Role of Psychosocial Factors in Chronic Low Back Pain: A Contemporary Review

Chronic low back pain represents a significant global health burden, with annual healthcare expenditures exceeding $90 billion in the United States alone.1 While anatomical and biomechanical factors contribute to pain genesis, mounting evidence demonstrates that psychosocial factors play a crucial role in pain chronification and treatment outcomes.2 The present review synthesizes current evidence regarding the complex interplay between psychological, social, and biological factors in chronic low back pain, with particular emphasis on implications for surgical decision-making and perioperative care.

The Biopsychosocial Model of Pain

Contemporary understanding of chronic low back pain has evolved from a purely biomechanical model to the recognition of pain as a complex biopsychosocial phenomenon.3

Psychological distress and chronic pain demonstrate a bidirectional relationship— pain can trigger or exacerbate psychological symptoms, while pre-existing psychological conditions may amplify pain perception and disability. 4 This relationship appears particularly relevant in degenerative spine conditions, where objective pathology often correlates poorly with symptom severity.

Psychological Risk Factors: Depression and Anxiety

Studies have reported rates of preoperative depression in patients undergoing spine surgery ranging from 29% to 54%, which may significantly affect surgical outcomes. 5 A recent study by Deshpande et al involving patients from the Michigan Spine Surgery Improvement Collaborative registry who underwent lumbar spine surgery demonstrated that patients with anxiety and depression reported worse baseline and postoperative back and leg pain resolution.6 Patients solely with depression faced over a 30% higher risk of readmission compared to those without depression or anxiety. 6 Furthermore, in a 10-year longitudinal study, Tuomainen et al found that patients who underwent surgery for lumbar spinal stenosis and who had preoperative depression exhibited persistently worse outcomes in terms of pain and disability compared to patients without depression.7 Additionally, a recent systematic review of 44 studies examining the impact of preoperative depression on outcomes after lumbar spine surgery revealed that while patients with depression showed comparable improvements in disability, pain, and physical function, their overall outcomes remained poorer. 8 Notably, patients with depression experienced a similar extent of improvement in their depressive symptoms compared to those without depression.8 However, these patients had worse postoperative depression severity. Therefore, identifying patients with preoperative depression may help improve outcomes in this challenging population. Collectively, these findings may be related to the known association between depression and inadequately controlled pain postoperatively.9

Similarly, previous research has suggested an association between preoperative anxiety and postoperative pain intensity.10 Pain-related anxiety and avoidance behavior are physiological responses following an acute incident. However, maladaptive coping mechanisms, such as catastrophizing and fear-avoidance behaviors, can contribute to the development or persistence of anxiety and depression after spine surgery.11 The fear-avoidance model suggests that catastrophizing leads to pain-related fear, resulting in activity avoidance and subsequent physical deconditioning.11 This cycle appears especially relevant in musculoskeletal conditions, where fear of movement can perpetuate disability independent of pain intensity. Therefore, the bidirectional relationship between pain and anxiety may create a negative feedback loop that could impair recovery if not adequately addressed.4 This also may explain why anxiety disorders demonstrate a significant association with chronic postsurgical pain, with meta-analyses suggesting a 55% to 110% increased risk of developing chronic postsurgical pain in patients with anxiety across various surgical procedures.10

Preoperative Optimization Strategies

Addressing psychosocial factors preoperatively through cognitive behavioral therapy (CBT), mindfulness-based stress reduction, and pain neuroscience education has shown promise in improving pain and disability in the short term.12 While limited evidence exists regarding the impact of preoperative psychological intervention on lumbar spine surgery outcomes, several studies have examined this relationship in cervical spine procedures. In a prospective study of 27 patients undergoing anterior cervical discectomy and fusion (ACDF), Adogwa et al demonstrated significantly improved postoperative neck pain at 1-year follow-up among patients who received preoperative anxiety treatment compared to untreated controls.13 Similarly, Elsamadicy et al evaluated 140 ACDF patients, including 25 with preoperative depression who underwent psychological intervention.14 At 24-month follow-up, treated patients showed comparable objective and patient-reported outcomes to those without depression, suggesting that preoperative psychological optimization may help mitigate historically observed outcome disparities. While these findings suggest potential benefits of psychological intervention, the optimal timing, duration, and specific treatment protocols remain undefined and warrant further investigation through well-designed prospective studies.

Access to Psychological Care and Healthcare Disparities

While evidence supports the value of preoperative psychological optimization, access to mental health services varies significantly across populations. Mental health providers with expertise in chronic pain are not uniformly available, and insurance coverage for psychological services remains variable. Language barriers and cultural factors may further complicate psychological screening and intervention. For example, validated translations of common screening tools may not be available in all languages, and cultural differences in expressing psychological distress may affect the interpretation of standard assessments.15 Therefore, cultural background and health literacy may influence expectations and how patients communicate about their symptoms and satisfaction.16 Structured preoperative education programs that address both physical and psychological aspects of recovery, delivered in a culturally competent manner, may help align expectations with likely outcomes.

These disparities in access to psychological care parallel broader inequities in spine care delivery. An analysis of 9941 patients with lumbar spondylolisthesis revealed that Black, Indigenous, and People of Color (BIPOC) were 32% less likely to receive surgical intervention despite reporting higher baseline pain interference scores.2 This disparity highlights systemic barriers to equitable spine care access, such as implicit provider bias and socioeconomic obstacles. Similarly, Medicaid beneficiaries demonstrated significantly lower odds of achieving minimal clinically important difference (MCID) in pain and disability compared to privately insured patients. Addressing these inequities requires healthcare systems to implement culturally tailored education programs, increase diversity among spine care providers, and ensure policy changes that promote insurance parity and access to specialized care.

Patient Expectations and Satisfaction

Patient expectations significantly influence satisfaction with surgical outcomes. Studies show that patients with depression and anxiety often report different expectations regarding postoperative pain improvement compared to those without mental health conditions. Notably, while patients with greater preoperative pain might intuitively be expected to have higher expectations for improvement, research suggests the opposite pattern. Jacob et al found that patients with worse mental health scores demonstrated lower expectations for pain improvement, despite having higher baseline pain levels following lumbar fusion.17 This counterintuitive finding may be explained by the psychological impact of chronic pain combined with depression—specifically, the hopelessness often experienced by patients with depression may lead them to have reduced expectations for symptom improvement.

Postoperative Rehabilitation Considerations

Psychological factors significantly influence engagement in postoperative rehabilitation, with implications that vary across racial and ethnic groups. Studies demonstrate that patients with elevated anxiety or catastrophizing scores show lower adherence to physical therapy and increased activity avoidance due to fear of pain.18 Enhanced recovery after surgery (ERAS) protocols that incorporate psychological support and standardized pain coping strategies show promise in improving rehabilitation participation and outcomes.19 However, recent evidence suggests that even with standardized ERAS protocols, significant disparities persist in postoperative outcomes between racial/ ethnic groups.

Research indicates that BIPOC patients face greater challenges during the rehabilitation period, with significantly longer hospital stays (3.8 vs 3.4 days) and higher rates of discharge to rehabilitation facilities compared to White patients (20.9% vs 11.8%).20 These disparities persist even after controlling for comorbidities, suggesting that social determinants of health and systemic barriers play important roles. ERAS protocols present an opportunity to provide consistent, high-quality postoperative care, but evidence shows that adherence to preoperative process measures may be lower among non-White patients (24.2% vs 36.6%).20 Early identification of high-risk patients using validated tools like the Risk Assessment and Prediction Tool along with culturally competent delivery of rehabilitation services may help address these disparities.20

Future Directions and Conclusion

Several opportunities exist to improve the integration of psychological care in spine surgery. The development of more sophisticated risk stratification tools incorporating both psychological and social factors could improve patient selection and guide individualized intervention strategies. Additionally, the implementation of virtual care platforms may help address disparities in access to psychological services. However, careful attention must be paid to the digital divide that may affect certain populations.

Psychological and social factors play crucial roles in the development, persistence, and treatment outcomes of chronic low back pain. Comprehensive preoperative screening and targeted interventions addressing these factors appear essential for optimizing surgical outcomes. Future research should focus on developing more sophisticated screening tools, identifying optimal timing for psychological interventions, and addressing healthcare disparities to ensure equitable access to effective treatment.

References

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Contributors:

Luis M. Salazar, MD

Vincent P. Federico, MD

Arash Sayari, MD

From the Department of Orthopaedic Surgery at Rush University Medical Center in Chicago, Illinois.