Much of the epidemiologic data on low back pain are nonspecic, meaning that a cause cannot be found in most cases. Despite evidence to the contrary in the 21st century, these older, inaccurate epidemiologic studies continue to be quoted by current authors. One of the oldest epidemiologic studies commonly quoted was published more than 40 years ago by Dillane and colleagues8 and was based on a retrospec­tive practice audit of data gathered more than 50 years ago. Dillane and colleagues8 reported that they could not detect a cause for low back pain in approximately 80% of female and 90% of male patients with acute back syndrome. ese authors did not report the use of any radiographic studies and appar­ently relied solely on history and physical examination.9 ey diagnosed approximately 11% of male patients and approxi­mately 4% of female patients with low back “strain.” Until more recently, the only tools to diagnose the etiology of low back pain have been history, physical examination, and some­times radiographs or computed tomography (CT).

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depends on who makes the diagnosis and sets the reference standards by which the diagnosis is “proven.” Who is right? For that matter, can anyone reliably diagnose the cause of chronic benign spinal pain? Many authors argue that chronic benign spinal pain is largely due to exaggerated functional complaints and irreversible central nervous system sensitization,11 making pain self-perpetuating and diagnosis all but impossible. ese contentions are not oen supported by primary studies,12 however, and authors and clinicians question this diagnosis.

hypothesized based on history, physical examination, imaging studies, and response to directed treatment. Interventional procedures are used to test the hypothesis that pain is related to a structural abnormality hypothesized by clinical and imaging ndings. (e word hypothesis is used loosely here; arguably, one can only conrm a clinical impression using diagnostic blocks. A hypothesis is conrmed using a study protocol that can show approximately <5% probability that the ndings are due to chance.) Foremost, interventional procedures are perhaps best used to refute one’s hypothesis that a particular structure is painful. at is, diagnosis is made through the process of systematically excluding various tissue causes of axial and extremity pain in the posterior, middle, and anterior columns.

systemic diseases, or referred from nonspinal structures, is not included; likewise, “yellow ag” conditions (psychosocial factors) are not discussed in detail. Evaluation of the anterior column using provocative discography is discussed elsewhere; the discussion in this chapter is focused on diagnosis of pain originating from the posterior and middle columns, in par­ticular, pain originating from the zygapophyseal joint and sacroiliac joint in the posterior column and from the nerve root, dorsal root ganglion, and dura in the middle column.

shoulder pain from spinal pain. Although so tissues may be painful, for the purpose and brevity of this chapter, these structures are considered a secondary source of pain in most chronic spinal conditions.