Applying an intersectional framework to characterize chronic pain disparities one year following traumatic spinal cord injury.

Chronic pain affects nearly 70% of individuals following traumatic spinal cord injury (SCI) and is frequently reported as a disabling and undertreated complication. While disparities in SCI recovery are well-documented, evidence in chronic pain remains limited, with prior studies involving smaller cohorts and evaluating isolated social determinants rather than their intersectional contributions. We conducted a retrospective cohort study using the US Spinal Cord Injury Model Systems database, including 3514 adults with traumatic SCI. Exposures were race/ethnicity (non-Hispanic White, non-Hispanic Black), annual income (<$25,000 vs ≥$25,000), and education (high school or less vs higher). Outcomes were pain severity (0-10 numeric rating) and pain interference (SF-12; severe[3-4] vs minimal/moderate[0-2]). Models adjusted for demographic and injury characteristics. Intersectional analyses quantified the combined effects of multiple social disadvantages, and causal mediation analyses estimated average causal mediation effects (ACME). Non-Hispanic Black, lower-income, and lower-education participants had higher pain severity and more frequent severe pain interference than their counterparts (all p<0.0001). Non-Hispanic Black participants, low-income, low-education participants had +2.43 points (95%CI 2.06-2.79) higher pain severity and 2.96-fold (95%CI 2.15-4.07) higher odds of severe pain interference than non-Hispanic White, higher-income, higher-education participants (q<0.0001). Mobility scores, days out-of-the-house, private health insurance, and perceived health status significantly mediated disparities in pain severity (ACME 0.158-0.312) and pain interference (ACME 0.017-0.043; all q<0.001). Chronic pain after traumatic SCI disproportionately affects socially disadvantaged groups. These findings highlight intersectional disparities and identify modifiable mediators as targets for interventions to reduce inequitable pain outcomes following traumatic SCI. PERSPECTIVE: This retrospective multicenter cohort study quantified intersectional disparities in chronic pain one year following spinal cord injury and characterized modifiable individual and structural mediators that account for these inequities.