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Avoidant/restrictive food intake disorder (ARFID) is characterized by restrictive or avoidant eating not driven by weight or shape concerns and is often associated with autism spectrum disorder (ASD). Superior mesenteric artery (SMA) syndrome may occur in ARFID with significant weight loss; however, overlapping gastrointestinal symptoms may obscure its recognition. A 16-year-old boy with a history of ASD and Klinefelter syndrome (47,XXY) presented with postprandial nausea, abdominal pain, fatigue, and rapid weight loss. He had chronic sensory hypersensitivity-related selective eating since early childhood and maintained a slender body habitus. Upon admission, his height and weight were 182 cm and 40.7 kg, respectively (body mass index [BMI] = 12.3). He had no drive for thinness, fear of weight gain, or body image disturbance and was diagnosed with ARFID. Abdominal ultrasonography revealed marked narrowing of the SMA-aorta angle (6.8°) and distance (3 mm), with duodenal compression, consistent with SMA syndrome. Enteral nutrition was initiated and gradually increased, accompanied by psychoeducation, meal support tailored to sensory sensitivities, and behavioral interventions. He showed weight restoration and improvement in gastrointestinal symptoms and duodenal obstruction, allowing a gradual transition to oral intake. Upon discharge, his weight was 49.0 kg (BMI = 14.8). Follow-up ultrasonography revealed partial improvement in the SMA-aorta angle. SMA syndrome should be considered in patients with ARFID who present with gastrointestinal symptoms and rapid weight loss. Klinefelter syndrome may increase vulnerability to SMA syndrome, complicating clinical recognition. Combining nutritional rehabilitation, medical evaluation, and psychosocial interventions is important for effective complex eating disorder management.
Gastrointestinal-origin urinary foreign bodies are rare and often overlooked, particularly because early Computed Tomography (CT) scans may be inconclusive, especially in cases involving wooden materials. A 19-year-old man presented with lower-abdominal pain and gross hematuria one week after accidentally ingesting a toothpick. Initial local CT scans were negative. At our center, bedside ultrasonography revealed a linear hyperechoic tract crossing the bladder wall, while thin-slice non-contrast CT only detected a punctate hyperdensity at the bladder dome. Cystoscopy confirmed the presence of a wooden toothpick partially penetrating the bladder; ureteroscopic extraction successfully removed the intact 6-cm toothpick, followed by an uneventful recovery. A detailed ingestion history along with thin-slice non-contrast CT and high-frequency ultrasonography can help identify subtle wooden foreign bodies. These diagnostic tools should prompt early cystoscopy, and selective gastrointestinal endoscopy is warranted when suspicion remains high. Endoscopic removal is preferred, with escalation reserved for cases of complex extraluminal migration.
Pseudomembranous colitis (PMC) is a severe manifestation of Clostridioides difficile infection and is exceedingly rare in early infancy. We report a unique case of a 2-month-old male infant who presented with fever, profuse watery diarrhea, vomiting, and the passage of multiple rope-like colonic mucosal casts in the stool, initially raising concern for intestinal parasitosis. Laboratory investigations revealed marked leukocytosis, severe hyponatremia, and elevated inflammatory markers. Abdominal ultrasonography revealed diffuse thickening of the colonic wall. Histopathological examination of the expelled material confirmed a complete cast of necrotic colonic mucosa consistent with severe colitis. Despite an initial negative toxin assay, subsequent polymerase chain reaction (PCR) testing detected C. difficile toxin genes (tcdA and tcdB). The patient responded well to aggressive supportive care and intravenous antimicrobial therapy. This case highlights a rare and misleading presentation of PMC in early infancy and underscores the critical role of histopathology in achieving an accurate diagnosis.
This case report describes a rare presentation of primary periumbilical endometriosis, also known as Villar's nodule, highlighting the diagnostic difficulties and the importance of maintaining clinical suspicion. A 37‑year‑old woman presented with a one‑year history of cyclical periumbilical pain along with severe menorrhagia and dysmenorrhea. Initial ultrasonography suggested an umbilical hernia, but subsequent imaging, including repeat ultrasound and contrast‑enhanced MRI, revealed subcutaneous periumbilical nodules without evidence of intraperitoneal extension or associated pelvic endometriosis. An incidental intramural uterine fibroid was also noted. The patient underwent surgical excision of the periumbilical nodules along with myomectomy. Histopathological examination confirmed the diagnosis of endometriosis. Her postoperative recovery was uncomplicated, and she remained asymptomatic at the six‑month follow‑up. This case underscores the need to consider primary periumbilical endometriosis in women presenting with cyclical umbilical pain and demonstrates that early diagnosis and complete surgical excision can lead to favorable clinical outcomes.
Sural nerve entrapment is a relatively uncommon cause of lateral ankle and foot pain and sensory disturbance. Conventional management generally lacks direct, targeted intervention at the site of nerve injury. We report a case of a 33-year-old male patient who developed sural neuropathy secondary to a right ankle sprain. Diagnosis was confirmed by electromyography (EMG) and high-resolution musculoskeletal ultrasonography (US). The patient underwent two sessions of ultrasound-guided perineural hydrodissection, achieving over 80% pain relief posttreatment, with sustained stability during follow-up. This case highlights the diagnostic synergy of EMG and US in peripheral nerve entrapment syndromes, enabling precise diagnosis and anatomical localization of the entrapment site. It also supports ultrasound-guided hydrodissection as a precise, safe, minimally invasive, and effective therapeutic intervention that may obviate the need for invasive surgery.
Ileocolic intussusception is a major cause of intestinal obstruction in children under 2 years of age. Diagnosis is typically confirmed using ultrasonography, and treatment often involves an air or hydrostatic enema performed by radiologists or surgeons outside of the pediatric emergency department (PED) without the provision of adequate sedation or analgesia. This study aimed to assess the efficacy and safety of a comprehensive bedside approach for the diagnosis and reduction of ileocolic intussusception within the PED of a tertiary care pediatric hospital. A retrospective cohort study conducted between January 2021 and July 2024. Key outcome variables included the reduction success rate, time to reduction, and adverse events. During the study period, 28 children diagnosed with ileocolic intussusception via point-of-care ultrasound were treated bedside with ultrasound-guided hydrostatic reduction performed by a pediatric radiologist under sedation provided by pediatric emergency medicine physicians. There were 20 (86%) successful bedside reductions with an average time from admission to reduction of 126 minutes and an average length of stay of 407 minutes, respectively. No adverse events were recorded, although early recurrence of intussusception within 48 hours occurred in 2 patients (7%). This is the first study that detailed a comprehensive bedside approach for the diagnosis and reduction of ileocolic intussusception in the PED. This approach has a high success rate, minimizes the need for interdepartmental transfers, and facilitates the administration of appropriate sedation and analgesia without significant adverse events. Further prospective studies are needed to confirm the safety and efficacy of this bedside approach.
According to the Bethesda System for Reporting Thyroid Cytopathology, surgery is recommended for Bethesda classes I-III thyroid nodules only in selected situations, such as large or growing tumors with compressive symptoms or clinical suspicion of malignancy. Clinical findings and cytopathologic evaluation are often considered together to reduce discrepancies between preoperative cytology and final pathology. This study aimed to evaluate surgical outcomes in Bethesda classes I-III nodules and to identify risk factors predictive of malignancy. In this retrospective review, we included patients who underwent thyroidectomy for thyroid nodules classified as Bethesda classes I-III based on preoperative US-guided fine-needle aspiration (FNA) between 2010 and 2020. We collected data including preoperative cytopathology and ultrasound findings to analyze the risk factors related to malignancy and to evaluate treatment outcomes. Among 192 patients, carcinoma was confirmed in 62 (32.3%). The malignancy rates for Bethesda classes I, II, and III were 23.5%, 20.4%, and 49.4%, respectively. The malignant histologic types included papillary thyroid carcinoma (PTC; n = 34, 54.8%) and follicular thyroid carcinoma (FTC; n = 23, 37.1%), while five cases (8.1%) showed coexisting histologic types, including multiple PTC variants or a combination of minimally invasive FTC and PTC. Bethesda class III showed a significantly higher incidence of malignancy than the other classes (p < 0.001). In a subgroup analysis of class III nodules, larger nodule size on ultrasonography and atypia with both nuclear and architectural features (AUS-N/A) were associated with malignancy (p = 0.045 and p = 0.028, respectively). In a multivariate analysis, AUS-N/A was an independent predictor of malignancy (odds ratio 13.275, 95% confidence interval 1.354-130.3, p = 0.026). Bethesda class III nodules showed a higher risk of malignancy. Surgical intervention should be considered, particularly when AUS-N/A is identified in Bethesda class III nodules. Even in cases where carcinoma was confirmed after surgery for Bethesda classes I, II, and III, the probability of recurrence was very low and the prognosis is favorable.
A 4-week-old, male domestic shorthair kitten presented with congenital abnormalities of the rectum and perineal region, including defecation through an aberrant opening within the scrotal area. Positive-contrast radiography and ultrasonography confirmed type II anal atresia with a ventral rectocutaneous fistula. An abnormally positioned urethra was also identified, coursing dorsally to the penile structure. Surgical transposition of the fistulous tract and reconstruction of the anal sphincter were performed using a fistula-flap technique to restore normal defecation. Recovery was uneventful, and spontaneous defecation resumed within 2 weeks. At a 20-month follow-up, the patient remained clinically well. This case represents the first documented use of a fistula-flap technique to successfully correct type II atresia ani with rectocutaneous fistula in a male feline patient, demonstrating that the technique can be safely adapted to different anorectal malformation patterns.
The presence of aortic plaque is an important risk factor for stroke in patients with atrial fibrillation (AF). A history of vascular disease, defined as the presence of complex aortic plaque (CAP), constitutes one of the components of the CHA₂DS₂-VA score. However, data regarding the frequency of abdominal aortic (AA) plaques in patients with AF are limited in the literature. Therefore, the present study aimed to investigate the prevalence of AA-CAP and its associated parameters in patients with AF. A total of 748-patients with AF who underwent abdominal ultrasonography (US) for aortic plaque assessment were included in this study. In addition to routine clinical evaluations, all patients were assessed for the presence of AA-CAP using US. The study population was subsequently divided into two groups according to the presence or absence of AA-CAP. AA-CAP was detected in 106 (14.2%) of the AF patients included in the study. Patients with AA-CAP were older and had higher CHA₂DS₂-VA scores and a greater burden of cardiovascular risk factors. In addition, blood pressure levels and glucose, urea, and creatinine values were higher, whereas hemoglobin levels were lower in patients with AA-CAP. In logistic regression analysis, age, CHA₂DS₂-VA score, and the presence of hypertension were found to be independently associated with AA-CAP (OR = 1.071,95%CI:1.031-1.111,p < 0.001;OR = 2.446,95%CI:1.900-3.149,p < 0.001;OR = 2.735,95%CI:1.441-5.190,p = 0.002). ROC curve analysis demonstrated that age and CHA₂DS₂-VA score, with cut-off values of 65 years and 3, respectively, identified the presence of AA-CAP with acceptable sensitivity and specificity. AA-CAP was observed at a considerable rate (14.2%) in patients with AF. Therefore, in AF patients without previously known coronary or peripheral arterial disease, assessment of AA-CAP using abdominal US may be useful for stroke risk stratification and for more accurate calculation of the CHA₂DS₂-VA score.
We present a Mexican multigenerational family series of type I hereditary angioedema (HAE) with predominant abdominal involvement, including three affected adult sisters and a child identified through family screening. The index case was a 44-year-old woman with recurrent abdominal attacks, chronic diarrhea, multiple hospitalizations, and previous abdominopelvic interventions with no conclusive findings. During her clinical course, she developed non-urticarial lip edema, and abdominal CT showed segmental thickening of jejunal loops and mesenteric edema, findings consistent with bowel wall edema during an abdominal attack. The diagnosis was confirmed by low C4, decreased C1-INH functional activity, and low C1-INH antigenic levels. Family evaluation identified additional cases compatible with type I HAE, supporting a pattern of vertical transmission. After diagnosis, the index case received on-demand icatibant and initiated long-term prophylaxis with lanadelumab, remaining asymptomatic at the most recent follow-up. This series highlights the importance of considering HAE in patients with unexplained recurrent abdominal pain, edema without urticaria, and a suggestive family history, particularly when imaging suggests reversible small-bowel involvement, in order to reduce diagnostic delay and prevent potentially avoidable interventions.
Mounier Kuhn Syndrome (MKS) is a rare chronic condition characterized by dilatation of the trachea and the major bronchi. The clinical presentation is variable, ranging from asymptomatic mild symptoms to severe diseases that can result in death. MKS often presents with chronic cough, dyspnea, and recurrent upper respiratory tract infections. Radiological imaging is important in diagnosing the condition to identify dilatation of the trachea and major bronchi with posterior tracheal diverticuli. The HRCT scan modality clearly demonstrates these features radiologically. Bronchoscopy can be used for diagnostic and therapeutic purposes. HRCT is also used to evaluate potential complications. The treatment for symptomatic individuals is conservative management. In this report, we describe the case of a 50-year-old man who presented with a productive cough for three weeks associated with headache, vomiting, and dizziness. He was found to have a grade II digital clubbing. Chest HRCT revealed tracheobronchomegaly with posterior tracheal diverticuli and bilateral distal bronchiectasis. Diagnostic bronchoscopy revealed a widened trachea with a distorted webbed appearance of the posterior and lateral walls, and bronchial secretions in the left lower lobe. A biofire test for the pneumonia panel revealed an active Haemophilus influenzae infection. The patient also had a malarial co-infection prior to admission. The patient completed an antimalarial regimen, intravenous antibiotics, and mucolytics, and was discharged upon improvement.
This study aimed to evaluate the diagnostic value of real-time shear wave elastography (SWE) combined with magnetic resonance imaging-ultrasound (MRI-US) cognitive fusion targeted biopsy in repeat prostate biopsy. The retrospective cohort study comprised 120 patients who underwent transperineal repeat biopsy. Group A (n = 64) had standard cognitive fusion targeted biopsy plus systematic biopsy; Group B (n = 56) had additional real-time SWE before cognitive fusion to refine targeting. The primary endpoint of the study was the clinically significant prostate cancer (csPCa), which was based on targeted cores. Secondary endpoints encompassed the following: overall PCa detection, core-specific cancer detection rate, agreement with final pathology, diagnostic performance, and complications. It is evident from the data that Group B had a significantly higher csPCa detection rate in comparison to Group A (p < 0.05). The number of biopsy cores was comparable, yet the core-specific cancer detection rate was higher in Group B (p < 0.05). In Group B, maximum elastic modulus of shear wave elastography (SWE-Emax) values and the proportion of the Prostate Imaging Reporting and Data System (PI-RADS) 5 lesions were significantly higher in csPCa lesions than in benign lesions (p < 0.001). Group B had superior sensitivity, specificity, accuracy, and agreement with final pathology. Receiver operating characteristic (ROC) curve analysis suggested that the combination of SWE-Emax with PI-RADS score yielded a higher diagnostic performance than either individual method (area under the curve (AUC) = 0.904, 95%confidence interval (CI): 0.825-0.983, p < 0.001). Subsequent analysis revealed no significant disparities in complication rates between the two groups (p > 0.05). The combination of real-time SWE and MRI-US cognitive fusion targeted biopsy has been shown to be associated with a higher detection rate of clinically significant prostate cancer and improved biopsy accuracy during repeat biopsies, offering incremental diagnostic value without additional risks.
Slipping rib syndrome is an under-recognised cause of thoracoabdominal pain that may present with atypical symptoms, leading to diagnostic delay. We report the case of a 23-year-old woman who presented with severe postprandial nausea as her dominant symptom, accompanied by episodic vomiting and unintentional weight loss. Extensive gastrointestinal and spinal investigations were unrevealing, and symptoms were subsequently interpreted as functional or psychosomatic. Careful clinical examination and targeted imaging ultimately identified slipping rib syndrome involving the eleventh right rib. Surgical resection of the mobile cartilaginous rib segment resulted in complete and sustained resolution of symptoms. This case highlights the importance of considering musculoskeletal causes in patients with unexplained gastrointestinal symptoms to avoid misdiagnosis and unnecessary investigations. Slipping rib syndrome may present predominantly with gastrointestinal symptoms such as postprandial nausea, leading to diagnostic delay.Reproducible mechanical symptoms on examination are key to diagnosis, and normal imaging does not exclude the condition.Surgical resection can provide definitive symptom relief in selected patients with persistent symptoms.
Peripheral Arterial Disease (PAD) is a prevalent but underdiagnosed pathology. Soluble CD146 (sCD146) was described as a marker of endothelial dysfunction and vascular congestion. We hypothesize that sCD146 may represent a novel biomarker of PAD. Our objective was to evaluate the association between plasma sCD146 levels and the occurrence and severity of PAD. In this case-control study, 184 Caucasian men with symptomatic PAD were compared to 163 age-matched healthy control patients. PAD diagnosis was confirmed using ankle-brachial index (ABI) and imaging. Plasma sCD146 was quantified using ELISA. Associations with clinical and biochemical parameters were analyzed through multivariable logistic regression models. sCD146 level was significantly reduced in PAD patients (mean [95% CI]: 288 ng/mL [269-306]) versus control patients (480 ng/mL [460-500], p < 0.0001). A 10 ng/mL decrease in sCD146 was associated with an age-adjusted odds ratio (OR) of 1.17 (95% CI 1.13-1.22) for PAD, increasing to OR 1.25 (95% CI 1.14-1.36, p < 0.0001) after adjustment for risk factors. sCD146 was not associated with PAD severity (by Fontaine stage). Notably, the association between sCD146 and HDL-C was positively correlated in controls (β = 0.220, p = 0.005), but negatively correlated in PAD patients (β = - 0.156, p = 0.041), with significant interaction (p = 0.002). Age-adjusted OR for PAD was highest in individuals with high HDL-C tertiles (OR = 1.41, 95% CI 1.22-1.63). A lower sCD146 concentration is independently associated with PAD. Additionally, an inverse relationship was observed between HDL-C and these patients. These findings suggest that sCD146 may reflect impaired endothelial homeostasis and metabolic dysregulation in PAD, indicating that it could serve as a diagnostic biomarker for the pathology. NCT00377897.
A patient with metastasized prostate adenocarcinoma underwent 18F-PSMA-11 PET/CT restaging following 177Lu-PSMA-617 treatment and rising PSA-level. The maximum intensity projection image (right-side of the figure) demonstrated an intense homogenous tracer uptake throughout the bone marrow containing skeleton, whereas CT images showed specific bone metastases but no diffuse involvement, and previously known lymph node and liver metastases exhibited significantly reduced or absent uptake (see also left-side of the image, 18F-PSMA-11 MIP prior to 177Lu-PSMA-617 therapy). None of the patients that underwent imaging with the same tracer-batch demonstrated similar findings excluding free 18F as a potential cause for the imaging findings. Furthermore, the patient did not suffer from any bone marrow disorder previously reported to present with diffuse bone marrow uptake on PSMA-targeting PET/CT imaging [1, 2]. Of interest, the patient had received recombinant human erythropoietin, 100 µg of Aranesp, 24 h prior to imaging to treat his renal failure associated anemia. At this dose, Aranesp reaches a nanomolar concentration in the bone marrow resulting in stimulation of the Tissue Protective Receptor on endothelial cells leading to the creation of a massive systemic reservoir of PSMA-positive neovasculature that outcompetes PSMA-expressing prostate carcinoma lesions for radiotracer availability [3, 4]. This may explain the diffuse marrow uptake and the decreased visibility of known metastases [4]. The effect of erythropoietin on bone marrow mobilization and neovascularization can persist for 7-10 days [5]. This should be taken into consideration in order to avoid erroneous interpretation of 18F-PMSA-11 PET/CT imaging and unnecessary bone marrow toxicity of 177Lu-PSMA-617 treatment.
Glucagon-like peptide-1 receptor agonists (GLP-1 RA) are now increasingly used for glycemic control in type 2 diabetes mellitus as well as for weight loss. Their effect on gastric emptying may increase the risk of aspiration in the perioperative setting; unfortunately, the optimal schedule of perioperative holding of GLP-1 RA is unclear. We conducted a cross-sectional prospective study at two university affiliated hospitals in Montreal, Canada, comparing the preoperative prevalence of increased residual gastric content (RGC) on gastric ultrasound (GUS) between two groups of fasted adults scheduled for elective surgery: (i) an exposure group of patients receiving a weekly injectable GLP-1 RA and discontinued for ≥ 7 days before surgery, regardless of indication; and (ii) a control group of patients not receiving any GLP-1 RA, preferentially with type 2 diabetes or with a body mass index ≥ 25 kg/m². The primary outcome was increased RGC, defined as the presence of solid content, thick liquid, or > 1.5 mL/kg of clear liquid. Confounding was addressed using overlap-weighting propensity-score adjustment. 93 patients were included. The unadjusted prevalence of increased RGC was 24% (10/41) in the control group and 42% (22/52) in the exposure group. Solid content accounted for 80% (8/10) and 82% (18/22) of positive exams in the control group and the exposure group, respectively. In the unadjusted analysis, there was no statistically significant difference in increased RGC between groups (prevalence ratio, 1.73; 95% CI, 0.96 to 3.75). There was no statistically significant difference between groups after adjustment for confounding (adjusted prevalence ratio, 1.65; 95% CI, 0.7 to 3.7) with an absolute average treatment effect of 15.4% (95% CI, -10 to 35.6). The prevalence of increased residual gastric content was 42% in patients who had discontinued weekly GLP-1 RA for at least 7 days, compared with 24% in non-exposed controls. Although this difference was not statistically significant, our study was underpowered. The findings therefore represent a clinically relevant but statistically inconclusive signal that the recommended 7-day discontinuation interval may not consistently restore an empty stomach in patients on weekly GLP-1 RA. This study was registered on clinicaltrials.gov (July 8th, 2024, NCT06500143).
Spontaneous spinal epidural hematoma (SSEH), with an annual incidence of 0.1 per 100 000 individuals, typically presents with acute spinal pain followed by neurological deficits. We describe the case of a 73-year-old woman who presented with acute posterior neck and back pain without overt neurological deficits. While contrast-enhanced computed tomography (CT) was primarily performed to exclude aortic dissection, it played a critical role in incidentally identifying a hyperattenuating epidural lesion, which was subsequently confirmed as a dorsal cervical epidural hematoma by magnetic resonance imaging. Given the patient's stable neurological condition, conservative management was adopted, resulting in complete recovery without sequelae. This case underscores that SSEH may manifest solely as pain and that CT, even when performed to exclude other vascular emergencies, can provide an incidental yet critical initial diagnostic clue, facilitating timely diagnosis and appropriate management.
Heat stroke is a life-threatening emergency characterized by severe hyperthermia and acute central nervous system (CNS) dysfunction. We describe a 72-year-old man who was found unresponsive in his vehicle on a day with ambient temperatures exceeding 90°F. On arrival, his core temperature was 105.8°F, and Glasgow Coma Scale (GCS) score was 5. Despite prompt initiation of active cooling and supportive care with normalization of body temperature, the patient developed persistent and fluctuating encephalopathy. Extensive metabolic, infectious, and toxicologic evaluations were unrevealing. Thyroid-stimulating hormone was normal, arterial blood gases showed no acid-base derangements, ammonia and liver function tests were within normal limits, and urine toxicology was negative. Electroencephalography demonstrated diffuse cerebral slowing without epileptiform activity. Brain MRI performed approximately 1 week after admission under anesthesia, including diffusion-weighted imaging, showed no acute abnormalities, revealing only mild age-related atrophy and chronic small-vessel ischemic changes. The patient's neurologic function failed to recover over a prolonged hospitalization, and he ultimately died following transition to comfort-focused care on hospital Day 27. This case highlights that severe and persistent encephalopathy may occur in the setting of probable heat stroke despite unrevealing conventional neuroimaging and underscores the diagnostic uncertainty and limitations of MRI in evaluating heat-related neurologic injury.
Discogenic Low Back Pain (DLBP) remains a major diagnostic and therapeutic challenge due to its heterogeneous pathophysiology and overlapping clinical presentation. Current management frequently relies on empirical stepwise strategies with limited mechanistic specificity. The distinct mechanisms of disc degeneration have drawn significant attention, highlighting the need for a phenotype-driven precision framework to support rational surgical and interventional decision-making. This narrative review evaluates literature from PubMed, Embase, and Web of Science up to April 2026, focusing on the pathophysiology and phenotype-based management of DLBP. Key terms included "discogenic low back pain," "phenotype," "basivertebral nerve ablation," "thoracolumbar fascia," "myofascial trigger point," and "ultrasound-guided dry needling." The review highlights the "triad" of disc degeneration-structural damage, functional impairment, and metabolic dysregulation-and integrates myofascial and thoracolumbar fascial dysfunction as functional modifiers that may coexist with structural disc phenotypes and influence diagnostic interpretation and therapeutic escalation. Existing evidence supports the conceptual stratification of DLBP into four clinical phenotypes based on dominant pain-generating mechanisms. Vertebrogenic DLBP is characterized by endplate inflammation and Modic changes, for which basivertebral nerve (BVN) ablation is the primary supported intervention in appropriately selected patients. Annulogenic DLBP involves annular fissures associated with high-intensity zones (HIZ), where bipolar cooled radiofrequency ablation (biacuplasty) provides a targeted option. Mixed DLBP features concurrent endplate and annular pathology, potentially necessitating combined denervation strategies, whereas neuro-sensitized DLBP is dominated by central and peripheral sensitization, for which neuromodulation may serve as a salvage option. Across these phenotypes, functional myofascial or fascial involvement may be assessed using clinical examination and, when available, ultrasound-based dynamic evaluation. A staged therapeutic pathway places rehabilitation and manual therapy as early global strategies, ultrasound-guided dry needling as a potential intermediate functional intervention, and ablative, neuromodulatory, or surgical procedures as options for refractory or structurally dominant cases. DLBP management should move from generalized algorithms toward mechanism-informed precision care. Integrating structural imaging, functional soft-tissue assessment, and phenotype-specific interventions may improve individualized treatment selection while reducing unnecessary procedural escalation.