The Association Between Amputation Level and Chronic Low Back Pain After Combat-Related Amputation

Chronic low back pain is a common long-term complication following lower limb amputation and may significantly impair mobility, rehabilitation, prosthesis tolerance, and quality of life. Patients with combat-related amputations are particularly vulnerable because of severe tissue trauma, altered gait mechanics, asymmetric loading, repeated surgical interventions, and prolonged rehabilitation.

Biomechanical alterations after amputation may lead to abnormal spinal loading, pelvic asymmetry, trunk compensation, and increased energy expenditure during ambulation. These changes may contribute to chronic mechanical stress on the lumbar spine and development of persistent low back pain. The level of amputation may play an important role in this process, as more proximal amputations are frequently associated with greater gait disturbance, increased compensatory trunk movements, and higher biomechanical demand during prosthetic walking.

Despite increasing recognition of chronic low back pain after amputation, limited prospective data are available regarding the relationship between amputation level and spinal pain severity in combat-related trauma populations.

The LEVEL-BACK Study is a prospective observational study designed to evaluate the association between lower limb amputation level and chronic low back pain after combat-related amputation.

Participants with transtibial, transfemoral, and bilateral lower limb amputations will undergo longitudinal clinical assessment during rehabilitation follow-up. Study evaluations will include assessment of low back pain intensity, duration of symptoms, prosthesis use, functional mobility, rehabilitation outcomes, and pain-related disability.

The study aims to improve understanding of spinal pain mechanisms after combat-related limb loss and identify patient groups at increased risk for chronic low back pain according to amputation level.

Inclusion criteria

• Age ≥18 years
• Combat-related lower limb amputation
• Transtibial, transfemoral, or bilateral lower limb amputation
• Time since amputation ≥3 months
• Current or planned prosthesis use
• Ability to participate in rehabilitation assessment
• Ability to report low back pain intensity
• Ability to provide written informed consent

Exclusion criteria

• Traumatic spinal injury related to the initial combat trauma
• Previous spinal surgery before amputation
• Known severe spinal deformity
• Active spinal infection or malignancy
• Severe neurological disorder affecting mobility
• Non-combat-related amputation
• Inability to complete follow-up assessments
• Refusal or inability to provide informed consent