Lumbar radiculopathy or spinal ligament sprain?

Radicular pain or “radiculopathy” (sometimes also referred to as a “pinched nerve”) is often described by patients as a deep  pain that travels down the leg. This pain is often accompanied by numbness or tingling, and muscle weakness in the limb.

The most common example of this type of problem is sciatica. This pain radiates down the leg along the sciatic nerve. Sciatica follows the path down the back of the thigh, into the calf and then into the foot via branches of the nerve.

Radicular pain may be caused by an injury to the spine. It may be from impact injuries that cause compression in the vertebrae, such as those in sports related injuries or motor vehicle accidents, i.e., disc herniation. Or it may be caused by a degenerative process discussed above such as stenosis or Degenerative Disc Disease. It is essential to perform a physical examination in cases of referred pain to isolate the problem.

A July 2023 study (1) examined improvements in pain following decompressive spinal surgery, in the form of laminectomy or discectomy. This was a large study of 25,349 patients of whom 92.2% reported significant back pain at baseline. Sixty-two percent of patients attained the minimal clinically important difference (a 30% reduction) in their back pain, with 51% reporting a substantial improvement (more than 50% pain reduction). This improvement was observed by 6 weeks post-surgery and was mostly maintained at 2 years.

Patients suffering with predominantly back pain faired slightly better than patients with predominantly leg pain. (63.6% vs 60.1% achieved minimal clinically important difference.)

In the end, low back pain improved in approximately 62% of patients who undergo lumbar decompressive surgery, with 51% experiencing substantial improvement.

The question is then why did 38% of patients not get good improvement?

A ligament injury that appears to be a nerve impingement

It may actually be a ligament injury that appears to be a nerve impingement and ligament trigger points may refer pain in a manner similar to radiculopathy.

This is why relying on an MRI as the sole diagnostic tool could lead to unnecessary surgery. An MRI may show a pre-existing condition that never caused pain. If surgery was performed to correct this condition and pain was actually generated by a ligament sprain, the surgery would fail.

A physical examination and conservative treatment will help determine if this is a ligament injury or a nerve problem.

It is important for the patient to know in cases of radiating pain that an MRI that indicates slippage of the vertebrae (Spondylolisthesis), an arthritic condition, or a bulging disc is NOT necessarily an indication that surgery is needed.

It has been suggested that a majority of lower back pain problems can be traced to problems of the ligaments. Why then aren’t most therapies geared to treating the ligaments? Because many physicians do not believe that the ligaments can be successfully treated. Why? Because ligaments have very poor circulation and therefore do not have the ability to heal. This is taught in basic anatomy. Muscles are big, red, and powerful because they are filled with blood. Ligaments and tendons are small and white because there is no blood in them.

A July 2023 study (2) looked at 294 elderly lumbar radiculopathy patients, treated with transforaminal epidural steroid injections to test the effectiveness of the injections. Treatment success was defined as a more than or equal to 50% reduction in pain scores at 6 months. This study revealed that the patient would have the best results, defined as a more than more than or equal to 50% reduction in pain scores at 6 months with the epidural if their symptoms were treated more quickly (short duration),  if they had a a good immediate postoperative response, and if the had high inflammatory markers (neutrophilic granulocyte percentage)

1 Knight J, Rangnekar R, Richardson D, McIlroy S, Bell D, Ahmed AI. Does low-back pain improve after decompressive spinal surgery? A prospective observational study from the British Spine Registry. Journal of Neurosurgery: Spine. 2023 Jul 14;1(aop):1-0.

2 Wang M, Ling H, Zheng B, Song L. Predictors of a Favorable Response to Transforaminal Epidural Steroid Injections for Lumbar Radiculopathy in the Elderly. Pain Physician. 2023 Jul 1;26(4):347-55. [Google Scholar]



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