What is the treatment for adhesive arachnoiditis?

Treatment of Adhesive Arachnoiditis

Adhesive arachnoiditis has no curative treatment, and management focuses on symptom control with corticosteroids for acute inflammation, pain management, and rehabilitation, while avoiding surgical lysis of adhesions due to inevitable recurrence and lack of long-term benefit. 1, 2, 3

Primary Treatment Approach

Medical Management (First-Line)

Corticosteroids for acute/early disease:

• High-dose intravenous methylprednisolone should be initiated immediately in patients with acute or early-stage adhesive arachnoiditis (disease duration <1 month), as this represents the only window where full recovery may be possible 2, 4
• For chronic cases (>1 year duration), corticosteroids show minimal to no benefit and should not be expected to reverse established adhesions 2
• Corticosteroids are recommended for patients with spinal cord dysfunction (paraparesis, incontinence) to reduce inflammation and prevent further neurological deterioration 5, 1

Steroid-sparing agents for prolonged therapy:

• Methotrexate should be considered when patients require extended anti-inflammatory therapy to minimize corticosteroid toxicity 5, 1
• However, methotrexate has shown poor efficacy in chronic adhesive arachnoiditis cases lasting several years 2

Pain management:

• Non-steroidal anti-inflammatory drugs (NSAIDs) for symptomatic relief, though avoid in patients with inflammatory bowel disease 1, 4
• Alpha lipoic acid and B vitamins may provide adjunctive neuropathic pain relief 4
• Preemptive oral analgesia should be provided before any interventional procedures 6

Surgical Considerations

Surgery should generally be avoided:

• Microscopic lysis of adhesions produces only short-term improvement (weeks to months) with inevitable reaccumulation of scar tissue and symptom recurrence 3
• A 1978 long-term study definitively concluded that surgical lysis should not be performed due to lack of methods preventing adhesion reformation 3
• Only 60% of patients show any improvement with surgery, and many experience no benefit 2

Limited surgical indications:

• Shunt surgery is recommended only when hydrocephalus develops from subarachnoid involvement 5, 7
• Surgical debulking may be considered in highly selected cases with localized, accessible adhesions causing severe cord compression 5
• When tethered cord syndrome develops from adhesive arachnoiditis, surgical untethering is indicated for progressive neurological deficits, bladder/bowel dysfunction, or worsening pain 1

Rehabilitation and Supportive Care

Physical therapy is essential:

• Intensive rehabilitation should be initiated early, as it provided the only measurable improvement in a fulminant case with severe paraparesis 8
• Physical and occupational therapy should focus on maintaining function and preventing contractures 1

Multidisciplinary monitoring:

• Collaborative management should include neurosurgery, urology (for bladder dysfunction), orthopedics (for musculoskeletal complications), and pain management 1
• Serial MRI of the spine is necessary for monitoring disease progression, particularly in patients receiving intrathecal therapies 1, 4

Prevention Strategies

Avoid iatrogenic causes:

• Use only absorbable, non-irritative contrast materials (such as Iohexol) for myelography, as non-absorbable agents like Pantopaque are major causative factors 9
• Ensure complete drying of chlorhexidine-alcohol skin antiseptic before neuraxial procedures to prevent neurotoxic contamination 5, 6
• Use 0.5% chlorhexidine in alcohol (not 2%) for skin preparation before spinal procedures to minimize neurotoxicity risk while maintaining infection control 5
• Minimize repeat spinal surgeries when possible, as multiple operations increase arachnoiditis risk 9, 3

Monitoring for high-risk patients:

• Scheduled MRI of the lumbosacral spine should be incorporated into monitoring algorithms for patients receiving intrathecal therapies (nusinersen, baclofen, chemotherapy) 1, 4
• Children with myelomeningocele require heightened surveillance for adhesive arachnoiditis and inclusion cysts 1

Critical Clinical Pitfalls

Timing is everything:

• The most critical error is delaying treatment beyond the acute phase (>1 month), as chronic adhesive arachnoiditis (>1 year) shows virtually no response to immunotherapy 2
• Performing surgery during active inflammation worsens outcomes; delay intervention until disease quiescence when surgery is absolutely necessary 1

Recognize irreversible complications:

• Long-standing orthopedic deformities will not improve even with successful surgical intervention, so prevent them through early aggressive management 1
• Severe neurological disability with profound flaccid paraparesis may be irreversible despite treatment, as demonstrated in fulminant cases 8

Avoid ineffective therapies:

• Plasmapheresis has shown no benefit in chronic adhesive arachnoiditis 2
• Surgical lysis of adhesions should not be offered as it provides no long-term benefit and symptoms inevitably recur 3

Prognosis and Expectations

Set realistic expectations:

• Conservative treatment and rehabilitation typically produce only small clinical improvements in established disease 8
• Patients with disease duration of several years show minimal to no response to immunotherapies 2
• The condition causes progressive neurological disability with profound paraparesis, bladder dysfunction, and unbearable pain in severe cases 8, 9
• Early intervention (within 1 month of symptom onset) offers the only realistic chance of full recovery 2