Arachnoiditis mimicing acute CES

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Posted by ccf neuro M.D.* on September 13, 1997 at 19:07:09:

In Reply to: Arachnoiditis mimicing acute CES posted by D.White on August 29, 1997 at 23:58:36:
  I am seeking validation for the proposition that postoperative lumbar arachnoiditis can present acutely and mimic CES, with bilateral limb paresthesia, urinary and bladder incontinence.  An MRI taken one month postoperatively shows extensive arachnoiditis.  I have been advised that such a clinical presentation is very unusual, but not unknown.  Could you direct me to clinicians who likely would have experience in dealing with such a case?
  Thank you very much.
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Arachnoiditis is inflammation and subsequent scarring in and around nerve roots as they exit the spinal cord, occurring after back surgery. It is an extremely difficult condition to treat. Although acute inflammation affecting so many roots so quickly is unusual, it is indeed not unheard of, and may be the lower extremity equivalent of a condition known as Parsonage-Turner syndrome, or acute brachial plexitis, or neuralgic amyotrophy, particularly if you end up having wasting or atrophy of leg muscles. Surgery is a common trigger for the former disorder. As of yet, however, no doctor has recognized and proclaimed the existence of a lower extremity (leg) version of this disease, thus it is difficult to diagnose anyone with it. Cauda equina syndrome refers to the signs and symptoms of damage to the nerves of the lower lumbar and sacral spinal nerve roots as they exit the spinal cord (they resemble the tail of a horse, hence the Latin name), and may be due to many causes--- multiple disc herniation, trauma, inflammation, cancerous infiltration (seen only in cases of known, widespread cancer) and on occasion infection of the surrounding disc or vertebral bodies. It is atypical to have prominent bowel and bladder incontinence as part of cauda equina syndrome, as to produce this requires damage to most or all of BOTH sides of the sacral nerves (#s2,3 and 4), which is difficult to do with a single herniated disk for instance; such prominent incontinence is more characteristic of a conus medullaris syndrome, where the very end of the spinal cord is compressed by a mass or disc (at the 1st or 2nd lumbar level); but exceptions do occur, and a diffuse inflammatory process could affect enough sacral nerves to accomplish this.
A test called an EMG can assess the severity of the ongoing damage to affected nerve roots.
If you are interested in a second opinion at the Cleveland Clinic, I would suggest that you see both a neurologist and a neurosurgeon. I would recommend Drs. Shields or Levin or Pioro on the neurology end and Dr. Ian Kalfas, our chief spinal neurosurgeon, on the neurosurgery end of things. If your symptoms are as severe as you describe, as aggressive and expedient a diagnosis and attempts at treatment should be made, especialy on the off chance that this may be another, more treatble condition than arachnoiditis. The phone number of the Cleveland Clinic is 1-800-223-2273. You of course can obtain a second opinion closer to home if Cleveland is far, but I would suggest you do so at a LARGE, TEACHING HOSPITAL, preferably connected to a medical school.
Information provided on the neurology forum is intended for general medical informational purposes only. The actual diagnosis and treatment of your condition, especially in a case as unusual as this, should be strictly in conjunction with your treating physician(s). We hope you find the information helpful.