A 62-year-old woman presents with complaints of pain in her lower back with heaviness in her legs especially in the back of her thighs after walking for five minutes. The pain in her back and legs become so bad that she has to sit down, otherwise, she would fall.

She is otherwise in good health. She has had 7 children all with normal delivery. She has no complaints of lower back pain with sitting or sleeping at night. Her back pain only comes with activity such as walking or standing.

After walking for a few minutes, she has to sit down. After sitting for five minutes, she can walk again for another five minutes. She says to get to her daughter’s house which is two blocks away, she has to sit 4-5 times along the way.

She has had this back pain for at least five years and she has noticed that the distance she could walk has become shorter and shorter every year.

When she cooks food, she has to sit down several times and has a chair in her kitchen for that.

She brought in X-rays of her back and MRI that is shown below:

What is the cause of back pain in this patient?

1. Arthritis
2. Multiple spinal fractures
3. Spinal Stenosis
4. Spondyloarthropathy

Arthritis

This is a common cause of back pain. It can also make it hard for patients to walk. The pain here however usually is limited to the lower back and does not radiate to the back of the thighs as it does with spinal Stenosis.

Multiple spinal fractures

This patient does have one old fracture but not multiple fractures. The pains are severe but are localized to the area of the back where the fracture is located.

Spinal Stenosis

This is the correct diagnosis. Here because of the disc herniation at two levels has caused significant spinal stenosis as shown below:

As a result, there is significant narrowing at these two levels as shown below. These patients can not walk far as with increase ambulation there is also increase pressure in the spinal canal causing weakness, heaviness, or tiredness in their legs.

Spondyloarthropathy

Spondyloarthropathies usually have opposite symptoms with pain occurring mostly at rest and also at night and unlike spinal stenosis back pain here, actually, improves with walking.

Spondyloarthropathies can involve any part of the spine and in the lower back, they involve sacroiliac joints causing sacroiliitis. This is inflammatory arthritis and usually, responds to NSAIDs.

The Spine

The spine is divided into four parts:

1. Cervical Spine
2. Thoracic Spine
3. Lumbar Spine
4. Sacrum and Coccyx

Common Spinal Problems include:

1. Bulging Disc. This usually causes no pain or pain only off and on.
2. Herniated Disc. This causes pain down the arm if in the neck or the leg if in the back. Pain here becomes worse with activity and gets better with rest. 
3. Radiculopathy. This can be caused by herniated disc and or arthritis causing narrowing of neural foramina where the spinal nerves exit causing nerve irritation and thus pain, numbness, and weakness.Pain here becomes worse with activity and gets better with rest. 
4. Inflammatory Back Pain. This is a common cause of pain due to spondyloarthropathies. These patients have spinal pain mostly with inactivity such as resting and at night sleeping. Their back pain improves with activity.   
5. Fractures. This usually causes a severe sudden onset of back pain and may last several months.
6. Scoliosis. This is not always problematic. When it causes pain, it is often associated with activity
7. Lower back and Neck are usually most problematic.
8. Sacrum and Coccyx are most problematic in Spondyloarthropathies causing significant pain and stiffness with rest. The pain here almost always improves with activity.