This retrospective study from an academic spine center asked: what is actually causing chronic low back pain, and does patient age change the answer? 170 patients with recalcitrant LBP underwent structured diagnostic procedures — discography, facet blocks, SIJ injections — until a definitive source was identified. Prevalence and mean age were compared across diagnostic categories.
Before this paper, the prevailing teaching held that 80-90% of chronic LBP cases had no identifiable cause. DePalma's data — built on structured diagnostic algorithms with controlled blocks and provocation discography. Challenged that directly, showing that a definitive structural source can be found in the vast majority of patients.
When a patient under 50 presents with chronic midline LBP, discogenic pain should be your primary working diagnosis. When a patient over 60 presents with paravertebral LBP worsened by standing, facet or SIJ pathology is more likely and should be interrogated first.
This age-stratified framework has a direct procedural consequence: performing medial branch neurotomy on a young patient with discogenic pain will fail, because the anterior column is untouched. Getting the diagnosis right before committing to any intervention is the whole point.
For the oldest patients (beyond 70), think outside the IDD-FJP-SIJP triad: insufficiency fractures and Baastrup's disease become increasingly relevant and are missed if not specifically considered.
This retrospective study from an academic spine center asked: what is actually causing chronic low back pain, and does patient age change the answer? 170 patients with recalcitrant LBP underwent structured diagnostic procedures — discography, facet blocks, SIJ injections — until a definitive source was identified. Prevalence and mean age were compared across diagnostic categories.
Before this paper, the prevailing teaching held that 80-90% of chronic LBP cases had no identifiable cause. DePalma's data — built on structured diagnostic algorithms with controlled blocks and provocation discography. Challenged that directly, showing that a definitive structural source can be found in the vast majority of patients.
When a patient under 50 presents with chronic midline LBP, discogenic pain should be your primary working diagnosis. When a patient over 60 presents with paravertebral LBP worsened by standing, facet or SIJ pathology is more likely and should be interrogated first.
This age-stratified framework has a direct procedural consequence: performing medial branch neurotomy on a young patient with discogenic pain will fail, because the anterior column is untouched. Getting the diagnosis right before committing to any intervention is the whole point.
For the oldest patients (beyond 70), think outside the IDD-FJP-SIJP triad: insufficiency fractures and Baastrup's disease become increasingly relevant and are missed if not specifically considered.