Special Poster Session 51st International Society for the Study of the Lumbar Spine Annual Meeting 2025

INTRODUCTION:  Low back pain (LBP) is the leading cause of disability world-wide. Current research postulates LBP as a linear spectrum consisting of predominantly nociceptive pain (NoP) on one end and neuropathic pain (NeP) on the other. Traditionally, NeP and NoP have been regarded as discrete entities, primarily attributed to patho-anatomical abnormalities within the lumbar spine. However, it is increasingly evident that the nature of both pain classifications is multifaceted, encompassing a range of physical, biomechanical, chemical, and psychosocial factors. As such this study aims to address current shortcomings in the literature regarding LBP classification by (1) investigating whether there is a difference in pain severity, disability, quality of life, and sociodemographic factors between patients with NeP and NoP, (2) exploring associations between radiological findings on MRI and X-ray and NeP and NoP, and (3) elucidate associations between non-spinal comorbid conditions and NeP and NoP.

METHODS: A retrospective analysis involving a cohort of adult patients (>18 years) presenting with chronic LBP (>3 months) to a tertiary spine clinic was conducted. Patients were excluded if they had a history of spinal surgery, were diagnosed with specific spinal pathologies or were diagnosed with non-spinal conditions that present with neuropathic symptoms. Patient demographic, radiology, and comorbidity analysis is outlined in Figure 1. The PainDETECT questionnaire was used to determine whether a patient had NoP or NeP. 

RESULTS: 512 patients were included in the study. The NeP group had a lower mean age than the NoP group (p<0.05), there was no difference in gender between the groups. The NeP group had higher pain severity (8.0+/-1.5 vs. 5.8+/-2.3, p<0.001), higher disability (48.7+/-21.4 vs. 25.7+/-19.4, p<0.001), and lower quality of life (0.562+/-0.26 vs. 0.278+/-0.25, p<0.001). Smokers and patients with no partner marital status were 2.4 times more likely to have NeP compared to NoP (P<0.01). Additionally, the NeP group were of lower income class (p<0.05). In the radiology study, patients with NeP had higher foraminal (U=18.962, p=0.002) and spinal stenosis (U=14.481, p=0.005) severity. A subgroup analysis of patients without stenosis revealed that the NeP group had higher prevalence of disk bulge (96% vs. 78%, p=0.002), high-intensity zones (51% vs. 19%, p<0.001) and Pfirmann grade (U=11.321, p=0.020). In the comorbidity analysis, patients with depression, rheumatoid arthritis (RA) and gastrointestinal disorders were 2.844, 2.726 and 2.847 times more likely to suffer NeP than NoP, respectively (p<0.05) (figure 1).

DISCUSSION: NeP is more severe, associated with higher disability and a lower quality of life, and is more prevalent in certain sociodemographic populations. Although compression of neuronal tissue is associated with neuropathia, it is not exclusive to NeP, disk degeneration alone and hyperinflammation due to comorbidities are also drivers of neuropathia. These findings emphasize the importance of individualized management plans tailored to the specific pain and medical profiles of patients, rather than relying on a one-size-fits-all approach. Furthermore, this study underscores the need to represent pain on a nociceptive-neuropathic continuum to achieve more accurate differentiation of pain components and reduce unnecessary pharmacotherapy, imaging, and non-targeted surgical interventions.

Figure 1