Oral Presentation 51st International Society for the Study of the Lumbar Spine Annual Meeting 2025

Paraspinal muscle fat content by MRI outperforms subcutaneous and visceral fat volumes in predicting history of back pain in the German National Cohort (GNC) (116196)

Jannis Bodden 1 , Paul Platzek 1 , Robert Graf 1 , Hendrik Möller 1 , Matan Atad 1 , Benedikt Wiestler 1 , Jan Kirschke 1
  1. Technical University of Munich, School of Medicine and Health, Munich, BAVARIA, Germany

Introduction

Paraspinal muscle strength is a hallmark of biomechanical lumbar spine stability. Intramuscular fat content is closely related to muscle strength and may therefore indicate muscle function and disbalance, which is linked to chronic low back pain (LBP). Intramuscular fat can quantitatively be assessed by fat-water-separation sequences in MR imaging, which are included in the German National Cohort (GNC) dataset. The aim of this study was thus to clarify associations between subcutaneous (SAT), visceral fat (VAT) and paraspinal muscle fat infiltration and LBP.

Methods

Paraspinal muscles (medial (ESM), lateral (ESL) erector spinae portions, psoas (PS), quadratus lumborum (QL)), SAT and VAT were automatically segmented in all GNC participants with available 6-point-DIXON imaging, using an in-house developed deep-learning based segmentation framework (Figure 1). Average proton density fat-fraction (PDFF, ‰) was measured for each muscle and VAT and SAT (cm3) were assessed. Multivariate logistic regression models were used to investigate associations between the predictors (SAT, VAT and muscle PDFF) and self-reported CLBP (no LBP vs. LBP ≤3mo; low, medium, or high LBP ≥3mo in the last 12mo) as outcome. To facilitate interpretation, PDFF, SAT and VAT were assessed as standard deviation (SD) from the mean. Models included age, weight and height, to account for confounding. PDFF, SAT and VAT distribution in LBP-groups was further investigated using density histograms.

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Figure 1: Automated segmentation framework.

Results

VAT and SAT were measured in 24634 participants, and PDFF for each muscle was calculated in ≥22875 participants, respectively. ESM, ESL and QL differentiated well between participants without and with low LBP in the last year (ORSD, 95%-CISD, p: ESM = 1.002, 1.002-1.004, <.001; ESL = 1.004, 1.003-1.006, <0.001; PS = 1.004, 1.001 - 1.008, .011; 1.003, 1.001 - 1.005, .008) while SAT(p = .406) and VAT(p = .870) did not. ORSD increased with LBP intensity for all muscles (medium LBP: ORSD= 1.004 - 1.006; high LBP: 1.005 - 1.009; p < .001, respectively;), SAT (ORSD = 1.00005 and 1.00006 for medium and high LBP; p < .001, respectively), but not VAT(medium LBP: p=0.788; high LBP: p=0.267). Moreover, ESM-, ESL- and QL-PDFF differentiated between participants who experienced less than 3mo LBP in the last year (ORSD≥1.002, p<.001). Conversely, SAT was not significantly (p=.455) and VAT was negatively associated with less than 3mo LBP (ORSD=0.99994, 95%-CI=0.99991-0.99997, p=.001).

 674c8354d436a-hist_fat_deposits_by_pain.jpg

Figure 2: Density plots depicting each predictors ability to differentiate between participants without and with LBP (≤3mo, low, medium and high). Group differences in PDFF (in ‰) occur at lower LBP compared to SAT and VAT (in cm3, respectively).

Discussion

Paraspinal muscle PDFF shows strong associations with presence and degree of LBP and outperforms VAT and SAT in LBP prediction models, corrected for age, height, and weight. Thus, paraspinal muscle fat content warrants further investigation as independent predictor of LBP. However, it remains unclear whether LBP precedes fatty muscle degeneration, as it leads to decreased activity, or, alternatively, increased intramuscular fat leads to decreased muscle strength, impairing trunk stability, resulting in pain and activity reduction.

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