1. A 35 year old woman comes with a long history of neck pain and back pain for the past few years which has become more troublesome in the past few years. She says her pain radiates throughout the back to her buttocks, sometimes leaving her numb. She gets cramps in the legs while standing or while walking almost suddenly and is relieved by sitting down or by flexing her hips. She complains of normal appetite and says that her sleep is good as before and undisturbed. Her leg raising test is not positive and there is no spinal tenderness or deformity. The most probable diagnosis is

1. somatization disorder
2. multiple sclerosis
3. ankylosing spondylitis
4. spinal canal stenosis
5. herniated disc

Choice D is correct – spinal canal stenosis occurs due to narrowing of the spinal canal thereby compressing nerve roots and causing pain, weakness, and numbness in the neck, back and buttocks. Leg cramping can occur at rest, standing or walking and is relieved by sitting or by hyperflexion of the hips.

Choice A is incorrect – Somatization disorder is characterised by multiple somatic complaints at least 4 – two gastrointestinal, one neurological and one sexual, all of which cannot be explained by other organic or general medical/ surgical disorders.

Choice B is incorrect – multiple sclerosis classically presents with sudden and spontaneously remitting neurological deficits that are separated in space and time

Choice C is incorrect – Ankylosing spondylitis is a seronegative arthropathy which commonly affects young individuals characterised by pain and stiffness of the back and other joints that are worse after rest or waking up and get relieved with exercise. There is also marked spinal deformity like kyphosis.

Choice E is incorrect   - Herniated disc also presents with pain, but it characteristically shooting sharp, electric pain radiating down the leg in an L4 – S3 pattern –‘sciatica’. Passive straight leg raising test and crossed straight leg raising test produce pain.