Refractory Radiculopathy Without a Surgical Target: Ketamine Analgesia and Psychiatric Risk in Multilevel Degenerative Spine Disease

Technical Summary: Refractory Radiculopathy Without a Surgical Target

Problem Statement
The paper addresses the clinical challenge of managing patients with multilevel degenerative spine disease who present with severe, persistent radicular pain and functional decline, yet lack a surgically actionable lesion. A central difficulty in this population is "clinical-radiographic discordance," where imaging findings (such as severe stenosis or nerve root impingement) do not correlate with symptom severity or fail to explain the full extent of the patient's disability. In cases where imaging remains stable across multiple admissions and neurosurgical evaluation rules out operative intervention, treatment must shift from structural correction to symptom management. This scenario creates a high-risk environment for patients with comorbid psychiatric conditions, particularly when procedural options are exhausted, potentially leading to feelings of abandonment and increased psychiatric risk.

Methodology
This study is a single-patient case report describing a 50-year-old male with a history of alcohol use disorder, nicotine dependence, depression, and anxiety. The patient presented with chronic neck and low back pain, radicular symptoms, and saddle anesthesia following a work-related fall.

• Diagnostic Workup: The patient underwent serial MRI imaging (cervical and lumbar) over a six-month period, electrodiagnostic testing (EMG/NCS), and physical examinations.
• Interventions: The management strategy included a cervical epidural steroid injection, a ketamine infusion, a cervical medial branch block, and multimodal pharmacotherapy (including hydrocodone-acetaminophen, pregabalin, duloxetine, cyclobenzaprine, acetaminophen, and tramadol).
• Psychiatric Monitoring: The patient's psychiatric status was monitored throughout the admission, specifically noting the onset of suicidal ideation following communication regarding the unavailability of further procedural interventions.

Key Results

• Imaging and Electrodiagnostics: MRI revealed severe canal and foraminal stenosis at C3-C4 and C4-C5, and foraminal stenosis with S1 nerve root impingement at L5-S1. These findings remained stable across two admissions six months apart. Electrodiagnostic testing confirmed C5-C6 radiculopathy, bilateral S1 radiculopathy, and right median/ulnar mononeuropathy.
• Surgical Determination: Neurosurgery evaluated the patient on two separate occasions and did not recommend operative intervention, citing a lack of a specific surgical target that would explain the presenting symptoms.
• Analgesic Response:
  • The cervical epidural steroid injection improved neck pain and upper extremity paresthesias but did not resolve lower extremity symptoms.
  • The ketamine infusion resulted in a reported decrease in overall pain intensity. However, it did not resolve the underlying neurologic symptoms; numbness, tingling, and paresthesias persisted despite the reduction in pain scores.
• Psychiatric Outcome: During the second admission, after being informed that no further procedural interventions were available, the patient developed passive suicidal ideation. He also had a history of active suicidal ideation two weeks prior. Psychiatry diagnosed generalized anxiety disorder and recommended a medication adjustment (discontinuing bupropion and duloxetine in favor of amitriptyline).

Significance and Claims
The authors claim this case highlights three critical issues in the management of refractory radiculopathy:

1. Clinical-Radiographic Discordance: The case demonstrates that severe imaging abnormalities do not always necessitate surgery, and conversely, severe symptoms can exist without a surgically correctable lesion. Treatment decisions cannot rely on imaging alone.
2. Ketamine as a Symptomatic Tool: Ketamine infusion is presented as a potential analgesic option for patients with limited benefit from targeted interventions. The paper clarifies that ketamine's mechanism (NMDA receptor antagonism) may reduce centrally amplified pain but does not reverse structural nerve compression or electrodiagnostic abnormalities. Therefore, a positive response to ketamine should be interpreted as analgesic benefit rather than neurologic recovery.
3. Psychiatric Risk in Procedural Exhaustion: The case underscores the psychiatric vulnerability of patients with chronic pain and comorbidities when told that procedural options are exhausted. The authors argue that the communication of "no further interventions" can be interpreted as hopelessness or abandonment. Consequently, they advocate for early psychiatric involvement to reframe treatment goals toward function, coping, and quality of life, rather than procedural escalation, to improve patient safety.

The paper concludes that multidisciplinary care involving pain medicine, rehabilitation, psychiatry, and primary care is essential for longitudinal management in these complex cases, shifting the focus from acute procedural interventions to chronic symptom control.