Catastrophizing contributes to the association between posttraumatic stress symptoms and pain outcomes in individuals with chronic low back pain: Differential effects as a function of sex.

Fear of movement is a key contributor to chronic low back pain (CLBP). Because patients with CLBP often fear specific activities only, self-reported fear of movement assessment should be context-specific. The Photograph Series of Daily Activities (PHODA) contains photos of activities that are rated on perceived harmfulness, yet potentially essential contextual information impacting item-interpretation is missing (eg, frequency of activity performance). Therefore, considerable variability in fear of movement in patients with CLBP with similar scores on a PHODA-item may be present. To investigate this, we first performed a hierarchical cluster analysis in patients with CLBP (n = 254) and high scores (≥70/100) on the PHODA-item showing a person lifting with a bent back (=PHODA-Lift). Cluster analysis was performed using scores on context-specific fear of movement measures, ie, how afraid participants would be if they had to perform the PHODA-Lift 1x, 10x, or 20x. We showed large variability in self-reported fear of movement when the task was specified by frequency, resulting in 5 different clusters with increasing levels of context-specific fear of movement. Further support for these clusters was provided, as higher fear clusters reported increased task-related disability and avoidance behaviour. Second, we performed exploratory path analyses to investigate reasons for variability in context-specific fear of movement. Strong relationships between context-specific pain intensity and context-specific fear of movement were present, which were partially mediated by context-specific pain self-efficacy. In conclusion, using more context-specific self-report measures revealed clinically relevant variability in fear of movement that would remain undetected by currently available self-report measures.

E-cohort profile: ComPaRe chronic low back pain (CLBP) cohort.

A bioactive hydrogel harnessing the regenerative potential of notochordal cells serves as instructive cell carrier for nucleus pulposus repair.

To assess normal [18F]fluorodeoxyglucose ([18F]FDG) uptake values in lumbar spine structures on PET/MRI in patients without low back pain. Asymptomatic adults receiving whole-body FDG PET/MRI for nononcological indications were prospectively included. Spinal structures of interest were manually annotated at each lumbar level. Maximum standardized uptake value (SUVmax) and mean SUV (SUVmean) values were extracted from ordered subset expectation maximization, block sequential regularized expectation maximization (BSREM) β450, and BSREM β300 images. The distributions of SUVmax and SUVmean values were evaluated across spinal levels and structures. We also evaluated normalization of SUV metrics with the liver and subcutaneous fat uptake values, and correlations between SUV metrics and BMI, age, and blood glucose level. Twenty-two patients were included for analysis. Average SUVmax on OSEM reconstructions was 2.99 (SD: 0.69) for the vertebral body and 1.95 (SD: 0.54) for the intervertebral disc. In the nervous system, SUVmax for articular, peri-articular, and ligamentous structures was lower, ranging between 1.26 and 1.62. Uptake values were significantly lower on BSREM β450 and higher on BSREM β300. There was a positive correlation between uptake values and BMI, but no correlation was found with age or blood glucose level. Normal uptake values in the lumbar spine on [18F]FDG PET/MRI in asymptomatic adults were assessed. The uptake values reported in this study could serve as a reference for the identification of abnormalities in patients with chronic low back pain, but the applied PET reconstruction method and patient BMI should be taken into account.

In cases of chronic non-specific neck and low back pain (CNLBP), where emotional disorders are identified, the involvement of a psychiatrist in patient management is considered. However, the effectiveness of this approach in patients with CNLBP and a confirmed anxiety or depressive disorder (F41, F33, F32) remains insufficiently studied. Objective: To conduct a comparative evaluation of the efficacy of a comprehensive approach (involving a psychiatrist, an educational programme incorporating elements of cognitive behavioural therapy (CBT), and personalised therapeutic exercise) versus a standard approach in the treatment of chronic non-specific low back pain (CNLBP) in patients diagnosed with an anxiety or depressive disorder (F41, F33, F32) by a psychiatrist. Material and methods. The study included 55 patients with CNLBP and anxiety (F41) or depressive disorder (F33, F32), who were randomized into two groups. The first group (comprehensive therapy – CT) consisted of patients (n=27) who received a comprehensive (multimodal) approach, including the involvement of a psychiatrist in patient management, 6 sessions of an individualized educational programme incorporating elements of CBT delivered by a certified specialist in chronic pain and emotional disorders, 4–5 individual sessions of therapeutic exercise (TE) with the development of a personalized exercise regimen, and recommendations on workplace ergonomics. The standard therapy (ST) group comprised patients (n = 28) who were treated using a standard therapy protocol (optimisation of drug therapy, a one-off educational programme to improve physical activity, and standard kinesiotherapy). The study protocol involved 6 months of therapy and fol-low-up with efficacy assessments at three time points – 1, 3 and 6 months after the start of treatment. A numerical rating scale (NRS) was used to assess pain intensity; the Spielberger test, which assesses state (ST) and trait (TT) anxiety, and the Beck Depression Inventory were used to assess anxiety and depressive disorders. The SF-12 questionnaire was used to assess quality of life, taking into account the division of this questionnaire into summary scales for physical (PCS-12) and mental health (MCS-12). To determine the impact of neck pain (NP), the Neck Disability Index (NDI) was used; to assess the impact of low back pain (LBP) on daily activities, the Oswestry Low Back Pain Disability Questionnaire was used. Results. Against the background of treatment, a more significant decrease in pain intensity according to the NRS was noted in the CT group than in the ST group – respectively, for NP to 1.46 ± 0.75 and 2.92 ± 1.0 after 3 months (p < 0.001) and to 0.69 ± 0.72 and 3.0 ± 1.41 after 6 months (p < 0.001), for LBP 2.04 ± 0.86 and 3.29 ± 1.31 after 3 months (p < 0.001), and to 1.04 ± 0.91 and 3.29 ± 1.48 after 6 months (p < 0.001), a decrease in functional impairment according to the Oswestry questionnaire to 15.57 ± 3.55 and 27.62 ± 3.27 after 3 months (p < 0.001) and up to 10.22 ± 2.54 and 29.67 ± 4.24 after 6 months (p < 0.001), a decrease in functional impairment according to the NDI to 12.54 ± 4.36 and 23.38 ± 4.5 after 3 months (p < 0.001) and up to 8.08 ± 2.81 and 25.23 ± 4.95 after 6 months (p < 0.001), an improvement in the quality of life according to PCS to 46.04 ± 4.31 and 43.21 ± 4.04 after 3 months (p < 0.05) and up to 50.07 ± 3.27 and 43.57 ± 3.17 after 6 months (p < 0.001), an improvement in the quality of life according to MCS to 47.3 ± 4.31 and 44.57 ± 3.13 after 3 months (p < 0.05) and up to 50.56 ± 2.86 and 44.75 ± 2.63 after 6 months (p < 0.001). During therapy, no significant differences were found between the CT and ST groups according to the Beck Depression Inventory, ST and TT, in both groups an improvement in the indicators was observed over time, however, when comparing the survey indicators after 3 and 6 months, the CT group showed a statistically significant improvement according to the Beck Depression Inventory (p = 0.04), while in the ST group no further changes were noted (p = 0.14). Conclusion. A comprehensive multidisciplinary approach (involving a psychiatrist) to the treatment of patients with chronic non-specific low back pain (CNLBP) and mental health disorders (anxiety and depressive disorders) leads to a more significant reduction in pain and an improvement in functional activity. Prescribed drug therapy for mental disorders improved the improvement in pain, functional activity and quality of life in the long term.

Rationing by Assumption: De-implementation of Spinal Injections Requires Rigorous Comparative Evidence.

To compare the change in the functional cross-sectional area (FCSA) of lumbar paraspinals (multifidus-primary; erector spinae-secondary) between participants prescribed rest before physical therapy (PT) and those starting PT immediately in adolescent athletes with active lumbar spondylolysis. Multicenter randomized controlled trial. Two pediatric hospitals in the United States. Fifty-three adolescent athletes (mean age 14.1 ± 1.5 years; 40% female) were randomized to immediate PT (n = 25) or rest before PT (n = 28). Immediate PT participants began within 1 week of diagnosis. Rest before PT participants delayed PT until their pain resolved with daily activities for 2 consecutive days. Change in FCSA of the lumbar multifidus (primary outcome) and erector spinae at the L4-L5 level, measured by magnetic resonance imaging at baseline and 3 months. The immediate PT group demonstrated significantly greater improvements in multifidus FCSA compared with the rest before PT group [7% increase vs 1.4% decrease; mean difference 8.4% (95% CI, 1.5-18.0); P = 0.03; partial η2 = 0.09]. Multifidus atrophy occurred in 50% of rest before PT group and only 20% of the immediate PT group. Time to PT initiation was associated with multifidus size at 3 months (r = 0.41, P < 0.001). No significant change or between-group differences were observed in erector spinae FCSA (P = 0.69). Immediate PT preserved and increased multifidus FCSA, while rest before PT was associated with higher rates of atrophy. Early rehabilitation may protect lumbar stabilizing musculature in adolescent athletes with spondylolysis, potentially reducing risk of recurrent or chronic low back pain.

Objective To compare the standard multi‐sequence MRI protocol (sMRI) of the sacroiliac joints with a single high‐resolution deep learning–reconstructed DIXON sequence (DL‐DIXON) in patients with suspected axial spondyloarthritis (axSpA). Methods Seventy‐six patients with chronic low back pain and suspected axSpA underwent clinical, laboratory, and genetic assessment followed by 3T sMRI (T1, T2‐FS, VIBE, STIR; 19:49 min) and high‐resolution DL‐DIXON imaging (1 mm isotropic; 5:24 min). Three blinded readers assessed overall imaging diagnosis, diagnostic confidence, and lesion presence (osteitis, fat metaplasia, erosions, sclerosis, joint space changes). DL was used solely for image reconstruction. The clinical diagnosis served as the reference for diagnostic accuracy; sMRI served as the reference for lesion analysis. Diagnostic accuracy was expressed as AUC (balanced accuracy). Non‐inferiority was tested using a predefined margin of 0.05. A decrease of ≤0.05 compared to sMRI was defined as clinically acceptable. Results Nineteen patients were diagnosed with axSpA. DL‐DIXON showed similar diagnostic performance (AUC 0.86 [95% CI 0.76–0.96]) compared to sMRI (0.87 [0.78–0.96]) and met non‐inferiority criteria. Interreader agreement was almost perfect for sMRI (κ = 0.81) and substantial for DL‐DIXON (κ = 0.71). At the lesion level, DL‐DIXON achieved good performance for erosions (AUC 0.83), fat metaplasia (0.80), and joint space changes (0.80), and fair performance for osteitis (0.73) and sclerosis (0.64). Using DL‐DIXON, scan time was reduced by 73%. Conclusions DL‐DIXON provides clinically acceptable diagnostic performance while substantially reducing scan time. This approach may improve efficiency and accessibility of MRI for axSpA assessment. image

Uncomfortable Transitions in Payment Models for Chronic Low Back Pain: Navigating Medicare's Mandatory Payment Reforms in Anesthesiology and Chronic Pain Management.

Introduction. Low back pain is one of the leading causes of disability worldwide and a significant burden on healthcare systems. Despite numerous studies, the mechanisms behind the relationship between clinical, structural, and psychoemotional factors influencing pain intensity and depressive symptoms remain poorly understood. Materials and methods. The study included 32 patients (17 men, 15 women) aged 22–72 years with pain lasting more than 3 months. All participants underwent clinical examinations, MRI to assess intervertebral herniation, and completed the Visual Analogue Pain Scale (VAS) and the PHQ-9 questionnaire to screen for depression. Patients were divided into groups with (n = 18) and without (n = 14) radicular syndrome. Multiple linear regression analysis was used to identify predictors of pain intensity and depression levels. Results. Multiple regression analysis showed that the level of depressive symptoms (β =- 1.71; p = 0.009) and the presence of radicular syndrome (β =-1.18; p = 0.036) were significantly associated with pain intensity. The presence of an intervertebral hernia showed a tendency to increase pain (β = 2.34; p = 0.055). Regarding depression, the presence of a hernia was the only significant factor associated with increased depressive symptoms (β = 10.64; p = 0.007). Comparing groups with and without radicular syndrome did not reveal statistically significant differences in the average pain level. Conclusions. The intensity of low back pain is influenced by a complex interplay of factors, including psychoemotional state and the presence of radicular syndrome, rather than only structural spine changes. These findings highlight the importance of a multidimensional and individualized approach to managing patients with chronic low back pain, considering both clinical and psychoemotional aspects.

Chronic nonspecific (musculoskeletal) low back pain (CNLBP) is one of the most common causes of temporary disability and decreased quality of life. Risk factors for CNLDP include heavy physical labor, excessive flexion and extension, frequent bending, heavy lifting, a sedentary lifestyle, and exposure to vibration. Chronic low back pain is facilitated not only by pathological changes (damage to the intervertebral disc, facet joint, sacroiliac joint, muscles, and ligaments), but also by inadequate treatment of acute pain, excessive limitation of physical activity, a “pain-prone” personality type, and anxiety and depressive disorders (social and psychological factors of pain). The diagnosis of CNLBP is based on a clinical examination and the absence of signs of dangerous disease (“red flags”), radiculopathy, and spinal stenosis. In chronic lower back pain, it is recommended to inform the patient about the favorable prognosis of the disease and its risk factors, the need to avoid excessive static and physical stress, incorrect positions and postures, and the advisability of maintaining physical, social, and professional activity. A multimodal approach is most effective in chronic lower back pain, which, as non-drug methods, should include an educational program, therapeutic physical exercises, manual therapy, and, for some patients, psychological therapy methods. Non-steroidal anti-inflammatory drugs (NSAIDs) are most often used to reduce pain in chronic lower back pain. The efficacy and safety of etoricoxib (Arcoxia) as an NSAID and local administration of Diprospan for lesions of the lumbar facet joints and lumbosacral articulation are discussed. To prevent low back pain, therapeutic exercises and an educational program on avoiding excessive static and physical stress, incorrect positions and postures are recommended.

Intervertebral disc degeneration (IVDD) is the primary pathological driver of chronic low back pain. While the mechanical role of skeletal muscle in spinal stability is well-established, its paracrine influence on IVDD-specifically via exosomes-remains poorly understood. This study investigated whether senescent skeletal muscle cell-derived exosomes (sSkM-Exos) aggravate metabolic dysregulation in nucleus pulposus cells (NPCs) and explored the underlying molecular mechanisms. Senescence was induced in skeletal muscle cells (SkMCs) using hydrogen peroxide (H₂O₂), and sSkM-Exos were isolated via differential centrifugation and characterized. The internalization of sSkM-Exos by NPCs was observed. In vitro, the effects of sSkM-Exos on NPCs proliferation, senescence, apoptosis, and extracellular matrix (ECM) metabolism (COL2, ACAN, MMP13, and ADAMTS5) were evaluated. The involvement of the p38MAPK pathway was assessed using the inhibitor SB203580. In vivo, the impact of sSkM-Exos was validated using a rat IVDD model, monitored by disc height, MRI T2-weighted signaling, and histological analysis. We induced senescent skeletal muscle cells (SkMCs) with hydrogen peroxide (H₂O₂), extracted and identified sSkM-Exos via differential centrifugation. Our findings demonstrate that sSkM-Exos can be internalized by NPCs. In vitro, sSkM-Exos enhanced H₂O₂-induced NPC proliferation inhibition, senescence, apoptosis, and extracellular matrix (ECM) imbalance (downregulated COL2/ACAN, upregulated MMP13/ADAMTS5). Mechanistically, these effects were associated with p38MAPK activation; the p38MAPK inhibitor SB203580 partially reversed these impairments. In vivo, local sSkM-Exos injection was observed to exacerbate disc height loss and histological degeneration in a rat IVDD model. In conclusion, sSkM-Exos were found to contribute to NPC senescence and ECM imbalance, likely through the activation of the p38MAPK pathway. These findings propose a cross-tissue regulatory network that supplements the traditional biomechanical model with a molecular perspective under experimental conditions. This study offers a new dimension to our understanding of IVDD pathogenesis and suggests that targeting sSkM-Exos or the p38MAPK pathway may hold promise as a therapeutic strategy to mitigate IVDD.

The diagnosis of chronic low back pain is frequently complicated by the absence of identifiable pathoanatomical causes on imaging. Consequently, clinical guidelines often advocate for interventional diagnostic procedures, such as medial branch nerve blocks, for suspected facet joint syndrome. Despite their utility, these interventions involve significant resource costs and potential risks associated with needle gauges and pharmacological agents. This study describes a protocol to evaluate percutaneous electrical nerve stimulation (PENS) as a safer, drug-free, and more cost-effective alternative. A parallel and multicenter study with an experimental design through a randomized clinical trial will be conducted. Adults with chronic low back pain and facet-mediated pain confirmed by two positive comparative medial branch diagnostic blocks will be randomized into four parallel groups: PENS, diagnostic medial branch nerve block (with local anesthetic), PENS + nerve block, and PENS + placebo block (full block ritual without active perineural anesthetic). The primary outcomes will be analgesic response. Secondary outcomes include pressure pain threshold, disability, health-related quality of life, rescue analgesic consumption, and the incidence/severity of local and systemic adverse events.Clinical Trial Registration: The www.clinicaltrials.gov identifier is NCT07273006.

Low back pain (LBP) is a prevalent and disabling musculoskeletal disorder that severely affects patients’ quality of life. Traditional rehabilitation training relies on therapists’ subjective observations, which have issues such as imprecise assessment and untimely feedback. A deep learning-based motion analysis system was developed to deliver an intelligent exercise training program with real-time, precise feedback. Through a randomized controlled trial (single-center design), 118 patients with chronic non-specific LBP were randomly assigned to an experimental group (receiving intelligent training based on the motion analysis system) and a control group (receiving conventional guided training). Outcome measures included the visual analog scale (VAS), Oswestry disability index (ODI), surface electromyography (sEMG) signals of core muscles, and system-generated movement quality scores. System performance tests indicated that the pose estimation model achieved a mean Average Precision (AP@0.5) of 96.7% in keypoint detection, with a mean per joint position error (MPJPE) of 25.3 mm and a pelvic angle estimation error of 3.1°, providing a reliable technical foundation for precise motion analysis. Supported by this system, after the 8-week intervention (T1), improvements in both VAS scores (2.6 ± 1.1 vs. 3.9 ± 1.3) and ODI scores (18.7 ± 6.3 vs. 28.3 ± 7.6) were significantly greater in the experimental group compared to the control group (P &lt; 0.05), and this advantage was maintained at the 1-month follow-up after the intervention ended (T2). The average movement quality score during the entire intervention period was also significantly higher in the experimental group (88.5±4.2 points) than in the control group (76.8±7.5 points). The sEMG results indicated more coordinated activation and less compensation in the core muscles of the experimental group. The training adherence rate was significantly higher in the experimental group (92.5%) compared to the control group (85.3%). The deep learning-based motion analysis system developed in this study is highly accurate and robust, capable of providing precise, real-time feedback for rehabilitation training for patients with LBP. It significantly alleviates pain, improves functional impairments, and optimizes movement patterns and neuromuscular control. This innovative rehabilitation method has good clinical application prospects.

A 28-year-old male presented with chronic low back pain persisting for two years following a civilian gunshot injury, with retained shrapnel fragments in the L2 vertebra. Despite multiple outpatient evaluations and extensive pharmacological treatments, including nonsteroidal anti-inflammatory drugs, gabapentinoids, antidepressants, and opioids, his pain remained inadequately controlled. Due to the presence of retained spinal foreign bodies, epidural interventions were avoided. As an alternative approach, an ultrasound-guided erector spinae plane block (ESPB) was performed at the T12 level. The patient experienced immediate and significant pain relief, with sustained improvement in pain scores, mobility, and quality of life. During a one-year follow-up period, no complications or recurrence of symptoms were observed, and the patient did not require additional analgesic interventions. This case highlights ESPB as a safe and effective option for managing chronic post-traumatic low back pain in patients with retained spinal fragments, particularly when conventional interventional techniques are contraindicated.

Chronic non-specific low back pain (CNLBP) is an important health problem affecting people of all ages in societies. This health problem increases especially with age and participation restrictions and quality of life are negatively affected accordingly. This study was conducted to investigate the participation levels, pain, kinesiophobia, functional status and depression among older adults with CNLBP. This descriptive and correlational study included 115 cognitively healthy older people over the age of 65 who applied to a state hospital with CNLBP. Data were collected using the Demographic Information Form, Montreal Cognitive Assessment, Visual Analog Scale, Tampa Scale of Kinesiophobia, Back Pain Function Scale, Keele Participation Assessment Scale and Geriatric Depression Scale. Data were evaluated using descriptive statistics, independent sample t-test, correlation and regression analyses. The mean age of the older adults participating in the study was 71.90 ± 6.64. According to the results obtained, it was found that as the level of social participation of the older adults decreased, their depression, kinesiophobia and pain levels increased and their functional levels decreased. It was determined that social participation could explain 45% of functional losses and 20-25% of psychological symptoms. According to the findings, CNLBP has critical effects not only on the physical but also on the psychosocial status of the older people. Therefore, incorporating psychosocial factors affecting older adults into holistic rehabilitation plans is key to the successful treatment of CNLBP. Not applicable.

Background/Objectives: Superior cluneal nerve entrapment syndrome (SCNES) is an underrecognized cause of chronic low back pain, particularly in adolescents where published experience is limited. This article describes a reproducible open surgical technique for superior cluneal nerve (SCN) decompression. Methods: We outline indications and relative contraindications, required instrumentation, key surface landmarks, and a stepwise operative approach. The nerve is identified where SCN branches traverse the thoracolumbar fascia and fibro-osseous tunnel near the posterior iliac crest. Decompression is performed via limited fasciotomy and release of surrounding soft tissues, with attention given to identifying additional branches requiring release. Results: The technique provides consistent exposure and decompression of the SCN branches using an approximately 5 cm oblique incision centered over the expected crossing point (about 7 cm lateral to the midline and roughly 4 cm lateral to the PSIS). Pearls and pitfalls are provided to reduce peri-incisional numbness and avoid thermal injury to the nerve. Conclusions: Open SCN decompression is a focused procedure that can be considered after confirmation of SCNES by clinical criteria and response to diagnostic block. Standardizing technique and postoperative care may facilitate broader adoption and future outcome studies in pediatric populations.

Intervertebral disc degeneration (IVDD) is a major cause of chronic low back pain and disability and imposes a substantial socioeconomic burden. Increasing evidence indicates that metabolic reprogramming is closely involved in the initiation and progression of IVDD. In this review, we summarize the major pathological processes associated with IVDD, including apoptosis, autophagy dysregulation, oxidative stress, inflammatory responses, and extracellular matrix (ECM) degradation. We further discuss alterations in glucose, lipid, and amino acid metabolism, with particular emphasis on the contribution of mitochondrial dysfunction to metabolic imbalance in disc cells. In addition, we outline the genetic, environmental, and signaling factors that regulate metabolic reprogramming, including pathways such as mTOR and AMPK. Finally, we review emerging metabolism-related therapeutic strategies, including metabolic enzyme modulation, antioxidants, and mitochondrial protectors. Collectively, current evidence suggests that metabolic reprogramming is an important component of IVDD pathogenesis and may provide a useful framework for the development of targeted therapeutic approaches.

Multimodal assessment of central and peripheral neuromuscular function during core stability tasks in chronic nonspecific low back pain