A retrospective review of 1293 cases of low back pain treated over a 12-year period revealed that sacroiliac joint syndrome and posterior joint syndromes were the most common referred-pain syndromes, whereas herniated nucleus pulposus and lateral spinal stenosis were the most common nerve root compression lesions. Referred pain syndromes occur nearly twice as often and frequently mimic the clinical presentation of nerve root compression syndromes. Combined lesions occurred in 33.5% of cases. Lateral spinal stenosis and herniated nucleus pulposus coexisted in 17.7%. In 30% of the cases of spondylolisthesis, the radiographic findings were incidental and the source of pain was the sacroiliac joint. Distinguishing radicular from referred pain, recognition of coexisting lesions, and correlation of diagnostic imaging with the overall clinical presentation facilities formulation of a rational plan of therapy. The above-outlined approach to managing low back pain evolved over a 12-year period. Designed to establish a specific diagnosis, it should yield excellent or good results in 84% of patients.