Neuroradiology 9, 139--144 (1975) © by Springer-Verlag 1975
A Clinical and Radiological Study of Chronic Lower Spinal Arachnoiditis J. JCrgensen, P. H. Hansen, V. Steenskov and N. Ovesen Neuroradiological, Neurosurgical and Neurological Departments, Aarhus Municipal Hospital, Denmark Received: January 20, 1975 Summary. A critical evaluation revealed no distinct clinical complex of symptoms related to the radiological picture of chronic adhesive arachnoiditis in the lower lumbar sac in 72 patients. In all cases the arachnoidilis was diagnosed by myelography with water soluble contrast media and, in 16 cases, verified by operation and microscopy. The assumed cause of arachnoiditis was, in more than half of the cases, the combination of myelography and operation in close relation, and, in ten cases, a previous operation. Le diagnostic radiologique d'arachnoidite chronique adhesive dans la partie inferieare du canal spinal et les consequences cliniques Rdsumd. Une 6valuation critique n'a d6voil6 distinctement
aucune association symptomatique 6vocatrice d'arachnoidite adh6sive chronique dans la pattie inf6rieure du cul-de-sac lombaire chez 72 patients. Dans tousles cas l'arachnoidite a ~t~ diagnostiqu6e h l'aide de my61ograpl~.iefaite avec un produit de contraste hydrosoluble et dans les 16 cas elle a ~t~
Introduction Chronic arachnoiditis in the spinal canal is a rather well known condition [12, 13, 26, 30, 35]. There is no reason to expect a fundamental difference between chronic arachnoiditis in the upper part or in the lower part of the spinal canal, but the latter claims attention because of the increasing number of reports of radiographically diagnosed cases and the assumed causal relation to myelography with water soluble contrast [1, 2, 3, 4, 6, 14, 19, 20, 31]. Unfortunately there is a scarcity of reports dealing with the clinical symptoms of the radiologically diagnosed chronic arachnoiditis in the lower part of the spinal canal. The symptomatology of this conceivably iatrogenic disease is important in order to decide whether there is reason to avoid myelography and because there might be some interference with the symptoms of other chronic diseases of the lumbar spine. This paper was planned to subject the symptoms of the radiologically diagnosed chronic, adhesive arachnoiditis in the lower part of the spinal canal to a critical evaluation.
Material This material consists of 72 patients (Table 1) classified as having leptomeningeal changes in the lower
confirm6e par l'intervention et l'examen microscopique. Dans plus de la moiti6 des cas, la cause suppos~e de l'arachnoidite 6tait double (my~lographie suivie d'intervention) et dans 10 cas, une intervention pr~alable. Eine klinische und radiologische Untersuchung von der chronischen A rachnoiditis in der lumbosacra-Region Zusammenfassung. Eine kritische Untersuchung yon 72
Patienten hat keinen distinkten Symptomkomplex in Zusammenhang mit dem radiologischen Bild der chronischen adh~isiven Arachnoiditis in der lumbosaeral-Region nachgewiesen. In allen Fiillen wurde die Arachnoiditis durch Myelographie mit wasserRislichem Kontrastmittel diagnostisiert und in 16 F~illen durch Operation und histologische Untersuchung verifiziert. Die vermutete Ursache der Arachnoiditis war in mehr als der H~ilfte der Fiille die Kombination von Myelographie und Operation kurz nach einander, und in zehn F~illen eine vorherige Operation.
dural sac radiologically diagnosed at lumbar myelography with a water soluble contrast medium (Conray meglumin 282), in the period from October 1968 to April 1973. Table 1. Distribution of age groups (in years) Age
Number
--20 21--30 31--40 41--50 50--
2 7 19 30 14
Total
72
Prior to the diagnosis of arachnoiditis, nine of the 72 cases had no myelography but a previous operation for disc herniation. 19 had Pantopaque myelography, 12 Conturex myelography and, of these, four with spinal anaesthesia. 36 had Conray myelography and five, myelography with Dimer. Nine had more than one myelography before the leptomeningeal changes were diagnosed. All patients were suspected of having a disc herniation at the first admission to hospital except one who had a neurinoma. Only three were not operated upon and 63 were found at operation to have a prolapse.
140
J. Jorgensen et al.: Chronic Lower Spinal Arachnoiditis
In eight cases the surgeon described extradural adhesions at the first operation and before arachnoiditis was diagnosed, but arachnoiditis was not found in any of the cases before the diagnosis was confirmed by myelography. In ten of the operated cases there was a perforation of the dura during the operation. Most of the patients were operated upon in close relation to the previous myelography, a few of them twice and some of them before the first myelography.
In this material the changes were divided into two types, each with corresponding findings at myelography and at operation. Type 1 (37 cases) is a pure adhesion of the root to the inside of the meninges in the lower part of the dural sac with a homogenous contrast pattern without root shadows and with a rounded shortening of the root pocket. In type 2 (35 cases) some proliferation is added inside the dural sac, localized or diffuse, with
Table2. Distribution of s y m p t o m s in number of patients. A comparison between the symptoms at first admission to hospital and at the time when arachnoiditis was diagnosed
Lumbar pain Radiating pain in one leg Radiating pain in both legs Paraesthesia Voiding disturbances
Symptoms before diagnosed arachnoiditis
Symptoms after diagnosed arachnoiditis Unchanged DisapEmerged peared
67 15 16 47 2
8 5 5 2
After the diagnosis of arachnoiditis, further myelographies were performed on 29 patients. 36 patients were reoperated once, 16 twice, and 3, three times, after arachnoiditis was diagnosed. In 29 cases reoperations revealed a new or a recurrent prolapse. In all cases scar tissue was found after a previous operation, in many cases rather pronounced. A thin or an atrophic nerve root was often described at the place of a previous prolapse. In every case the leptomeningeal changes were evaluated and classified in causual relation to: 1) the last myelography; 2) the last myelography and operation in close relation (less than three weeks); 3) the last operation where no myelography was performed. There was some doubt in one of the cases classified as caused by operation. This patient had a neurinoma which itself may produce arachnoiditis. Pantopaque myelography had also been performed, but only with 2 ml of contrast which was removed during the operation.
2 1 4 1
67 5 10 38
filling defects, narrowing, shortening or occlusion of the spinal canal. There was no histological difference between the two types, and type 1 was seen to change into type 2 after repeated injuries (myelography and surgery). So there is no fundamental difference between the two types, but type 1 seems to represent the slightest changes. Type 2 was not seen following a single myelography with Conray, Dimer or Conturex, without
Radiological Findings
The characteristic radiological features of chronic adhesive spinal arachnoiditis are described as a homogenous contrast pattern in the lower lumbar sac combined with defective root pocket filling and a narrowing and shortening of the dural sac [1, 2, 6, 14, 19, 20,
Fig. 1. Type 1 arachnoiditis, a) the configuration at first myelography with 7.5 ml Conray meglumin 280. b) Ten months later, renewed myelography with 5 ml Dimer. Typical type 1 arachnoiditis in the lower part of the spinal canal
J. J~rgensen et al.: Chronic Lower Spinal Arachnoiditis spinal anaesthesia, but it was seen in all cases where the cause of arachnoiditis was traced back to an operation. In eight cases the changes were located at the region of a previous operation for a prolapse in the lumbar region while associated diffuse changes could
141
not be demonstrated. These cases were classed as type 2. Some of them showed a picture similar to what is previously described as changes due to postoperative scarring [8]. Four of these cases had proved by operation and microscopy to be a chronic arachnoiditis. In the other type 2 cases the proliferative changes were located mostly on the side where the operation had been performed. Except for the eight cases with localized arachnoiditis, all had diffuse changes in the bottom of the dural sac. The upper border of the pathological changes was found at the level of or below the fifth nerve root in 24 cases and above that level in the rest. Only in three cases was the extension higher than the level of the third root. In many cases the upward extension of the changes was asymmetrical and in those was always higher on the operated side. Only one in group two was not operated. This patient had had Pantopaque myelography where 6 ml of Pantopaque was left in the spinal canal. Type 2 arachnoiditis makes it impossible to make the myelographic diagnosis of herniated disc.
Results
Fig. 2. Myelograply with 5 ml Dimer. Severe type 2 arachnoiditis with diffuse changes after two operations for disc herniation and pantopaque myelography eight years before this investigation
Based on previous reports of clinical findings with chronic arachnoiditis, a number of symptoms and signs were selected and the symptoms were recorded from the case sheet. A comparison was made between the clinical symptoms at the first admission to the hospital beforearachnoiditis was found and the clinical symptoms at the time when the arachnoiditis was diagnosed (Table 3). Table 3. The suspected causes of chronic arachnoiditis in the lower lumbar part of the spinal canal
Fig. 3. Myelography with 4 ml Conray meglumin 280. Oblique and lateral projections show a block with slightly irregular limits, bulging in the contrast, but without dislocation of the nerve roots. Surgery revealed localised fibrous arachnoiditis. The patient had an operation for disc herniation at this level ten years before. No previous myelography
Pantopaque myelography Pantopaque myelograply and operation Methiodal sodium myelography Methiodal sodium and operation Mcthiodal sodium and spinal anaesthesia Myelography with Conray meglumin Myelography with Conray meglumin and operation Myelography with Dimer Myelography with Dimer and operation Operation Unknown
3 7 0 6 4 8 28 1 4 10 1
Total
72
In 61 of the cases, the duration of the symptoms was greater than one year before the first admission to hospital and were of a remittant nature. Lumbar pain was the most frequent symptom when the patient was readmitted to hospital. Most of the
142
J. Jorgensen et al.: Chronic Lower Spinal Arachnoiditis
other symptoms were decreasing, but if they persisted they had mainly the same location before and after the assumed commencement of the arachnoiditis. A complete description of the objective signs was not available in all cases, especially not from the first admission to hospital. In many cases objective signs of root compression had disappeared after a successful operation, in other cases the sequelae after such a root compression remained. No obvious difference could be demonstrated between the distribution of the symptoms before and after the assumed onset of araclmoiditis (Table 3). In 20 of the reoperated cases, some improvement was obtained after the operation. In most cases the remitting course of the disease was continued after the supposed onset of arachnoiditis and also after the diagnosis of arachnoiditis. In five cases there was an unquestionable relation between the clinical symptoms and the leptomeningeal changes found at myelography and in three of the cases at operation. All of them were rather pronounced type 2 araclmoiditis, two of them with a block and one with localised changes. Two were assumed to be caused by a previous operation, two caused by previous Pantopaque myelography and operation in close relation, and one was of unknown origin. All of the five patients had lumbar pain, the two patients with contrast medium block had a rather sudden aggravation of the previous symptoms with the onset of new symptoms of a cauda equina syndrome which clinically was mistaken for a disc herniation. The one with localised leptomeningeal changes had pain in the leg and back with a slow onset after a rather long period free of symptoms. The remaining two cases developed a weakness in one leg slowly with paresis. Only in the two cases where a block was found, was some improvement obtained by the intradural operation. Later reexamination of the working capacity revealed that 39 patients could not manage their usual employment, five of them due to other reasons than the lumbar disease. 16 were working as usual but with symptoms now and then. 13 were working and had no symptoms. Four of the patients could not be contacted. The average observation time from the probable onset of the arachnoiditis was 5.7 years and 3.6 years from the radiographic diagnosis. Symptoms and cause of the disease had no significant relation to any of the other recorded investigations such as sex, age, and protein content in spinal fluid. In 16 cases the dura was opened and the radiographic diagnosis was certified by operation and microscopy.
Discussion
Experimental studies on animals have shown that injection of drugs, including contrast media, into the spinal subarachnoid space could cause acute and chronic inflammation of the leptomeninges [5, 11, 15, 23, 24, 29]. A few reports have confirmed that similar changes could take place in man [3, 16, 17, 18, 25, 27, 33, 34]. Without any doubt the new water soluble contrast media for myelography may produce arachnoiditis, and at the same time they make the diagnosis of arachnoiditis easier by the diagnostic improvement introduced. It is clearly demonstrated from this material that there might be many different causes for arachnoiditis in the lower lumbar sac (Table 3). In a rather high percentage myelography can be excluded as a cause. The relation of operation and myelography within a short time as the possible cause of arachnoiditis is striking, an observation also made by other authors [1, 19,201. It is remarkable that so many of the patients are dissabled, more than 50yo, but not much more than in newer reports on the surgical results of disc hernation [32]. The rather high percentage of symptoms is remarkable, but it must be noted that the material is not comparable to other series of patients with disc herniation because of the long duration and the high frequency of repeated operations and myelographies. Clinically the investigation has disclosed no distinctive complex of symptoms and signs related to the radiographic picture. In some cases new symptoms and signs appeared, possibly caused by the arachnoiditis, but on the whole, little alteration in the location and nature of the symptoms appeared so that the pathological picture had a remittant but slowly progressive course, as often seen in chronic lumbar spine diseases. Table 4. Protein content in spinal fluid in number of patients (elevated protein content >/50 mglml)
Elevated Normal Not informed
Before arachnoiditis was diagnosed
After arachnoiditis was diagnosed
30 31 11
31 32 9
The protein content in the spinal fluid is not helpful in the diagnosis of chronic spinal arachnoiditis (Table
4).
J. J,~rgensen et aI.: Chronic Lower Spinal Arachnoiditis A l t h o u g h it cannot be denied that the persistence of symptoms is caused by the arachnoiditis, it is natural to believe that most of the symptoms are related to the degenerated disc and to the consequences of the previous disc herniation and the operation for the disc herniation. It cannot be excluded that further symptoms will arise although the observation time is rather long. Operative treatment of the &~ronic arachnoiditis has been helpful for the symptoms in a couple of cases where the patients had rather p r o n o u n c e d symptoms and neurological signs and a localised block caused by the arachnoid fibrosis was found, but in most of the cases there was no i m p r o v e m e n t and in six of these cases later m y e l o g r a p h y disclosed a much worse myelographic picture. To prevent arachnoiditis, some authors have used intraspinal cortisone, which also has been mixed with contrast for myelography, [1, 9, 10] but according to Ahlgren no effect was obtained.
Conclusion It is w o r t h y of note that there is a variety of possible causes of chronic arachnoiditis in the lower part of the spinal canal. M o r e o v e r there is no clinical and symptomatical c o r r e s p o n d a n c e to the radiological and surgical picture of the arachnoiditis. I n the few cases where arachnoiditis, without doubt, is playing a role in the pathological picture, this cannot be distinguished f r o m other chronic diseases in the lower spinal canal. In the m a j o r part of the group it is impossible to distinguish between the symptoms before and after the arachnoiditis arose. These symptoms correspond to what is f o u n d in patients with chronic lumbar diseases. A strict indication has to be r e c o m m e n d e d for introducing drugs (including contrast media) into the spinal canal and for other injuries to the spinal canal as, for example, operation. Repeated injuries should be avoided.
References 1. Ahlgren, P.: Long term side effects after myelography with water soluble contrast media: Conturex, Conray Meglumin 282 and Dimer--X. Neuroradiology 6, 206-211 (1973) 2. Autio, E., Suolanen, J., Norrebiick, S., Sl~itis, P.: Adhesive arachnoiditis after lumbar myelography with meglumine iothalamate (Conray). Acta radiok Diagn. 12, 17--24 (1972) 3. Bauer, H.: Einbringen yon Medikamenten in den Subarachnoidalraum -- M~iglichkeiten und Gefahren. Die Wirbelsiiule in Forschung und Praxis. 41, 19--28 (1969) 4. Baumgartner, J., Braun, J.-P., Rust, F., Wipf-Scheibel, M., Kummert, J., Kiesel, R.: Am61ioration de la technique de Neuroradiology,Vol. 9
143
l'examen radiculos accographique par utilisation d'un nouveau produit de contraste. Neuro-chirurgie 14, 909-916 (1968) 5. Bergeron, R. T., Rumbaugh, C. L., Fang, H., Cravioto, H.: Experimental pantopaque arachnoiditis in the monkey. Radiology 99, 95-- 101 (1971) 6. Bidstrup, P.: A case of chronic adhesive arachnoiditis after lumbar myelography with methiodal-sodium. Neuroradiology 3, 157-159 (1972) 7. Cecile, J. P., Regnier, G., Guagui6re, A., Doffiny, L., Curelier, A.: Postural protection against complication in radiculography with Dimer X. Neuroradiology 7, 167-172 (1974) 8. Cronquist, S.: The postoperative myelogram. Acta radiol. (Stockh.) 52, 45-51 (1959) 9. Davis, F. M., Llewllyn, R. C., Kirgis, H. D.: Watersoluble contrast myelography using meglumine iothalamate (Conray) with methylprednisolone acetate (DepoMedrol). Radiology 90, 705--544 (1968) 10. Feldman, S., Behar, A. J., Samueloff, Mcni: Effect of cortisone and hydrocortisone on piarachnoid adhesions. Arch. Neurol. Psychiat. (Chic.) 74, 681--688 (1955) 11. Fisher, R. L.: An experimental evaluation of pantopaque and other recently developed myelographic contrast media. Radiology 85, 537--544 (1965) 12. French, J. D.: Clinical manifestations of lumbar spinal arachnoiditis. Surgery 20, 718--729 (1946) 13. French, J. D.: Recurrent arachnoiditis in the dorsal spinal region. Arch. Neurol. Psychiat. 58, 200-206 (1947) 14. Halaburt, H , Lester, J.: Leptomeningeal changes following lumbar myelography with water-soluble contrast media (meglumine iothalamate and methiodal sodium). Neuroradiology 5, 7 0 - 7 6 (1973) 15. Howland, W. J., Curry, J. L.: Experimental studies of pantopaque arachnoiditis. Radiology 87, 253--261 (1966) 16. Howland, W. J. and Curry, J. L.: Pantopaque arachnoiditis. Acta radiol. (Stockh.) 5, 1032-1041 (1966) 17. Hurteau, E. F., Baird, W. C., Sinclair, E.: Arachnoiditis following the use of iodized oil. J. Bone Jt. Surg. 36--A, 393--400 (1954) 18. Imielinski, L., Chmielewski, J. M.: Arachnoiditis adh6sive intrarachidienne a la suite de my61ographies a l'ethiodane (Pantopaque). J. Radiol. Electrol. 52, 31--34 (1971) 19. Irstam, L., Rosencrantz, M.: Water-soluble contrast media and adhesive arachnoiditis I. Reinvestigation of nonoperated cases. Acta Radiol. Diag. 14, 497--506 (1973) 20. Irstam, L., Rosencrantz, M.: Water-soluble contrast media and adhesive arachnoiditis. II. Reinvestigation of operated cases. Acta radiol. Diagn. lg, 1-- 15 (1974) 21. Irstam, L., Sundstrom, R., Sigstedt, B.: Lumbar myelography and adhesive arachnoiditis. Acta radiol. Diagn. 15, 356--368 (1974) 22. Jackson, I. J.: Aseptic hemogenic menigitis. Arch. Neurol. Psychiat. (Chic.) 62, 572--589 (1949) 23. Jakobsen, J. K.: On the side-effects of contrast media for myelography. Acta path. microbiol, scand. 81, 323--336 (1973) 24. Jakobsen, J. K.: Clinical evaluations of a histologie examination of the side effects of myelographic contrast media. Acta radiol. (Stockh.) 14, 638--646 (1973) 25. Kennedy, F., Effron, A. S., Perry, G.: The grave spinal cord paralyses caused by spinal anesthesia. Surg. Gynec. Obstet. 91, 385--398 (1950) 26. Kraus, H.: Die Arachnitis chronica cerebralis und spinalis und ihre operative Behandlung. Arch. klin. Chir. 261, 3 3 - 6 7 (1948) 11
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J. J~rgen sen et al.: Ctironic Lower Spinal Arachnoiditis
27. Kuhlendahl, H.: Schiiden durch Kontrastmittel bei der Myelographie. Die Wirbels~iule in Forschung und Praxis. 41, 31--49 (1969) 28. Paine, K. W. E., Haung, P. W. H.: Lumbar disc syndrome. J. Neurosurg. 37, 75--82 (1972) 29. Praestholm, J., Olgaard, K.: Comparatis histological investigation of the sequelae of experimental myelography using sodium methiodal and meglumine iothalamate. Neuroradiology 4, 14-- 19 (1972) 30. R~tif, J., Brihaye, J., P6rier, O.: L'arachno~dite spinale. Neuro-chirurgie 10, 3 7 0 - 386 (1964) 31. Rgtdberg, C., Wennberg, E.: Late sequelae following lumbar myelography with water-soluble contrast media. Acta radiol. Diagn. 14, 507-512 (1973)
32. Spgmgfort, E. V.: The lumbar disc herniation. Acta orthop. scand. Suppl. 142, 1--95 (1972) 33. Wende, S., Schliack, H.: Zur Frage von Pantopaque-Spiitschiiden. Nervenarzt 32, 415--416 (1961) 34. Williams, J. M.: Focal spinal arachnoiditis complicating spinal anesthesia. J. int. Coll. Surg. 22, 18--27 (1954) 35. Winkelman, N. W., Gotten, N., Scheibert, D.: Localised adhesive spinal arachnoiditis. Trans. Amer. neurol. Ass. 78, 15--18 (1953) J. Jorgensen, M.D. Radiological Department Arhus Municipal Hospital DK--8000 Arhus C Danmark
A Clinical and Radiological Study of Chronic Lower Spinal Arachnoiditis J. JCrgensen, P. H. Hansen, V. Steenskov and N. Ovesen Neuroradiological, Neurosurgical and Neurological Departments, Aarhus Municipal Hospital, Denmark Received: January 20, 1975 Summary. A critical evaluation revealed no distinct clinical complex of symptoms related to the radiological picture of chronic adhesive arachnoiditis in the lower lumbar sac in 72 patients. In all cases the arachnoidilis was diagnosed by myelography with water soluble contrast media and, in 16 cases, verified by operation and microscopy. The assumed cause of arachnoiditis was, in more than half of the cases, the combination of myelography and operation in close relation, and, in ten cases, a previous operation. Le diagnostic radiologique d'arachnoidite chronique adhesive dans la partie inferieare du canal spinal et les consequences cliniques Rdsumd. Une 6valuation critique n'a d6voil6 distinctement
aucune association symptomatique 6vocatrice d'arachnoidite adh6sive chronique dans la pattie inf6rieure du cul-de-sac lombaire chez 72 patients. Dans tousles cas l'arachnoidite a ~t~ diagnostiqu6e h l'aide de my61ograpl~.iefaite avec un produit de contraste hydrosoluble et dans les 16 cas elle a ~t~
Introduction Chronic arachnoiditis in the spinal canal is a rather well known condition [12, 13, 26, 30, 35]. There is no reason to expect a fundamental difference between chronic arachnoiditis in the upper part or in the lower part of the spinal canal, but the latter claims attention because of the increasing number of reports of radiographically diagnosed cases and the assumed causal relation to myelography with water soluble contrast [1, 2, 3, 4, 6, 14, 19, 20, 31]. Unfortunately there is a scarcity of reports dealing with the clinical symptoms of the radiologically diagnosed chronic arachnoiditis in the lower part of the spinal canal. The symptomatology of this conceivably iatrogenic disease is important in order to decide whether there is reason to avoid myelography and because there might be some interference with the symptoms of other chronic diseases of the lumbar spine. This paper was planned to subject the symptoms of the radiologically diagnosed chronic, adhesive arachnoiditis in the lower part of the spinal canal to a critical evaluation.
Material This material consists of 72 patients (Table 1) classified as having leptomeningeal changes in the lower
confirm6e par l'intervention et l'examen microscopique. Dans plus de la moiti6 des cas, la cause suppos~e de l'arachnoidite 6tait double (my~lographie suivie d'intervention) et dans 10 cas, une intervention pr~alable. Eine klinische und radiologische Untersuchung von der chronischen A rachnoiditis in der lumbosacra-Region Zusammenfassung. Eine kritische Untersuchung yon 72
Patienten hat keinen distinkten Symptomkomplex in Zusammenhang mit dem radiologischen Bild der chronischen adh~isiven Arachnoiditis in der lumbosaeral-Region nachgewiesen. In allen Fiillen wurde die Arachnoiditis durch Myelographie mit wasserRislichem Kontrastmittel diagnostisiert und in 16 F~illen durch Operation und histologische Untersuchung verifiziert. Die vermutete Ursache der Arachnoiditis war in mehr als der H~ilfte der Fiille die Kombination von Myelographie und Operation kurz nach einander, und in zehn F~illen eine vorherige Operation.
dural sac radiologically diagnosed at lumbar myelography with a water soluble contrast medium (Conray meglumin 282), in the period from October 1968 to April 1973. Table 1. Distribution of age groups (in years) Age
Number
--20 21--30 31--40 41--50 50--
2 7 19 30 14
Total
72
Prior to the diagnosis of arachnoiditis, nine of the 72 cases had no myelography but a previous operation for disc herniation. 19 had Pantopaque myelography, 12 Conturex myelography and, of these, four with spinal anaesthesia. 36 had Conray myelography and five, myelography with Dimer. Nine had more than one myelography before the leptomeningeal changes were diagnosed. All patients were suspected of having a disc herniation at the first admission to hospital except one who had a neurinoma. Only three were not operated upon and 63 were found at operation to have a prolapse.
140
J. Jorgensen et al.: Chronic Lower Spinal Arachnoiditis
In eight cases the surgeon described extradural adhesions at the first operation and before arachnoiditis was diagnosed, but arachnoiditis was not found in any of the cases before the diagnosis was confirmed by myelography. In ten of the operated cases there was a perforation of the dura during the operation. Most of the patients were operated upon in close relation to the previous myelography, a few of them twice and some of them before the first myelography.
In this material the changes were divided into two types, each with corresponding findings at myelography and at operation. Type 1 (37 cases) is a pure adhesion of the root to the inside of the meninges in the lower part of the dural sac with a homogenous contrast pattern without root shadows and with a rounded shortening of the root pocket. In type 2 (35 cases) some proliferation is added inside the dural sac, localized or diffuse, with
Table2. Distribution of s y m p t o m s in number of patients. A comparison between the symptoms at first admission to hospital and at the time when arachnoiditis was diagnosed
Lumbar pain Radiating pain in one leg Radiating pain in both legs Paraesthesia Voiding disturbances
Symptoms before diagnosed arachnoiditis
Symptoms after diagnosed arachnoiditis Unchanged DisapEmerged peared
67 15 16 47 2
8 5 5 2
After the diagnosis of arachnoiditis, further myelographies were performed on 29 patients. 36 patients were reoperated once, 16 twice, and 3, three times, after arachnoiditis was diagnosed. In 29 cases reoperations revealed a new or a recurrent prolapse. In all cases scar tissue was found after a previous operation, in many cases rather pronounced. A thin or an atrophic nerve root was often described at the place of a previous prolapse. In every case the leptomeningeal changes were evaluated and classified in causual relation to: 1) the last myelography; 2) the last myelography and operation in close relation (less than three weeks); 3) the last operation where no myelography was performed. There was some doubt in one of the cases classified as caused by operation. This patient had a neurinoma which itself may produce arachnoiditis. Pantopaque myelography had also been performed, but only with 2 ml of contrast which was removed during the operation.
2 1 4 1
67 5 10 38
filling defects, narrowing, shortening or occlusion of the spinal canal. There was no histological difference between the two types, and type 1 was seen to change into type 2 after repeated injuries (myelography and surgery). So there is no fundamental difference between the two types, but type 1 seems to represent the slightest changes. Type 2 was not seen following a single myelography with Conray, Dimer or Conturex, without
Radiological Findings
The characteristic radiological features of chronic adhesive spinal arachnoiditis are described as a homogenous contrast pattern in the lower lumbar sac combined with defective root pocket filling and a narrowing and shortening of the dural sac [1, 2, 6, 14, 19, 20,
Fig. 1. Type 1 arachnoiditis, a) the configuration at first myelography with 7.5 ml Conray meglumin 280. b) Ten months later, renewed myelography with 5 ml Dimer. Typical type 1 arachnoiditis in the lower part of the spinal canal
J. J~rgensen et al.: Chronic Lower Spinal Arachnoiditis spinal anaesthesia, but it was seen in all cases where the cause of arachnoiditis was traced back to an operation. In eight cases the changes were located at the region of a previous operation for a prolapse in the lumbar region while associated diffuse changes could
141
not be demonstrated. These cases were classed as type 2. Some of them showed a picture similar to what is previously described as changes due to postoperative scarring [8]. Four of these cases had proved by operation and microscopy to be a chronic arachnoiditis. In the other type 2 cases the proliferative changes were located mostly on the side where the operation had been performed. Except for the eight cases with localized arachnoiditis, all had diffuse changes in the bottom of the dural sac. The upper border of the pathological changes was found at the level of or below the fifth nerve root in 24 cases and above that level in the rest. Only in three cases was the extension higher than the level of the third root. In many cases the upward extension of the changes was asymmetrical and in those was always higher on the operated side. Only one in group two was not operated. This patient had had Pantopaque myelography where 6 ml of Pantopaque was left in the spinal canal. Type 2 arachnoiditis makes it impossible to make the myelographic diagnosis of herniated disc.
Results
Fig. 2. Myelograply with 5 ml Dimer. Severe type 2 arachnoiditis with diffuse changes after two operations for disc herniation and pantopaque myelography eight years before this investigation
Based on previous reports of clinical findings with chronic arachnoiditis, a number of symptoms and signs were selected and the symptoms were recorded from the case sheet. A comparison was made between the clinical symptoms at the first admission to the hospital beforearachnoiditis was found and the clinical symptoms at the time when the arachnoiditis was diagnosed (Table 3). Table 3. The suspected causes of chronic arachnoiditis in the lower lumbar part of the spinal canal
Fig. 3. Myelography with 4 ml Conray meglumin 280. Oblique and lateral projections show a block with slightly irregular limits, bulging in the contrast, but without dislocation of the nerve roots. Surgery revealed localised fibrous arachnoiditis. The patient had an operation for disc herniation at this level ten years before. No previous myelography
Pantopaque myelography Pantopaque myelograply and operation Methiodal sodium myelography Methiodal sodium and operation Mcthiodal sodium and spinal anaesthesia Myelography with Conray meglumin Myelography with Conray meglumin and operation Myelography with Dimer Myelography with Dimer and operation Operation Unknown
3 7 0 6 4 8 28 1 4 10 1
Total
72
In 61 of the cases, the duration of the symptoms was greater than one year before the first admission to hospital and were of a remittant nature. Lumbar pain was the most frequent symptom when the patient was readmitted to hospital. Most of the
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J. Jorgensen et al.: Chronic Lower Spinal Arachnoiditis
other symptoms were decreasing, but if they persisted they had mainly the same location before and after the assumed commencement of the arachnoiditis. A complete description of the objective signs was not available in all cases, especially not from the first admission to hospital. In many cases objective signs of root compression had disappeared after a successful operation, in other cases the sequelae after such a root compression remained. No obvious difference could be demonstrated between the distribution of the symptoms before and after the assumed onset of araclmoiditis (Table 3). In 20 of the reoperated cases, some improvement was obtained after the operation. In most cases the remitting course of the disease was continued after the supposed onset of arachnoiditis and also after the diagnosis of arachnoiditis. In five cases there was an unquestionable relation between the clinical symptoms and the leptomeningeal changes found at myelography and in three of the cases at operation. All of them were rather pronounced type 2 araclmoiditis, two of them with a block and one with localised changes. Two were assumed to be caused by a previous operation, two caused by previous Pantopaque myelography and operation in close relation, and one was of unknown origin. All of the five patients had lumbar pain, the two patients with contrast medium block had a rather sudden aggravation of the previous symptoms with the onset of new symptoms of a cauda equina syndrome which clinically was mistaken for a disc herniation. The one with localised leptomeningeal changes had pain in the leg and back with a slow onset after a rather long period free of symptoms. The remaining two cases developed a weakness in one leg slowly with paresis. Only in the two cases where a block was found, was some improvement obtained by the intradural operation. Later reexamination of the working capacity revealed that 39 patients could not manage their usual employment, five of them due to other reasons than the lumbar disease. 16 were working as usual but with symptoms now and then. 13 were working and had no symptoms. Four of the patients could not be contacted. The average observation time from the probable onset of the arachnoiditis was 5.7 years and 3.6 years from the radiographic diagnosis. Symptoms and cause of the disease had no significant relation to any of the other recorded investigations such as sex, age, and protein content in spinal fluid. In 16 cases the dura was opened and the radiographic diagnosis was certified by operation and microscopy.
Discussion
Experimental studies on animals have shown that injection of drugs, including contrast media, into the spinal subarachnoid space could cause acute and chronic inflammation of the leptomeninges [5, 11, 15, 23, 24, 29]. A few reports have confirmed that similar changes could take place in man [3, 16, 17, 18, 25, 27, 33, 34]. Without any doubt the new water soluble contrast media for myelography may produce arachnoiditis, and at the same time they make the diagnosis of arachnoiditis easier by the diagnostic improvement introduced. It is clearly demonstrated from this material that there might be many different causes for arachnoiditis in the lower lumbar sac (Table 3). In a rather high percentage myelography can be excluded as a cause. The relation of operation and myelography within a short time as the possible cause of arachnoiditis is striking, an observation also made by other authors [1, 19,201. It is remarkable that so many of the patients are dissabled, more than 50yo, but not much more than in newer reports on the surgical results of disc hernation [32]. The rather high percentage of symptoms is remarkable, but it must be noted that the material is not comparable to other series of patients with disc herniation because of the long duration and the high frequency of repeated operations and myelographies. Clinically the investigation has disclosed no distinctive complex of symptoms and signs related to the radiographic picture. In some cases new symptoms and signs appeared, possibly caused by the arachnoiditis, but on the whole, little alteration in the location and nature of the symptoms appeared so that the pathological picture had a remittant but slowly progressive course, as often seen in chronic lumbar spine diseases. Table 4. Protein content in spinal fluid in number of patients (elevated protein content >/50 mglml)
Elevated Normal Not informed
Before arachnoiditis was diagnosed
After arachnoiditis was diagnosed
30 31 11
31 32 9
The protein content in the spinal fluid is not helpful in the diagnosis of chronic spinal arachnoiditis (Table
4).
J. J,~rgensen et aI.: Chronic Lower Spinal Arachnoiditis A l t h o u g h it cannot be denied that the persistence of symptoms is caused by the arachnoiditis, it is natural to believe that most of the symptoms are related to the degenerated disc and to the consequences of the previous disc herniation and the operation for the disc herniation. It cannot be excluded that further symptoms will arise although the observation time is rather long. Operative treatment of the &~ronic arachnoiditis has been helpful for the symptoms in a couple of cases where the patients had rather p r o n o u n c e d symptoms and neurological signs and a localised block caused by the arachnoid fibrosis was found, but in most of the cases there was no i m p r o v e m e n t and in six of these cases later m y e l o g r a p h y disclosed a much worse myelographic picture. To prevent arachnoiditis, some authors have used intraspinal cortisone, which also has been mixed with contrast for myelography, [1, 9, 10] but according to Ahlgren no effect was obtained.
Conclusion It is w o r t h y of note that there is a variety of possible causes of chronic arachnoiditis in the lower part of the spinal canal. M o r e o v e r there is no clinical and symptomatical c o r r e s p o n d a n c e to the radiological and surgical picture of the arachnoiditis. I n the few cases where arachnoiditis, without doubt, is playing a role in the pathological picture, this cannot be distinguished f r o m other chronic diseases in the lower spinal canal. In the m a j o r part of the group it is impossible to distinguish between the symptoms before and after the arachnoiditis arose. These symptoms correspond to what is f o u n d in patients with chronic lumbar diseases. A strict indication has to be r e c o m m e n d e d for introducing drugs (including contrast media) into the spinal canal and for other injuries to the spinal canal as, for example, operation. Repeated injuries should be avoided.
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