Differential Diagnosis for Pain Worsening when Seated and Improving when Walking

Single Most Likely Diagnosis

• Lumbar Spinal Stenosis: This condition is characterized by the narrowing of the spinal canal, which can cause pain, numbness, or weakness in the legs, calves, or buttocks. Symptoms often worsen with standing or walking, but in some cases, sitting can also exacerbate the pain due to the position of the spine. However, walking can sometimes relieve the pain as it can help to flex the spine and reduce the pressure on the nerves.

Other Likely Diagnoses

• Herniated Lumbar Disc: A herniated disc can cause pain that radiates down the leg and worsens with certain positions, including sitting. The pain may improve with walking as movement can help reduce the pressure on the affected nerve root.
• Spondylolisthesis: This condition involves a vertebra slipping out of place onto the vertebra below it, which can cause nerve compression and pain. Symptoms can vary but may include pain that worsens with sitting and improves with walking.
• Piriformis Syndrome: This condition occurs when the piriformis muscle, located in the buttock region, compresses or irritates the sciatic nerve. Sitting can exacerbate the pain, while walking or stretching may provide relief.

Do Not Miss Diagnoses

• Cauda Equina Syndrome: A serious condition that occurs when the nerves in the spinal canal are compressed, leading to pain, numbness, and weakness in the legs, as well as potential bladder and bowel dysfunction. It is a medical emergency that requires immediate attention.
• Spinal Epidural Abscess: An infection that can cause severe back pain, fever, and neurological deficits. It is a rare but potentially life-threatening condition that requires prompt diagnosis and treatment.
• Spinal Tumor: Tumors in the spine can cause a variety of symptoms, including pain that worsens with certain positions. While less common, spinal tumors are a critical diagnosis not to miss due to their potential impact on neurological function and overall health.

Rare Diagnoses

• Tarlov Cyst: A rare condition where fluid-filled sacs form in the spine, potentially causing pain, numbness, and weakness. Symptoms can be variable and may include pain that changes with position.
• Arachnoiditis: Inflammation of the membranes surrounding the spinal cord, which can cause severe pain, numbness, and tingling. It is a rare condition but should be considered in the differential diagnosis of chronic back pain that worsens with sitting.