neurogenic pain syndrome, it would seem beneficial to adopt this approach.

Clearly, it is vital to exclude treatable causes of the presenting symptoms, but, this done, the onus is on the clinician to maintain an active programme and doctor-patient relationship to ensure that the unfortunate sufferers of arachnoiditis do not feel they have been "just left to get on with it.”

Table of Contents

Introduction
THE SCALE OF THE PROBLEM
ARACHNOIDITIS OR EPIDURAL FIBROSIS?
NOMENCLATURE
THE INFLAMMATORY NATURE OF ADHESIVE ARACHNOIDITIS
PATHOLOGY
CLASSIFICATION
CAUSES
THE IATROGENIC ASPECT OF ADHESIVE ARACHNOIDITIS
PRESERVATIVES IN SPINAL INJECTIONS
PROGNOSIS
THE SYNDROMIC NATURE OF SYMPTOMS IN ADHESIVE ARACHNOIDITIS (Warning: LONG)
COMPLICATIONS OF ADHESIVE ARACHNOIDITIS
DIFFERENTIAL DIAGNOSIS
CLINICAL ASSESSMENT
NEXT: DIAGNOSTIC TESTS
TREATMENT OPTIONS (Warning: LONG)
MULTIPLE CHEMICAL SENSITIVITY
LOOKING TO THE FUTURE
APPENDIX I: AUTOIMMUNE ASPECTS
APPENDIX II: SYRINGOMYELIA
ADDENDUM - May 2000
REFERENCES