Effect of Alexithymia on Treatment Response to Transforaminal Epidural Steroid Injections in Chronic Low Back Pain

The Effectiveness of Transforaminal Epidural Steroid Injection in Patients With Chronic Low Back Pain and the Impact of Alexithymia on Treatment Response: A Prospective Observational Cohort Study

Low back pain and lumbosakral radiculopathy represent common clinical challenges substantially diminishing health-related quality of life and work productivity. Transforaminal Epidural Steroid Injection (TFESI) is widely performed in routine practice to reduce radicular pain, enhance functional capacity, and mitigate the need for surgery. However, clinical response to TFESI remains notably heterogeneous, indicating that biomedical parameters alone may not fully account for treatment efficacy and that psychosocial variables play a critical role.

Alexithymia, defined as difficulty in identifying and describing emotions coupled with an externally oriented cognitive style, is prevalent among individuals with chronic spinal pain and linked to heightened pain perception and affective distress.

This prospective observational cohort study aims to investigate the influence of baseline alexithymia levels (measured by the 20-item Toronto Alexithymia Scale [TAS-20]) on treatment response (defined as pain relief and functional improvement) following routine clinically indicated TFESI in patients with chronic low back pain and radiculopathy.

Study Overview

• Status: Not yet recruiting
• Conditions: Chronic Low Back Pain; Radiculopathy; Alexithymia
• Intervention / Treatment: Other: Psychometric Assessment and Clinical Follow-up Battery

Detailed Description

This single-center, prospective observational cohort study is conducted at Marmara University Pendik Training and Research Hospital, Division of Algology, in collaboration with the Department of Psychiatry.

Transforaminal Epidural Steroid Injection (TFESI) is performed strictly based on routine clinical indications under fluoroscopic guidance (using 3 ml bupivacaine, 1 ml saline, and 1 ml betamethasone); no experimental intervention or additional procedural risk is introduced by this research protocol.

Eligible adult patients providing written voluntary informed consent undergo comprehensive baseline evaluations prior to injection, including:

1. Sociodemographic and Clinical Questionnaire
2. 20-Item Toronto Alexithymia Scale (TAS-20)
3. Visual Analog Scale (VAS 0-10 cm) for pain severity
4. Hospital Anxiety and Depression Scale (HADS)
5. 12-Item Short Form Health Survey (SF-12)
6. Childhood Trauma Questionnaire (CTQ-33)

Prospective follow-up evaluations are conducted post-procedure:

• Week 1: Pain intensity via VAS
• Month 1: Pain intensity via VAS and quality of life via SF-12
• Month 3: Pain intensity via VAS and quality of life via SF-12

Treatment response is primarily categorized at Month 1 post-injection (responder: ≥30% or ≥2-point reduction in VAS; non-responder: <30% or <2-point reduction). The primary analysis will compare baseline TAS-20 scores between responders and non-responders, evaluate correlations between alexithymia subdimensions and clinical changes, and identify independent predictors of treatment success through multivariable regression models adjusted for depression, anxiety, and baseline pain duration.

• Study Type: Observational
• Enrollment (Estimated): 60

Contacts and Locations

• Study Contact: Name: Konuralp Karbeyaz, MD; Phone Number: +905326209392; Email: karbeyazkonuralp@gmail.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

Patients presenting to the Algology outpatient clinic at Marmara University Pendik Training and Research Hospital with chronic low back pain who are clinically indicated and scheduled for Transforaminal Epidural Steroid Injection.

Description

Inclusion Criteria:

1. Adults aged 18 years or older.
2. Clinical diagnosis of chronic low back pain persisting for at least 3 months.
3. Clinical indication and scheduled for Transforaminal Epidural Steroid Injection (TFESI) due to failure of conservative management.
4. Literate and possessing sufficient cognitive capacity to understand and complete self-report instruments.
5. Voluntary written informed consent.

Exclusion Criteria:

1. Significant cognitive impairment or communication barriers impairing informed consent capacity or questionnaire completion.
2. Active psychotic disorder or current manic episode.
3. Suspected acute self-harm or suicidal risk identified during clinical examination.
4. Chronic back pain secondary to malignancy, acute fracture, or active local/systemic infection.
5. Severe active psychiatric illness currently undergoing medical treatment (e.g., severe mental illness, schizophrenia, bipolar affective disorder).

(Note: Depressive symptoms alone are not an exclusion criterion; they are systematically quantified via HADS and controlled for as covariates).

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Chronic Low Back Pain Patients Receiving TFESI; Adult patients aged 18 years or older with chronic low back pain with or without radiculopathy scheduled to receive clinically indicated fluoroscopy-guided Transforaminal Epidural Steroid Injection due to failure of conservative therapies	Other: Psychometric Assessment and Clinical Follow-up Battery; Pre-procedural assessment (VAS, TAS-20, HADS, SF-12, CTQ-33, sociodemographic form) followed by longitudinal clinical evaluations at Week 1 (VAS), Month 1 (VAS, SF-12), and Month 3 (VAS, SF-12) post-TFESI

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Difference in Baseline TAS-20 Scores Between Responders and Non-Responders	Evaluates whether baseline total alexithymia severity differs significantly between patients achieving clinical treatment response versus non-responders. Treatment response is defined as a reduction of ≥30% or ≥2 points in the 10-cm Visual Analog Scale (VAS) from baseline to 1 month post-TFESI. TAS-20 total score ranges from 20 to 100, where higher scores reflect greater alexithymia severity.	Baseline (pre-injection) compared against clinical response status evaluated at 1 month post-TFESI

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Pain Intensity via Visual Analog Scale (VAS)	Measured on a 10-cm horizontal line ranging from 0 (no pain) to 10 (worst imaginable pain). Higher scores reflect greater pain severity.	Baseline, 1 week, 1 month, and 3 months post-procedure
Change in Health-Related Quality of Life via SF-12	12-item health survey evaluating Physical and Mental Component Summary scores. Scores range from 0 to 100, with higher scores reflecting better health-related quality of life	Baseline, 1 month, and 3 months post-procedure
Baseline Psychological Symptoms via Hospital Anxiety and Depression Scale (HADS)	Assesses anxiety (HADS-A) and depression (HADS-D) subscale scores (each scored 0 to 21, higher scores indicate greater symptom severity). Used to control for confounding effects on treatment response	Baseline (immediately prior to TFESI)
Baseline Childhood Trauma Questionnaire (CTQ-33) Total Score	Assesses retrospective childhood maltreatment across subscales. Total scores range from 25 to 150, where higher scores reflect greater childhood trauma severity.	Baseline (immediately prior to TFESI)

Collaborators and Investigators

• Sponsor: Marmara University

Study record dates

Study Major Dates

• Study Start (Estimated): September 1, 2026
• Primary Completion (Estimated): September 1, 2027
• Study Completion (Estimated): October 1, 2027

Study Registration Dates

• First Submitted: September 14, 2026
• First Submitted That Met QC Criteria: September 14, 2026
• First Posted (Actual): September 18, 2026

Study Record Updates

• Last Update Posted (Actual): September 18, 2026
• Last Update Submitted That Met QC Criteria: September 14, 2026
• Last Verified: September 1, 2026

More Information

Terms related to this study

• Keywords: Quality of Life; Chronic Low Back Pain; Treatment Outcome; Alexithymia; Radicular Pain; TFESI; Transforaminal Epidural Steroid Injection; TAS-20
• Additional Relevant MeSH Terms: Nervous System Diseases; Neuromuscular Diseases; Behavioral Symptoms; Peripheral Nervous System Diseases; Behavior; Radiculopathy; Affective Symptoms
• Other Study ID Numbers: 09.2026.877

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No