---------------- Begin Forwarded Message ----------------
Date: 11/06 11:39 am
Received: 11/06 4:25 pm
From: Sarah Smith, [log in to unmask]
To: James Carroll, [log in to unmask]
James,
Please could you forward on the following:(I have already e-mailed Dr.Sood)
Many thanks,
sarah
Copy of e-mail to Dr. Sood:
Dear Dr. Sood,
In answer to your question about back pain after spinal anesthesia:
no it isn't coincidental.
I am a doctor in UK researching arachnoiditis and have just completed a
paper about it that you can access at the following website:
http://homepages.nildram.co.uk/~backtalk/
follow the Arachnoiditis Trust link.
the section you will find of interest is entitled "Iatrogenic Aspects of
arachnoiditis"
Briefly,I will copy some of it for you:
Epidural anaesthetics are another group of drugs implicated in causing
arachnoiditis. (See below). Vandermeulen () includes arachnoiditis as a
"mishap"… "solely due to … epidural anaesthesia". Haisa et al () state that
lumbar adhesive arachnoiditis should be considered for differential
diagnosis of back and leg pain after epidural anaesthesia.
Furthermore, epidural anaesthesia may cause subarachnoid cysts or cavities,
which are also recognised complications of arachnoiditis. (See below)
If the epidural space is already compromised by disc herniation, stenosis or
epidural fibrosis, the risk is greater. Yuen et al () state that
neurological complications " may be more severe in the presence of spinal
stenosis".
Rocco et al () in a study of pressure gradients in the epidural space,
concluded that as resistance to inflow of fluid was significantly higher in
the diseased epidural space, "spread of anesthetics might be difficult to
predict".
In 1955, Hurst conducted studies on monkeys (), which demonstrated that a
wide range of chemicals, when introduced into the CSF, produced an immediate
pathological response, which "proceeds steadily to its termination". The
early stages are asymptomatic, but after a latent period, the clinical
picture is then one of "severe and progressive signs and symptoms". This is
similar to the picture in arachnoiditis, and therefore all short-term
studies (which make up the majority of the evidence concerning safety of
ESI) will fail to address the issue of arachnoiditis, which tends to occur
after an indeterminate interval following exposure.
PRESERVATIVES IN SPINAL INJECTIONS
In 1975, Kelly et al () wrote a paper describing the neuropathological
effects of intrathecal water. They concluded that infusion of distilled
water intrathecally could cause distinctive lesions of spinal roots and
cord.
It follows therefore, that if a substance as inert as water can cause
damage, that more complex preparations are likely to carry some risk also.
As early as 1954, Moore () advised that local anaesthetic administered
epidurally should be free of preservatives.
Malinovsky () suggests that "neurotoxicity can result from decrease in
neuronal blood supply, elicited by high concentrations of the solutions,
long duration exposure to local anaesthetics, and the use of adjuvants."
Some authors suggest that arachnoiditis occurs as a result of the
vasoconstrictive component of the anaesthetic, whilst others say that
contaminants () or preservative agents are responsible.
It must be stressed that ANY drug preparation injected in to the spine, may
contain preservatives such as benzyl alcohol, polyethylene glycol, and
chlorobutanol (a derivative of chloroform) and that these carry a risk of
neurotoxic effects. Another preservative that can cause reaction is sodium
bisulfate, which may trigger a severe allergic reaction if the patient is
susceptible (and it is unclear how many of the general population may be
susceptible).
Burm () states that epidural anaesthesia results from the interactions of
local anaesthetics with nerve structure within the subarachnoid space, which
they reach by uptake into the epidural fat and via systemic absorption, and
that consequently, epidural doses need to be much higher than spinal doses.
Bearing this in mind, it is unsurprising that there is evidence that
epidural anaesthetic agents such as those used in childbirth also carry a
risk of neurological damage.
COMPLICATIONS OF ADHESIVE ARACHNOIDITIS
1.Subarachnoid cysts 2.Syringomyelia 3.Communicating hydrocephalus
1. Subarachnoid cysts: These are a recognised complication of arachnoiditis,
in particular that caused by myelographic dyes or epidural anaesthesia. ()
They tend to be more common in the thoracic region than cervical or lumbar.
REFERENCES:
Vandermeulen E, Gogarten W, Van Aken H Anaesthetist 1997 Sep;46 Suppl 3:
S179-S186 [Risks and complications following peridural anesthesia]
Haisa t, Todo T, Mitsui I, Kondo T Neuro Med Chir(Tokyo) 1995
Feb;35(2):107-9 Lumbar adhesive arachnoiditis following attempted epidural
anesthesia—case report
Yuen EC, Layzer RB, Weitz SR, Olney RK Neurology 1995 Oct; 45(10): 1795-801
Neurological complications of lumbar epidural anesthesia and analgesia.
Rocco AG, Philip JH, Boas RA, Scott D Reg Anesth 1997 Mar-Apr; 22(2):167-77
Epidural space as a Starling resistor and elevation of inflow resistance in
a diseased epidural space.
Hurst E, Weston J. Pathol Bacteriol 1955 38(70): 167-178 Adhesive
Arachnoiditis and Vascular Blockage Caused by Detergents and other Chemical
Irritants: An Experimental Study.
Kelly JM, Asbury AK, King JS J Neuropathol Exp neurol 1975 Sep; 34(5):
388-400 Neuropathological effects of intrathecal water.
Moore DC, Hain RH JAMA 1954 156: 1050-1053 Importance of the perineural
spaces in nerve blocking
Malinovsky JM, Pinaud M Ann Fr Anesth Reanim 1996; 15(5): 647-58
[Neurotoxicity of intrathecally administered agents.]
Sghirlanzoni A, Marazzi R, Pareyson D, Olivieri A, Bracchi M Anaesthesia
1989 Apr;44(4):317-21 Epidural anaesthesia and spinal arachnoiditis
Sklar EM, Quencer RM, Green BA, Montalvo BM, Post MJ Radiology 1991 Nov;
181(2): 549-554 Complications of epidural anesthesia: MR appearance of
abnormalities.
Burm AG Clin Pharmacokinet 1989 May; 16(5): 283-311 Clinical
pharmacokinetics of epidural and spinal anaesthesia.
Torres D, Bauso Toselli L, Vecchi E, Leiguarda R, Doctorovich D, Merello M,
Guevara J, Nogues M Medecina (B Aires) 1993;53(50):391-396 [Spinal
arachnoiditis as a complication of peridural anesthesia]
Sklar EM, Quencer RM, Green BA, Montalvo BM, Post MJ Radiology 1991
Nov;18(2):549-554 Complications of epidural anesthesia: MR appearances of
abnormalities
Nogues MA, Merello M, Leiguarda R, Guevara J, Figari A Eur Neurol
1992;32(2):99-101 Subarachnoid and intramedullary cysts secondary to
epidural anesthesia for gynecological surgery
Tseng SH, Lin SM Clin Neurol Neurosurg 1997 Dec; 99(4): 256-8 Surgical
treatment of thoracic arachnoiditis with multiple subarachnoid cysts caused
by epidural anesthesia.
I hope this is of some help in answering your question. Chemically-induced
arachnoiditis causes not only back and leg pain of a neuropathic type, but
also other neurological deficits including bladder dysfunction as well as
more systemic effects such as heat intolerance, sweating (and other
autonomic effects) and may result in an auto-immune type picture.(skin
rashes, joint pains,raised ESR/WCC etc.)
Please do not hesitate to contact me if you would like further
information.You mention that you are seeing a number of patients with back
pain following spinal anesthetic: what sort of numbers are you talking
about?
Yours,
Sarah Smith (MB BS)
Patron of the Arachnoiditis Trust
PS. To members of the physio group: If you have any contact with patients
with arachnoiditis or indeed persistent low back pain after spinal
anesthetic/epidural steroid injection/ myelogram(the latter may have
occurred several years previously) I would be grateful if you could contact
me : e-mail address: [log in to unmask]
Thanks!
-----Original Message-----
From: James Carroll <[log in to unmask]>
To: Sarah Smith <[log in to unmask]>
Date: 10 June 1999 22:58
Subject: Re: BACK- PAIN:After Spinal Anaesthesia
>you wamt me to post a reply or make a request of the list
>
>give me the words and I'll post it to the list
>
>
>
>Sarah Smith 10/6/99 7:31 pm [log in to unmask]
>
>>Sure is what I'm looking for James, but no, I haven't heard from Kevin.
>>Thanks for passing the info. : any more you see, chuck it my way!!
>>Regards,
>>Sarah
>>-----Original Message-----
>>From: James Carroll <[log in to unmask]>
>>To: Sarah Smith <[log in to unmask]>
>>Date: 10 June 1999 19:08
>>Subject: Fwd: BACK- PAIN:After Spinal Anaesthesia
>>
>>
>>>did kevin moore call you yet ?
>>>
>>>
>>>is this the kind of thing you are interested in ?
>>>
>>>It is off a physio discussion list
>>>
>>>
>>>---------------- Begin Forwarded Message ----------------
>>>Date: 10/06 12:33 pm
>>>Received: 10/06 2:02 pm
>>>From: sood, [log in to unmask]
>>>Reply-To: Physio list, [log in to unmask]
>>>To: Physio list, [log in to unmask]
>>> [log in to unmask]
>>> [log in to unmask]
>>>
>>>Dear Friends,
>>> We are seeing lot of patients ,who report
>>>with back pain after having spinal anaethesia ,I seek opinion of the
>>>house for any relevance,or is it just a coincidence.
>>> thanking you in advance
>>>
>>>----------------- End Forwarded Message -----------------
----------------- End Forwarded Message -----------------
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