The sacroiliac joint (SIJ) can cause pain after lumbosacral fusion. Diagnosis requires >75% relief after local anesthetic SIJ injection. This study is a retrospective review of patients with low back pain after lumbosacral fusion who had SIJ injections. Percentage and duration of pain relief were noted. Results are as follows: there were 34 patients; 8 fused at L5-S1, 14 fused at L4-S1, and 12 had multilevel fusions. Twenty had >75% relief within 45 minutes, and 11 had prolonged relief. Six had relief >20% but <75%, and one had prolonged relief. Eight never improved. Eight had posterior iliac crest bone harvested, and there was no correlation between donor side and pain side. In 34 patients with low back pain after lumbosacral fusion, SIJ was the cause of pain in 32% and possibly the cause in 29%. This is the first detailed description of this problem.

We were able to establish a predominant diagnosis in 94% of our patients. Foraminal stenosis remains the leading cause of FBSS, but painful discs are also common. Recurrent disc herniation is seen less often than in the past, and there is increased recognition of neuropathic pain. Knowledge of the potential causes of FBSS leads to a more efficient and cost-effective evaluation of these patients.

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Repeated radiofrequency neurotomies are an effective long-term palliative management of lumbar facet pain. Each radiofrequency neurotomy had a mean duration of relief of 10.5 months and was successful more than 85% of the time.

The use of long-term opioids (LTOs) to treat chronic pain of nonmalignant origin (CNMP) is controversial. Most physicians had felt there was essentially no role for LTOs in CNMP, but successful treatment outcomes have recently been reported. Tolerance, organ toxicity, or fear of addiction are not reasons to limit LTOs. The significant question is efficacy. Does LTO therapy improve pain and increase function with minimal side effects or risk? It is useful to divide chronic pain patients into three types. Type 1 patients are "typical" chronic pain patients with pain and disability far out of proportion to the peripheral stimulus. Psychological factors are significant. In this type of patient, opioids appear to do more harm than good. Type 2 patients have ongoing nociception and moderate refractory pain. Type 3 patients have refractory severe nociception or neuropathic pain. The latter types might be considered for LTOs. LTO use is appropriate for a very small, carefully selected group of patients.

Low back pain that continues or recurs after apparently solid posterolateral spinal fusion may be caused by painful disc(s) at motion segment(s) within the fusion. A solid posterolateral spinal fusion may not protect the residual disc(s) from injury. Anterior interbody fusion can provide significant improvements in pain and function and a high degree of patient satisfaction in this clinical setting.

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Both the 360 degrees and 270 degrees fusions significantly reduce pain and improve function, and there are no significant clinical differences between them. However, there were shorter operating times, less blood loss, lower costs, and less utilization of health care resources associated with the 270 degrees fusions.