Neurogenic claudication (NC), also known as pseudoclaudication, is the most common
symptom
Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition. A sign for example may be a higher or lower temperature than normal, raised or lowered blood pressure or an abnormality showin ...
of
lumbar spinal stenosis
Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the nerves and blood vessels at the level of the lumbar vertebrae. Spinal stenosis may also affect the cervical or thoracic region, in which case ...
(LSS) and describes intermittent leg pain from impingement of the nerves emanating from the
spinal cord
The spinal cord is a long, thin, tubular structure made up of nervous tissue, which extends from the medulla oblongata in the brainstem to the lumbar region of the vertebral column (backbone). The backbone encloses the central canal of the spi ...
.
''Neurogenic'' means that the problem originates within the
nervous system
In biology, the nervous system is the highly complex part of an animal that coordinates its actions and sensory information by transmitting signals to and from different parts of its body. The nervous system detects environmental changes th ...
. ''
Claudication
Claudication is a medical term usually referring to impairment in walking, or pain, discomfort, numbness, or tiredness in the legs that occurs during walking or standing and is relieved by rest. The perceived level of pain from claudication can be ...
'', from the Latin word for ''to limp'', refers to painful cramping or weakness in the legs. should therefore be distinguished from
vascular claudication, which stems from a
circulatory
The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...
problem rather than a neural one.
The term neurogenic claudication is sometimes used interchangeably with
spinal stenosis
Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in on ...
. However, the former is a clinical term, while the latter more specifically describes the condition of spinal narrowing.
is a medical condition most commonly caused by damage and
compression
Compression may refer to:
Physical science
*Compression (physics), size reduction due to forces
*Compression member, a structural element such as a column
*Compressibility, susceptibility to compression
* Gas compression
*Compression ratio, of a ...
to the lower spinal nerve roots.
It is a neurological and orthopedic condition that affects the motor nervous system of the body, specifically, the lower back, legs, hips and
glutes
The gluteus maximus is the main extensor muscle of the hip. It is the largest and outermost of the three gluteal muscles and makes up a large part of the shape and appearance of each side of the hips. It is the single largest muscle in the human ...
.
does not occur by itself, but rather, is associated with other underlying spinal or neurological conditions such as spinal stenosis or abnormalities and degenerative changes in the spine. The
International Association for the Study of Pain
The International Association for the Study of Pain (IASP) is an international learned society promoting research, education, and policies for the understanding, prevention, and treatment of pain. IASP was founded in 1973 under the leadership of ...
defines neurogenic claudication as, "pain from intermittent compression and/or
ischemia
Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems wi ...
of a single or multiple
nerve root A nerve root (Latin: ''radix nervi'') is the initial segment of a nerve leaving the central nervous system. Nerve roots can be classified as:
*cranial nerves, Cranial nerve roots: the initial or proximal segment of one of the twelve pairs of crania ...
s within an
intervertebral foramen
The intervertebral foramen (also called neural foramen, and often abbreviated as IV foramen or IVF) is a foramen between two spinal vertebrae. Cervical, thoracic, and lumbar vertebrae all have intervertebral foramina.
The foramina, or opening ...
or the central spinal canal.
This definition reflects the current hypotheses for the
pathophysiology
Pathophysiology ( physiopathology) – a convergence of pathology with physiology – is the study of the disordered physiological processes that cause, result from, or are otherwise associated with a disease or injury. Pathology is the ...
of , which is thought to be related to the compression of
lumbosacral
The vertebral column, also known as the backbone or spine, is part of the axial skeleton. The vertebral column is the defining characteristic of a vertebrate in which the notochord (a flexible rod of uniform composition) found in all chordates ...
nerve roots by surrounding structures, such as hypertrophied
facet joint
The facet joints (or zygapophysial joints, zygapophyseal, apophyseal, or Z-joints) are a set of synovial, plane joints between the articular processes of two adjacent vertebrae. There are two facet joints in each spinal motion segment and e ...
s or
ligamentum flavum
The ligamenta flava (singular, ''ligamentum flavum'', Latin for ''yellow ligament'') are a series of ligaments that connect the ventral parts of the laminae of adjacent vertebrae. They help to preserve upright posture, preventing hyperflexion, a ...
,
bone spur
An exostosis, also known as bone spur, is the formation of new bone on the surface of a bone. Exostoses can cause chronic pain ranging from mild to debilitatingly severe, depending on the shape, size, and location of the lesion. It is most commonl ...
s, scar tissue, and bulging or herniated discs.
The predominant symptoms of involve one or both legs and usually presents as some combination of tingling, cramping discomfort, pain, numbness, or weakness in the lower back, calves, glutes, and/or thighs and is precipitated by walking and prolonged standing. However, the symptoms vary depending on the severity and cause of the condition. Lighter symptoms include pain or heaviness in the legs, hips, glutes and lower back, post-exercise.
Mild to severe symptoms include prolonged constant pain, tiredness and discomfort in the lower half of the body.
In severe cases, impaired
motor function
Motor control is the regulation of movement in organisms that possess a nervous system. Motor control includes reflexes as well as directed movement.
To control movement, the nervous system must integrate multimodal sensory information (both ...
and ability in the lower body can be observed, and
bowel or bladder dysfunction may be present.
Classically, the symptoms and pain of are relieved by a change in position or
flexion
Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relative ...
of the waist.
Therefore, patients with have less disability in climbing steps, pushing carts, and cycling.
Treatment options for depends on the severity and cause of the condition, and may be nonsurgical or surgical. Nonsurgical interventions include drugs, physical therapy, and spinal injections.
Spinal decompression
Spinal decompression is the relief of pressure on the spinal cord or on one or more compressed nerve roots passing through or exiting the spinal column. Decompression of the spinal neural elements is a key component in treating spinal radiculopath ...
is the main surgical intervention and is the most common back surgery in patients over 65.
Other forms of surgical procedures include:
laminectomy
A laminectomy is a surgical procedure that removes a portion of a vertebra called the lamina, which is the roof of the spinal canal. It is a major spine operation with residual scar tissue and may result in postlaminectomy syndrome. Depending ...
,
microdiscectomy
A discectomy (also called open discectomy, if done through a 1/2 inch or larger skin opening) is the surgical removal of abnormal disc material that presses on a nerve root or the spinal cord. The procedure involves removing a portion of an in ...
and
laminoplasty
Laminoplasty is an orthopaedic/neurosurgical surgical procedure for treating spinal stenosis by relieving pressure on the spinal cord. The main purpose of this procedure is to provide relief to patients who may have symptoms of numbness, pain, or ...
.
Patients with minor symptoms are usually advised to undergo physical therapy, such as stretching and strengthening exercises. In patients with more severe symptoms, medications such as
pain relievers and
steroids are prescribed in conjunction with physical therapy. Surgical treatments are predominantly used to relieve pressure on the spinal nerve roots and are used when nonsurgical interventions are ineffective or show no effective progress.
Diagnosis of neurogenic claudication is based on typical clinical features, the physical exam, and findings of spinal stenosis on
Computer Tomography (CT) or
X-Ray
An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30&nb ...
imaging.
In addition to vascular claudication, diseases affecting the spine and
musculoskeletal system
The human musculoskeletal system (also known as the human locomotor system, and previously the activity system) is an organ system that gives humans the ability to move using their muscular and skeletal systems. The musculoskeletal system provid ...
should be considered in the
differential diagnosis
In healthcare, a differential diagnosis (abbreviated DDx) is a method of analysis of a patient's history and physical examination to arrive at the correct diagnosis. It involves distinguishing a particular disease or condition from others that p ...
.
Signs and Symptoms
Neurogenic claudication commonly describes pain, weakness, fatigue, tingling, weakness, heaviness and/or
paresthesia
Paresthesia is an abnormal sensation of the skin (tingling, pricking, chilling, burning, numbness) with no apparent physical cause. Paresthesia may be transient or chronic, and may have any of dozens of possible underlying causes. Paresthesias ar ...
s that extend into the lower extremities.
These symptoms may involve only one leg, but they usually involve both. Leg pain is usually more significant than back pain in individuals who have both.
is classically distinguished by symptoms improving or worsening with certain activities and manoeuvres. Pain may occur with walking, standing, and/or back extension. Sitting and bending or leaning forward tend to provide relief. Patients may also report that pain is worse while walking down stairs and improved while walking up stairs or using a bicycle or shopping cart.
A positive "shopping cart sign" refers to the worsening of pain with spinal
extension
Extension, extend or extended may refer to:
Mathematics
Logic or set theory
* Axiom of extensionality
* Extensible cardinal
* Extension (model theory)
* Extension (predicate logic), the set of tuples of values that satisfy the predicate
* E ...
and improvement with spinal
flexion
Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relative ...
.
Whilst these common symptoms are usually present in many patients with , rarer and more serious symptoms can occur in severe cases of . In extreme cases of constant discomfort, pain or numbness is experienced. This results in patients to have decreased mobility and function as excessive or constant movements cause pain. Exercise and prolonged walking often become difficult and are triggers of pain, tiredness, numbness and heaviness in the legs, lower back and hips.
Common tasks such as standing upright for an extended duration or picking up heavy objects may become increasingly difficult to perform.
In addition, patients with severe may experience difficulties sleeping as lying down on their back causes discomfort and pain.
In very extreme cases, bowel or bladder dysfunction can occur. However, this is a consequence of the underlying cause of rather than the condition itself. As most causes of involve increased pressure or damage to the nerves in the lower spine, damage and pressure on the nerves that extend to the bowel or bladder may occur, leading to bowel or bladder dysfunction.
On physical examination, patients with have normal peripheral pulses.
The
neurologic exam,
straight leg raise, and
femoral nerve stretch are typically normal. Abnormal signs may be revealed if the patient is observed walking until they exhibit . For example, a positive "stoop test" is observed if bending forward or stooping while walking relieves symptoms.
Occasionally, patients may have other signs such as
sensory loss Many types of sense loss occur due to a dysfunctional sensation process, whether it be ineffective receptors, nerve damage, or cerebral impairment. Unlike agnosia, these impairments are due to damages prior to the perception process.
Vision loss
...
or
gait
Gait is the pattern of movement of the limbs of animals, including humans, during locomotion over a solid substrate. Most animals use a variety of gaits, selecting gait based on speed, terrain, the need to maneuver, and energetic efficiency. Di ...
changes.
Causes
Neurogenic claudication is the fundamental clinical feature of
, which may be
congenital
A birth defect, also known as a congenital disorder, is an abnormal condition that is present at birth regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities can ...
or acquired. As a result of , the spinal canal in the lumbar spine narrows, causing damage and arthritic changes in the spine.
These changes, such as bulging disks, thickening of ligaments and overgrowth of bone spurs, lead to pressure and potentially damage to the spinal nerve roots.
The compression of the spinal nerve roots that control movements and sensations in the lower body subsequently causes the symptoms of .
The causes of are most commonly acquired and include degenerative changes such as
degenerative disc disease
Degenerative disc disease (DDD) is a medical condition typically brought on by the normal aging process in which there are anatomic changes and possibly a loss of function of one or more intervertebral discs of the spine. DDD can take place with ...
and spinal
osteoarthritis
Osteoarthritis (OA) is a type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone which affects 1 in 7 adults in the United States. It is believed to be the fourth leading cause of disability in the w ...
. may also be acquired from changes due to spinal surgery such as excess scar tissue or bone formation.
Other secondary causes include space-occupying
lesion
A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals.
Types
There is no designated classifi ...
s,
ankylosing spondylitis
Ankylosing spondylitis (AS) is a type of arthritis characterized by long-term inflammation of the joints of the spine typically where the spine joins the pelvis. Occasionally areas affected may include other joints such as the shoulders or hip ...
,
rheumatoid arthritis
Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and hands are involv ...
, and
Paget's disease. Less commonly, the cause of spinal stenosis may be present at birth as seen in
achondroplasia
Achondroplasia is a genetic disorder with an autosomal dominant pattern of inheritance whose primary feature is dwarfism. In those with the condition, the arms and legs are short, while the torso is typically of normal length. Those affected ha ...
,
spina bifida
Spina bifida (Latin for 'split spine'; SB) is a birth defect in which there is incomplete closing of the spine and the membranes around the spinal cord during early development in pregnancy. There are three main types: spina bifida occulta, me ...
, and certain
mucopolysaccharidoses
Mucopolysaccharidoses are a group of metabolic disorders caused by the absence or malfunctioning of lysosomal enzymes needed to break down molecules called glycosaminoglycans (GAGs). These long chains of sugar carbohydrates occur within the ce ...
.
In addition to spinal stenosis, other lower back conditions such as
spondylosis
Spondylosis is the degeneration of the vertebral column from any cause. In the more narrow sense it refers to spinal osteoarthritis, the age-related wear and tear of the spinal column, which is the most common cause of spondylosis. The degenera ...
,
tumors
A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
, infections and
herniated or ruptured discs can cause . These conditions contribute to the potential narrowing of the spinal cord, increasing pressure and inducing damage on the spinal nerve roots, thus, causing paing, tingling or weakness in the lower body.
Risk factors for include:
* Age
* Degenerative changes of the spine
* Obesity
* Family history of spinal stenosis
* Tobacco use
* Occupation involving repetitive mechanical stress on the spine
*Past deformities or injuries to the spine
Diagnosis and Evaluation
![SPINAL_STENOSIS](https://upload.wikimedia.org/wikipedia/commons/c/cd/SPINAL_STENOSIS.JPG)
Neurogenic claudication is one subtype of the clinical syndrome of
lumbar spinal stenosis
Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the nerves and blood vessels at the level of the lumbar vertebrae. Spinal stenosis may also affect the cervical or thoracic region, in which case ...
(LSS).
No
gold standard
A gold standard is a monetary system in which the standard economic unit of account is based on a fixed quantity of gold. The gold standard was the basis for the international monetary system from the 1870s to the early 1920s, and from the la ...
diagnostic criteria currently exist, but evaluation and diagnosis is generally based on the patient history, physical exam, and
medical imaging
Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to rev ...
.
The accuracy of a diagnosis of increases with each additional suggestive clinical finding. Therefore, a combination of signs and symptoms may be more helpful in diagnosing NC than any single feature of the history or physical exam. These signs and symptoms include pain triggered by standing, pain relieved by sitting, symptoms above the knees, and a positive "shopping cart sign".
Specific questions that may aid diagnosis include:
* "Does the patient have leg or buttock pain while walking?"
* "Does the patient flex forward to relieve symptoms?"
* "Does patient feel relief when using a shopping cart or bicycle?"
* "Does the patient have motor or sensory disturbance while walking?"
* "Are the pulses in the foot present and symmetric?"
* "Does the patient have lower extremity weakness?"
* "Does the patient have low back pain?"
The physical exam may include observation, evaluation of
pulse
In medicine, a pulse represents the tactile arterial palpation of the cardiac cycle (heartbeat) by trained fingertips. The pulse may be palpated in any place that allows an artery to be compressed near the surface of the body, such as at the nec ...
s in the foot, lumbar spine
range of motion
Range of motion (or ROM), is the linear or angular distance that a moving object may normally travel while properly attached to another. It is also called range of travel (or ROT), particularly when talking about mechanical devices and in mechanic ...
, and components of a
neurological exam
A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired. This typically includes a physical examination and a review of the patient's medical hist ...
.
Helpful imaging may include x-rays, CT,
CT myelogram, and
magnetic resonance imaging (MRI), but MRI is preferred.
Abnormal MRI findings may be present in two-thirds of asymptomatic individuals, and imaging findings of
spinal stenosis
Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in on ...
do not correlate well with symptom severity. Therefore, imaging findings must be considered in the context of a patient's history and physical exam when seeking a diagnosis.
The evidence for using objective imaging findings to define has been conflicting.
Differential diagnosis
Neurogenic claudication must be differentiated from other causes of leg pain, which may be present in a number of conditions involving the spine and
musculoskeletal system
The human musculoskeletal system (also known as the human locomotor system, and previously the activity system) is an organ system that gives humans the ability to move using their muscular and skeletal systems. The musculoskeletal system provid ...
. The differential diagnosis for includes:
*
Vascular claudication
*
Lumbosacral
The vertebral column, also known as the backbone or spine, is part of the axial skeleton. The vertebral column is the defining characteristic of a vertebrate in which the notochord (a flexible rod of uniform composition) found in all chordates ...
radicular pain
Radicular pain, or radiculitis, is pain "radiated" along the dermatome (sensory distribution) of a nerve due to inflammation or other irritation of the nerve root (radiculopathy) at its connection to the spinal column. A common form of radiculit ...
secondary to lumbar
disc herniation
Spinal disc herniation is an injury to the cushioning and connective tissue between vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical ...
*
Referred pain
Referred pain, also called reflective pain, is pain perceived at a location other than the site of the painful stimulus. An example is the case of angina pectoris brought on by a myocardial infarction (heart attack), where pain is often felt in ...
from spinal structures, hip or sacroiliac joint,
myofascia, or
viscera
In biology, an organ is a collection of tissues joined in a structural unit to serve a common function. In the hierarchy of life, an organ lies between tissue and an organ system. Tissues are formed from same type cells to act together in a ...
*
Trochanteric bursitis
*
Piriformis syndrome
Piriformis syndrome is a condition which is believed to result from compression of the sciatic nerve by the piriformis muscle. Symptoms may include pain and numbness in the buttocks and down the leg. Often symptoms are worsened with sitting or ru ...
*
Muscle pain
Myalgia (also called muscle pain and muscle ache in layman's terms) is the medical term for muscle pain. Myalgia is a symptom of many diseases. The most common cause of acute myalgia is the overuse of a muscle or group of muscles; another like ...
*
Vertebral compression fracture
A compression fracture is a collapse of a vertebra. It may be due to trauma or due to a weakening of the vertebra (compare with burst fracture). This weakening is seen in patients with osteoporosis or osteogenesis imperfecta, lytic lesions from ...
*
Compartment syndrome
Compartment syndrome is a condition in which increased pressure within one of the body's anatomical compartments results in insufficient blood supply to tissue within that space. There are two main types: acute and chronic. Compartments of the ...
*
Peripheral neuropathy
Peripheral neuropathy, often shortened to neuropathy, is a general term describing disease affecting the peripheral nerves, meaning nerves beyond the brain and spinal cord. Damage to peripheral nerves may impair sensation, movement, gland, or or ...
Neurogenic vs vascular claudication
Both neurogenic claudication and vascular claudication manifest as leg pain with walking, but several key features help distinguish between these conditions.
In contrast to , vascular claudication does not vary with changes in posture.
Patients with vascular claudication may experience relief with standing, which may provoke symptoms in . The walking distance necessary to produce pain in vascular claudication is more consistent than in neurogenic claudication.
Pathophysiology
Degenerative disc disease
Degenerative disc disease (DDD) is a medical condition typically brought on by the normal aging process in which there are anatomic changes and possibly a loss of function of one or more intervertebral discs of the spine. DDD can take place with ...
(DDD) may trigger the
pathogenesis
Pathogenesis is the process by which a disease or disorder develops. It can include factors which contribute not only to the onset of the disease or disorder, but also to its progression and maintenance. The word comes from Greek πάθος ''pat ...
of neurogenic claudication. When
intervertebral disc
An intervertebral disc (or intervertebral fibrocartilage) lies between adjacent vertebrae in the vertebral column. Each disc forms a fibrocartilaginous joint (a symphysis), to allow slight movement of the vertebrae, to act as a ligament to hold t ...
s degenerate and change shape in , the normal movements of the spine are interrupted. This results in spinal instability and more degenerative changes in spinal structures including
facet joint
The facet joints (or zygapophysial joints, zygapophyseal, apophyseal, or Z-joints) are a set of synovial, plane joints between the articular processes of two adjacent vertebrae. There are two facet joints in each spinal motion segment and e ...
s,
ligamentum flavum
The ligamenta flava (singular, ''ligamentum flavum'', Latin for ''yellow ligament'') are a series of ligaments that connect the ventral parts of the laminae of adjacent vertebrae. They help to preserve upright posture, preventing hyperflexion, a ...
, and intervertebral discs. These pathologic changes result in narrowing of the
vertebral canal
The spinal canal (or vertebral canal or spinal cavity) is the canal that contains the spinal cord within the vertebral column. The spinal canal is formed by the vertebrae through which the spinal cord passes. It is a process of the dorsal body c ...
and
neurovascular compression at the
lumbosacral
The vertebral column, also known as the backbone or spine, is part of the axial skeleton. The vertebral column is the defining characteristic of a vertebrate in which the notochord (a flexible rod of uniform composition) found in all chordates ...
nerve root A nerve root (Latin: ''radix nervi'') is the initial segment of a nerve leaving the central nervous system. Nerve roots can be classified as:
*cranial nerves, Cranial nerve roots: the initial or proximal segment of one of the twelve pairs of crania ...
s.
The compression of these spinal nerve roots that control sensation and movement in the lower body results in the tingling, pain and weakness patients often experience. However, because the severity of symptoms does not correlate well with the degree of stenosis and nerve root compression, a clear understanding of the specific pathogenesis remains challenging.
It is currently unknown which exact cellular mechanisms within the body causes the pain of as a response to the compression of spinal nerves. The two main proposed mechanisms agree that neurovascular compression plays a role. The
ischemic
Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems w ...
theory proposes that poor blood supply to the spinal nerve roots results in . In contrast, the venous stasis theory proposes that a combination of low oxygen levels and
metabolite
In biochemistry, a metabolite is an intermediate or end product of metabolism.
The term is usually used for small molecules. Metabolites have various functions, including fuel, structure, signaling, stimulatory and inhibitory effects on enzymes, c ...
buildup are responsible due to venous backup at the
cauda equina
The cauda equina () is a bundle of spinal nerves and spinal nerve rootlets, consisting of the second through fifth lumbar nerve pairs, the first through fifth sacral nerve pairs, and the coccygeal nerve, all of which arise from the lumbar enlarg ...
.
Pain with walking may be partially explained by the corresponding increase in nerve root oxygen requirements.
These changes in blood flow may occur during back
extension
Extension, extend or extended may refer to:
Mathematics
Logic or set theory
* Axiom of extensionality
* Extensible cardinal
* Extension (model theory)
* Extension (predicate logic), the set of tuples of values that satisfy the predicate
* E ...
when shifts in vertebral structures and
ligament
A ligament is the fibrous connective tissue that connects bones to other bones. It is also known as ''articular ligament'', ''articular larua'', ''fibrous ligament'', or ''true ligament''. Other ligaments in the body include the:
* Peritoneal li ...
s narrow the spinal canal and compress the neurovasculature.
Compared to a neutral position, extended spines exhibit 15% less cross-sectional area of the
intervertebral foramina
The intervertebral foramen (also called neural foramen, and often abbreviated as IV foramen or IVF) is a :wikt:foramen, foramen between two spinal vertebrae. Cervical vertebrae, Cervical, thoracic vertebrae, thoracic, and lumbar vertebrae all ...
, and nerve root compression is present one-third of the time.
These dynamic changes in the shape of the spinal canal are more pronounced in individuals with
spinal stenosis
Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in on ...
. The amount of narrowing may be 67% in compared to 9% in healthy spines.
Treatment
![Blausen 0354 EpiduralSteroidInjection](https://upload.wikimedia.org/wikipedia/commons/b/b9/Blausen_0354_EpiduralSteroidInjection.png)
Treatment options for aim to cure the underlying cause of the condition, such as
lumbar spinal stenosis
Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the nerves and blood vessels at the level of the lumbar vertebrae. Spinal stenosis may also affect the cervical or thoracic region, in which case ...
(LSS) or other degenerative spinal diseases. Decreased walking and lower body motor ability due to is the primary disabling feature of LSS.
Constant discomfort and pain in the lower extremities and an inability to sleep lying down are also disabling features of that affect a patient's quality of life. Therefore, the target of most treatments is to solve these complications.
Currently, several treatment options are available to patients, and they can be grouped broadly into nonsurgical and surgical options.
Nonsurgical treatments include medications, physical therapy, and spinal injections. Medication options for neurogenic claudication have included
non-steroidal anti-inflammatory drugs (NSAIDs),
prostaglandin-based drugs,
gabapentin
Gabapentin, sold under the brand name Neurontin among others, is an anticonvulsant medication primarily used to treat partial seizures and neuropathic pain. It is a first-line medication for the treatment of neuropathic pain caused by diabet ...
, and
methylcobalamin
Methylcobalamin (mecobalamin, MeCbl, or MeB) is a cobalamin, a form of vitamin B. It differs from cyanocobalamin in that the cyano group at the cobalt is replaced with a methyl group. Methylcobalamin features an octahedral cobalt(III) centre and ...
. However, the quality of evidence supporting their use is not high enough for specific recommendations. Physical therapy is commonly prescribed to patients, but the quality of evidence supporting its use for neurogenic claudication is also low.
One quarter of all
epidural injections are administered to treat symptoms of .
Preparations may contain
lidocaine
Lidocaine, also known as lignocaine and sold under the brand name Xylocaine among others, is a local anesthetic of the amino amide type. It is also used to treat ventricular tachycardia. When used for local anaesthesia or in nerve blocks, lidoca ...
and/or
steroids. They may be considered for short-term pain relief or to delay surgery, but their benefit is considered small.
Physical Therapy
Patients that experience light to mild symptoms are commonly treated through physical therapy, which involves stretching and strengthening the lower back,
abdominal
The abdomen (colloquially called the belly, tummy, midriff, tucky or stomach) is the part of the body between the thorax (chest) and pelvis, in humans and in other vertebrates. The abdomen is the front part of the abdominal segment of the torso ...
(core) and leg muscles.
Common stretches used include the
knee to chest stretch, posterior pelvic tilt, neural stretching of the legs, hip-flexor stretch and lower trunk rotation.
In conjunction with these stretches, various strengthening exercises are often implemented, targeting the core, lower back and hip muscles. Common exercises include bridges, bird to dog, tabletop leg press, clamshell and knees to chest.
[ “Lumbar/Core Strength and Stability Exercises”, Princeton University Athletic Medicine, accessed 2 October 2020, https://uhs.princeton.edu/sites/uhs/files/documents/Lumbar.pdf.] Depending on the age, mobility and physical health of patients, a combination of easier and more difficult exercises should be prescribed to suit the patient's needs. More difficult exercises may include the incorporation of
resistance training
Strength training or resistance training involves the performance of physical exercises that are designed to improve strength and endurance. It is often associated with the lifting of weights. It can also incorporate a variety of training te ...
(weights),
gym equipment and more explosive movements. Other exercises such as cycling (stationary), swimming and
water-based activities have also been found to strengthen and improve overall stability and strength in the core, lower back and hips.
Ultimately, the aim of physical therapy is to loosen and relax the tight muscles and
ligament
A ligament is the fibrous connective tissue that connects bones to other bones. It is also known as ''articular ligament'', ''articular larua'', ''fibrous ligament'', or ''true ligament''. Other ligaments in the body include the:
* Peritoneal li ...
s that contribute to the symptoms, and to strengthen those muscles to prevent further reocurrences of the condition. However, studies have found conflicting conclusions in regards to the effectiveness of physical therapy as a treatment option for patients.
Thus, the low quality of evidence supporting its use has prompted further research into physical therapy as a treatment option for to be necessary.
Stretching Exercises
Common stretching exercises used to relieve pain and treat include:
* Knee to chest stretch - Laying down on the back, bring one leg up and pull it towards the chest and hold for 30–45 seconds.
* Posterior pelvic tilt (bridges) - Laying on the back, bend both legs and place your feet on the floor. Raise stomach from the ground, lifting the back and
pelvis
The pelvis (plural pelves or pelvises) is the lower part of the trunk, between the abdomen and the thighs (sometimes also called pelvic region), together with its embedded skeleton (sometimes also called bony pelvis, or pelvic skeleton).
The ...
, until the back is straight. Hold for 5–10 seconds and relax.
* Neural Stretching of the legs - Laying on the back, bring one leg up with a
stretching band until a stretch is felt in the legs. Ensure your legs are straight. Once the stretch is felt, hold for 30–45 seconds and relax.
*
Hip-flexor stretch - To stretch the right hip-flexor, bring the left leg forward, and kneel on the right knee. Push the pelvis forward (lean forward), whilst keeping the upper body straight. Hold the position for 30–45 seconds and relax. To stretch the left hip-flexor, bring swap the positions of the legs.
* Lower trunk rotation - Laying down on the back, bring both knees towards your chest whilst keeping the back flat on the floor. Rotate the bent legs from the left to right side and vice versa whilst keeping back flat on the ground.
Strengthening Exercises
Common strengthening exercises used to treat and prevent future reocurrences of include:
* Posterior pelvic tilt (bridges) - Laying on the back, bend both legs and place your feet on the floor. Raise stomach from the ground, lifting the back and pelvis, until the back is straight. Hold for 5–10 seconds and relax.
* Quadruped opposite arm/leg (bird to dog) - On all fours (knees on ground and arms against floor supporting upper body) straighten one knee whilst straightening the opposite side arm and hold for 3 seconds and repeat for the other arm/leg pair.
* Tabletop leg press press - Laying on the back, bring both knees towards the chest and then straighten both legs (such that legs are hanging in the air), whilst keeping the back flat on the ground.
* Clamshell - Whilst laying on the side with knees bent inwards, bring the top knee up (whilst keeping leg bent) and hold for 3 seconds. To exercise the opposite leg, lay on the opposite side and repeat.
* Abdominal draw-in (knee to chest ) - Laying flat on the back, bend both legs and bring knees towards the chest without lifting the back from the ground and then straighten legs again. For a more difficult version of the exercise, keep one leg bent and feet on the ground and bring the other leg towards the chest.
Medications
Medications such as NSAIDs, prostaglandin-based drugs, gabapentin, methylcobalamin and epidural steroid injections are often used in conjunction with physical therapy to treat patients with mild or moderate symptoms of .
The main goal of these medications is to reduce pain and provide temporary relief for patients. NSAIDs and prostaglandin-based medications control
inflammation
Inflammation (from la, wikt:en:inflammatio#Latin, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or Irritation, irritants, and is a protective response involving im ...
at sites of nerve damage or pressure by inhibiting
cyclooxygenase
Cyclooxygenase (COX), officially known as prostaglandin-endoperoxide synthase (PTGS), is an enzyme (specifically, a family of isozymes, ) that is responsible for formation of prostanoids, including thromboxane and prostaglandins such as pr ...
activity, and reducing the production of
prostaglandin
The prostaglandins (PG) are a group of physiologically active lipid compounds called eicosanoids having diverse hormone-like effects in animals. Prostaglandins have been found in almost every tissue in humans and other animals. They are derive ...
s, a key contributor of inflammation. By reducing inflammation, less pressure is put on the nerve roots, decreasing pain, and providing relief for patients. Gabapentin aims to reduce pain and provide relief by altering the normal functioning of
neurotransmitter
A neurotransmitter is a signaling molecule secreted by a neuron to affect another cell across a synapse. The cell receiving the signal, any main body part or target cell, may be another neuron, but could also be a gland or muscle cell.
Neuro ...
s that induce a sensation of pain and discomfort.
However, the exact mechanism of Gabapentin’s functioning in the body is not completely understood and current knowledge is based on experimental studies that target the nervous system. Methylcobalamin is another medication that targets the nervous system to reduce pain and provide patients with temporary pain-relief. The drug produces
myelin
Myelin is a lipid-rich material that surrounds nerve cell axons (the nervous system's "wires") to insulate them and increase the rate at which electrical impulses (called action potentials) are passed along the axon. The myelinated axon can be ...
to cover and protect nerves from damage, preventing pain induced from damaged nerve roots, as described in some cases of .
Epidural steroid injections are the main epidural injections prescribed to treat . They inhibit the inflammatory cascade signalling to reduce inflammation at sites of spinal nerve damage or pressure. Consequently, they reduce pain and provide relief to individuals with . Whilst the use of medications is common among patients that experience frequent or constant pain, their effectiveness has yielded mixed results in studies.
Further research into their viability as a medication for is necessary to allow doctors to provide better care and treatment options for patients.
Surgical Interventions
Depending on the cause and severity of the condition, surgical options for vary. Symptoms of , including , are the most common reason patients 65 and older undergo spinal surgery. Surgery is generally reserved for patients whose symptoms do not improve with nonsurgical treatments, and the main objective of surgery is to relieve pressure on the spinal nerve roots and recover normal mobility and quality of life.
Lower Spinal Decompression is considered the mainstay of surgical treatment.
In this procedure, the
ligamentum flavum
The ligamenta flava (singular, ''ligamentum flavum'', Latin for ''yellow ligament'') are a series of ligaments that connect the ventral parts of the laminae of adjacent vertebrae. They help to preserve upright posture, preventing hyperflexion, a ...
is first removed, followed by the removal of the
superior facet osteophyte in the spinal canal, and then the decompression of the spinal nerve root.
Another surgical method of decompression is the Fenestration method, which involves creating a small window in the spinal canal and then decompressing the nerves.
Alternative surgical options include the use of
interspinous process spacers, minimally invasive lumbar decompression (MILD) procedure, laminectomy, microdiscectomy and placement of a
spinal cord stimulator
A spinal cord stimulator (SCS) or dorsal column stimulator (DCS) is a type of implantable neuromodulation device (sometimes called a "pain pacemaker") that is used to send electrical signals to select areas of the spinal cord (dorsal columns) for ...
. The MILD procedure aims to relieve spinal cord compression by
percutaneous {{More citations needed, date=January 2021
In surgery, a percutaneous procedurei.e. Granger et al., 2012 is any medical procedure or method where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using ...
removal of portions of the ligamentum flavum and
lamina
Lamina may refer to:
Science and technology
* Planar lamina, a two-dimensional planar closed surface with mass and density, in mathematics
* Laminar flow, (or streamline flow) occurs when a fluid flows in parallel layers, with no disruption betwee ...
.
Laminectomy also involves partial or complete removal and sacrifice of the lamina, but in addition,
facets
A facet is a flat surface of a geometric shape, e.g., of a cut gemstone.
Facet may also refer to:
Arts, entertainment, and media
* ''Facets'' (album), an album by Jim Croce
* ''Facets'', a 1980 album by jazz pianist Monty Alexander and his tri ...
in one or more segments of the spinal cord are usually sacrificed as well.
Microdiscectomy is another surgical alternative which uses small incisions, and a miniature camera for viewing, to enter the spinal cord and release pressure on the nerve roots.
Laminoplasty and
spinal fusion surgeries are other alternative surgical procedures that can be performed. However, they are relatively new methods which still require more research and advancements in order for it to be safely performed with minimal risks.
The use of interspinous spacers is associated with increased costs and rates of reoperation, while evidence comparing effectiveness of the MILD procedure to spinal decompression is insufficient.
The effectiveness of laminectomy, microdiscectomy, laminoplasty and spinal fusion surgeries as an alternative to spinal decompression has also been heavily debated, with studies showing conflicting results. While studies show that surgery improves walking ability, minimizes constant pain and improves quality of life, comparisons between the efficacy of surgical and nonsurgical treatment of have yielded mixed results.
Prognosis
Individuals with may be asymptomatic for many years before developing symptoms such as .
However, most patients that present with often seek medical help and treatment due to the condition causing pain and affecting their quality of life.
Consequently, the prognosis of untreated and has not been well reported and is unknown. Based on the physiological cause of , it is projected that the symptoms of NC can worsen over time, with roughly one-third of patients showing signs of improvement with time.
For patients that develop worse symptoms over time, severe consequences can occur. Over time, untreated and can lead to chronic pain and muscle weakness.
In severe cases,
caudea equina syndrome can develop, disrupting sensory and motor function in the lower body and bladder.
Consequently,
disability
Disability is the experience of any condition that makes it more difficult for a person to do certain activities or have equitable access within a given society. Disabilities may be Cognitive disability, cognitive, Developmental disability, dev ...
in the lower extremities may develop over time in individuals with untreated and .
Whilst some patients may recover and improve their condition over time, without the help of medical treatment or interventions, this is only prevalent in individuals with light or very mild symptoms of . In most scenarios, the prognosis of can lead to potential disability, muscle weakness or constant pain in the lower body.
Epidemiology
is a
noncommunicable condition and thus, does not pose any community risks in terms of infectiousness. Rather, NC is associated with increasing age and mostly affects individuals over the age of 60. Age is a major contributing factor to the onset of due to spinal degenerative changes that are brought by aging and the weakening of bones and ligaments in the lumbar area.
is also more likely present in individuals with other spinal
comorbidities
In medicine, comorbidity - from Latin morbus ("sickness"), co ("together"), -ity (as if - several sicknesses together) - is the presence of one or more additional conditions often co-occurring (that is, concomitant or concurrent) with a primary ...
.
A history of spinal injuries or deformities is also a contributing factor to the increased likelihood of the onset of . Other factors such as exercise and
bone density
Bone density, or bone mineral density, is the amount of bone mineral in bone tissue. The concept is of mass of mineral per volume of bone (relating to density in the physics sense), although clinically it is measured by proxy according to optica ...
have also been found to be associated with . Increased exercise activity in the form of strength training has also been found to increase bone density, muscle strength and thus, decrease the likelihood of as aging occurs.
One of the main causes of is the onset of
in elderly patients. Relative to their respective age groups, 16% of individuals aged less than 40 experience
whilst 38.8% of individuals aged over 60 experience
.
Between the ages of 60 and 69, the prevalence of
relative to this population group is 47.2%.
Data obtained from medical practitioners suggest that the incidence of
is 5 cases per 100 000.
This increased prevalence of
as a consequence of aging, heavily contributes to the epidemiology and acquiring of . Among individuals with spinal stenosis, is present in greater than 90% of patients and present in almost half of patients that present with low back pain, with over 200,000 people being affected in the United States.
The prevalence of and spinal stenosis in elderly men is also evident, with studies finding that roughly 1 in 10 elderly men experience leg pain in combination with low back pain (symptoms of ) and this incidence rate is also doubled in retirement communities.
As the global
life expectancy
Life expectancy is a statistical measure of the average time an organism is expected to live, based on the year of its birth, current age, and other demographic factors like sex. The most commonly used measure is life expectancy at birth ...
increases, the impact of spinal disease symptoms such as is likely to increase.
Current research
Current treatment options for are not diverse and lack extensive and detailed research to support their effectiveness, resulting in patients having to choose from a small pool of treatment options, some of which may not be effective.
This lack of evidence to support the effectiveness of treatment options for is especially prevalent in nonsurgical treatments, such as physical therapy and medications.
Among surgical interventions for , current research into improving methods of surgery to minimize post-surgery complication and to improve quality of life have also been of concern.
Physical Therapy
Studies have found that physical therapies such as stretches and strengthening exercises have yielded mixed results in terms of its effectiveness in treating . Reports have shown that physical therapy does aid in treating in patients with light to mild symptoms,
whilst others have shown the contrary.
It has also been found that patients with more severe symptoms of find less long-term success in treating the condition through physical therapy. Thus, doctors have concluded that further research into the effectiveness of physical therapy as a treatment option for is necessary. With more detailed research, doctors will then be able to suggest the best treatment options for their patients, to help them recover from the condition.
Medications
Medications commonly prescribed to patients are generally steroids, pain relievers or anti-inflammatories that aim to reduce pain and provide pain-relief. However, studies have found that these medications only provide temporary relief for patients, and do not provide a permanent solution, with symptoms often reoccurring several months following the disuse of medications.
Hence, doctors have reported that it is important to research possible medications that can provide long term relief or a permanent solution for patients.
Currently,
Tanezumab
Tanezumab (INN, codenamed RN624) is a monoclonal antibody against nerve growth factor as a treatment for pain via a novel mechanisms different from conventional pain-killer drugs. Tanezumab was discovered and developed by Rinat Neuroscience and ...
, a monoclonal
antibody
An antibody (Ab), also known as an immunoglobulin (Ig), is a large, Y-shaped protein used by the immune system to identify and neutralize foreign objects such as pathogenic bacteria and viruses. The antibody recognizes a unique molecule of the ...
that suppresses nerve activity, has been in development for use in patents with back pain, such as .
The drug functions by selectively targeting and inhibiting
Nerve Growth Factors
Nerve growth factor (NGF) is a neurotrophic factor and neuropeptide primarily involved in the regulation of growth, maintenance, proliferation, and survival of certain target neurons. It is perhaps the prototypical growth factor, in that it was on ...
(NGF) in the body. By blocking NGF in the body, Tanezumab aims to prevent pain signals produced in the body from reaching the brain, thus, reducing pain and providing relief for patients. Whilst positive results have been shown in several studies, further research is still necessary for its safe and effective use.
Surgical Procedures
Whilst surgical procedures exist to treat , current methods involve partial or complete removal of the lamina and segments of the spinal cord, leading to poor stability.
Hence, orthopedic surgeons and neurosurgeons have been developing and researching other surgical techniques that reduce this side effect. Haruo Tsuji, in 1990, introduced a procedure known as
Laminoplastie En-block expansive Laminoplasty as an alternative to laminectomy and since then, variations and further developments have been made on that procedure, with developments still being currently. This procedure involves a reconstruction of the vertebral lamina such that it creates a hinge on one side, allowing for decreased pressure on spinal nerve roots. Advances in this procedure involve finding ways to access the spinal cord with minimal incisions and to more effectively create hinges that replicate normal functioning of the spine. In addition to Laminoplasty, spinal fusion surgeries have also been of growing interest to orthopedic surgeons and neurosurgeons. This process involves connecting two vertebrae of the bones together to reduce pain or correct any spinal deformities. As such this form of surgery has the potential to treat the underlying cause of . However, these types of surgeries are difficult and dangerous to perform due to the sensitive nature of the spinal area. Additionally, these techniques are relatively new and thus, more research and advances in its methodology is still required for it to be considered a reliable and viable option to treat patients.
See also
*
Lumbar spinal stenosis
Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the nerves and blood vessels at the level of the lumbar vertebrae. Spinal stenosis may also affect the cervical or thoracic region, in which case ...
*
Spondylosis
Spondylosis is the degeneration of the vertebral column from any cause. In the more narrow sense it refers to spinal osteoarthritis, the age-related wear and tear of the spinal column, which is the most common cause of spondylosis. The degenera ...
*
Spinal disease
Spinal disease refers to a condition impairing the backbone. These include various diseases of the back or spine ("dorso-"), such as kyphosis. Dorsalgia refers to back pain. Some other spinal diseases include spinal muscular atrophy, ankylosing ...
*
Lumbar disc disease
*
Claudication
Claudication is a medical term usually referring to impairment in walking, or pain, discomfort, numbness, or tiredness in the legs that occurs during walking or standing and is relieved by rest. The perceived level of pain from claudication can be ...
*
Orthopedic surgery
Orthopedic surgery or orthopedics ( alternatively spelt orthopaedics), is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...
*
Neurosurgery
Neurosurgery or neurological surgery, known in common parlance as brain surgery, is the medical specialty concerned with the surgical treatment of disorders which affect any portion of the nervous system including the brain, spinal cord and peri ...
References
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Nerve, nerve root and plexus disorders