Developing a broad differential for chronic back pain is important in terms of work-up, and eventual treatment. We present a case of a sixty-nine-year old male with chronic back pain, failing multiple treatments and medications, which were eventually diagnosed with non-obstructing renal calculi. We believe it is imperative that pain management physicians are cognizant of small stone syndrome, and that they widen their differential to include rarer causes of back pain when treatment modalities prove ineffective. As demonstrated by our case, ineffective treatment, unneeded procedures, and poor patient satisfaction, may result when a broad differential is not utilized.