Emergency Protocol- When Time Matters Most

If you have recently had an epidural injection, spinal tap, or spinal surgery and you are now experiencing new or worsening neurological symptoms, this article is for you.

The window immediately following a spinal procedure is critical. Adhesive Arachnoiditis can begin developing before it is even visible on an MRI. Acting quickly during this period may make a significant difference in how the disease progresses.

This protocol is based on Dr. Forest Tennant's Emergency Protocol for Suspected or Likely Adhesive Arachnoiditis (TF#3, revised December 2024) and Bulletin 43 on treatment after epidural injections and spinal punctures. Both are available to download below.

The FDA Black Box Warning You May Not Have Been Told About

Before a spinal procedure, most patients are not informed of a critical regulatory warning. In April 2014, the FDA required that all injectable corticosteroid labels carry a warning stating that serious neurologic events, some resulting in death, have been reported with epidural injection of corticosteroids, and that the safety and effectiveness of epidural administration of corticosteroids have not been established. Corticosteroids are not FDA-approved for epidural use.

The serious neurologic events the FDA identified include loss of vision, stroke, paralysis, and death. Between 1997 and 2014 alone, the FDA identified 131 cases of serious neurologic events including 41 cases of arachnoiditis linked to epidural corticosteroid injections.

This does not mean every ESI leads to arachnoiditis. But it does mean that if you are reading this after a procedure and something feels wrong, your instinct deserves to be taken seriously.

How a Spinal Procedure Can Trigger Arachnoiditis

A puncture, crack, or fissure from any spinal procedure — epidural injection, spinal tap, or surgery — can allow spinal fluid or a contaminant into the interior of the spinal canal covering. When this happens, inflammation at the damage site can spread to multiple surrounding tissues including the cauda equina nerve roots, the arachnoid membrane, the dura, the ligamentum flavum, and intervertebral discs.

Dr. Tennant compared this to a cut on the hand that becomes inflamed and causes cellulitis to spread up the arm. Once that inflammatory cascade begins in the spinal canal, it can progress through several stages:

• Spinal fluid leakage

• Non-adhesive arachnoiditis

• Epidural fibrosis

• Cauda equina symptoms — burning feet, saddle numbness, stabbing pains

• Urinary or bowel dysfunction

• Disc protrusion

• Adhesive arachnoiditis

Pain may begin immediately after the procedure or within 72 hours. Occasionally it is delayed longer. Do not assume a delayed onset means you are safe.

Who This Protocol Is For

This emergency protocol applies to people within approximately 120 days of a spinal procedure who are experiencing symptoms suggesting cauda equina inflammation or early AA, including:

• Sharp or persistent back pain that won't resolve

• Sensations of insects crawling or water dripping on the skin

• Headache, dizziness, or vertigo

• Burning pain in the feet

• Tingling in the upper or lower extremities

• New bladder or bowel symptoms

A Critical Note on MRI

MRI evidence of Adhesive Arachnoiditis may not appear for 6 to 12 weeks following a procedure. In the first 2 to 3 weeks, the only signs may be thickening of the spinal canal cover or nerve root swelling. Nerve root clumping and adhesions typically don't appear until after 2 to 3 weeks. Disc protrusions and clear AA findings may take 6 to 8 weeks or more.

Do not wait for imaging confirmation if symptoms are present. Anti-inflammatory treatment should be based on symptoms, not on MRI findings alone. A normal or inconclusive MRI does not rule out early AA.

If Pain Begins Within 24 Hours of Your Procedure

Start a 6-Day Medrol Dose Pak immediately. Do not wait. This is the fastest way to suppress the initial inflammatory cascade before it spreads.

If Pain Persists Beyond 72 Hours

If pain is not resolving, one of the following treatment options should be pursued urgently:

Emergency Option 1 — Intravenous CorticosteroidIntravenous methylprednisolone 100 to 500mg daily for 3 to 5 days. This is the most aggressive option and requires hospital or infusion center administration. If you are in acute distress, go to your nearest emergency department and bring a copy of this protocol.

Emergency Option 2 — Outpatient ProtocolIf IV treatment is not accessible:

1. Ketorolac (Toradol®) 30 to 60mg by injection, once daily for 3 consecutive days

2. Medrol® (methylprednisolone) 6-Day Dose Pak

3. Medroxyprogesterone 100 to 200mg twice daily for 3 to 5 days

All three should be administered simultaneously for 6 days, then transition to the starting protocol for AA.

If symptoms are not suppressed within 3 to 4 weeks of beginning treatment, transition to the full Arachnoiditis treatment protocol. See our Three Component Protocol article for the next steps.

For more detail on how and why corticosteroids work for AA, see our article on the 6-Day Medrol Dose Pak.

Blood Tests to Request

To help confirm the presence of spinal canal inflammation, ask your physician to order:

• WBC, ESR, CRP — standard inflammatory markers

• Cytokine panel — the most sensitive diagnostic marker. Dr. Tennant found that approximately 70% of cases show one or more leukotriene elevations

Additional Risk Factors to Assess

Any patient requiring emergency intervention should be evaluated for known risk factors that increase susceptibility to AA:

• Genetic connective tissue disorders — particularly Ehlers-Danlos Syndrome (EDS)

• Epstein-Barr Virus (EBV) reactivation

• Autoimmune conditions

What to Do Right Now

1. Print or download TF#3 and Bulletin 43 and bring them to your physician or emergency department

2. Do not accept reassurance based on a normal MRI alone if symptoms are present

3. Request emergency treatment based on your timeline — Medrol Dose Pak within 24 hours, Emergency Option 1 or 2 if beyond 72 hours

4. Document everything — date of procedure, date symptoms began, what they feel like, any changes

5. Contact ACMCRN — our community and physician directory can help connect you with physicians who understand AA

📄 Download Emergency Protocol TF#3📄 Download Bulletin 43 — Treatment After Epidural Injections📄 Find an AA-aware physician

This Is Not the End

Catching potential AA early and treating it aggressively gives you the best available chance of limiting progression. You are not alone — thousands of patients have navigated this and found their footing. Our community is here.

Visit our Starting Point page for a broader overview of next steps after a suspected or confirmed diagnosis.

This article is for educational purposes only and does not constitute medical advice. Always consult a qualified physician before making changes to your treatment plan. See our Disclaimer.