Nancy A. Melville

September 23, 2015

NATIONAL HARBOR, MD — A clinical profile of chronic back pain accompanied by a specific report of severe pain upon standing for too long and leg tremors may suggest an often overlooked diagnosis of arachnoiditis, researchers say.

"Every pain specialist should be aware that if they see a back pain patient who claims to have severe, constant back pain with the hallmark signs of not being able to stand for very long without having to sit or even lay down on the floor, then they could be dealing with arachnoiditis," said lead author Forest Tennant, MD, a chronic pain specialist with the Veract Intractable Pain Clinic in West Covina, California.

Their research was presented here at the American Academy of Pain Management (AAPM) 2015 Annual Meeting.

Inflammatory Process

While most back pain is degenerative, arachnoiditis involves an inflammatory process of the arachnoid surrounding spinal cord nerves, which can lead to a host of serious issues, including severe pain, lower-extremity paralysis, bowel dysfunction, and systemic autoimmune disorder, Dr Tennant explained.

To better identify symptoms, Dr Tennant conducted a small survey of 26 patients with chronic pain in whom arachnoiditis was confirmed by MRI.

The survey results showed striking consistency: All of the patients reported pain that was constant and severe and was associated with standing too long, causing the patient to sit or lie down.

The patients all also reported tremors or "jerking" in their legs. Most patients (23 [88.5%]) reported intense episodes of heat and sweating, difficulty urination and/or defecation, and episodes of blurry vision.

The patients had all undergone various spinal surgeries and procedures, which are among the leading causes of arachnoiditis, according to the National Institute of Neurological Disorders and Stroke (NINDS).

Other common causes include irritation from infection, direct injury to the spine, chemicals, or chronic compression of spinal nerves.

Dr Tennant notes that with the ever-increasing array of spine interventions, rates of arachnoiditis are likewise on the rise.

"Arachnoiditis is listed as a rare disorder, but with all of the spinal taps, epidurals and manipulations of the spinal cord that have become available in the last 10 years, the prevalence and incidence is soaring, and we believe this is very underdiagnosed and all pain clinics in the country now have some of these cases."

The inflammation associated with arachnoiditis can cause the spinal nerves to "stick" together, exacerbating symptoms, and can, in the most severe cases, lead to paralysis of the lower limbs, according to the NINDS.

Treatment of arachnoiditis is notoriously difficult, with unpredictable long-term outcomes, but Dr Tennant said a combination of pain management methods can offer improvement.

"These used to be considered hopeless cases, but today you can use treatments including hormones, corticoids, some of the potent anti-inflammatory agents, specific stretching exercises and electromagnetic therapies."

"There's a lot we can do for patients besides just offering them high-dose opioids," he added.

Dr Tennant noted that the 18-item questionnaire he compiled from a literature review and clinical observations can be useful in identifying potential arachnoiditis patients.

The questions are as follows:

  1. Does it hurt to lie flat on your back?

  2. When you stand with your leg straight and raise it, does this cause pain in your back?

  3. Do you lose water (bladder) or stool (colon) without warning?

  4. Does standing too long cause so much pain you have to sit or lie down?

  5. Do you have periods or episodes of intense sweating or heat (temperature)?

  6. Do you sometimes have to stand to relieve your pain?

  7. Do you sometimes have shooting pains, tremors, or jerks in your legs?

  8. Do you sometimes sleep sitting up?

  9. Do you sometimes have pain behind your eyes?

  10. Do you have trouble starting your bladder to urinate or bowel to defecate?

  11. Is your pain constant?

  12. Is your vision ever blurred?

  13. Have you ever collapsed while standing or walking?

  14. Are your hands and/or feet often cold?

  15. Do you get twitching or crawling feelings over your back and spine area?

  16. Do you get burning or electrical pains in your feet?

  17. Do you have to set on a pillow or cushion at times?

  18. Do you have pain when you walk up steps?

"If your patient answers 'yes' to more than about half of these, there's a good chance you are dealing with arachnoiditis," Dr Tennant said.

Dr Tennant receives speaker's bureau fees from Ethos Labs, Regenesis Biomedical, and INSYS Therapeutics.

American Academy of Pain Management (AAPM) 2015 Annual Meeting. Presented September 19, 2015.

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