What do spinal stenosis and “Goldilocks and the Three Bears” have in common?

Hello Doctor,

I have been bothered a lot by pain in the center of my low back near the waistline with  leg pain sometimes in both legs for the last few years. This problem acts up at strange times regardless of what I am doing at the time.  It feels like it is getting worse because not only is the lower pain more intense lately, but it is easier to provoke and lasts longer when it does act up.

I am female, and a retired school teacher 59 years old.  I am not overweight and I have always taken good care of myself.  I have two grown children and the only time in my life I had lower back pain before this was during both of my pregnancies.  As soon as the pregnancies ended with delivery of each child my back pain stopped. I have never been in a bad accident to my lower back, and my blood pressure and glucose are good.  Recent blood work came back normal.

What confuses me is that I don’t have to be doing much of anything and my back aches and leg pain can act up.  I thought if I rest and take it easy that the back pain should go away, but this is not the way my back reacts.  Being inactive seems to make it worse.  I have even tried to go in the other direction and get more active to limber up and loosen my tight muscles and get better back strength, but this also makes it worse.  No matter how little or how much I do I seem to aggravate my back pain.  What I have found to get some pain reduction is to do a moderate amount of work and exercise, meaning not too much and not too little. And when it is at its worse the pain seems to spread down into both legs but worse on the left. 

Last week I went to our family doctor about my back pain.  She examined my back, tapped my reflexes, bent my back and legs in different directions, and took lumbar x-rays and some blood work.  First she said I had something called spinal stenosis, but then she said my problem was arthritis in my back.  Saying I have two problems confuses me because I do not know which is the cause of my complaints. She said I had to learn to live with the pain, then grabbed the door knob and quickly backed out of the room.  I did not have time to ask her the questions that were raised by what she told me.  I know I didn’t understand everything she said and I wanted to ask her if the real problem was arthritis or spinal stenosis, but she was gone too fast.       

I have just three questions for you, please.  What is spinal stenosis?  What is the relation of spinal stenosis to arthritis?  Why do both under-activity and over-activity bother my back? It makes sense to me that only one of them should make my pain worse, and the other should make it feel better, since they are doing opposite things to me.

I am looking forward to your reply.  Thank you for a different kind of website about back problems that is really informative and easy to understand.

E. H.

Greetings E. H.,

Your experience with your general practitioner is fairly common.  You were told what she wanted to tell you – “spinal stenosis, arthritis, live with it” – and she had to move on before you slowed her down with questions. What has happened to medical practice these days is terrible.  Time is money these days, after all.       

The explanation for spinal stenosis is not especially complex or difficult; actually it is rather straightforward and easy.  Spinal stenosis occurs when spinal arthritis gets to be bad enough that it causes compression of nerve tissue; you might say spinal stenosis is spinal arthritis that is bad enough to put pressure on the nearby nerve structures like the spinal cord and spinal nerve roots (where the nerves leave the spine to branch out to other parts of the body).   In these more advanced stages of arthritis extra pieces of bone (called spurs that look like stubby icicles) on the vertebrae puts pressure on the nerve tissue and this hurts and also creates numbness or weakness.  Additionally, advanced spinal arthritis can result in areas of swelling and distortion of the spinal discs that can be great enough to reduce the space that is available for the delicate nerve tissue in the area. The arthritic region of the spine becomes too crowded since there is now additional “stuff” in the spine (facet joint hypertrophy, thickened ligamentum flavum, boney projections form a part of the spinal vertebra called the lamina and disc bulging) that are not part of the original design of the spine, and this result creates physical pressure on the nerves.  When this happens the problem is called spinal stenosis.  

Another way of saying it, is that spinal stenosis is the medical name for an exaggerated or extensive degree of arthritis that has gone far enough that the arthritic changes press upon and cause symptoms from nearby spinal tissue like the spinal cord and the beginning point of major nerve branches.   

Spinal stenosis is a problem that is a lot more common than people realize because it occurs as a result of slow and gradually worsening spinal arthritis, and we all know how common it is to have arthritis in the neck and low back. This is why you have noticed your symptoms slowly worsening.  

Many people after the age of 40 have arthritis somewhere in the spine, and by the age of 60 you can say with great confidence that most or even all people have arthritis somewhere in the spine.  For this reason, spinal stenosis is the most common spinal problem to occur in people over 60 years of age that leads to back or neck surgery.    

An interesting thing about spinal stenosis is that some people are born with a built-in ability to tolerate the spinal changes that all of us eventually develop when arthritis starts.  Some people are in a lot of pain and have a lot of other symptoms with a small amount of spinal stenosis, while other people have hardly any problem in spite of have terrible arthritis and advance spinal stenosis in their spine.  The explanation for this difference is this:  Some people are born with big hands, or a small nose, or big feet.  Every part or area of the body can be smaller or larger than normal in some people.  We are all different and these size variations make us not only look different but are the reasons that some of us function differently.  This is the reason that some people are faster, stronger, healthier, taller, digest food, sing, make babies, hold their breath or avoid allergies better than other people.  In the case of spinal stenosis, some people are born with more space – or less space – in their spines where the spinal cord and spinal nerves pass through.  If you are lucky enough to be born with a large spinal canal you can tolerate a lot of arthritis developing in that area of the body and you will not be bothered much by spinal stenosis.  But, as I suspect in your case, if you are born with a smaller than average spinal canal you cannot tolerate much arthritis in the spine because the area is tight to begin with, and you will be bothered earlier and to a greater degree by your spinal stenosis.

The location and degree of spinal stenosis signs and symptoms – pain, numbness and weakness – depend on where in the spine the arthritis has developed and what particular nerve tissue is being pressed on by the arthritic changes. If the arthritis is in the lower back, as in your case, the symptoms will be felt not only in that part of the back where the arthritis is located, but also in a large or small area of the legs and feet.  If the arthritis is in the neck the symptoms will be felt not only in that part of the neck where the arthritis is located, but also in a large or small area of the arms and hands.

Because you have arthritis you will find, as with most people who have arthritis anywhere in their skeleton, that both under-activity and over-activity can aggravate painful joints.  The explanation is simple.   

Under-activity (like from lying in bed all night long, or sitting through a long movie or car ride) can aggravate your back (or anywhere you have arthritis like knees, hips, hands or elsewhere) because during the time that you are moving less than normal you allow tissue fluid to build up in and around arthritic joints. Activity and movement moves tissue fluid around the body, and once this activity and movement stop the fluid begins to accumulate. As  this joint fluid accumulates and applies pressure in the surrounding area, resulting in pain.  Once you start moving as when you get out of bed and slowly walk to the bathroom you once again start to naturally pump that extra fluid out of those swollen joints by normal movement, and the pain slowly begins to decrease by the time you get out of the bathroom. 

Over-activity (like from a long day of shopping, raking leaves or washing the car when you are not accustomed to this kind of work) temporarily abuses and stresses the muscles, tendons and ligaments around your arthritic joints.  The unusual activity makes the joints swell and this causes pain.  If you reduce or stop the unusual activity and give the body a chance to recover, the pain will eventually go away.

Just like the children’s bedtime story of “Goldilocks’ and the Three Bears,” the answer is “not too hard and not too soft” and “not to cold and not too hot,” or in your case, “not too much and not too little activity, but just right.”  Whatever your activity might be you must find that perfect balance of activity levels that are “just right” for you. This is found by trial-and-error that you eventually learn over time.  You must study what you do, how you do it, and how long you do it, to learn how your back and spinal stenosis will respond.  Once you eventually learn your safe limits you must follow them or pay the price – stay in bed too long (no activity) or carry too many heavy bags of groceries at one time (excess activity) and you will pay the price of back pain.  The way arthritis works, these two opposites extremes of over- and under-activity both result in joint swelling and pain. Your job is to keep your activity somewhere in the middle and avoid the extremes. I hope this explanation makes sense to you.  Let me know if you are still confused, please.          

Take care of your back.  You do not have settle for living the way you have been with constant and variable back pain.  With a little luck and some hard work there is a good chance you can actually feel better. Find a good chiropractor in your area and see if he/she can make small physical changes in the lower back over time that can results in huge reduction of your lower back and leg pain.  I made a successful career for 42 years by helping people just like you who were also told to learn to live with their spinal stenosis and back pain.  Just because your family doctor does not have the skills, knowledge or experience to deal with a non-drug and non-surgical treatment for your problem does not mean that it does not exist and that there are not other people who can help you.    

Thank you for educating our children during your professional career.  What a rewarding way to spend your life.  It must be wonderful to know you have touched so many lives in such a meaningful way. 

Please let me know how you are doing.   DL

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