A 66-year-old man complains of a 1-year history of low back and buttock pain that worsens with walking and is relieved by sitting or bending forward. He has hypertension and takes hydrochlorothiazide but has otherwise been healthy. There is no history of back trauma, fever, or weight loss. On examination, the patient has a slightly stooped posture, pain on lumbar extension, and has a slightly wide based gait. Pedal pulses are normal and there are no femoral bruits. Examination of peripheral joints and skin is normal. What is the most likely cause for this patient’s back and buttock pain?A) Lumbar spinal stenosis
Lumbar spinal stenosis is a frequent cause of back pain in the elderly. Patients typically have pain that radiates into the buttocks (and sometimes thighs) and is aggravated by walking and by lumbar extension. Decreased vibratory sensation and a wide based gait may also be seen. Narrowing of the spinal canal is usually caused by age-related degenerative changes. A recent randomized controlled trial demonstrated that surgery was more effective than medical therapy in the relief of symptoms for patients with lumbar spinal stenosis. Symptoms often recur several years after surgery. Disc herniation and facet joint arthropathy usually cause unilateral radicular symptoms. Leg pain associated with walking can also be caused by vascular disease, but the symptoms often are unilateral and usually occur in the distal leg. Normal pedal pulses and the classic history make vascular claudication an unlikely diagnosis in this patient. The bone pain of metastatic cancer is rarely positional and is usually unremitting, causing pain both day and night.