A 69-year-old man presents to clinic with a six-month history of progressive lower back pain which radiates down to his buttock. He found the pain was exacerbated while taking his daily morning walk and noticed that it eased going uphill but worsened downhill. He stopped his daily walks as a result and he now walks only slowly to the shops when he needs to, taking breaks to sit down and ease the pain. He has a history of hypertension, diabetes and prostatic hyperplasia. What is the diagnosis?
A. Peripheral vascular disease
B. Osteoporotic fracture
C. Spinal stenosis
E. Metastatic bone disease
Ans: C This man gives a good history of spinal claudication (C), lower back pain and sciatica on walking. The pain worsens when the spine is extended (walking, especially downhill, and improves when flexed, going uphill, sitting). It is caused by narrowing of the spinal canal as a result of spondylosis (degenerative disease). Intermittent claudication from peripheral
vascular disease (A) can be similar in timing, worse on walking and relieved by rest, but the pain comes from ischaemic muscles, typically calf or buttock, and has no relation to the incline. There is nothing to suggest osteoporotic fracture (B), and in addition, his sex is protective for osteoporosis. Sciatica (D) presents as sharp pain shooting down the posterior leg and occurs as a result of impingement of the nerve roots forming the sciatic nerve. It is a symptom rather than a diagnosis. Metastatic bone disease (E) could result in spinal stenosis or sciatica but in itself does not explain the patient’s exact symptoms and there is nothing else to suggest malignancy in the stem such as constitutional symptoms or a nodular prostate.