Background: Low back pain (LBP) is a common health problem and a major contributor to disability. Modic changes, or vertebral marrow changes visible on MRI, are frequently observed in individuals with LBP. However, there is inconsistent evidence assessing the relationship between Modic changes and LBP, pain-related disability, and quality of life. Questions/purposes: (1) Are Modic change parameters, including their type, number, and extent, positively associated with the characteristics of LBP, particularly when classified into intermittent LBP and chronic LBP? (2) Are Modic change parameters associated with participant-reported longer duration and higher intensity of LBP? (3) Are Modic change parameters associated with worsened pain-related disability and poorer quality of life? Methods: This study was a Phase III, single-center, cross-sectional analysis drawing its data from the ongoing Berlin Back Study (research unit FOR5177). A total of 1218 participants who met the inclusion and exclusion criteria were recruited between January 2022 and January 2024. Of these, 18% (217 of 1218) were excluded because of the lack of results from orthopaedic clinical examination and MRI evaluation. After clinical examination and completion of questionnaires, another 24% (289 of 1218) were excluded because of pain in other locations or pain experienced in the past, leaving 58% (712 of 1218) of participants in our study. The individuals included in this study had a mean age of 42 ± 11 years, with 57% women and 43% men. Data on demographic characteristics, LBP features, pain-related disability, and quality of life were collected using structured questionnaires and clinical evaluations. Three independent evaluators, blinded to the participants’ demographic information and health status, assessed the Modic change parameters, referring to signal alterations in the vertebrae’s endplate. The relationship between Modic change parameters and individual health status was assessed using multiple regression analysis after adjustment for age, gender, BMI, smoking and alcohol consumption, disc herniation, facet joint degeneration, and spinal instability. Results: Among the common Modic change parameters, when Type I Modic changes were observed, we found higher odds of chronic LBP (OR 7.3 [95% confidence interval (CI) 3.1 to 17.0]; p < 0.001) and intermittent LBP (OR 4.9 [95% CI 1.7 to 14.0]; p = 0.003) after adjusting for potential confounders. However, when greater depth and area of Modic changes were observed, we found higher odds of chronic LBP (OR 3.1 [95% CI 1.3 to 7.3]; p = 0.01 and OR 1.3 [95% CI 1.0 to 1.7]; p = 0.03, respectively) but not of intermittent LBP (OR 1.2 [95% CI 0.4 to 4.1]; p = 0.72 and OR 1.0 [95% CI 0.7 to 1.3]; p = 0.86, respectively). In the chronic LBP subgroup, we found that Type I Modic changes were associated with slightly higher maximum pain intensity (β 1.1 [95% CI 0.4 to 1.7]; p = 0.001), and multiple Modic changes were associated with modestly longer duration of chronic LBP (β 5.1 [95% CI 1.2 to 9.0]; p = 0.01). Increased Modic change depth and area were associated with slightly higher pain intensity in the chronic LBP group but not in the intermittent LBP group. In addition, Type II and single Modic changes were associated with slightly worsened pain-related disability (β 1.1 [95% CI 0.1 to 2.0]; p = 0.03 and β 1.5 [95% CI 0.6 to 2.4]; p = 0.001, respectively). The presence of Modic changes was also associated with slightly poorer quality of life, particularly in terms of physical health. Conclusion: Modic changes were found to be associated with higher odds of LBP, greater pain intensity, worsened pain-related disability, and reduced quality of life. The Type I and larger Modic changes were associated with slightly higher intensity of chronic LBP and slightly reduced physical function. Our study associated Modic changes with these findings, but it was not designed to demonstrate a causal relationship. Future studies will need to explore the causal relationship between Modic changes and health conditions, as well as whether targeting Modic changes could offer a potential approach to alleviating LBP. Level of Evidence: Level III, prognostic study.

Introduction: Psychosocial function in people with chronic low back pain (cLBP) is often impaired, indicating poor well-being. Fear-avoidance beliefs (FAB) are common concomitants of cLBP. Fear-avoidance beliefs are gaining attention as a potential prognostic factor for chronification and resulting disability in cLBP. This article aims to examine the associations of back function with FAB. Methods: This study presents data from a cohort study (DRKS00027907). In the present cross-sectional analyses, we included 914 participants (480 nonchronic LBP [ncLBP], 227 cLBP, 207 asymptomatic). Fear-avoidance beliefs were assessed using the fear-avoidance belief questionnaire (FABQ). The association between the FAB and clinical measures (Ott and Schober test, the sit-to-stand test [STS], and the finger-floor distance [FFD]) were analyzed. Back shape and function were also measured using a noninvasive device. The association between FABQ scores and clinical measures was assessed using age, body mass index, sex, and pain intensity–adjusted multiple linear regression models. Results: Associations between FAB and both clinical (Ott, Schober, STS, FFD) and noninvasive device measures were small. All relevant clinical measures were attenuated in individuals with elevated FAB. Discussion: We were able to demonstrate the association of both back shape and function in both clinical tests and noninvasive device measurements with self-reported fear-avoidance beliefs. However, the effect sizes were small. This may be attributed to the different assessment methods (objective vs self-report), resulting in reduced common method variance. In addition to the FAB, there may be other factors (eg, altered neuronal pathways; actual avoidance behavior such as reduced physical activity) that contribute to functional impairment.

Purpose: Segmental instability guides surgical decision-making in isthmic lumbar spondylolisthesis (ILS). Despite concerns regarding radiation exposure, reproducibility and applicability in patients with pain or limited mobility, flexion–extension (FE) radiographs remain the standard for instability assessment. Combining upright radiographs with supine magnetic resonance imaging (MRI), both routinely obtained in clinical practice, may offer a comparable, lower-radiation alternative. This study aimed to compare segmental motion at L5/S1 between FE and upright–supine (US) imaging and to evaluate their ability to detect radiographic instability. Methods: In this retrospective cross-sectional study, consecutive patients surgically treated for isolated L5/S1 ILS were screened for eligibility. Segmental motion was assessed using FE radiographs and US imaging, including measurements of dynamic sagittal translation and the proportion of patients identified with radiographic signs of instability. Preoperative pain intensity was assessed using the Numeric Rating Scale (NRS). Results: Of 126 screened patients, 78 met inclusion criteria (59% female; median age 48.5 years; median BMI 26.4 kg/m²). Dynamic sagittal translation was significantly greater on US than on FE ( p < 0.001). US imaging identified more cases of radiographic instability ( p < 0.001). Only US-measured translation was associated with preoperative low back pain intensity ( p = 0.025) and was inversely associated with intervertebral disc degeneration ( p = 0.014). Conclusions: US imaging detected a higher proportion of radiographically unstable ILS cases than FE radiographs. Furthermore, only US-derived translation was associated with pain intensity, suggesting greater clinical relevance. Combining upright radiographs with supine MRI may offer a practical, low-radiation alternative for preoperative instability assessment.

Low back pain (LBP) is the leading cause of disability worldwide. While studies often focus on the relationship between magnetic resonance imaging (MRI) findings and symptoms or the link between pain and disability, comprehensive assessments that incorporate both structural and functional impairments are lacking. This study prospectively includes standardized questionnaires, medical histories, clinical exams, and lumbar–pelvic MRI. Participants were grouped by pain status, physical activity, structural impairments (e.g., Pfirrmann, Krämer, Fujiwara, Meyerding), and posture/mobility deviations. Data were analyzed using the Kruskal–Wallis test. Of the 1262 participants, 392 (31%) reported chronic low back pain (cLBP), 226 (18%) had intermittent low back pain (iLBP), and 335 (27%) were pain-free. Significant differences were observed in high physical activity levels based on WHO criteria (cLBP: 79%, iLBP: 78%, no-BP(2): 86%, p = 0.020, η² = 0.008). Morphological impairments were more prevalent in cLBP (75%) and iLBP (76%) compared to no-BP(2) (55%) (p = 0.000, η² = 0.043). Functional impairments showed similar patterns (cLBP: 42%, iLBP: 51%, no-BP(2): 38%, p = 0.014, η² = 0.010). Participants with functional impairments tended to be younger. Consequently, the current classification system for diagnostics needs to incorporate alternative categories to more accurately differentiate types of back pain, which could enhance therapeutic outcomes.

Background: Diagnosing cLBP is complex due to its heterogeneity, lack of definitive biomarkers, and the subjective nature of pain. This study aims to analyze cLBP patients comprehensively, characterizing demographic and clinical profiles of patients and evaluating the types and effectiveness of previous treatments.Methods: From January 2022 to April 2024, we recruited 1262 participants aged between 18 and 72 years from the general population by advertisements and word‐of‐mouth propaganda. Collected data included a detailed medical history, standardized questionnaires (e.g., Von Korff) and a clinical examination.Results: Our population included 471 (38%) with chronic back pain, 335 (27%) without back pain, and an additional group in between of 327 (26%) with intermittent back pain. The majority of participants experienced multifocal back pain, which was further subdivided based on the predominant pain localization. In patients with localized cLBP (median: 5 years, IQR: 1–10 years), the pain persisted for a shorter time than in the group with predominant back pain other than the lower back (median: 10 years, IQR: 5–15 years). The majority of participants did either use no pain medication at all (cLBP: 32%; iLBP: 37%; no‐BP(2): 55%) or on‐demand medication (cLBP: 56%; iLBP: 56%; no‐BP(2): 39%).Conclusion: Our data show considerable heterogeneity underlying the widespread diagnosis “chronic back pain.” Quantitative differentiation is difficult due to the low pain intensity on the day of the examination, and adequate treatment recommendations are challenging. To better understand chronic back pain, there is a strong need for a subclassification.Trial Registration: German Clinical Trial Register: DRKS‐ID: DRKS00027907

Introduction: In adolescent idiopathic scoliosis (AIS), the choice of upper and lowest instrumented vertebrae and related complications remain debated. Bone quality is a relevant factor in this context. The vertebral bone quality (VBQ) score has recently been proposed as a radiation-free magnetic resonance imaging (MRI)-based measure of bone quality. However, the role of the VBQ score in AIS and its relationship with the severity of scoliosis characteristics has not yet been explored. We hypothesize that the VBQ score is associated with key features of AIS, including curve type, Cobb angle, lumbar modifier, and thoracic kyphosis. Methods: This retrospective study included AIS patients who underwent posterior spinal fusion between 2011 and 2025 at a university hospital. The lumbar VBQ score was determined using preoperative MRI, and the Lenke classification was assessed based on preoperative radiographs. To ensure comparability, curve types were categorized based on the flexibility of the lumbar curvature into non-structural (Lenke types 1 and 2) and structural (Lenke types 3 to 6) groups. The association between VBQ and curve type, Cobb angle, lumbar modifier, and thoracic kyphosis—while considering MRI field strength, age, sex, and body mass index (BMI)—was analyzed using multiple linear regression analyses. Results: This single-center study included 60 patients (male: 15%, female: 85%) with a median age of 15 years (interquartile range (IQR): 14–16 years) and a median BMI of 18.9 kg/m2 (IQR: 17.5–22.4 kg/m2), diagnosed with AIS presenting with non-structural (55%) and structural (45%) lumbar curves. A significant association was found with lumbar curve flexibility (r2 = 0.298, p = 0.035), indicating that structural lumbar curves correlated with lower bone quality. Additionally, female patients showed significantly better bone quality (r2 = -0.446, p = 0.005). No significant correlation was observed between the VBQ score and Cobb angle (r2 = -0.003, p = 0.370), thoracic kyphosis (r2 = 0.001, p = 0.734), lumbar modifier (r2 = -0.116, p = 0.123), MRI field strength (r2 = -0.181, p = 0.098), age (r2 = 0.018, p = 0.558), or BMI (r2 = -0.014, p = 0.275). Conclusion: Our study demonstrated a significant correlation between the VBQ score and both lumbar curve flexibility and sex. Opportunistic assessment of the VBQ score may therefore be particularly useful in male patients with a structural lumbar curve to identify individuals who may benefit from further evaluation of bone quality.