Hyaluronidase as an adjuvant in the management of tuberculous spinal arachnoiditis

Spinal arachnoiditis, a complication of tuberculous meningitis, is not uncommon; it may develop despite specific chemotherapy and steroids, and existing avenues of treatment for it are unsatisfactory. The enzyme hyaluronidase, by virtue of its action of hydrolysing the glucosaminidic bonds of hyaluronic acid and other mucopolysaccharides of the ground substance, offers a promising mode of treatment. Sixty-six patients with spinal arachnoiditis secondary to tuberculous meningitis were seen over an 8-year period. All these patients received antituberculous drugs and steroids; 39 of them (group A), who, in addition, were given intrathecal hyaluronidase, fared better than the remaining 27 (group B), who did not receive this enzyme. This study was non-randomised. The disability and functional deficit score showed a significant decrease from 7.6 to 3.7 in the enzyme-treated group in contrast to a mild change from 8.1 to 6.9 in the untreated group. Further, in group A the mortality was 5.2% whereas in group B it was 25.9%. There was a marked 5-fold decrease in mean CSF protein in group A while in group B there was no significant change. There were no serious side effects due to repeated administration of intrathecal hyaluronidase. Thus this study provides convincing evidence of the therapeutic role of hyaluronidase in the management of tuberculous spinal arachnoiditis and replicates our earlier observation of the safety of hyaluronidase given intrathecally.