Lower back pain is a common condition that affects people’s lives. It usually presents as pain localized to the iliac crest. It has been reported that 15-25% of the pain in the posterior iliac crest region is caused by injury to the posterior branch of the T12 nerve due to fracture or degenerative changes, and this pain is confounded with pain originating in the sacral region. We describe a case of lower back pain in the right hip region with refractory vertebroplasty and autogenous bone grafting that was improved by management of thoracolumbar syndrome. Case report A 42-year-old female patient with weakness and loss of appetite was followed up for 8 years due to hypertension, hyperlipidemia and osteogenesis imperfecta. The patient was diagnosed with osteoporosis by dual-energy X-ray bone densitometry 8 years ago and was treated with monthly injections of pamiphosphate 15 mg, but the bone density did not improve. 6 years ago the patient underwent vertebroplasty for a T11 vertebral fracture, but the lower back pain persisted. The patient was diagnosed with osteogenesis imperfecta at the orthopedic clinic 4 years ago due to lower back pain, while MRI confirmed a T11 fracture and a posterior thoracolumbar synostosis. One year ago, due to persistent lower back pain and a 30° posterior derangement, the patient underwent correction of the posterior derangement and autologous bone grafting. After a period of symptom relief, the symptoms worsened, and medication and physical therapy were administered for the past three months to control the pain. In addition to improvement of the posterior synovial deformity, there was no significant change from the previous pelvic plain and MRI of the thoracic spine, and the patient complained of pain in the posterior region of the left iliac crest with a VAS score of 8/10. Physical examination revealed localized pressure and pain hypersensitivity with pressure in the thoracolumbar spinous process and intervertebral joints. Based on imaging and physical examination, the patient was diagnosed with thoracolumbar spine syndrome. Patient sexual intervertebral joint injections were ineffective and the patient was treated with an epidural block with 0.5% mepivacaine, and the pain score decreased to 4-5 after treatment, and when the patient’s pain score increased to 5.5, a lumbar sympathetic block with 0.5% mepivacaine was performed on day 8 after hospitalization. The pain score was reduced to 2 after the treatment oh. The patient’s symptoms of abdominal distension and lower abdominal pain had improved after the cervical epidural block. The symptoms indicated thoracolumbar syndrome accompanied by functional disorders. The patient was discharged from the hospital after 11 days of hospitalization following improvement of symptoms. Discussion Lower back pain affects the patient’s quality of life, there are many causes of back pain, and imaging and metabolic related tests are needed for a definitive diagnosis. x-ray’s can determine the status of pelvic and thoracolumbar disorders. We should remember that imaging and symptoms are not consistent. The conditions that cause low back pain may not be specific and degenerative changes of the lumbar spine may be present in asymptomatic patients. Physical examination is more important, as the examples in this article illustrate well. Thoracolumbar syndrome refers to palpable pressure pain in the thoracolumbar segment and iliac crest, accompanied by approximately 60% of spinal pathology. When there is a lesion in the thoracolumbar segment T12-L1, most cases present with symptoms. In addition, it can also be present when there are functional abnormalities in T11-12 or L1-2. Clinical symptoms are associated with nerve root lesions. The posterior branch supplies the upper buttock and its subcutaneous tissue, the anterior branch innervates the abdomen and inguinal region, and the lateral cutaneous branch supplies the femoral trochanter. As a result, patients may present with small abdominal pain, sciatica and symptoms of irritable bowel and low back pain, which may lead to misdiagnosis. Examination of the thoracolumbar segment must be done carefully to check for pressure pain in the spinous and kyphotic joints, and pressure pain behind the iliac crest is also very important. Thoracolumbar syndrome is particularly suitable for chiropractic treatment of the spine, but osteoporosis is not suitable for that treatment. For patients with osteoporosis, the application of hormonal joint injections is beneficial. General lumbar intervertebral joint injection therapy may be effective. For intractable pain, local injections of the iliac crest may be effective, and epidural blocks may also reduce the symptoms of low back pain. If the above treatments are ineffective, sympathetic nerve blocks may be indicated. CONCLUSION: A detailed history and physical examination and different treatments are effective in the treatment of patients with lower back pain without clinical imaging manifestations.