Hi Everyone, I would like some thoughts on a difficult case I saw today. 82 yo male who underwent L4-S1 fusion 5 years ago for unstable spondy. Was doing well until last yr when he started to develop severe right anterior thigh pain and some weakness. Imaging showed spondy grade 3 above prior fusion site at L2-3. Patinet was taken by surgeon in for revision of his fusion, old hard ware removed is now fused from L2 to Sacrum. Patient doing fine post op for 3 weeks, right thigh pain has resolved. However he then starts to develop excruciating left lower lumbar pain. Surgeon thought it may be sacroiliac joint irritation, had him sent to for SI joint injection, no relief. Tried L2, L3 TFESI no real relief. Imaging shows screws are intact no displacement. He saw another doc in the community for injection who knows what he is doing. Surgeon was asked me to see him to see if I have any other thoughts. He is a reliable surgeon who does good work and also sends me a lot of referrals (I was on vacation when he sent to other doc). On exam patient is exquisitely in the left L5 area approximate 3 cm lateral of midline. Wheel chair bound, can stand and pain is actually better when he stands, its worse when he sits or is supine. Rolling over is extremely painful. No spinal percussion tenderness, some pain with palpation over the left approxiamte L5-S1 facet level, SI joint not really tender. I ask him to point out pain and it is actually more lateral overlying oblique muscles. He can barely tolerate touch to the area as even skin is painful. Imaging shows no sign of discitis, CT shows intact hardware. CT myelogram shows what is expected, no red flags. He has tried all meds, no relief. I try a TPI in the area and deliberately flood the area with anesthetic just to see if he is numb if he will get any relief. I inject all tender points generously with lidocaine. No relief. One consideration is hardware related pain, however he was so thin, I actually was able to palapate his lower pedicle screw and I also injected over that area. No relief either. Any thoughts?