Ruben’s miracle: extreme back pain eliminated by ketamine

This is a crazy story.

In 2022, Ruben Laukkonen was rescued from extreme back pain by a dose of ketamine given to him in an ambulance. Ketamine is a weird, trippy drug used for anaesthesia, which can deliver out-of-body experiences (“dissociative”). After a few weeks of hell, Ruben’s recovery was sudden and total and lasting — an apparently perfect recovery from crippling pain.

Wow.

This is a riveting and tantalizing case, but also baffling. No intellectually honest clinician should dare to claim to understand what happened here. But it’s the kind of story that every curious professional wants to speculate about. I sure did.

Me: “My back pain book is long enough!”

Also me: “Yeah, but this case study is soooo gooooood.”

What is it about ketamine that could extinguish such agony? How can someone recover so brilliantly from such severe pain? Can we learn anything from this?

How bad was the pain?

First, let’s make it clear just how severe this pain was, and its nature, at least initially: Ruben’s nightmare began with an intervertebral disk “sequestration.” That’s when lots of spinal disc material actually escapes the confines of the disc, spilling out. This is a major spinal trauma. It’s not necessarily horrifying — some cases are less dramatic, and more temporary — but it can cause very severe neuropathic pain.

The full range of intervertebral disc herniation severity. “Sequestration” is as bad as it gets. Click to embiggen.

Some highlights from Ruben’s account:

If you haven’t had serious nerve pain, you’ve probably had a taste of it at the dentist when they hit the nerve root of your tooth. Yeah, you want to be anaesthetised for that, right? It’s bad. Imagine that, 10x worse, on repeat, running from your lower back to your toes.

There was a direct highway to my nervous systems pain centre, just banging the pure-pain button over and over again. … This thing just keeps getting worse as the days go on. … I gradually become completely bedridden.

Another week later [four weeks in all, if I read it right], on a Saturday night, around midnight, I’m starting to lose it. I can’t even open my eyes any more. It’s that bad. I’m considering chopping off my leg, but I wouldn’t be able to get my hands on a knife. I call out for my girlfriend to call an ambulance.

Ketamine to the rescue

The paramedics gave him ketamine, which produce a two-stage miracle:

1. It entirely relieved his pain. From "11" to 0 in minutes. None of this barely-clinically significant 20% bollocks you'd be lucky to get from an ibuprofen with more ordinary back pain. We're talking about 100% relief here, from as bad as it gets to as good as it gets in less time that it takes to cook some pasta.
2. This is the really bonkers part: his pain did not return when the ketamine wore off!

That is as good a cure story as I have ever heard. Here’s Ruben’s attempt to describe his ludicrously delicious relief:

In just a few seconds, every bit of tension in my back softened, like an ice-cube melting. Not just the feeling tone changed, but literally the muscles that had been contracted for weeks just totally “let go”.

My mind slowed to a standstill and in full awareness I could feel my body and there was… no pain… no tension. And eventually… no body at all. Nobody. Just lightness. Just light... All encompassing relief. At the level of body, mind, energy (or whatever you want to call those channels for the torture signals). All pervading peace. Delicious.

Fast forward, I’m still high but coming back as we approach the hospital. I sort of know what’s going on. I tell them, “wow, that was amazing, thank you, all my pain is gone”.

Now I’m in the hospital bed. A neurologist comes and I try to explain what happened. It’s a miracle. I can cough and I have no pain. I don’t think you realise how big this shift was. Night and day don’t contrast well enough.

The ketamine wears off and I’m fine.

For me, that is the most impressive thing about this story. While the initial relief is obviously incredible, sustaining it is definitely more incredible.

I walk by myself to the bathroom. It’s inconceivable how different my state is. I still have some fear, though, and my body is tender and I’m careful—but I already know that the central issue has been resolved. The contracted muscles pinching the nerve have relaxed. The loop is broken.

Wowsers. “I’ll have what he’s having.” 🤣

What does it all mean?

When Ruben shared his story on Twitter, many professionals could not resist its siren call, including myself. Here are some of our ideas (all of which have major flaws):

• Ketamine is known for its effects on neuropathic pain specifically, so the most obvious hypothesis is that the ketamine was just exactly the right medicine for the job. But the limitations of this tidy answer are glaring — such as the fact that ketamine is not known for being a miracle drug for neuropathy.
• There was never any neuropathy to begin with, or not much! Psychosomatic. The trip got him unstuck psychologically like the Fonz smacking a malfunctioning appliance. I think this is generally unlikely, but here’s one specific example of how it could have been be significantly psychosomatic: one reason paramedics use ketamine is that it can be effective for acute agitation and delirium. “Suffering” is impossible to separate from pain, and sometimes pain is probably dominated by our psychological distress about it. And suffering can be eased in ways that pain cannot.
• Coincidence! He just happened to have a miraculous recovery within five minutes of being injected with ketamine. Yes, someone actually suggested this. I don’t buy it. Coincidence can explain more recoveries than people want to admit — the darkest-before-dawn effect — but, as told, this recovery was so dramatic that it would mysterious even without the ketamine.
• Ketamine blocks NMDA receptors in the spinal cord and central nervous system, which “shuts down maladaptive sequelae of chronic pain” like hyperalgesia and allodynia. But note that this was not chronic pain. It was, in fact, still very acute pain.
• The ketamine had an unusually powerful muscle relaxant effect. I’ll elaborate on this one below.
• It did the same thing that psychedelics supposedly do: “self-transcendence,” such that you can feel like it’s not “me” hurting, leading to a psychological “reboot” or “reset,” breaking a vicious cycle. This seemed to be a popular theme in the reactions. And it might also be Ruben’s favourite hypothesis…

Or maybe it is not what it seems

There’s a strong theme in Ruben’s scientific publications and social media postings: profound excitement about psychedelics, meditation, and altered states. He’s not just interested in phenomena like this, he appears to be defined by that interest. He cares about these topics a lot. And it’s cool stuff.

It seems noteworthy to me that someone so interested in psychoactive drugs and altered states would just happen to have a truly amazing story that demonstrates their power. How might this be significant?

• Powerful expectations can drive potent pain-relief placebos, and Ruben may have had an unusually strong expectation of “self-transcendence.” Ketamine might actually work much better on Ruben than it would on someone who doesn’t even know what the stuff is.
• Maybe the story wasn’t actually as dramatic as it seems. It is a story, after all, and stories can be wrong in all kinds of subtle ways. Maybe Ruben exaggerated in a variety of ways, unconsciously making it a better story about a drug. In this scenario, the truth would still be a success story … but might would fall short of being a “miracle” worthy of our amazement.
• Most uncharitably, the story could be fictional. I’m am definitely not making that accusation. I’m just acknowledging that it’s possible, this is something humans do, for all kinds of reasons.

I think it’s very unlikely that this story is fictional, or even much exaggerated. But I would be remiss if I didn’t at least acknowledge the possibility. And the powerful expectations definitely could have been a major factor.

My own food-for-thought hypothesis…

Many smart folks will reasonably object to this. It’s spitballing, and it’s all debatable, and debating it is the point.

Maybe the primary pain driver slowly transitioned over the weeks from disc to muscle. Ketamine can act as a potent muscle relaxant. That would have failed if used earlier…but could have worked brilliantly in that late stage.

Anticipating one likely objection: ketamine not a “muscle relaxant” per se. In fact, it’s used when a skeletal muscle relaxant is not required (see Ketamine.). But … all psychoactive substances have considerable (albeit unpredictable) potential as muscle relaxants. Citation needed? Yes, but “it’s complicated” — painful muscle contraction is a zoo of uncertainties, and the impact of psychoactive drugs is even more dizzyingly diverse. Ketamine in particular is both potent and strange, extremely sedative.

In my back pain book (long free intro), I explore the hypothesis that muscle pain is an underestimated mechanism of back pain. This story does not clearly support that hypothesis … but it is consistent with it. Just sayin’. 🙂