PATHOANATOMIC BASIS FOR STRETCH-INDUCED LUMBAR NERVE ROOT INJURY WITH A REVIEW OF THE LITERATURE

OBJECTIVE: Persistent pain originating from a dysfunctional lumbar motion segment poses significant challenges in the clinical arena. Although the predominance of the existing spine literature has addressed nerve root compression as the principal cause of pain, it is equally likely that a stretch mechanism may be responsible for all or part of the pathology. METHODS: The literature supporting the role of stretch damage as a primary cause of nerve root injury and pain was systematically reviewed. Pathoanatomic considerations between nerve roots and juxtaposed environment are described and correlated with the available literature. Potential anatomic relationships that may lead to stretch-induced injury are delineated. RESULTS: A dynamic lumbar functional spinal unit that encloses a tethered nerve root can create significant stretch and/or compression. This phenomenon may be present in a variety of pathological conditions. These include anterior, posterior, and rotatory olisthesis as well as degenerative conditions such as the loss of disc interspace height and frank multisegment spinal deformity. Although numerous studies have demonstrated that stretch can result in nerve damage, the pathophysiology that may associate nerve stretch with chronic pain has yet to be determined. CONCLUSION: The current literature concerning stretch-related injury to nerve roots is reviewed, and a conceptual framework for its diagnosis and treatment is proposed and graphically illustrated using cadaveric specimens. The dynamic biomechanical and functional interrelationships between neural structures and adjacent connective tissue elements are particularly important in the face of spinal deformity.