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The effects of bacterial invasion of the pia-arachnoid, cerebrospinal subarachnoid space, ventricles, and ependyma are described in Chap 32 and summarized in Table 32-1 The point being made here is that these structures may also be involved in a number of noninfective processes, some of obscure origin Since the ventricular and subarachnoid spaces are in continuity, one would expect that a noxious agent entering any one part would extend throughout the CSF pathway Such is not always the case The lower spinal roots or spinal cord alone may be implicated in spinal arachnoiditis A similar process may affect the optic nerves and chiasm exclusively ( opticochiasmatic arachnoiditis, see below) This may be accompanied by a pachymeningitis, and the latter may also be restricted to the cervical dura, also discussed below A predominant localization to these basal or cervical structures may be apparent even in cases of diffuse cerebrospinal meningeal reactions, perhaps because of an uneven concentration of the noxious agent In other instances, the primary disease appears to have arisen in the dura, with extension only to the adjacent piaarachnoid In yet other instances, the ependyma of the aqueduct or fourth ventricle is primarily involved The mechanisms by which these meningeal reactions affect parenchymal structures (brain, cord, and nerve roots) are not fully understood The most obvious sequela is an obstruction to the ow of CSF in hydrocephalus; here, simple brotic narrowing of the CSF circulatory pathway is causative Progressive constriction of nerve roots and spinal cord, literally a strangulation of these structures, is another plausible mechanism, but it is dif cult to separate vascular factors from mechanical ones Since any toxic agent introduced into the subarachnoid space has free access, via VirchowRobin spaces, to the super cial parts of the brain and spinal cord, direct parenchymal injury may follow Perivascular reactions of subpial vessels, as in infectious processes, would be a plausible mechanism of injury to optic nerves and spinal cord, where long stretches of myelinated bers abut the pia Regional Arachnoiditis Arachnoiditis limited to the lumbosacral roots has followed ruptured discs, myelograms, and spinal surgery Usually, there is sciatica and chronic neuropathic pain in the back and lower extremities, but sensorimotor and re ex changes in the legs are variable The MRI shows irregularly enhancing roots and arachnoidal thickening; myelography discloses loculated pockets of imaging media (Fig 11-6) This condition is discussed further in Chap 11, under The Failed-Back Syndrome Another form of spinal arachnoiditis, in which both the spinal cord and roots are entrapped in thickened pia-arachnoid, sometimes with arachnoid-dural adhesions, is rare but well-known entity An account of this condition is included with the spinal cord diseases (see Chap 44) The etiologic factors have been singularly elusive although in the past it followed the instillation of iophendylate (Pantopaque) for myelography and corticosteroids (for pain or multiple sclerosis) and other irritative agents The condition may be accompanied by cranial basilar meningeal brosis with optic nerve involvement and hydrocephalus (see below), or it may occur in.

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isolation The most familiar form of spinal arachnoiditis was, in the past, that which followed the use of chemically contaminated spinal anesthetics Our colleagues saw more than 40 cases of this type, now rare, dating from the time when vials of anesthetic were stored in detergent sterilizing solutions Instillation of the anesthetic agent was followed immediately by back pain and a rapidly progressive lumbosacral root syndrome (are exic paralysis, anesthesia of the legs, and paralysis of sphincters) Several cases have, in our more recent experience, followed prolonged spinal anesthesia with the patient in a decubitus position, usually for orthopedic procedures, but the resulting myelopathy or cauda equina radiculopathy is then dif cult to separate from a direct toxic effect of the anesthetic The CSF protein rises rapidly in cases that were precipitated by injection of substances in the subarachnoid space, but pleocytosis is minimal In other instances, protracted back pain lasting days to weeks is the only effect but is followed, after a period of months or years, by a progressive myelopathy This takes the form of some combination of spinal arachnoiditis with ataxic paraparesis and sensory disturbance, hydrocephalus, or opticochiasmatic arachnoiditis The point to be made is that there is always some risk attached to the subarachnoid instillation of any foreign agent Opticochiasmatic Arachnoiditis This condition was well known to neurologists during the period when neurosyphilis was a common disease It occurs after years of chronic syphilitic meningitis, sometimes in conjunction with tabes dorsalis or meningomyelitis However, there were always nonsyphilitic cases, the cause of which was never ascertained A constriction of visual elds, usually bilateral and asymmetrical (rarely scotomas), developed insidiously and progressed Pathologically, the optic nerves were found to be enmeshed in thickened, opaque pia-arachnoid The optic nerves are atrophic in apperance Idiopathic cases are likely to be confused with multiple sclerosis Pachymeningitis The term pachymeningitis refers to a chronic, circumscribed, in ammatory thickening of the dura The term is somewhat confusing insofar as the pia and arachnoid are usually equally involved in the in ammatory thickening and all three membranes are bound together by dense brous adhesions This type of meningeal reaction, which is now exceedingly uncommon, was rst described by Charcot and Joffroy It occurred mainly in the cervical region (hence the name pachymeningitis cervicalis hypertrophica) and was attributed to syphilis Indeed, in some instances there was a gummatous thickening of the dura Involvement of cervical roots and compression of the spinal cord gave rise to variable degrees of paraparesis in association with root pain, paresthesias, sensory loss, and amyotrophy of the upper limbs In the modern era, rheumatoid arthritis, sarcoidosis, and chronic local infection (fungal, tuberculous) have been the main causes, but some of the cases remain unexplained Idiopathic instances continue to be reported; a summary of published cases and two personally studied ones is given by Dumont and colleagues The subdural space and dura can be involved by extension of a pathologic process from the arachnoid, especially in infants and children, in whom subdural hygromas regularly follow meningitis The brous connective tissue of which the dura is composed may also undergo pronounced thickening in the course of a mucopolysaccharidosis, especially in cases where broblasts are implicated The basal pia-arachnoid may be involved, leading to obstructive hydrocephalus Older medical writings often made reference to syphilitic cranial pachymeningitis, which later proved to be the.

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terminal is connected to the anode (Fig 19-4A) No current will flow if the battery is reversed (Fig 19-4B) The resistor is included in the circuit to prevent destruction of the diode by excessive current It takes a certain minimum voltage for conduction to occur This is called the forward breaker voltage of the junction Depending on the type of material, it varies from about 03 V to 1 V If the voltage across the junction is not at least as great as the forward breaker value, the diode will not conduct This effect can be of use in amplitude limiters, waveform clippers, and threshold detectors You ll learn about the various ways diodes are used in the next chapter

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