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Background: Discogenic, facet joint, and sacroiliac joint mediated axial low back pain may be associated with overlapping pain referral patterns into the lower limb. Differences between pain referral patterns for these three structures have not been systematically investigated. Objective: To examine the individual and combined relationship of age, hip/girdle pain, leg pain, and thigh pain and the source of internal disc disruption (IDD), facet joint pain (FJP), or sacroiliac joint pain (SIJP) in consecutive chronic low back pain (CLBP) patients. Design: Retrospective chart review. Setting: Community based interventional spine practice. Patients: 378 cases from 358 consecutive patients were reviewed and 157 independent cases from 153 patients who underwent definitive diagnostic injections were analyzed. Methods: Charts of consecutive low back pain patients who underwent definitive diagnostic spinal procedures were retrospectively reviewed. Patients underwent provocation lumbar discography, dual diagnostic medial branch blocks, or intra-articular diagnostic sacroiliac joint injections based on clinical presentation. Some subjects underwent multiple diagnostic injections until the source of their chronic low back pain (CLBP) was identified. Main Outcome Measurements: Based on the results of diagnostic injections, subjects were classified as having IDD, FJP, SIJP, or other. The mean age/standard deviation and the count/percentage of patients reporting hip girdle pain, leg pain, or thigh pain were estimated for each diagnostic group and compared statistically among the IDD, FJP, SIJP, and other source groups. Next, the 4 predictor variables were simultaneously modeled with a single multinomial logistic regression model to explore the adjusted relationship between the predictors and the source of CLBP. Results: The mean age was significantly different among the source groups. IDD cases were significantly younger than FJP, SIJP, and other source groups and FJP cases were significantly younger than other sources. The age by thigh pain interaction effect was statistically significant (P = 0.021), indicating that the effect of age on the source of CLBP depends on thigh pain, and similarly, that the effect of thigh pain on the source of CLBP depends on age. Limitations: Retrospective study design. Conclusions: The presence or absence of thigh pain possesses a significant correlation on the source of CLBP for varying ages, whereas the presence of hip/girdle pain or leg pain did not significantly discriminate among IDD, FJP, or SIJP as the etiology of CLBP. Younger age was predictive of IDD regardless of the presence or absence of thigh pain. Key words: low back pain, intervertebral disc, zygapophyseal joint, sacroiliac joint, pain referral patterns

Background: Recurrent or persistent low back pain (LBP) after surgical discectomy (SD) for intervertebral disc herniation has been well documented. The source of low back pain in these patients has not been examined. Objective: To compare the distribution of the source of chronic LBP between patients with and without a history of SD. Study Design: Retrospective chart review. Setting: Academic spine center. Patients: Charts from 358 consecutive patients were reviewed. Charts noting the absence/ presence of SD in patients who subsequently underwent diagnostic injections to determine the source of chronic LBP were included resulting in 158 unique cases for analysis. Methods: Patients underwent either dual diagnostic facet joint blocks, intra-articular diagnostic sacroiliac joint injections, provocation lumbar discography, or anesthetic injection into putatively painful interspinous ligaments/opposing spinous processes/posterior fusion hardware. If the initial diagnostic procedure was negative, the next most likely structure in the diagnostic algorithm was interrogated. Subsequent diagnostic procedures were not performed after the source of chronic LBP was identified. Outcome: The source of chronic LBP was diagnosed as discogenic pain (DP), facet joint pain (FJP), sacroiliac joint pain (SIJP), or other sources of chronic LBP. Results: Based on a Fisher’s exact test, there was marginal evidence the distribution of the source of chronic LBP differed for those with and without a history of SD (P = 0.080). Posthoc comparisons suggested that patients with a history of SD have a higher probability of DP compared to those without a history of SD (82% versus 41%; P = 0.011). Differences in the probability of FJP, SIJP, or other sources between the SD history groups were not significant. Limitations: Small sample size, restrospective design, and possible false-positive results. Conclusions: This is the first published investigation of the tissue source of chronic LBP after SD. It appears that DP is the most common reason for chronic LBP after SD. If more rigorous study confirms our findings, future biologic treatments may hold value in repairing symptomatic annular fissures after SD. Key words: surgical discectomy, chornic low back pain, discogenic pain, facet joint, sacroiliac joint, low back pain, diagnostic injections, medial branch block, lumbar provcation discography

Discogenic, facet joint, and sacroiliac joint mediated axial low back pain may be associated with overlapping pain referral patterns into the lower limb. Differences between pain referral patterns for these three structures have not been systematically investigated.To examine the individual and combined relationship of age, hip/girdle pain, leg pain, and thigh pain and the source of internal disc disruption (IDD), facet joint pain (FJP), or sacroiliac joint pain (SIJP) in consecutive chronic low back pain (CLBP) patients.Retrospective chart review.Community based interventional spine practice.378 cases from 358 consecutive patients were reviewed and 157 independent cases from 153 patients who underwent definitive diagnostic injections were analyzed.Charts of consecutive low back pain patients who underwent definitive diagnostic spinal procedures were retrospectively reviewed. Patients underwent provocation lumbar discography, dual diagnostic medial branch blocks, or intra-articular diagnostic sacroiliac joint injections based on clinical presentation. Some subjects underwent multiple diagnostic injections until the source of their chronic low back pain (CLBP) was identified.Based on the results of diagnostic injections, subjects were classified as having IDD, FJP, SIJP, or other. The mean age/standard deviation and the count/percentage of patients reporting hip girdle pain, leg pain, or thigh pain were estimated for each diagnostic group and compared statistically among the IDD, FJP, SIJP, and other source groups. Next, the 4 predictor variables were simultaneously modeled with a single multinomial logistic regression model to explore the adjusted relationship between the predictors and the source of CLBP.The mean age was significantly different among the source groups. IDD cases were significantly younger than FJP, SIJP, and other source groups and FJP cases were significantly younger than other sources. The age by thigh pain interaction effect was statistically significant (P = 0.021), indicating that the effect of age on the source of CLBP depends on thigh pain, and similarly, that the effect of thigh pain on the source of CLBP depends on age.Retrospective study design.The presence or absence of thigh pain possesses a significant correlation on the source of CLBP for varying ages, whereas the presence of hip/girdle pain or leg pain did not significantly discriminate among IDD, FJP, or SIJP as the etiology of CLBP. Younger age was predictive of IDD regardless of the presence or absence of thigh pain.

Recurrent or persistent low back pain (LBP) after surgical discectomy (SD) for intervertebral disc herniation has been well documented. The source of low back pain in these patients has not been examined.To compare the distribution of the source of chronic LBP between patients with and without a history of SD.Retrospective chart review.Academic spine center.Charts from 358 consecutive patients were reviewed. Charts noting the absence/presence of SD in patients who subsequently underwent diagnostic injections to determine the source of chronic LBP were included resulting in 158 unique cases for analysis.Patients underwent either dual diagnostic facet joint blocks, intra-articular diagnostic sacroiliac joint injections, provocation lumbar discography, or anesthetic injection into putatively painful interspinous ligaments/opposing spinous processes/posterior fusion hardware. If the initial diagnostic procedure was negative, the next most likely structure in the diagnostic algorithm was interrogated. Subsequent diagnostic procedures were not performed after the source of chronic LBP was identified.The source of chronic LBP was diagnosed as discogenic pain (DP), facet joint pain (FJP), sacroiliac joint pain (SIJP), or other sources of chronic LBP.Based on a Fisher's exact test, there was marginal evidence the distribution of the source of chronic LBP differed for those with and without a history of SD (P = 0.080). Post-hoc comparisons suggested that patients with a history of SD have a higher probability of DP compared to those without a history of SD (82% versus 41%; P = 0.011). Differences in the probability of FJP, SIJP, or other sources between the SD history groups were not significant.Small sample size, restrospective design, and possible false-positive results.This is the first published investigation of the tissue source of chronic LBP after SD. It appears that DP is the most common reason for chronic LBP after SD. If more rigorous study confirms our findings, future biologic treatments may hold value in repairing symptomatic annular fissures after SD.