The following report was commissioned by the
New Zealand Ministry of Health.
Ministry input into the development of the report
was received from Mr Stephen Lungley and Dr Gillian Durham.
Supplementary Observations by Charles V. Burton, M.D.
Editor, Burton Report®
This report, by Peter Day and associates at the Christchurch School of
Medicine, prepared under the auspices of the New Zealand Health Technology
Assessment Clearing House, is a landmark document. This is the first time, in
a century of global medical practice, that any government agency, in any
country, has commissioned a report on this important subject.
The people of New Zealand, The New Zealand Ministry of Health and the
Christchurch School of Medicine are to be complimented for having taken on
this difficult challenge.
Any unbiased review of the subject of arachnoiditis is a difficult task because
of the paucity of prior hard science on the subject. Part of this problem has
been a lack of awareness on the part of the medical profession in general as
well as some of the medical reporting which has reflected hidden agendas
and conflicts of interest not made apparent to their readers. The foundation
for legitimate health care planning is well-performed incidence and
prevalence studies and data. Such have never yet been developed for this
disease entity.
In a manner similar to that demonstrated by the tobacco industry, there has
been an expenditure of many millions of dollars intended to obfuscate and
provide "damage control" by the manufacturers of oil mydogram substances
to thwart their being held responsible, in the legal arena, for their
transgressions against the public. This is also an important part of the
history of the arachnoiditis saga. Today, many of the leading medical
journals require full disclosure, by authors, of any real or potential conflicts
of interest- These requirements were not in place when the literature
reviewed by Day and associates was published.
Day and associates accurately point out the many limitations of the
information they reviewed but also make the point that this information base
"can produce valid results".
How "rare" is clinically significant adhesive arachnoiditis?
It has become clear that every person who has ever had a oil mydogram (i.e.
lipiodol, pantopaque or myodil) has been left with permanent scarring of
their pia-arachnoid membranes and some related impairment of
cerebrospinal fluid production. From the 1940s to the 1980s there were
approximately 1 million oil myetograms performed each year throughout the
world. Scarring of the meninges secondary to exposure to these foreign body
substances occurred in every single case. How many of these situations
progressed to the stage of advanced "chronic adhesive arachnoiditis" is
simply not known. The actual number of cases is which this inflammatory
process ascended up the spine to the brain producing death is also not
known. Sensitivity to inflammation is now known to be a complex process
involving issues such as the individual's own immunotogic makeup.
It is readily apparent that although prevalence data is lacking the numbers of
those afflicted with meningeal scarring is quite high. What then is the
incidence of those individuals from this group who have become disabled by
this condition (referred to as:("clinically significant adhesive arachnoiditis"?)
What is "rare"? Its meaning is different to each beholder. Long has
estimated that 1 of those with adhesive arachnoiditis are "clinically
significant". This editor believes that 5 is a more accurate estimate.
Why is the prevalence of chronic adhesive arachnoiditis so high and clinically
significant adhesive arachnoiditis so low? The answer to this enigma may
very well lie in the remarkable ability of the human body to successfully deal
with insult and injury if the progression of adversity is sufficiently slow. This
is particularly true of the nervous system. This means that if the progression
of an inflammatory process is sufficiently slow the nerves are then allowed to
have the opportunity of surviving in their function despite progressive
encapsulation with scar, progressive loss of vascular supply and progressive
decrease in nutrition normally supplied by the surrounding cerebro-spinal
fluid. This also means that if the nerves are not allowed to have the
opportunity of accommodating they then signal their distress to the brain by
transmitting constant nociceptive information. The nature of the resulting
regional complex pain disorder is very often totally disabling to the
individual.
This also means that many who have the scarring and are asymptomatic
exist in a precarious state. Additional insult can, in these cases, upset the
balance producing decompensation and associated clinically evident
problems. This type of situation is well known in medicine where large,
benign, brain tumors progressively enlarge over many years and a minor
incident (i.e. being struck in the head with a soccer ball) causes
decompensation, unconsciousness, and even death. In the adhesive
arachnoiditis cases the additional insult can be another myelogram, trauma
such as a motor vehicle accident, or even an additional spinal surgery.
It is interesting to observe that clinically significant "chronic adhesive
arachnoiditis" may be infrequent, or even "rare", compared to the huge
reservoir of existing cases. But it is also important to point out that even if
these individuals appear normal they live with a "sword hanging over their
heads" and are typically unaware of this liability. It is also important to
recognize that even if there is no apparent clinical problem significant bodily
injury has occurred. This is a situation similar to the "post-polio syndrome"
where individuals afflicted with poliomyelitis at a eariy age loose many of
their spinal neurons to the viral infection. Many individuals appear to recover
completely and clinical problems may only become evident later in life when
the paucity of remaining neurons is diminished further by the process of
aging, are no longer able to meet the needs of the body.
If it is a "rare" entity why should New Zealand, and the rest of
the world, be concerned with "clinically significant adhesive
arachnoiditis"?
There are few disease processes more cruel and disabling than adhesive
arachnoiditis when it is "clinically significant". The nature of the constant
pain is such that it prevents NORMAL ACTIVITY, INTELLECTUAL PURSUITS and SLEEP.
Adhesive arachnoiditis does not affect longevity and sufferers do not have the
relative blessing of the limited life expectancy afforded by terminal cancer.
These individuals are non-productive and require long-term supportive care.
It would have been nice to see that with the phasing out of oil myelography
in the early 1980s that the issue of adhesive arachnoiditis would have
become something of only historic interest- This has not been the case- The
advent of Epidural Steroid Injection as a Primary Treatment for Back Pain has
created new populations of sufferers. How rare is this? Once again data on
incidence and prevalence do not exist. In the United States the most reliable
data on incidence are the number of physicians being brought to court by
their patients. This sad state of affairs seems to reflect only ignorance on the
part of physicians and their patients as epidural steroid administration can
(and should be) a safe procedure performed with appropriate INFORMED
CONSENT.
What needs to be done?
As correctly noted by Day and associates scientific study and further
assessment of this disease entity are required. The most important role of
this report, in my opinion, is being a first step in promoting awareness. In
1968 ago a physician wrote a letter to the editor of the New England Journal
of Medicine noting that whenever he ate at a Chinese restaurant he would
experience symptoms similar to those of a heart attack. Before long there
were similar experiences shared by a multitude of other physicians. The
entity became referred to as "the Chinese restaurant syndrome".
Investigation finally determined that a hypet sensitivity to monosodhnn
glutamate (NSG) and high salt content in the food appeared to be the
etiology of this entity.
Only with increased awareness will physicians and patients begin to suspect,
and then identify adhesive arachnoiditis. It should not be that a popular
treatment for low back pain be allowed to create devastating disease for the
patient. How much is the prevention of this sad patient experience worth to a
concerned health care system?
The importance of awareness
In 1926 French neurologists Foix and Alajouanine published the description
of a pathologic entity producing adhesions, spinal cord degeneration and
paralysis. We now appreciate that the Poix-AIajouanine syndrome probably
represented a congenital arterio-venous malformation of the spinal cord
associated with small intermittent bleeds producing local adhesive
arachnoiditis, spinal cord restriction and impairment of blood supply
producing mydomalacia, cavitation and neurologic problems. This appears to
have been the first medical description of adhesive arachnoiditis.
Is this something of only historic interest?
Recently the editor has become aware of a number of cases in which epidural
injections for the purpose of analgesia were used to assist in childbirth in
young and previously healthy women. Following these injections the women
developed severe, and in some cases permanent, neurologic problems.
Subsequent imaging studies documented thoracic adhesive arachnoiditis.
Although these were standard epidural injections the anesthesiologists
involved have been accused of producing the problem. From reviewing the
MRI studies I am convinced that these situations represented long-standing
cases of clinically insignificant Fbix-Alajouanine syndrome activated by the
epidural injection (probably the included epinephrine) and thus becoming
"clinically significant".
How many anesthesiologists know about the Foix-Alajouanine syndrome,
adhesive arachnoiditis, or the dangers of injecting foreign body substances
into the subarachnoid space? This knowledge is truly a "rare" situation.
Appreciation to the New Zealand Ministry of Health
The literature review by Day and associates is a really important
contribution, it is also something, which should have been done a long time
ago by Health agencies in the United States or England. New Zealand clearly
has less resource available than these world neighbors. The fact that
concerned citizens were able to reach the responsive ears of government to
commission a valuable first-step technology assessment is exemplary and
worthy of acknowledgement. The editor's highest compliments and personal
appreciation are extended to all involved.
And our highest compliments to you Doctor Burton for being there for us.
....................................................................................................
Big Question here is...
Why are these proceedures still being done, when it is clear the damage it does.?
ACC has accepted some cases of Chemically Induced Adhesive Arachnoiditis,
Under Med Mis-adventure/ Med Mis-hap...
Gaffa09 clearly has this problem, I see see effects of, this on a regular basis.
and it was he who has to date exposed and produced most of the info that has assisted others in their claims...
SO WHY WILL ACC NOT ACCEPT HIS CLAIM IN THIS...???
They have "closed" his file on this...
Read the rest of whats here on this subject....
From The British House of Commons.
http://www.accforum....p?showtopic=253
The anatomy of Arachnoiditis.
http://www.accforum....p?showtopic=270
TC.
Some Media articles...
http://www.accforum....p?showtopic=943
The Holmes Show.
http://www.accforum.org/forums//index.php?...st=0entry7618
60 Minutes video...
If its clear, xray shows the Myodil in the brain.
http://www.accforum....p?showtopic=933
Attached File(s)
-
New_Zealand_Ministry_of_Health_Report_on_Adhesive_Arachnioditis.pdf (21.44K)
Number of downloads: 27