Impact of lower extremity amputation on spinal health: a cohort study of back pathologies in transfemoral and transtibial amputees

Introduction

Lower extremity amputation is a serious and life-altering procedure in which numerous patients undergo it due to both traumatic and non-traumatic causes. Each year in the United States (U.S.), between 115,000 and 150,000 people undergo lower extremity amputation with approximately 50,000 to 60,000 of those being above the ankle (1,2). The majority of these amputations are due to non-traumatic causes, with diabetes and peripheral vascular disease being the most common non-traumatic causes of amputation (1-3). Major lower extremity amputations include transtibial amputee (TTA) or a transfemoral amputee (TFA), both of which cause alterations in gait and walking mechanics (4,5).

Alterations to body mechanics in amputees have potential implications for the development of low back pain and spinal pathologies. A common finding following lower extremity amputation is low back pain with a prevalence that is approximately twice that compared to the general population (6). Along with the disability caused by losing a limb, back pain following amputation can contribute as a secondary cause of disability in patients, disrupting daily activities. Several factors, including changes to muscle activity, can cause low back pain following amputation (7,8).

Static muscle asymmetry arising from the use of prosthetic limbs has been found to create significant imbalances in the lumbar muscles, which in turn can lead to structural alterations in the spine. This lumbar muscle imbalance is often attributed to discrepancies in pelvic inclination between the amputated side and the intact side of the body. Additionally, the adoption of a prosthetic limb usually brings about changes in gait, further exacerbating muscle asymmetries (9,10).

As individuals walk, the asymmetric movements of their trunk about their pelvis place an increased demand on the lower back muscles, heightening the load experienced by the spine. These interconnected factors contribute not only to a pronounced imbalance in the lower back but also to a heightened risk of low back injuries, emphasizing the need for awareness and targeted interventions in the rehabilitation of individuals with prosthetic limbs (8,10).

While several studies have investigated generalized lower back pain in lower extremity amputees, there is a relative deficiency in the literature regarding specific spinal pathology following amputation. A survey of lower extremity amputees by Butowicz et al. [2023] demonstrated a progression to intervertebral disc degeneration and facet arthropathy following amputation (11). Following this, Butowicz et al.
[2025] conducted a larger study which suggested that lower extremity amputation may lead to symptomatic spondylolisthesis (12). Spinal pathology developed in these studies may lead to surgeries such as spinal canal decompression or vertebral body fusion to provide pain and symptom relief. Understanding the development of specific spine pathologies following lower extremity amputation is crucial due to the variety of treatments which are used for different pathologies. For example, spondylolisthesis causing central stenosis would could require decompression with fusion, conversely, facet arthropathy could be treated with radiofrequency ablation (13,14).

There is emerging evidence suggesting that lower extremity amputation may contribute to the development of future spinal pathologies that necessitate surgical intervention; however, the existing literature on this topic is limited. This study aims to enhance our understanding of the relationship between amputation and spinal pathology, specifically investigating the potential connection between the two.

To achieve our study objectives, we undertook a comprehensive retrospective analysis utilizing the PearlDiver database (15). Our investigation focused on patients with TFAs and TTAs, specifically examining the prevalence of back pathologies and the frequency of spinal surgeries within these cohorts compared to matched able-bodied control subjects. We hypothesize that TFA and TTA patients experience a significantly higher incidence of spinal pathology and surgery when compared to the general population. The back pathologies considered in this study included a spectrum of conditions such as anterior and posterior lumbar abnormalities, radiculopathy, chronic low back pain, and sciatica. Each of these conditions carries significant implications for quality of life and functional ability, particularly among amputees who are already navigating the challenges associated with limb loss. We present this article in accordance with the STROBE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-25-145/rc).

Methods

Study design

This study was designed as a retrospective cohort analysis comparing patients with TFA and TTA to able-bodied controls. The primary aim was to evaluate differences in lumbar spine pathology and spine surgery utilization between these groups over time.

Data source

All data were obtained from the PearlDiver Mariner database, a large U.S. claims database containing longitudinal medical and procedural records for approximately 165 million patients. The database includes de-identified patient demographics, diagnoses, and surgical procedures across multiple insurance groups. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was exempt from receiving IRB approval as data was obtained from an anonymized national healthcare database and did not involve direct or indirect interaction with patients or protected health information.

Participant selection

Participant cohorts were identified using International Classification of Diseases, 10th Revision (ICD-10) diagnosis codes for TFA and TTA, along with Current Procedural Terminology (CPT) procedural codes to ensure precise classification of both diagnostic conditions and surgical management strategies. Individuals without any history of lower-limb amputation served as able-bodied controls. Continuous insurance enrollment after each patient’s index date was required to ensure adequate follow-up. Two analytic cohort structures were generated for this study. First, in the non-matched cohort analysis, all patients with TFA and TTA were directly compared with the full pool of eligible controls within the database. Second, a matched cohort analysis was performed in which patients were matched 1:1 with controls based on age, gender, and the Elixhauser comorbidity index (ECI), thereby reducing potential confounding associated with demographic and medical differences.

Control subjects were selected from the same PearlDiver database population and were required to have no ICD-10 diagnosis codes indicating lower-extremity amputation at any time. For each case’s index date, eligible controls were individuals who were active in the database during the same period and met continuous enrollment requirements to ensure comparable follow-up time. In the non-matched analysis, all qualifying able-bodied individuals served as the control pool. For the matched cohort, controls were randomly selected and paired 1:1 with each TFA or TTA case based on exact matching criteria age, gender, and ECI to minimize confounding and improve comparability between groups.

Outcomes

The primary exposures were the presence of TFA or TTA. Outcomes included lumbar spine pathologies—such as anterior/posterior abnormalities, radiculopathy, chronic low back pain, and sciatica—identified using ICD-10 codes. Procedural outcomes, including sacroiliac joint fusion, anterior lumbar interbody fusion (ALIF), posterolateral fusion (PLF), transforaminal lumbar interbody fusion (TLIF), discectomy, and circumferential (360°) fusion, were identified using CPT codes. Potential confounders included age, sex, and comorbidity burden as measured by the ECI.

Statistical analysis

In addition to matching, a multivariate logistic regression analysis was performed to adjust for potential confounders and to provide a more rigorous methodology of estimating true associations. Multivariate logistic regression was used to evaluate the odds of developing back pathologies and undergoing lumbar sur surgery. Variables which were analyzed included age, male gender, tobacco use, obesity, and several select co-morbidities. Baseline demographic differences were assessed using t-tests for continuous variables and Chi-squared tests for categorical variables. Odds ratios (ORs) with corresponding P values were calculated for all diagnostic and surgical outcomes, with statistical significance defined as P<0.05. Analyses were performed using the R-based statistical environment integrated within the PearlDiver platform to ensure reproducibility.

Results

In both the TFA and TFA control (TFA-C) groups, 23,079 patients were analyzed while 16,350 patients were analyzed in both the TTA and TTA control (TTA-C) groups. Matching patients based on age, gender and ECI resulted in a sample size of 2,457 TFA matched controls and 1,642 TTA matched controls. Within the multivariate logistic regression analysis, the TFA and control group resulted in a sample size of 46,158 patients. The TTA and control groups result in 32,700 patients. The TFA matched group and control group resulted in a sample size of 4,914 patients while the TTA matched group and control group resulted in a sample size of 3,284 patients. The number of controls were equal the average age, ECI, and male-to-female gender ratios are described on the demographics table (Table 1). A total of 30 co-morbidities were selected for each group and expressed as a percentage (Table 2). Asthma was found to be the only statistically nonsignificant co-morbidity in both the TFA and TTA groups.

Non-matched TFAs demonstrated increased odds of pathology compared to controls which included anterior lumbar pathologies, posterior lumbar pathologies, radiculopathy, low back pain, and sciatica. Matched TFAs demonstrated reduced odds of all pathologies except for anterior lumbar pathologies which were not found to be statistically significant (Table 3). Non-matched TTAs demonstrated increased odds of all included pathologies while matched TTAs demonstrated reduced odds of low back pain and sciatica (Table 4). Comparison between TFAs and TTAs demonstrated no statistically significant difference in the odds of developing pathology (see Table S1
for more information).

In the analysis of surgical outcomes, non-matched TFA patients exhibited significantly heightened odds of undergoing lumbar fusion and decompression procedures. Notably, among these individuals, the likelihood of receiving posterolateral fusions was particularly pronounced. Conversely, when examining matched TFA patients, a trend emerged indicating elevated odds of both lumbar decompression and lumbar fusion surgeries (Table 5).

Turning to non-matched TTA patients, a similar pattern was observed, with these individuals also displaying increased odds for lumbar decompression and fusion interventions, particularly favoring posterior fusion. However, when the matched TTA cohort was scrutinized, the results failed to reveal any statistically significant associations regarding the likelihood of undergoing either fusion or decompression surgeries (Table 6).

Furthermore, a comparative analysis between the non-matched TFA and non-matched TTA patients uncovered compelling differences. The data indicated a 30% greater likelihood [OR =1.30; 95% confidence interval (CI): 1.08–1.56; P=0.01] for TTA patients to undergo lumbar decompression in comparison to their TFA counterparts. Additionally, TTA patients also demonstrated notably higher odds of receiving lumbar fusion (OR =1.66; 95% CI: 1.32–2.07; P=0.01), underscoring significant discrepancies in surgical intervention rates between the two groups (see Table S2 for further details).

Non-matched TFA patients were found to have increased odds of undergoing anterior lumbar interbody fusion (OR =1.64; 95% CI: 1.03–2.63; P=0.01), posterolateral lumbar fusion (OR =1.95; 95% CI: 1.40–2.71; P=0.01), and combined posterolateral fusion with posterior interbody fusion (OR =1.64; 95% CI: 1.12–2.41; P=0.02). Matched TFA patients were not found to have statistically significant odds of sacroiliac (SI) joint fusions, discectomies, anterior lumbar fusions, or posterolateral lumbar fusions (Table 7). Both non-matched and matched TTA patients did not show statistically significant differences in the odds of undergoing SI joint fusions, discectomies, anterior lumbar fusions, or posterolateral lumbar fusions (Table 8). Comparison between TFA and TTA patients, both non-matched and matched, demonstrated no statistically significant changes in odds of undergoing SI joint fusions, discectomies, anterior lumbar fusions, or posterolateral lumbar fusions (see Table S3 for further details).

Within the multivariate logistic regression, TFA patients were found to have increased odds of developing back pathologies compared to controls (OR =1.23; 95% CI: 1.18–1.29; P<0.001). However, TFA patients were not found to have increased odds of undergoing lumbar surgery compared to controls (OR =1.08; 95% CI: 0.92–1.27; P=0.32). Complete multivariate logistic regression results for the TFA group can be seen in Table 9. Multivariate logistic regression for TTA patients versus controls demonstrated increased odds of developing back pathologies (OR =1.23; 95% CI: 1.17–1.40; P<0.001) and demonstrated no increased odds of undergoing lumbar surgery (OR =0.95; 95% CI: 0.79–1.13; P=0.55). Complete multivariate logistic regression results for the TTA group can be seen in Table 10.

Multivariate logistic regression analysis of the matched amputee groups demonstrated nonsignificant difference in odds of developing back pathologies or undergoing lumbar surgery in TFA patients compared to controls (Table 11). However, the TTA matched group versus controls demonstrated that matched TTA patients had reduced odds of developing back pathologies compared to controls (OR =0.76; 95% CI: 0.66–0.92; P=0.002). However, matched TTA patients did not demonstrate a difference in odds of undergoing spine surgery compared to controls (Table 12).

Discussion

Main findings

To our knowledge, this is the first database study that investigated the relationship between lower extremity amputees and back pathologies and spine surgery. We found that both TFA and TTA patients had increased odds of developing all selected back pathologies, although when matched with controls using age, gender and the ECI, both TFA and TTA patients demonstrated reduced odds of developing back pathologies. The difference in findings between the groups may be the result of the matched group’s significantly smaller sample size. Regarding the odds of undergoing spine surgery, both TFA and TTA patients were found to have increased odds of undergoing posterolateral fusions, lumbar decompressions, and lumbar fusions. Although when matched to controls only TFA patients showed increased odds of undergoing lumbar decompression and lumbar fusion. Interestingly, there was no difference between the prevalence of back pathologies when comparing TFA and TTA patients directly, while TFA patients had greater odds of undergoing lumbar decompressions and fusions.

Interpretation of results

Our finding that lower extremity amputees have an increased prevalence of low back pain compared to the general population agrees with the previously published literature. Depending on the study, the prevalence of low back pain is two to four times greater in lower extremity amputees compared to the general public (16,17). Additionally, the prevalence of low back pain among amputees does not seem to differ significantly between traumatic and non-traumatic amputees (18). We found increased odds of undergoing spinal decompression and fusion among amputees, which agrees with the findings of two studies by Butowicz et al. [2023] and [2025] where it was found that lower extremity amputees were predisposed to developing intervertebral disc degeneration and facet arthropathy. Both these findings can lead to treatment with lumbar decompression and fusion (11,12).

After lower limb amputation, patients experience alterations in biomechanics which are notably significant with walking. Lower limb amputees develop changes to trunk and pelvic movement to assist with reducing the load on the weaker thigh muscles of the amputated side (19). This was supported by a systematic review by Devan et al. [2015] revealed that TFA patients demonstrated increased anterior pelvic tilt and lateral flexion of the trunk towards the amputated side (5). There is strong evidence to suggest that altered walking biomechanics in lower extremity amputees can lead to accelerated degeneration of the spine, specifically the lumbar spine. Alterations to gait, seen in amputees, has been shown to increase the loading forces experienced by the spine, especially to facet joints (19). A study by Hendershot & Wolf [2014] revealed that unilateral amputees displayed alterations to spinal load and movement of the trunk muscles. These changes were proposed as a mechanism that can cause an increased risk of injury, especially with repeated exposure (20).

Support of these findings is furthered by a biomechanical study by Butowicz et al. 2024 where walking gait was examined in unilateral TTAs. It was found that amputees alter their gait to reduce the shear forces experienced at the L5–S1 joint achieved through asymmetric activation of trunk muscles. The study postulated that repeated exposure to these alterations can cause low back pain to persist and act as a mechanism for spinal degeration (21). Another possible mechanism for the development of low back pain in amputees could be excessive lumbar lordosis as a result of adaptations to the missing limb. Excessive lumbar lordosis has been associated with low back pain in non-amputee individuals (22). One study by Matsumoto et al. [2019] found no association between excessive lumbar lordosis and low back pain in TFA patients, although the limited sample size of nine highlights the needs for further investigation (23).

Differences in biomechanics of walking and standing between TFA and TTA patients may have an impact on the development of low back pain and spine pathology. Although our results showed a broadly similar development of spine pathology between the groups, the TFA group had a higher likelihood of undergoing some spine surgeries. Biomechanical differences have been shown to exist between TFA and TTA patients, yet there are no studies that examine these effects on the development of spine pathology (24). A biomechanical study on this topic would help us better understand our findings and possibly develop tailored treatment strategies based on the type of amputation.

Limitations

While we believe the findings of this investigation to be valuable, we acknowledge certain limitations within our study. When matched to controls, the sample sizes of the TFA and TTA groups were significantly reduced, where sample sizes were reduced by approximately ninety percent both cases. Despite the decrease in sample size, both control matched groups had a sample size greater than 1,000 which we believe is still significant to draw meaningful conclusions. Additionally, clinical database studies, such as this one, have inherent limitations. Administrative clinical databases may contain inaccuracies within the diagnosis and procedure codes used for individual patients, and the accuracy of coding may differ between the sources that compose the database. The use of ICD codes for diagnosis alongside CPT codes for procedures performed can mitigate database coding inaccuracies and this method was utilized within our study (25).

Implications

The heightened risk of lower extremity amputees developing spinal pathologies and necessitating surgical intervention has significant implications for clinical practice and health policy. Healthcare professionals responsible for the rehabilitation of amputees should recognize the potential for these patients to experience back and spine-related issues. It has also been shown that certain co-morbidities affect successful rehabilitation in lower extremity amputees (26). It is advisable for physicians and other providers to implement proactive monitoring of spinal health and to address any symptoms or pain promptly, thereby reducing the likelihood of future surgical procedures and enhancing patient outcomes. Additionally, there should be an emphasis on specialized physical therapy to mitigate the risk of spinal degeneration and subsequent pathology. Training focused on core musculature and postural alignment has been demonstrated to improve spinal health and diminish disability associated with spinal conditions (27,28). The addition of these physical therapy goals to standard treatment of rehabilitation following amputation could help prevent future back and spine problems among patients.

Regarding health policy, amputees may require long-term musculoskeletal follow-ups, which would need to be addressed by those receiving treatment through disability programs such as the Veterans Affairs Disability Compensation Program or Workers’ Compensation. The unexpected impact on spine health in amputees adds a significant burden to patients, and insurance or disability benefits may need to account for secondary spine-related disability risk. Finally, there is a need for further research on this topic, particularly in the context of the relationship between lower extremity amputees and spine surgery. A comprehensive review of existing literature highlighted a significant number of studies focused on back pathology; particularly low back pain experienced by amputees. However, there remains a notable gap concerning research on spine surgeries necessitated by amputation. Expanding clinical research in this domain is essential for enhancing our understanding of the expectations for amputees and developing effective strategies aimed at preventing the future necessity for spine surgery.

Conclusions

The findings indicate that lower extremity amputees are at a significantly higher risk of developing back pathologies when compared to non-amputee controls. This increased risk is not only evident in the prevalence of back issues. Still, it is also reflected in the surgical interventions required, as amputees are more likely to undergo spine surgeries such as spinal decompression and vertebral body fusions. The data suggest that both TFA and TTA face elevated odds of requiring surgical treatment for spinal conditions. Notably, TFAs exhibit a greater likelihood of undergoing spine surgery, specifically lumbar decompression and fusion.

These insights underline the critical need for proactive clinical measures, including early and regular monitoring of spine health in amputees. Additionally, tailored physical therapy programs aimed at strengthening the core and enhancing spinal stability could play a vital role in preventing spine deterioration among this population. Thus, integrating these practices into patient care protocols could significantly improve the overall quality of life for amputees and mitigate the long-term consequences associated with back pathologies.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-25-145/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-25-145/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-25-145/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was exempt from receiving IRB approval as data was obtained from an anonymized national healthcare database and did not involve direct or indirect interaction with patients or protected health information.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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