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Q&A: Does a diagnosis of "nerve impingement" definitely mean that my pain is "structural"?

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Question

I would like to properly interpret my diagnosis. My MRI report reads the following: Mild exaggerated lumbar lordosis with a right foraminal herniation resulting in impingement upon the right exiting L4 nerve root at L4-L5. My symptoms have been on-going since November 16, 2009, with some positive spontaneous, progressive healing while I was attending physical therapy two times a week. On January 8th, 2010, I received some very emotionally upsetting news which resulted in a second attack that was much worse than the first on November 16th. I have pain deep in the right buttocks that radiates down my thigh and sometimes into the knee and instep. As of now, I have had two epidural cortisone injections. I have read Dr. Sarno's book and have been journaling. I have also been in therapy, even before the first attack. I am a person who has always "thought psychological," however, does my diagnosis regarding "nerve impingement" mean that my pain is most likely "structural," and I should be treating it as such? Any advice would be greatly appreciated. Thank you.
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Answer by John Stracks, MD

An image of Practitioner John Stracks
Practitioner Johns Stracks

Dr. Stracks' Profile Page / Survey Response / Bio Page / Psychophysiologic Disorders Association (PPDA) Board Member

That's a very good question, and any time you have nerve impingement you should be working closely with a physician, ideally one who is trained in the area of TMS. The types of symptoms that should make you seek care urgently would include muscle weakness, bowel changes, bladder changes, sexual dysfunction, complete loss of feeling on the inside of both thighs, or severe symptoms in both legs not just one.

That said, you've got two factors that point very strongly to a TMS explanation of your pain.

The pain has at times gone away (which it shouldn't if it was primarily "structural")

The pain worsened significantly with an emotional trauma

A 1995 study of people without any back pain at all showed that 76% of them had at least one disk herniation and 22% of them had nerve "compromise" as a result of the herniation. Most of that compromise was minor (e.g. the disc touched the nerve but did not compress it), but 4% of asymptomatic individuals had major nerve root compression. So, your MRI does not necessarily mean the pain is structural, and I don't know from your MRI how significant the impingement is.

Remember also that all pain has a physical component, a cognitive component, and an emotional component, that is it's a product of how the pain feels, how you think about the pain, and how you feel about the pain. For a vast majority of people it is the latter two factors that make the pain extreme. The L4 impingement may cause you to feel a sensation in your instep but the underlying emotions are likely what is causing you to register that sensation as excruciating pain.

In summary, unless you begin to suffer the dangerous symptoms I mention above, you would likely benefit from continuing to "think psychologically" and doing the difficult but potentially very rewarding work of healing the TMS.

Dr. Stracks

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