Read the Full Video Transcript
DISCLAIMER: Transcript lightly edited for clarity and readability. The views expressed are intended to explore the full range of clinical considerations in spine care and do not constitute medical advice. For guidance specific to your situation, consult a spine specialist.
Chronic low back pain can feel like an isolating experience — particularly when it seems like every treatment has been tried and answers remain elusive. This explainer addresses why that is so common, and why arriving at a precise diagnosis is the most important step any patient in this situation can take.
The experience of significant pain accompanied by a normal MRI is one of the most frustrating clinical moments patients describe. It is also more common than most are told. The imaging appears unremarkable, yet the pain is real. Rather than being a dead end, this is a meaningful clinical signal — it means the problem lies somewhere the MRI cannot capture.
The emotional dimension of chronic pain is not secondary. It is part of the clinical picture. The exhaustion of explaining persistent pain repeatedly, the grief over a life that has changed, the fear that this is permanent — these are not side effects of the diagnosis. They are part of what needs to be assessed and addressed. Any complete evaluation must account for them.
This brings us to a critical distinction: chronic low back pain is a label, not a diagnosis. It describes duration and location. It says nothing about cause. As Dr. Kamal Woods at Vertrae® in Dayton, Ohio frames it: treating the wrong source is one major reason patients cycle through treatments that provide only partial or temporary relief. A degenerative disc, a facet joint problem, a sacroiliac joint issue, and multifidus dysfunction all behave differently and require different approaches. Applying one treatment to all of them produces predictably incomplete results.
A normal MRI is not the end of the diagnostic road. It is a signal that standard structural findings do not explain the pain, which means the evaluation needs to go further. In one 2024 MRI cohort study, Stoecklein and colleagues documented that depression and anxiety were stronger predictors of back pain severity than most spinal imaging findings. This does not mean the pain is imagined. It means the nervous system itself is involved. Central sensitization — the process by which the nervous system becomes sensitized and amplifies pain signals beyond what structural damage alone would produce — is a real physiological process, and it is not visible on a standard MRI.
A large body of evidence confirms that chronic back pain co-occurs with depression and anxiety at high rates — documented at approximately 71 percent in some studies. This bidirectional relationship reflects the interconnection between the nervous system’s processing of physical pain and emotional state. Neither can be addressed effectively while the other is ignored.
Identifying the type of pain pattern is an important diagnostic step. Mechanical pain is load-dependent: it worsens with activity and physical stress, and relieves with rest. Inflammatory pain behaves in the opposite pattern: it tends to improve with activity and worsen with rest, producing characteristic severe morning stiffness lasting over 30 minutes or pain that disrupts sleep at night. Inflammatory pain patterns may point toward a systemic inflammatory condition requiring a different type of specialist and a fundamentally different treatment approach.
Certain conditions that contribute substantially to chronic back pain are not reliably identified on standard MRI. Vertebrogenic pain involves damage to the endplates between vertebral bodies, which can allow inflammatory chemicals to make direct contact with adjacent nerve tissue — producing significant ongoing pain from a source that standard imaging may not characterize well. Multifidus dysfunction occurs when the deep stabilizing muscle of the lumbar spine is reflexively inhibited following injury, effectively deactivated by the nervous system as a protective response. Conventional exercise alone may not reliably restore a muscle that has become reflexively inhibited by the nervous system. These conditions require specific evaluation and targeted interventions.
Red flag symptoms require immediate emergency evaluation rather than a scheduled appointment. Sudden loss of bladder or bowel control accompanying back pain is a medical emergency. New numbness in the groin or saddle area, sudden bilateral leg weakness, or severe back pain following a fall or injury also require immediate assessment. These are uncommon, but they indicate serious nerve compression that cannot wait.
Comprehensive evaluation — the kind that leads to an actual diagnosis rather than a label — begins with listening. It involves a detailed clinical history, an assessment of how the pain behaves with movement and position, a careful physical examination, and targeted imaging interpreted in the context of what the patient describes. The sequence matters: precise diagnosis first, then identification of all contributing factors, then conservative care starting with the simplest effective option, with more invasive interventions considered only when clearly indicated for a clearly defined problem.
The question worth carrying out of any clinical encounter where chronic back pain has not been adequately explained: was the conclusion a genuine clinical diagnosis, or was it the limit of that particular evaluation? Because those are not the same thing — and the difference may be the beginning of a different path forward.
Quick Answer: What Is Chronic Low Back Pain and Why Is It So Hard to Treat?
- Chronic low back pain is pain that persists or recurs for more than three months — but it is not a single condition. It is a label applied to dozens of distinct problems with different causes and different treatments.
- A normal MRI does not mean nothing is wrong. In one 2024 MRI cohort study, depression and anxiety predicted back pain severity more strongly than most imaging findings (Stoecklein et al., 2024).
- The most common sources include degenerative disc disease, facet joint arthropathy, sacroiliac joint dysfunction, vertebrogenic pain, and multifidus dysfunction — each requiring a different approach.
- Treating the wrong source is one major reason patients cycle through treatments that provide partial or temporary relief.
- A thorough evaluation — including history, movement assessment, and targeted imaging — is what separates a label from a diagnosis.
→ If you’ve been told your MRI is fine and you’re still in pain, you are not out of options. You may just need someone willing to ask different questions.
The Appointment That Left You Feeling Invisible
You’ve probably said some version of this out loud — or thought it alone, late at night, when the pain made sleep impossible:
“I’ve tried everything. Physical therapy, injections, and three different doctors. They look at my MRI and tell me everything appears normal. And I am still in agony every single day.”
If that is where you are right now, this blog is written for you.
Not to offer another round of the same tests. Not to add another specialist to the list. But to explain something that most clinical appointments don’t make time for: why chronic back pain is one of the most complex, misunderstood, and incompletely diagnosed conditions in medicine — and why the label you’ve been given may be the single biggest obstacle between you and real answers.
The exhaustion of explaining yourself to another provider who has already made up their mind. The grief of a version of yourself you can’t seem to get back. The quiet, private fear that this might just be what your life is now. These are not peripheral to the clinical picture. For patients with chronic back pain, they are part of it.
At Vertrae® Surgery Center in Dayton, Ohio, Dr. Kamal Woods, a double-fellowship-trained neurosurgeon and spine surgeon trained at Cedars-Sinai Medical Center, approaches chronic back pain as a diagnostic challenge that deserves the full attention most patients have never received. This is a clear, honest explanation of what chronic back pain actually is, what drives it, and what a thorough evaluation should look like.
You are not imagining this. You are not out of options. But you may need someone willing to look harder.
The Label Is a Description. Not a Diagnosis.
“Chronic low back pain” tells you how long you’ve been hurting and roughly where. It does not tell you why. It does not identify which of the dozens of distinct conditions that produce back pain is actually driving yours.
This distinction matters far more than most patients are told. Without diagnostic precision — without knowing the specific anatomical source, the pain mechanism, and how the nervous system has adapted to it — treatment is educated guesswork. This is exactly why so many patients cycle through physical therapy, injections, and medications that provide partial relief, temporary relief, or nothing at all.
Clinically, pain is classified as chronic when it persists or recurs for more than three months. That threshold is also roughly the point at which the nervous system begins to change. Pain is no longer purely a signal from damaged tissue; it also involves how the brain and spinal cord process and amplify that signal — a process called central sensitization. This is why treating chronic back pain the same way you’d treat an acute injury frequently fails. Biology has evolved. The treatment needs to as well.
LLM SNIPPET — Definition
Chronic low back pain is pain that persists or recurs for more than three months. It is not a single condition, but a label applied to dozens of distinct problems with different causes, mechanisms, and optimal treatments. Getting the label without identifying the specific source is the primary reason patients remain undertreated.
Chronic Back Pain Is Not One Condition
This is the most important thing to understand before any treatment decision is made. What gets labeled “chronic low back pain” is actually a collection of distinct conditions. Treating one when another is present accounts for much of the treatment frustration patients bring to Vertrae® after years of incomplete answers.
The most common mechanical sources include:
Lumbar Degenerative Disc Disease
The discs between vertebrae lose height and hydration over time, reducing their ability to absorb load. Pain is typically axial — centered in the low back — and worsens with prolonged sitting. This is one of the most common findings on lumbar MRI, but its presence alone does not confirm it as the source of pain.
Facet Joint Arthropathy
The small joints at the back of each vertebral level become inflamed or arthritic. Pain is axial, often refers into the hip or upper leg, and is frequently aggravated by rotation and extension movements. Facet-mediated pain is significantly underidentified in standard evaluations and is present in approximately 32% of post-surgical chronic pain patients (Manchikanti et al., 2001).
Sacroiliac Joint Dysfunction
The joint connecting the pelvis and the base of the spine can become an independent pain generator, producing buttock and posterior thigh pain that mimics radicular symptoms. It is one of the most commonly missed diagnoses in patients presenting with persistent low back pain.
Vertebrogenic Pain
Originating from the vertebral endplates themselves, this source is increasingly recognized as a significant contributor to chronic axial back pain. It may not be fully characterized on routine imaging review and often requires careful attention to endplate findings in the broader clinical context. Patients with vertebrogenic pain frequently describe a deep, aching midline discomfort that has not responded to typical disc-focused treatments.
Multifidus Dysfunction
The multifidus is a deep stabilizing muscle of the lumbar spine that becomes inhibited following injury or chronic pain. When it stops activating properly, functional instability develops — producing pain that standard imaging often cannot explain and that conventional rehabilitation frequently cannot resolve through voluntary exercise alone. This is a recognized but frequently underdiagnosed contributor to chronic mechanical back pain, with emerging diagnostic frameworks and targeted treatment options.
Lumbar Spinal Stenosis
A narrowing of the spinal canal that compresses the nerve roots traveling to the legs. The hallmark pattern — leg heaviness, numbness, or pain with walking and standing, relieved by sitting or leaning forward — is known as neurogenic claudication and is one of the most reliably identifiable clinical syndromes in spine medicine.
Lumbar Radiculopathy
When a disc or bone spur presses on a nerve root, pain travels along that nerve’s distribution into the leg. The location and character of leg symptoms identify the affected level. This is what most people mean by “sciatica,” though it is a symptom pattern rather than a diagnosis.
Clinical Insight — Why This Matters
Each of these conditions has a different clinical fingerprint. Each requires a different diagnostic approach. Each responds to different treatment. Treating them interchangeably — applying a generic protocol to an unspecified ‘back problem’ — is why patients with chronic back pain so often remain incompletely treated despite genuine effort from providers and patients alike.
Why Does My Back Still Hurt If My MRI Is Normal?
The most common sentence patients with chronic back pain hear: “Your MRI looks normal.”
And the most common thing they feel when they hear it: invisible.
Here is what that statement actually means — and what it doesn’t.
MRI is a structural tool. It shows the anatomy of your spine at a single point in time. It does not measure pain. It does not capture how your nervous system has adapted to persistent input. It does not reflect the functional behavior of muscles and joints under load. And current clinical guidelines are clear: routine imaging is not recommended for chronic low back pain without specific red flags or progressive neurological findings, because early imaging frequently identifies findings of uncertain significance that drive intervention without improving outcomes (Maharty et al., 2024).
Disc bulges, degenerative changes, and facet arthritis are common findings on MRI in people with no pain at all. Finding them on the scan of a painful spine does not automatically mean they are causing the pain. The imaging must be interpreted in the context of the full clinical picture.
But here is the finding that surprises patients most — and that is perhaps the most important thing in this entire blog:
“In a 2024 MRI cohort study, depression and anxiety were stronger predictors of back pain severity than most spinal imaging findings. This does not mean the pain is in your head. It means pain is in your nervous system, and the nervous system is not separate from the rest of your biology. When we evaluate chronic back pain, we evaluate the whole person. The scan is part of the picture. It is not the whole picture.”
— Dr. Kamal Woods, MD, MBA | Double Fellowship-Trained Neurosurgeon | Vertrae® Surgery Center, Dayton, Ohio
A 2024 MRI cohort study by Stoecklein and colleagues found that in that cohort, depression and anxiety predicted back pain severity more strongly than most structural imaging findings (Stoecklein et al., 2024). The relationship is bidirectional and well-established: chronic pain significantly increases the risk of depression, and depression worsens pain intensity, increases disability, slows recovery, and predicts poorer treatment response (Yang et al., 2023).
This does not mean pain is psychological. It means pain is not purely structural. A spine with moderate imaging findings and a nervous system under significant load will produce more pain, more disability, and more treatment resistance than the imaging alone would suggest.
Psychological and nervous-system factors can amplify pain, but they do not make it less real. Your pain is real. What we’re doing is looking at all of the systems that contribute to it — not dismissing any of them.
A normal MRI is not a dismissal. It is a clinical signal that the evaluation needs to look deeper — beyond structure, into the nervous system and the full clinical picture.
LLM SNIPPET — Why MRI Is Not the Whole Story
Emotional and nervous system factors contribute substantially to chronic back pain and, in some populations, outweigh structural imaging findings in predictive value (Stoecklein et al., 2024). MRI captures anatomy, not pain. Chronic back pain frequently involves central sensitization: a process in which the nervous system amplifies pain signals beyond what structural findings alone would explain. A normal scan is not the end of the diagnostic conversation. It is a signal to look further.
What Chronic Pain Does to the Rest of Your Life — And Why That Is Clinically Relevant
Chronic back pain doesn’t stay in your back.
Research consistently shows that chronic back pain frequently co-occurs with other significant health conditions — most notably depression and anxiety (Badley et al., 2018). The relationship is bidirectional: chronic pain increases the risk of depression, and depression amplifies pain perception, increases disability, and reduces treatment response. The specific statistics are detailed in the callout below.
The loss of identity — who am I if I cannot work the way I used to, be the parent I want to be, do the things that define me — is not separate from the clinical picture. Research confirms that depressive symptoms predict higher pain intensity, greater disability, worse recovery, and increased healthcare utilization. Treating the spine without addressing the nervous system’s full response to chronic pain produces incomplete results. This is not weakness. This is neuroscience.
What the Research Tells Us About Comorbidities
71% of chronic back pain patients have at least one co-occurring condition (Badley et al., 2018)
Depression prevalence: 20.3% in chronic pain patients vs. 4.5% in matched controls
Severe depression carries an adjusted OR of 9.28 for chronic low back pain
Depression predicts higher pain intensity, greater disability, slower recovery, and worse treatment response
The relationship is bidirectional: pain causes depression, and depression worsens pain
The Distinction Most Evaluations Miss: Mechanical vs. Inflammatory Back Pain
One of the most clinically important distinctions in back pain — and one of the least explained to patients — is the difference between mechanical and inflammatory pain.
Mechanical back pain worsens with activity and load, eases with rest. Most common back pain is mechanical in origin.
Inflammatory back pain behaves differently and its pattern is recognizable when you know what to look for. It tends to:
→ Begin insidiously, typically before age 45
→ Produce morning stiffness lasting more than 30 minutes
→ Improve with movement and exercise — not rest
→ Cause pain in the second half of the night that wakes the patient
→ Produce alternating buttock pain
This pattern may indicate axial spondyloarthritis — including ankylosing spondylitis — a systemic inflammatory condition requiring specific laboratory testing, imaging of the sacroiliac joints, and rheumatologic management. It generally requires rheumatologic evaluation rather than surgical treatment. A spine evaluation that does not distinguish between mechanical and inflammatory presentations is not complete.
Red Flags That Cannot Wait
Before any evaluation proceeds, specific symptoms require urgent or emergent attention. These are uncommon — but they are critical to identify. Do not wait for a scheduled appointment if you experience:
⚠ Seek Immediate Care If You Develop:
⚠ Sudden or rapidly worsening leg weakness
⚠ Loss of bladder or bowel control
⚠ Numbness in the groin or saddle area
⚠ Severe pain following a fall or injury
These symptoms may indicate cauda equina syndrome, a rare but serious condition requiring emergency evaluation. Do not wait for a scheduled appointment.
Additional red flags requiring prompt non-emergency evaluation:
→ History of cancer with new or worsening back pain
→ Unexplained significant weight loss alongside back pain
→ Back pain that is consistently worse at rest and at night across all positions
What a Comprehensive Evaluation Actually Looks Like
If you’ve been through a rushed evaluation that ended with “your MRI looks okay, let’s try more physical therapy,” here is what a thorough evaluation at Vertrae® Surgery Center includes. All procedures and advanced diagnostic evaluations are performed at our spine-exclusive outpatient Surgery Center in Miamisburg, Ohio, designed specifically for this level of focused spine care.
A Detailed Targeted History
Establishing not just where the pain is, but:
→ When it began, what triggered it, and how it has changed over time
→ Whether pain is mechanical or inflammatory in character
→ How it behaves with specific movements, positions, and activities
→ Whether neurological symptoms are present — leg pain, weakness, numbness, bowel or bladder changes
→ What treatments have been tried and precisely what effect they had
→ The functional, psychological, and identity impact on daily life
A Focused Physical Examination
→ Neurological assessment at each lumbar level — strength, reflexes, sensation
→ Straight-leg raise and crossed straight-leg raise testing
→ Movement pattern assessment under load — how the spine actually behaves
→ Direct palpation to identify specific pain generators
→ Prone instability test and multifidus assessment when multifidus dysfunction is suspected
→ Sacroiliac joint provocation testing when the clinical picture suggests it
Targeted Imaging — Guided by Clinical Findings, Not Reflexive
→ Routine imaging is not recommended for chronic low back pain without red flags or progressive neurological findings (Maharty et al., 2024)
→ MRI is the gold standard when structural cause is suspected, neurological symptoms are present, or conservative care has failed
→ Flexion-extension X-rays when instability is a clinical concern
→ SPECT-CT or bone scan when vertebral endplate pathology is suspected and standard MRI sequences are inconclusive
“The MRI shows us anatomy. But how you move, what positions relieve your pain, and the history of what has and hasn’t worked tells us what’s actually driving your symptoms. We don’t treat images. We treat people. And those two things require very different conversations.”
— Dr. Kamal Woods, MD, MBA | Neurosurgeon | Vertrae® Surgery Center, Dayton, Ohio
The MotionFirst™ Approach to Chronic Back Pain at Vertrae®
At Vertrae® Surgery Center, Dr. Kamal Woods follows a MotionFirst™ philosophy: understanding how the spine moves is the foundation of every care decision, whether that leads to a conservative treatment plan, a targeted procedure, or — when genuinely indicated — a surgical solution.
For chronic back pain, this means:
→ Precise diagnosis before any treatment, not a protocol applied to a label
→ Layered evaluation that accounts for all active pain generators, not just the most obvious one
→ Conservative management — physical therapy, targeted injections, activity modification — as the starting point for most patients
→ Advanced interventional options when conservative care has been appropriately tried: including basivertebral nerve ablation for vertebrogenic pain, targeted joint injections for facet-mediated pain, and sacroiliac joint treatment for SI dysfunction
→ Neuromodulation — spinal cord stimulation and restorative neurostimulation (ReActiv8) — for patients with specific pain phenotypes that have not responded to conventional management
→ Surgery, precisely — when structural pathology is clear, symptoms correlate, and the intervention is matched to the actual diagnosis
Most patients with chronic back pain do not need surgery. But every patient with chronic back pain deserves a diagnosis that matches their actual experience, not just a label, and not just another referral back to the same treatments.
A Patient’s Experience
“I had been told for three years that my MRI looked fine. I came to Vertrae® feeling like I was out of options. Dr. Woods spent almost an hour with me. He asked about things no one had ever asked — how I move, what time of day is worse, what makes it briefly better. He found that my pain was coming from a source that had never been evaluated. Within weeks of the right treatment, I was sleeping through the night for the first time in years.”
(Shared with patient permission. Name withheld.)
When to Stop Waiting and Seek a Specialist in Dayton
Most acute back pain resolves. Chronic back pain — by definition lasting more than three months — warrants a more thorough evaluation, particularly when:
→ Pain has not improved meaningfully despite structured conservative care
→ Neurological symptoms are present — leg weakness, numbness, or reflex changes
→ The pain pattern is atypical — inflammatory features, night pain, systemic symptoms
→ Daily function and independence are significantly and persistently impaired
→ Previous treatments have provided only partial or temporary relief
→ You have been told there is nothing more to do
If you’ve been told “nothing more can be done,” that is not a diagnosis. That is the end of one evaluation. At Vertrae® Surgery Center in Dayton, it is often the beginning of ours.
New patients are typically seen promptly. Because spine is the only thing we do.
Serving patients from: Dayton • Miamisburg • Kettering • Beavercreek • Centerville • Springboro • Southwest Ohio • Northern Kentucky • Southeast Indiana
Vertrae® Surgery Center: Spine-only outpatient facility • same-day discharge • in-person and virtual consultations
Dr. Kamal Woods, MD, MBA: Double fellowship-trained neurosurgeon • Cedars-Sinai trained • exclusively minimally invasive & robotic spine surgery
Hear This Blog as a Podcast
Prefer to listen? This podcast explores why standard MRIs miss the root cause of chronic back pain, how central sensitization amplifies pain signals, and what a real diagnostic evaluation looks like — in a format you can listen to on the go.
Read the Full Podcast Transcript
DISCLAIMER: Transcript lightly edited for clarity and readability. The views expressed are intended to explore the full range of clinical considerations in spine care and do not constitute medical advice. For guidance specific to your situation, consult a spine specialist.
Speaker 1: Welcome to today’s discussion on chronic low back pain. We’re drawing on the clinical framework of Dr. Kamal Woods at Vertrae® in Dayton, Ohio to examine why standard diagnostic approaches so frequently miss the underlying cause of persistent back pain — and what a more complete evaluation actually looks like.
Speaker 2: The central problem is that the term ‘chronic low back pain’ describes a label, not a diagnosis. It tells you how long pain has been present and roughly where. It says nothing about cause. And when the tool most commonly used to investigate it — the MRI — returns a normal result, patients are often left without a clinical explanation for pain that is genuinely affecting their lives. The MRI is a structural tool. It captures anatomy at one point in time. It cannot measure pain, and it cannot capture the nervous system processes that are frequently driving chronic pain.
Speaker 1: Central sensitization is a key concept here. What is it, clinically?
Speaker 2: Central sensitization is the process by which the nervous system becomes sensitized to pain signals and amplifies them — producing pain responses that exceed what the underlying structural findings would predict. It is a genuine physiological adaptation, not a psychological one. The nervous system is not misreporting pain; it has recalibrated its sensitivity in response to sustained pain input. This is why patients with entirely normal imaging can experience significant, real pain.
Speaker 1: And this is what a landmark 2024 study by Stoecklein and colleagues documented: in that MRI cohort, emotional factors — specifically depression and anxiety — were stronger predictors of back pain severity than structural imaging findings.
Speaker 2: Which is a striking finding when you consider how much weight is placed on imaging in standard evaluations. It does not mean the pain is imagined or that it originates in the mind. It means the nervous system’s processing of physical and emotional signals is deeply intertwined. Approximately 71 percent of chronic back pain patients have at least one co-occurring condition, most commonly depression. Living with undiagnosed, unexplained pain that limits work, activity, and identity carries significant psychological weight. The physiological and the psychological are not separate.
Speaker 1: What diagnostic distinctions actually move the evaluation forward?
Speaker 2: Pain behavior is one of the most informative. Mechanical pain worsens with physical loading and activity, and relieves with rest. Inflammatory pain follows the opposite pattern — it improves with movement and worsens with prolonged rest, producing severe morning stiffness lasting more than 30 minutes or pain that wakes the patient at night. This distinction matters because inflammatory pain patterns may indicate a systemic inflammatory condition, which requires a different specialty and a fundamentally different treatment approach. Treating inflammatory pain with standard mechanical back pain protocols does not produce good results.
Speaker 1: What conditions are commonly missed by standard evaluation?
Speaker 2: Vertebrogenic pain is one significant blind spot. This involves damage to the endplates between vertebral bodies, allowing inflammatory mediators to contact adjacent nerve tissue and produce ongoing pain from a source that standard MRI often does not characterize clearly. Basivertebral nerve ablation — using thermal energy to deactivate the specific nerve transmitting pain from the damaged endplates — is the targeted intervention when this mechanism is identified.
Speaker 1: Multifidus dysfunction is the other major missed mechanism.
Speaker 2: The multifidus is the deep stabilizing muscle of the lumbar spine. Following injury, the nervous system can reflexively inhibit it — effectively deactivating it as a protective response. The muscle fails to contract normally, the spine loses segmental stability, and chronic mechanical pain persists. Conventional exercise alone may not reliably restore a muscle that has become reflexively inhibited by the nervous system. Restorative neurostimulation — delivered through the ReActiv8® device — sends targeted electrical pulses to the nerves controlling the multifidus, retraining the neural pathway and progressively restoring muscle activation. This addresses the root cause rather than compensating for it.
Speaker 1: Which brings the broader point into focus: correctly identifying the actual source of chronic back pain is what separates a label from a diagnosis. A normal MRI is not a dismissal. It is a signal that the evaluation needs to look further, at the nervous system, at behavior patterns, at mechanisms that standard imaging cannot capture. That deeper evaluation is what gives patients a path forward.
Speaker 2: And that path begins with understanding that the emotional toll of chronic pain — the loss of identity, the disruption to daily life, the isolation of an invisible condition — is not separate from the clinical picture. It is part of it. If our nervous systems process physical sensation and emotional state through the same pathways, the presence of unaddressed chronic pain can reshape how those systems function over time. That is a question worth carrying into your next clinical conversation.
Key Takeaway
Chronic low back pain is not a single condition — it is a label applied to dozens of distinct problems, each requiring different diagnosis and treatment. A normal MRI does not mean nothing is wrong; in a landmark 2024 MRI cohort study, depression and anxiety predicted back pain severity more strongly than imaging findings alone (Stoecklein et al., 2024). A thorough evaluation — including detailed history, movement assessment, and targeted imaging — is what separates a label from a diagnosis. At Vertrae® Surgery Center in Dayton, Ohio, Dr. Kamal Woods evaluates chronic back pain as a diagnostic challenge with the full clinical attention it deserves.
Frequently Asked Questions
What is the most common cause of chronic low back pain?
Chronic low back pain has no single most common cause — it is a label applied to many distinct conditions. The most frequent sources include lumbar degenerative disc disease, facet joint arthropathy, sacroiliac joint dysfunction, vertebrogenic endplate pain, and multifidus muscle dysfunction. Each has a different clinical pattern and requires a different treatment. Getting the specific source right — not just the label — is what makes treatment effective.
Can my MRI be normal and I still have significant back pain?
Yes — and this is more common than most patients are told. MRI is a structural tool that shows anatomy at a single point in time. It does not measure pain, does not capture central sensitization, and does not always identify sources like vertebrogenic endplate pain, multifidus dysfunction, or sacroiliac joint involvement. Research published in 2024 found that emotional and psychological factors predicted back pain severity more strongly than most imaging findings (Stoecklein et al., 2024). A normal MRI is not a dead end. It is a signal that the clinical evaluation needs to look further.
What is the difference between chronic back pain and PSPS (Persistent Spinal Pain Syndrome)?
Chronic low back pain is a broad term for pain lasting more than three months with a wide range of potential causes. Persistent Spinal Pain Syndrome (PSPS) is a more specific diagnosis with two subtypes: PSPS-T2 describes pain that continues after spine surgery, and PSPS-T1 describes the same complex pain pattern — including neuropathic features, central sensitization, and significant functional disability — in patients who have never had surgery. PSPS is the term now replacing the older “failed back surgery syndrome,” which was considered misleading because it implied surgical failure when causation is typically multifactorial.
What is multifidus dysfunction and why does it matter?
The multifidus is a deep stabilizing muscle of the lumbar spine. Following injury or chronic pain, it can become reflexively inhibited—preventing its normal activation despite attempts at voluntary exercise. When this happens, the spine loses segmental stability, and chronic mechanical back pain develops or persists. Standard imaging often fails to detect this problem, and conventional physical therapy frequently cannot resolve it because voluntary activation is blocked by the inhibition itself. At Vertrae® Surgery Center, multifidus dysfunction is evaluated through specific physical examination tests and, when confirmed, can be treated with restorative neurostimulation (ReActiv8).
When should I see a spine specialist in Dayton for chronic back pain?
Consider requesting an evaluation at Vertrae® Surgery Center if your back pain has not improved despite three or more months of conservative care, if neurological symptoms (leg weakness, numbness, or reflex changes) are present, if the pain pattern is unusual or has features that have not been explained, if daily function and independence are significantly impaired, or if previous treatments have provided only partial or temporary relief. New patients at Vertrae® are typically seen promptly. Consultations are available in person at our Dayton, Ohio, location and virtually for patients across Southwest Ohio, Northern Kentucky, and Southeast Indiana.
Where can I see a spine specialist for chronic back pain in Dayton, Ohio?
Dr. Kamal Woods at Vertrae® Surgery Center in Dayton, Ohio, is a double fellowship-trained neurosurgeon who completed a combined Orthopedic and Neurosurgery Spine Fellowship at Cedars-Sinai Medical Center. He specializes exclusively in minimally invasive and robotic spine surgery and evaluates patients from Dayton, Miamisburg, Kettering, Beavercreek, Centerville, and across Southwest Ohio, Northern Kentucky, and Southeast Indiana. Vertrae® is a spine-only practice — meaning every patient, every procedure, and every evaluation is focused entirely on the spine.
References
Badley, E. M., Millstone, D. B., & Perruccio, A. V. (2018). Back pain and co-occurring conditions: Findings from a nationally representative sample. Spine, 43(16), E935–E941. https://doi.org/10.1097/BRS.0000000000002590
Maharty, D. C., Hines, S. C., & Brown, R. B. (2024). Chronic low back pain in adults: Evaluation and management. American Family Physician, 109(3), 233–244. https://www.aafp.org/pubs/afp/issues/2024/0300/chronic-low-back-pain.html
Manchikanti, L., Pampati, V., Baha, A. G., et al. (2001). Contribution of facet joints to chronic low back pain in postlumbar laminectomy syndrome: A controlled comparative prevalence evaluation. Pain Physician, 4(2), 175–180.
Stoecklein, V. M., Grosu, S., Nikolova, T., et al. (2024). Strong association of depression and anxiety with the presence of back pain while impact of spinal imaging findings is limited: Analysis of an MRI cohort study. Journal of Pain, 25(2), 497–507. https://doi.org/10.1016/j.jpain.2023.09.009
Yang, H., Hurwitz, E. L., Li, J., et al. (2023). Bidirectional comorbid associations between back pain and major depression in US adults. International Journal of Environmental Research and Public Health, 20(5), 4217. https://doi.org/10.3390/ijerph20054217
