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British Journal of Anaesthesia 93 (2): 3017 (2004)

Chronic adhesive arachnoiditis
EditorThe review on the topic of chronic adhesive arachnoiditis (CAA) from obstetric epidurals by Rice and colleagues1 was apparently triggered by a series of articles that appeared in one of the London tabloids, fostered by some of the members of the Arachnoiditis Trust. These articles were unreasonable to many of us that remember the statistics of maternal deaths in the 1970s in the UK,2 when general anaesthesia was the predominant form of analgesia; aspiration of gastric contents and difculty with tracheal intubation were the main culprits. I also feel that it is the right of women in labour to ask for pain relief, and anaesthetists ought to provide it for them. But we cannot deny that neuroaxial anaesthesia produces morbidity and that neurological decits are probably one of the most serious. Unfortunately, the authors of the review lost the opportunity to assess the subject of neurological decit and arachnoiditis (ARC) after epidural anaesthesia. Instead of being impartial, they attempted to prove that adhesive arachnoiditis does not happen as frequently as the patrons of the Trust claimed it did and, when it does occur, they dismissed it as irrelevant. Allow me to say for the record, that I do not belong to the Arachnoiditis Trust and I do not agree with their attempt to ban epidural anaesthesia for women in labour. Properly executed, epidural analgesia is, at the present time, the safest approach. However, by focusing mostly on the old concept of CAA, the authors of the review failed to recognize that ARC is an integral feature in most injuries to the intrathecal neural structures resulting in a variety of neurological decits occurring after spinal interventions.3 4 These causes include: myelograms; spinal or epidural anaesthesia; invasive pain relief procedures; infections and blood entering the cerebrospinal uid (CSF) from epidural blood patches; haematomas; trauma; or spinal operations. The arachnoid is now recognized as an active organ that responds to any invasion by initiating an inammatory response proportional to the degree of injury. This reaction lasts $2 months; if not treated, it may progress into a chronic proliferative phase in which scarring, brosis and adhesions become permanent.4 These two phases are distinctly identied in radiological images with enhanced or oedematous nerve roots,5 located in the anterior half of the dural sac with the appearance of stars (Fig. 1) in the inammatory phase and clumped nerve roots3 4 6 forming bizarre patterns adhering to each other and to the dural sac, in the chronic proliferative phase (Fig. 2). Concerning the recognition of symptoms typical of ARC, Rice and colleagues1 listed in Table 1 vague symptoms described in a list of publications before 1992; no mention was made specically of the severe, continuous, burning pain in the lower back and extremities, accompanied by dysaesthesia and muscle spasms, as well as bladder, bowel and=or sexual dysfunction, which are all frequent manifestations of this disease. No reference was made to the burning characteristic implying neuropathic pain, as this concept had not yet been understood in that period. The injury may be traumatic from needle tips,7 8 catheters,9 dural tears,10 etc. or chemical from such substances as lidocaine 5%,11 2-chloroprocaine 3%,12 Myodil,13 neurolytics,14 blood,15 etc. There were also some inconsistencies present in this review. There were nine previous publications describing similar lesions in the literature, before the 1909 article by Victor Horsley was published.16 The diagram on p. 110 of Rices paper1 was taken (with permission) from a 1972 publication; much has been found since then about the anatomy of the spinal meninges; the arachnoid has indeed two layers with the CSF in between them, but the spinal cord does not occupy 90% of the dural sac as represented in their Figure 1. The authors quoted Long17 stating that less than 1000 cases of arachnoiditis have been reported in the 50 years prior to 1992; this is incorrect as it did not include Eastern European, Latin American or Asian publications. In 14 yr, I have obtained the medical history, examined and reviewed all the radiological studies in 374 patients with conrmed ARC; however, the incidence of a disease cannot be determined by the number of cases reported in the literature, nor by insurance claims or by mail surveys, especially in a disease with a high degree of iatrogenicity, which hampers accurate reporting.17 18 The authors cited a 1964 reference (no. 108) noting that local anaesthetics cross the dura; more recently, elegant studies done by Bernards and colleagues19 have found that this passing is selective and that they are not transported by the arachnoid villi at the dural cuff,20 nor through the radicular arteries.21 Current understanding suggests that an arachnoiditic process is part of most post-interventional neurological decits such as the cases of cauda equina syndrome after spinal or epidural anaesthesia.8 22 The most common radiological nding is clumped nerve roots (Fig. 2), but the empty sac syndrome, deformity of the dural sac, intrathecal calcication, and brosis are also forms of arachnoiditis,8 6 17 23 as well as some cases of syringomyelia caused by needle puncture,7 and postlaminectomy pseudomeningoceles.2 Cauda equina lesions may be recognized by obtaining coronal views in MRI.6 22 In essence, the authors searched for the subject adhesive arachnoiditis and found the citations to the old cases of constrictive pachymeningitis after repeated intrathecal injections of dyes or steroids, infection or multiple surgical procedures. With the diagnostic tools at hand, specically MRI, and CAT scan postmyelogram (Figs 1 and 2), the diagnosis of ARC can be made promptly. If it is in the inammatory phase, treatment may prevent ARC from progressing into the chronic proliferative stage.4 6 By emphasizing old concepts, they missed the chance to impartially analyse the subject and give an important message that would advance everyones knowledge. J. A. Aldrete Birmingham, AL, USA EditorWe would like to thank Dr Aldrete for his letter regarding our review article,1 supported by a large volume of his own work. We would like to make it clear that, whilst our concern about CAA after obstetric epidurals was initially aroused owing to articles by the Arachnoiditis Trust, it is because we realize that: (i) epidural intervention may have an effect on the arachnoid mater, and (ii) that a link between CAA and obstetric epidurals as claimed by the Arachnoiditis Trust would have devastating clinical implications for the women and the practice of obstetric regional analgesia and anaesthesia, that we constructed our review. We do not dismiss CAA as irrelevant in any way. As Aldrete correctly points out, the remit of our review was to nd a link betweenCAA andobstetricepidurals.Wewouldlike toreassure him that we undertook this task with an open mind and reject his accusation of our partiality. We conducted a thorough and impartial review of all the evidence published in peer-reviewed journals. We are not the only reviewers who have failed to nd a link between CAA or indeed arachnoiditis and obstetric epidurals.24 26 However, we did report on the few specic cases of CAA directly related to epidural anaesthesia from 1983 to 2000 in Table 2 of our review.1 We were interested to read of Aldretes

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The Board of Management and Trustees of the British Journal of Anaesthesia 2004


Fig 1 Computer axial tomography, post myelogram showing enhanced nerve roots, located abnormally (arrow) on the anterior (upper) half of the dural sac, which have become deformed from a combination of a broadly herniated intervertebral disc, spondylosis and ligamentum avum hyperthrophy.

Fig 2 Computer axial tomography, post myelogram depicting clumped nerve roots (arrow) in the middle of the thecal sac (proliferative phase) at L3L4 level.

personal series of 374 patients with arachnoiditis and wondered how many were related to obstetric epidurals; unfortunately, this has not been reported or published. Table 1 in our review referred to a summary of the symptoms reported in CAA and not early changes of arachnoiditis as it was referred to by Aldrete. We would also disagree with Aldrete in his interpretation of Reynolds report8 that an arachnoiditic process was involved in the conus damage during spinal anaesthesia. Direct trauma, as evidenced by a syrinx in the conus, was the cause. We have conrmed this with Prof. Reynolds. We are glad that Aldrete agrees with us that in the light of current evidence, we should not withhold regional analgesia from women in labour, and also that he supports our conclusion that a full clinical examination and MRI investigation will help in the detection and diagnosis of arachnoiditis in obstetrics. I. Rice1 M. Y. K. Wee2 K. Thomson3 1 Isle of Wight, UK 2 Poole, UK 3 Basingstoke, UK

1 Rice I, Wee MYK, Thomson K. Obstetric epidurals and chronic adhesive arachnoiditis. Br J Anaesth 2004; 92: 10920 2 Morris S, Harmer M, Reynolds F. The impact of regional anaesthesia on maternal mortality. In: Reynolds F, ed. Regional Anaesthesia in Obstetrics. London: Springer-Verlag, 2000; 34756 3 Aldrete JA, Ghaly RF. Postlaminectomy pseudomeningocele: an unexpected cause of low back pain. Reg Anesth 1995; 20: 759 4 Aldrete JA. Anatomopathology. In: Aldrete JA, ed. Arachnoiditis: the Silent Epidemic. Denver: Futuremed, 2000; 718 5 Avidan A, Gomari M, Davidson E. Nerve root inammation demonstrated by MRI in a patient with transient neurological symptoms after intrathecal injection of lidocaine. Anesthesiology 2002; 97: 2578 6 Aldrete JA, Brown TL. Laboratory and radiological diagnosis. In: Aldrete JA, ed. Arachnoiditis: the Silent Epidemic. Denver: Futuremed, 2000; 22152 7 Aldrete JA, Ferrari H. Myelopathy with syringomyelia following thoracic epidural anaesthesia. Anesth Intensive Care 2004; 323: 1003 8 Reynolds F. Damage to the conus medularis following spinal anasthesia. Anaesthesia 2001; 56: 23847 9 Aldrete JA, Vascello LA, Ghaly RF, Tomlin D. Paraplegia in a patient with an intrathecal catheter and a spinal cord stimulator. Anesthesiology 1994; 81: 15425 10 Goodkin R, Laska LL. Unintended incidental durotomy during surgery of the lumbar spine: medicolegal implications. Surg Neurol 1995; 43: 414 11 Snyder R Hui G, Flugstad P, et al. More cases of possible neurologic toxicity associated with single subarachnoid injections of 5% hyperbaric lidocaine. Anesth Analg 1994; 78: 41113 12 Reissner LS, Hachman BL, Plummer HL. Persistent neurologic decit and adhesive arachnoiditis following intrathecal 2chloroprocaine injection. Anesth Analg 1994; 78: 41113 13 Aldrete JA, Brown TL. Myelography. In: Aldrete JA, ed. Arachnoiditis: the Silent Epidemic. Denver: Futuremed, 2000; 4964 14 Aldrete JA, Zapata JZ, Ghaly RF. Arachnoiditis following epidural adhesiolysis with hypertonic saline. Pain Digest 1996; 6: 36870 15 Aldrete JA, Brown TL. Intrathecal hematoma and arachnoiditis after prophylactic blood patch through a catheter. Anesth Analg 1997; 84: 2334 16 Aldrete JA. Historical perspective. In: Aldrete JA, ed. Arachnoiditis: the Silent Epidemic. Denver: Futuremed, 2000; 36 17 Long DM. Chronic adhesive spinal arachnoiditis: pathogenesis prognosis and treatment. Neurosurgery Q 1992; 2: 296319 18 Renk H. Neurologic complications of central nerve blocks. Acta Anaesthesiol Scand 1995; 39: 8598 19 Bernards CM, Hill HF. Morphine and alfentanil permeability through the spinal dura, arachnoid and pia mater of dogs and monkeys. Anesthesiology 1990; 73: 121219 20 Bernards CM, Hill HF. The spinal nerve root sleeve is not a preferred route of redistribution of drugs from the epidural space to the spinal cord. Anesthesiology 1991; 75: 82732 21 Bernards CM, Sorkin LS. Radicular artery blood ow does not distribute fentanyl from the epidural space to the spinal cord. Anesthesiology 1994; 80: 8728 22 Diaz JH. Permanent paraparesis and cauda equina syndrome after epidural blood patch for postdural puncture headache. Anesthesiology 2002; 96: 151517 23 Aldrete JA. Neurologic decits and arachnoiditis following neuroaxial anesthesia. Acta Anaesthesiol Scand 2003; 47: 312

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24 Douglas J, Choi D. Immediate complications of regional blockade in obstetrics. In: Reynolds F, ed. Regional Analgesia in ObstetricsA Millennium Update. London: Springer-Verlag, 2000; 185303 25 Holdcroft A. Long term neurological sequelae of childbirth. In: Reynolds F, ed. Regional Analgesia in ObstetricsA Millennium Update. London: Springer-Verlag, 2000; 33346 26 Loo CC, Dahlgren G, Irestedt L. Neurological complications in obstetric regional anaesthesia. Int J Obstet Anesth 2000; 9: 99124 DOI: 10.1093/bja/aeh591

Anaesthetists understand their work in different ways

EditorWe read with interest the investigation by Larsson and colleagues1 reporting their qualitative study of how trainee anaesthetists understand their work. We congratulate them on their decision to pursue this type of enquiry. Only by addressing those aspects of anaesthetic expertise, which cannot be set out in syllabuses and measured as competencies, can a true picture of the complexity of our work be drawn. We have a few questions and would be interested to read the authors responses. First, we liked the categories that the data suggested, but we wondered if the authors had thought of arranging them into any sort of hierarchy? (We note that they did so with the four categories which they used for experienced anaesthetists in their previous study.2) In the Lancaster expertise study3 we found that, as trainees gain experience, they seem to move from one level of understanding to another, which is not completely separate but rather incorporates and builds on what went before. Hence we suggest, in contrast to the ndings of Larsson and colleagues, that changes to more comprehensive ways of understanding do in fact take place over time and this is brought about by the developing relationship between tacit and explicit knowledge. Furthermore, we would challenge the authors assertion that their category Fwhere experience from patients is used to learn new thingsis exclusive to trainees. One of our unexpected ndings was the importance which fully-formed experts attach to the potential for continuing learning from working with colleagues.3 In the UK, there are moves to train non-physicians to administer anaesthesia. Central to this debate is the problem of how such practitioners might work, not only in the practical limits to their activities, but also in how they understand and conceptualize their work. We note that the rst of Larsson and colleagues transcripts refers to a trainee supervising a nurse and how he=she recognized when the nurse had a problem. We recognize that this is not directly within the scope of their work, but to what extent would the authors expect to see the same breadth of understanding in a nurse anaesthetist? Finally, we would endorse the authors implication that dening different aspects of the anaesthetists role will help trainees (and specialists) further their understanding. Although not a nding from our study, we have previously attempted to suggest a number of roles or styles related to anaesthetic practice. These are in no particular order and there may of course be others, but we offer them as a further contribution to the conceptualization of anaesthetic work: (i) Craftsman. An anaesthetist who takes pleasure in the simple exercise of his=her hard-won professional skill. (ii) Workhorse. An anaesthetist who sees their role as getting the job done.

(iii) Salesman. An anaesthetist who is not as competent as they can make themselves appear by their clinical behaviour. (iv) Engineer. Someone who thinks mechanistically about the process of anaesthesia, making the patient follow a predetermined plan where possible. (v) Ecologist. Someone who works in response to the individuality of the patient (these last two styles are drawn from Klemolas objectivistic and reactive types4). (vi) Priest. Someone who is aware of the mysteries of anaesthesiathe almost mystical temporary loss of self which although often disregarded by anaesthetists, is of great signicance to patients. (vii) Virtuoso. A true master. A.F. Smith1 D.S. Goodwin1 M.Mort1 C. Pope2 1 Lancaster, UK 2 Southampton, UK EditorWe thank Smith and colleagues for their interest in our study,1 and would like to respond to the points that they have raised. Concerning the structural relationship between the categories of description, we have in a previous study reported the different ways specialist anaesthetists understand their work. We described a work map with the understandings arranged in a hierarchical way.2 In the present study,1 trainee anaesthetists gave expression to four similar ways of understanding work (BE in the article). For the young trainees, anaesthesia work is still a fairly diffuse phenomenon and their ways of understanding are not as clear as those of specialist anaesthetists. We are convinced that the categories in the trainees group are hierarchically related, but this is a result inferred from the previous study. However, understanding A, the novice, was not found among specialist anaesthetists and should be regarded as a lower level of understanding work than understanding B. One result of our two studies is that the novice way of understanding was found only among the trainees. Obviously, young anaesthetists during training move from understanding A to B. They will meet situations were protocol driven anaesthesia will not work and they will be forced to take the step from understanding A to B, after considering the individual patients physiology. In addition, all four types of understanding of the specialists were represented already among trainees, indicating that anaesthetists normally do not change their understanding during years of work. This is in line with the ndings of educational research that competence development preferentially takes place within the connes of present understanding.5 To acquire a new way of understanding, confrontation with anothers meaning (reective dialogue) or meeting a provoking situation is necessary.6 The learner was the predominant way of understanding work for some of the trainees but for none of the specialist anaesthetists. In the phenomenographic method we used, only the predominant ways of understanding the phenomenon in question will be dened. Therefore the learner was not dened as a category in the study on specialist anaesthetists. We agree with Smith and colleagues that many anaesthetists do use experience from patients for learning. The question about nurse anaesthetists is not within the scope of our studies and this part of our answer is my (JL) personal view. I believe that young nurse anaesthetists are, and should be, relying more on protocols and detailed guidelines, whereas experienced nurse anaesthetists can work independently considering the vast amount of tacit knowledge that they express in their work. The anaesthetist should, nevertheless, be very much present in the theatres of which he or she is in charge (usually two or three theatres at a time). This means going in and out at regular intervals, depending on what is going on in theatre and on the nurses experience.

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