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Her YF, McWilliams RT, Ovrom EA, Watson JC. Corticosteroid Therapy in Acute and Subacute Arachnoiditis - A Case Series. Int Med Case Rep J 2024; 17:235-240. [PMID: 38559495 PMCID: PMC10981380 DOI: 10.2147/imcrj.s445705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 03/20/2024] [Indexed: 04/04/2024] Open
Abstract
Arachnoiditis is difficult to treat. Patients are often left frustrated after many failed trials of conservative therapies without symptom resolution. Surgery may provide symptom relief for a short period of time, but their pain often returned. Herein, we present three cases of acute arachnoiditis following three different pain procedures: epidural blood patch, IDDS implant, and epidural steroid injection. The patients were diagnosed and treated with corticosteroids within 10 days of the procedure. Two patients were treated with the same oral steroid regiment, while the third patient was treated with both oral and IV steroid. All three patients had good outcomes at the completion of their steroid therapy. This case series may provide insight into treating acute and subacute arachnoiditis from pain interventions.
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Affiliation(s)
- Yeng F Her
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | | | - Erik A Ovrom
- Mayo Clinic Alix School of Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - James C Watson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
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Brenna CTA, Khan S, Poots C, Brull R. Association between perioperative neuraxial local anesthetic neurotoxicity and arachnoiditis: a narrative review of published reports. Reg Anesth Pain Med 2023:rapm-2023-104941. [PMID: 38050164 DOI: 10.1136/rapm-2023-104941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/16/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND/IMPORTANCE Arachnoiditis is a rare but devastating disorder caused by various insults, one of which is purported to be local anesthetic neurotoxicity following neuraxial blockade. However, the relationship between local anesthetics administered into the neuraxis and the development of arachnoiditis has not been clearly elucidated. OBJECTIVE We aimed to summarize the existing complex body of literature and characterize both the essential features and strength of any association between neuraxial local anesthetic neurotoxicity and arachnoiditis with a view toward mitigating risk, enhancing prevention, and refining informed consent discussions. EVIDENCE REVIEW We reviewed all published reports of arachnoiditis attributed to local anesthetic neurotoxicity following perioperative neuraxial anesthesia. This narrative review was based on a systematic search methodology, which included articles published up until December 2022. FINDINGS Thirty-eight articles were included, comprising 130 patients, over one-half of which were published prior to this century and inconsistent with modern practice. Neuraxial techniques included 78 epidurals, 48 spinals, and 5 combined spinal-epidurals, mostly for obstetrics. Reporting of essential procedural data was generally incomplete. Overall, at least 57% of patients experienced complicated needle/catheter insertion, including paresthesia, pain, or multiple attempts, irrespective of technique. The onset of neurological symptoms ranged from immediate to 8 years after neuraxial blockade, while the pathophysiology of arachnoiditis, if described, was heterogeneous. CONCLUSIONS The existing literature attributing arachnoiditis to local anesthetic neurotoxicity is largely outdated, incomplete, and/or confounded by other potential causes, and thus insufficient to characterize the features and strength of any association.
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Affiliation(s)
- Connor T A Brenna
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shawn Khan
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Poots
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
| | - Richard Brull
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesia, Women's College Hospital, Toronto, Ontario, Canada
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3
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Lu S, Reddy AJ, Fei M, Wagh H, Iskandar NP, Lien J, Nawathey N, Arakji GH, Patel R. A Systematic Review of the Usage of Lidocaine in Hip Replacement Surgery. Cureus 2023; 15:e37498. [PMID: 37187655 PMCID: PMC10181844 DOI: 10.7759/cureus.37498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 05/17/2023] Open
Abstract
Hip replacement procedures, professionally known as hip arthroplasty, are one of the most common orthopedic procedures. Due to the variation in this procedure, the use and types of anesthetics differ. One such commonly used anesthetic is lidocaine. Since there are currently no standardized or general procedures for the application of lidocaine for perioperative hip arthroplasty procedures, this review aims to delve into this topic. A literature review surrounding the key terms "hip replacement" and "lidocaine" was performed on PubMed. After reviewing 24 randomized control trials, statistical analyses between groups that had no lidocaine versus groups that did were performed. The results showed that there was no statistical significance between various age groups and the use of lidocaine. One percent (1%) and 2% injected into the lumbar region were the most commonly reported doses of lidocaine, with 2% often being the first test dose. Other conclusions were that lidocaine was used for general anesthesia for individuals that underwent hip arthroplasty due to an underlying condition (cauda equina syndrome, ankylosing spondylitis, etc.). Lidocaine was also used for postoperative pain relief, which is a potential concern from its addictive qualities. This investigation outlines the current stance and usage of lidocaine in perioperative hip arthroplasty while noting its limitations.
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Affiliation(s)
- Sarah Lu
- Medicine, California University of Science and Medicine, Colton, USA
| | - Akshay J Reddy
- Medicine, California University of Science and Medicine, Colton, USA
| | | | - Himanshu Wagh
- Miscellaneous, California Northstate University, Elk Grove, USA
| | - Nicholas P Iskandar
- Medicine, Campbell University School of Osteopathic Medicine, Lillington, USA
| | - Justin Lien
- Medicine, Western University of Health Sciences, Pomona, USA
| | - Neel Nawathey
- Health Sciences, California Northstate University, Rancho Cordova, USA
| | - Gordon H Arakji
- Health Sciences, California Northstate University, Rancho Cordova, USA
| | - Rakesh Patel
- Internal Medicine, East Tennessee State University Quillen College of Medicine, Johnson City, USA
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Palackdkharry CS, Wottrich S, Dienes E, Bydon M, Steinmetz MP, Traynelis VC. The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis). PLoS One 2022; 17:e0274634. [PMID: 36178925 PMCID: PMC9524710 DOI: 10.1371/journal.pone.0274634] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 08/31/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND & IMPORTANCE This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward. METHODS The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions. RESULTS Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic. DISCUSSION & CONCLUSION DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.
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Affiliation(s)
| | - Stephanie Wottrich
- Case Western Reserve School of Medicine, Cleveland, Ohio, United States of America
| | - Erin Dienes
- Arcsology®, Mead, Colorado, United States of America
| | - Mohamad Bydon
- Department of Neurologic Surgery, Orthopedic Surgery, and Health Services Research, Mayo Clinic School of Medicine, Rochester, Minnesota, United States of America
| | - Michael P. Steinmetz
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine Neurologic Institute, Cleveland, Ohio, United States of America
| | - Vincent C. Traynelis
- Department of Neurosurgery, Rush University School of Medicine, Chicago, Illinois, United States of America
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Hackert J, Maßmann L, Sure U, Forsting M, Kleinschnitz C, Pul R, Hagenacker T. Immunotherapies in chronic adhesive arachnoiditis - A case series and literature review. eNeurologicalSci 2021; 24:100350. [PMID: 34195394 PMCID: PMC8225987 DOI: 10.1016/j.ensci.2021.100350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/10/2021] [Accepted: 06/09/2021] [Indexed: 01/02/2023] Open
Abstract
Chronic spinal adhesive arachnoiditis (CSAA) is a rare condition with limited therapeutic options. Surgical treatment proves effective in approximately 60% of cases. Conservative treatment options have not been extensively investigated. Here, we report the course of the disease, analyze the effect of immune treatments in patients with CSAA who were treated in the University Hospital Essen between 2015 and 2020, and conduct a literature review. Three out of four patients showed no improvement after treatment with corticosteroids, methotrexate, or plasmapheresis. All non-responders suffered from CSAA for several years, while one patient who had a disease duration of less than one month fully recovered. It is necessary to verify whether treatment at an early stage of the disease is better than treatment after chronic adhesion manifestation, as it interrupts the development of adhesions and all subsequent complications. Surgical treatment of CSAA patients proves effective in approx. 60% of cases. High-dose steroid treatment may be effective in early stages of CSAA. Only conservative therapy cannot be recommended in long-standing CSAA.
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Affiliation(s)
- Jana Hackert
- University Medicine Essen, Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, Hufelandstrasse 55, 45147 Essen, Germany
| | - Louisa Maßmann
- University Medicine Essen, Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, Hufelandstrasse 55, 45147 Essen, Germany
| | - Ulrich Sure
- University Medicine Essen, Department of Neurosurgery and Spine Surgery, Hufelandstrasse 55, 45147 Essen, Germany
| | - Michael Forsting
- University Medicine Essen, Institute of Diagnostic and Interventional Radiology and Neuroradiology, Hufelandstrasse 55, 45147 Essen, Germany
| | - Christoph Kleinschnitz
- University Medicine Essen, Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, Hufelandstrasse 55, 45147 Essen, Germany
| | - Refik Pul
- University Medicine Essen, Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, Hufelandstrasse 55, 45147 Essen, Germany
| | - Tim Hagenacker
- University Medicine Essen, Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, Hufelandstrasse 55, 45147 Essen, Germany
- Corresponding author.
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LoRusso S. Disorders of the Cauda Equina. Continuum (Minneap Minn) 2021; 27:205-224. [PMID: 33522743 DOI: 10.1212/con.0000000000000903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Cauda equina dysfunction (often referred to as cauda equina syndrome) is caused by a diverse group of disorders that affect the lumbosacral nerve roots. It is important to recognize dysfunction of the cauda equina quickly to minimize diagnostic delay and lasting neurologic symptoms. This article describes cauda equina anatomy and the clinical features, differential diagnosis, and management of cauda equina disorders. RECENT FINDINGS The diagnosis of disorders of the cauda equina continues to be a challenge. If a compressive etiology is seen, urgent neurosurgical intervention is recommended. However, many people with clinical features of cauda equina dysfunction will have negative diagnostic studies. If the MRI is negative, it is important to understand the diagnostic evaluation and differential diagnosis so that less common etiologies are not missed. SUMMARY Cauda equina dysfunction most often occurs due to lumbosacral disk herniation. Nondiskogenic causes include vascular, infectious, inflammatory, traumatic, and neoplastic etiologies. Urgent evaluation and surgical intervention are recommended in most cases of compressive cauda equina syndrome. Other types of treatment may also be indicated depending on the etiology.
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Riquelme I, Reina MA, Boezaart AP, Tubbs RS, Carrera A, Reina F. Spinal arachnoid sleeves and their possible causative role in cauda equina syndrome and transient radicular irritation syndrome. Clin Anat 2021; 34:748-756. [PMID: 33449372 DOI: 10.1002/ca.23721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/08/2021] [Accepted: 01/09/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION We have previously described arachnoid sleeves around cauda equina nerve roots, but at that time we did not determine whether injections could be performed within those sleeves. The purpose of this observational study was to establish whether the entire distal orifice of a spinal needle can be accommodated within an arachnoid sleeve. MATERIALS AND METHODS We carefully dissected the entire dural sacs off four fresh cadavers, opened them by longitudinal incision, and immersed them in saline. Under direct vision, we penetrated the cauda equina roots nerves traveling almost vertically downward at 30 locations each with a 27- and a 25-G pencil-point needle (60 punctures total). We captured the images with a stereoscopic camera. RESULTS The nerve root offered no noticeable resistance to needle entry. Although the arachnoid sleeves could not be identified with the naked eye, they were translucent but visible under microscopy. In 21 of 30 attempts with a 27-gauge needle, and in 20 of 30 attempts with a 25-gauge needle, the distal orifice of the spinal needle was completely within the arachnoid sleeve. CONCLUSION It seems possible to accommodate the distal orifice of a 25- or a 27-gauge pencil-point spinal needle completely within the space of the arachnoid sleeve. An injection within this sleeve could potentially lead to a neurological syndrome, as we have previously proposed.
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Affiliation(s)
- Irene Riquelme
- Pain Clinic, Hospital Universitario Sanitas La Moraleja, Madrid, Spain
| | - Miguel A Reina
- CEU-San-Pablo University School of Medicine, Madrid, Spain.,Department of Anesthesiology, Madrid-Montepríncipe University Hospital, Madrid, Spain.,Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - André P Boezaart
- Division of Acute and Perioperative Pain Medicine, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA.,Alon P. Winnie Research Institute, Still Bay, Western Province, South Africa
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA.,Department of Anatomical Sciences, St. George's University, St. George's, West Indies, Grenada.,Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, Louisiana, USA.,Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA.,Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Anna Carrera
- Neuroscience, Embryology, Molecular Oncology and Clinical Anatomy Group (NEOMA), School of Medicine, University of Girona, Girona, Spain
| | - Francisco Reina
- Neuroscience, Embryology, Molecular Oncology and Clinical Anatomy Group (NEOMA), School of Medicine, University of Girona, Girona, Spain
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