MEDICAL PROTOCOL FOR ARACHNOIDITIS

Transcription

1 MEDICAL PROTOCOL FOR ARACHNOIDITIS c arachnoiditis education project METHOD OF Forest Tennant M.D., Dr. P.H. Veract Intractable Pain Clinic 338 S. Glendora Ave. West Covina, CA Fax: veractinc@msn.com Websites: May 1, rd Edition This protocol should only be used on patients who have constant spinal pain, impairment of standing, sitting, or lower extremity function, and MRI evidence of cauda equina, nerve root neuroinflammation and adhesions. THE ARACHNOIDITIS PROJECT IS A PUBLIC SERVICE OF THE TENNANT FOUNDATION 1

2 c arachnoiditis education project PROTOCOL COMPONENTS AND GOALS This regimen or protocol is comprised of 4 major components: 1. Control of Neuroinflammation 2. Exercises to Prevent and Break-Up Adhesions 3. Pain Relief 4. Neuroprotection and Neurogenesis (nerve growth) The primary goals of the protocol are: 1. Provide enough pain relief to function and have a quality of life 2. Stop progression of the disease including pain flares 3. Reverse some neurologic impairments THIS PROTOCOL IS INTENDED FOR USE IN AMBULATORY, PRIMARY CARE SETTINGS. THE ARACHNOIDITIS PROJECT IS A PUBLIC SERVICE OF THE TENNANT FOUNDATION 2

3 CONTROL OF NEUROINFLAMMATION COMPONENT NO. 1 A. Ketorolac (Toradol ) injection IM mg once weekly and prn severe pain flares B. Methylprednisolone 4 to 8 mg PO or Prednisone 5 to 10 mg PO (Take at 3:00-4:00 PM on 3 to 5 days a week) C. One or two of the following: 1. Acetazolamide (Diamox ), 75 to 250 mg daily -5 days a week 2. Pentoxifylline (Trental ), 400 to 800 mg daily -5 days a week 3. Minocycline, 100 to 200 mg daily -5 days a week 4. Indomethacin (Indocin ), 25 to 50 mg PO with food 3 to 5 days a week Monitor effectiveness by normalization of erythrocyte sedimentation rate (ESR) and/or C-Reactive Protein (CRP), symptom control of heat/sweating episodes, and pain flares. Periodically assess renal and liver function, gastrointestinal bleeding, and other side-effects, and stop any medication with sideeffects. Long-term control of neuroinflammation may or may not require all measures listed here. COMPONENT NO. 2 EXERCISES TO PREVENT AND BREAK-UP NERVE ROOT ADHESIONS A. Stretching/ Range of Motion 1. Straight let raising lying down or standing 2. Bend knees and bring legs to abdomen 3. Foot flexing 4. Arm stretch upward over head 5. Bend forward gently 6. Rock back and forth on feet (heel/toe) B. Walking: daily outside house for at least ½ a block C. Motions to increase spinal fluid flow: daily, do one or more of the following for 5 or more minutes 1. Rock in a rocking chair or swing 2. Trampoline walking 3. Power walking/swing arms D. Optional: water soaking/wading THE ARACHNOIDITIS PROJECT IS A PUBLIC SERVICE OF THE TENNANT FOUNDATION 3

4 COMPONENT NO. 3 PAIN RELIEF: Use agents from multiple categories for best response. Starting doses are given. They are low as arachnoiditis patients may be very sensitive to medications. An agent from every category may not be needed. A. Neuropathic Agents (Choose 1 or 2 agents, if no sedation) Starting Dose 1. Pregabalin (Lyrica ) 50 mg TID 2. Topirimate (Topamax ) 25 mg BID 3. Diazepam (Valium ) 2 mg BID 4. Duloxetine (Cymbalta ) 20 mg BID 5. Gabapentin (Neurontin ) 100 mg TID 6. Baclofen (Lioresal ) 5 mg TID 7. Carisoprodol (Soma ) 350 mg BID 8. Tizanidine (Zanaflex ) 2-4 mg TID B. N-Methyl-D-Asparate Receptor Antagonist (Choose One) 1. Ketamine 15 to 25 mg sublingual or oral BID 2. Methadone 5 mg BID to QID 3. Dextromethorphan mg daily (Mucinex DM, Delsym ) 4. Pregnenolone 100 mg daily C. Opioids Any available opioid(s) given by any route or dosage that provides enough pain relief to perform exercises, carry out activities of daily living, and minimize bed-couch bound hours. Tramadol should be attempted in all patients as it has microglial suppressing effects. If the patient is not on opioids, low dose naltrexone can be a very effective analgesic. Starting dose is 1 to 4 mg a day. D. Sleep-Aid (Choose One) 1. Zolpidem (Ambien ) mg HS 2. Temazepam (Restoril ) mg HS 3. Practitioner choice Melatonin, 3 to 10 mg is a good adjunct. E. Topical Agents (One or more. Apply as needed) 1. Lidocaine/Prilocaine gel 2. Lidocaine patch 3. Carisoprodol 700 mg in 1 ounce of cream or gel 4. Morphine 90 mg in 1 ounce of base cream or gel 5. Any other single or multi-agent topical that has been found to provide relief SEVERE FLARE TREATMENT 1. Wear brace 2. Topical lidocaine 3. Injection, Choice of: a. Ketorolac mg IM b. Meperidine mg IM c. Hydromorphone 2-4 mg IM 4. Methylprednisolone 4 mg-6 day dose pak F. Adrenergic Agent for Descending Pain (Choose One) Dose 1. Methylphenidate (Ritalin ) 5-10 mg BID 2. Amphetamine/dextroamphetamine Salts (Adderal ) 5-10 mg BID 3. Dextroamphetamine 5-10 mg BID 4. Other adrenergic agent practitioner choice THE ARACHNOIDITIS PROJECT IS A PUBLIC SERVICE OF THE TENNANT FOUNDATION 4

5 COMPONENT NO. 4 NEUROPROTECTION AND NEUROGENESIS (NERVE GROWTH) A. Hormone Replacement Replace with low doses if serum testing shows a deficiency: CORTISOL PREGNENOLONE DEHYROEPIANDROSTERONE (DHEA) THYROID ESTRADIOL PROGESTERONE TESTOSTERONE Maintain replacement until serum levels return to normal. Long-term maintenance may be necessary. B. Neuronutrients 1. Vitamin B Provider Choice: fatty acids, taurine, glutamine, vitamin B, C, D, carnitine, CQ-10, tumeric C. High Protein Diet D. Options 1. Human chorionic gonadotropin: starting dose is 250 to 500 units sublingual or injection on 3 days a week 2. Oxytocin: starting dose is 20 to 40 units sublingual or nasal on 3 days a week 3. Pulsed radiofrequency electromagnetic energy (Provant or other): apply for 15 to 30 minutes over affected area. Use once or twice a day and continue as long as patient experiences increased extremity range of motion, relaxation, and/or pain reduction following a treatment. THE ARACHNOIDITIS PROJECT IS A PUBLIC SERVICE OF THE TENNANT FOUNDATION 5

6 SPECIAL NOTES RELATIVE TO THIS ARACHNOIDITIS PROTOCOL 1. While once considered a rare disease the incidence of arachnoiditis has increased at least 400% in the past decade, and it is now being commonly recognized throughout the Country. 2. Arachnoiditis is a neuroinflammatory process involving nerve roots of the cauda equina and the arachnoid lining of the thecal sac. It may be a progressive, crippling disease that can produce lower extremity paralysis, bladder and bowel dysfunction, inability to sit or stand very long, excruciating pain, dementia, and systemic autoimmune symptoms that may mimic rheumatologic disorders. Due to its severe impairments and potential for progression, the clinical protocol required to treat it is aggressive, potent, and carries some risks that must be explained to the patient and family. 3. This protocol has been developed by trial and error in treating over 100 documented patients. Over 200 MRI s in documented cases have been reviewed. 4. The control of neuroinflammation is quite different than the control of peripheral inflammation. The agents used in this protocol to control neuroinflammation have been shown in animal studies to suppress neuroinflammation. (References available on request.) Most agents that control neuroinflammation carry a risk of complications. Consequently, ketorolac, indomethacin, and methylprednisolone are not used on a daily basis. 5. Specific exercises are deemed a critical part of this protocol, since a failure to exercise may allow the inflamed nerve roots in the cauda equina to form additional adhesions, scarring, and produce permanent paralysis and other neurologic deficits. 6. It is recognized that the neurogenic component is neither well-known nor universally accepted. In our hands, we have witnessed the neurogenic component reverse some neurologic deficits caused by arachnoiditis. EMERGENCY TREATMENT FOR ARACHNOIDITIS Emergency treatment should be provided to any patient who develops severe pain, low extremity weakness or paralysis, headache, and bladder dysfunction immediately after: (1) epidural anesthesia; (2) spinal tap; (3) para-spinal intervention; or (4) spinal surgery. 1. Methylprednisolone 80 mg IM for 3 consecutive days. 2. Ketorolac mg IM for 3 consecutive days. 3. Injections of hydromorphone (2 to 4 mg) or meperidine (50 to 100 mg) prn for severe flares. 4. Acetazolamide 75 to 250 mg a day. 5. Minocycline 100 to 200 mg a day. 6. Any oral opioid for prn pain relief. Transition to the long-term protocol given here. THE ARACHNOIDITIS PROJECT IS A PUBLIC SERVICE OF THE TENNANT FOUNDATION 6