Neurogenic Claudication
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Neurogenic claudication (NC), also known as pseudoclaudication, is the most common
symptom Signs and symptoms are diagnostic indications of an illness, injury, or condition. Signs are objective and externally observable; symptoms are a person's reported subjective experiences. A sign for example may be a higher or lower temperature ...
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 that extends from the medulla oblongata in the lower brainstem to the lumbar region of the vertebral column (backbone) of vertebrate animals. The center of the spinal c ...
. ''Neurogenic'' means that the problem originates within the
nervous system In biology, the nervous system is the complex system, highly complex part of an animal that coordinates its behavior, actions and sense, sensory information by transmitting action potential, signals to and from different parts of its body. 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 ...
'', , refers to painful cramping or weakness in the legs. should therefore be distinguished from vascular claudication, which stems from a
circulatory In vertebrates, the circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the body. It includes the cardiovascular system, or vascular system, that consists of the heart an ...
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 ...
. 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 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 in humans. 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 ...
. 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 ...
of a single or multiple
nerve root A nerve root () is the initial segment of a nerve leaving the central nervous system. Nerve roots can be classified as: * Cranial nerve roots: the initial or proximal segment of one of the twelve pairs of cranial nerves leaving the central nervous s ...
s within an
intervertebral foramen The intervertebral foramen (also neural foramen) (often abbreviated as IV foramen or IVF) is an opening between (the intervertebral notches of) two pedicles (one above and one below) of adjacent vertebra in the articulated spine. Each interve ...
or the central spinal canal". This definition reflects the current hypotheses for the
pathophysiology Pathophysiology (or physiopathology) is a branch of study, at the intersection of pathology and physiology, concerning disordered physiological processes that cause, result from, or are otherwise associated with a disease or injury. Pathology is ...
of , which is thought to be related to the compression of
lumbosacral Each vertebra (: vertebrae) is an irregular bone with a complex structure composed of bone and some hyaline cartilage, that make up the vertebral column or spine, of vertebrates. The proportions of the vertebrae differ according to their spinal ...
nerve roots by surrounding structures, such as hypertrophied
facet joint The facet joints (also zygapophysial joints, zygapophyseal, apophyseal, or Z-joints) are a set of synovial joint, synovial, plane joints between the articular processes of two adjacent vertebrae. There are two facet joints in each functional s ...
s or
ligamentum flavum The ligamenta flava (: 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, and ensuring ...
,
bone spur An exostosis, also known as a osteochondroma, is a benign chondrogenic lesions derived from aberrant cartilage from the perichondral ring. Exostoses can cause chronic pain ranging from mild to moderate, but rarely severe, depending on the shape, s ...
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 A cramp is a sudden, involuntary, painful skeletal muscle contraction or overshortening associated with electrical activity. While generally temporary and non-damaging, they can cause significant pain and a paralysis-like immobility of the affe ...
discomfort, pain,
numbness Hypoesthesia or numbness is a common side effect of various medical conditions that manifests as a reduced sense of touch or sensation, or a partial loss of sensitivity to Sensory receptor, sensory stimuli. In everyday speech this is generally r ...
, or weakness in the lower back, calves, glutes, and 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 movements in organisms that possess a nervous system. Motor control includes conscious voluntary movements, subconscious muscle memory and involuntary reflexes, as well as instinctual taxes. To control move ...
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 terminology, anatomical terms. Motion includes movement of Organ (anatomy), organs, joints, Limb (anatomy), limbs, and specific sections of the body. The terminology used de ...
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 radiculopat ...
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 of the vertebral arch, lamina, which is the roof of the spinal canal. It is a major spine operation with residual scar tissue and may result in postla ...
,
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 int ...
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 w ...
. 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 A steroid is an organic compound with four fused rings (designated A, B, C, and D) arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter mem ...
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 (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...
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 system, muscular and Human skeleton, skeletal systems. ...
should be considered in the
differential diagnosis In healthcare, a differential diagnosis (DDx) is a method of analysis that distinguishes a particular disease or condition from others that present with similar clinical features. Differential diagnostic procedures are used by clinicians to di ...
.


Signs and symptoms

Neurogenic claudication commonly describes pain, weakness, fatigue, tingling, heaviness and
paresthesia Paresthesia is a sensation of the skin that may feel like numbness (''hypoesthesia''), tingling, pricking, chilling, or burning. It can be temporary or Chronic condition, chronic and has many possible underlying causes. Paresthesia is usually p ...
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 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 (proof theory) * Extension (predicate logic), the set of tuples of values that ...
and improvement with spinal
flexion Motion, the process of movement, is described using specific anatomical terminology, anatomical terms. Motion includes movement of Organ (anatomy), organs, joints, Limb (anatomy), limbs, and specific sections of the body. The terminology used de ...
. 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 The straight leg raise is a test that can be performed during a physical examination, with the leg being lifted actively by the patient or passively by the clinician. If the straight leg raise is done actively by the patient, it is a test of fu ...
, 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 or
gait Gait is the pattern of Motion (physics), movement of the limb (anatomy), limbs of animals, including Gait (human), humans, during Animal locomotion, locomotion over a solid substrate. Most animals use a variety of gaits, selecting gait based on s ...
changes.


Causes

Neurogenic claudication is the fundamental clinical feature of , which may be
congenital A birth defect is an abnormal condition that is present at childbirth, birth, regardless of its cause. Birth defects may result in disability, disabilities that may be physical disability, physical, intellectual disability, intellectual, or dev ...
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 aging process in which there are anatomic changes and possibly a loss of function of one or more intervertebral discs of the vertebral column, spine. DDD can take ...
and spinal
osteoarthritis Osteoarthritis is a type of degenerative joint disease that results from breakdown of articular cartilage, joint cartilage and underlying bone. A form of arthritis, it is believed to be the fourth leading cause of disability in the world, affect ...
. 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 injury or diseases. The term ''Lesion'' is derived from the Latin meaning "injury". Lesions may occur in both plants and animals. Types There is no de ...
s,
ankylosing spondylitis Ankylosing spondylitis (AS) is a type of arthritis from the disease spectrum of axial spondyloarthritis. It is characterized by long-term inflammation of the joints of the spine, typically where the spine joins the pelvis. With AS, eye and bow ...
,
rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects synovial joint, joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and h ...
, 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. It is the most common cause of dwarfism and affects about 1 in 27,500 people. In those with the condition, the Rhizomeli ...
,
spina bifida Spina bifida (SB; ; Latin for 'split spine') is a birth defect in which there is incomplete closing of the vertebral column, spine and the meninges, membranes around the spinal cord during embryonic development, early development in pregnancy. T ...
, 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 cel ...
. 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 degeneration of the spinal column, which is the most common cause of spondylosis. The degener ...
,
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

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 backed currency, monetary system in which the standard economics, 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 ...
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 revea ...
. 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, the pulse refers to the rhythmic pulsations (expansion and contraction) of an artery in response to the cardiac cycle (heartbeat). The pulse may be felt ( palpated) in any place that allows an artery to be compressed near the surfac ...
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. In biomechanics and strength training, ROM refers to the angular distance and direction a joint can move be ...
, 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 his ...
. 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 ...
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 system, muscular and Human skeleton, skeletal systems. ...
. The differential diagnosis for includes: * Vascular claudication *
Lumbosacral Each vertebra (: vertebrae) is an irregular bone with a complex structure composed of bone and some hyaline cartilage, that make up the vertebral column or spine, of vertebrates. The proportions of the vertebrae differ according to their spinal ...
radicular pain Radicular pain, or radiculitis (from the ), 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 ...
secondary to lumbar
disc herniation A disc herniation or spinal disc herniation is an injury to the intervertebral disc between two 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, ...
*
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 t ...
from spinal structures, hip or sacroiliac joint, myofascia, or
viscera In a multicellular organism, 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 a ...
*
Trochanteric bursitis Greater trochanteric pain syndrome (GTPS), a form of bursitis, is inflammation of the trochanteric bursa, a part of the hip. This bursa is at the top, outer side of the femur, between the insertion of the gluteus medius and gluteus minimus musc ...
*
Piriformis syndrome Piriformis syndrome is a condition which is believed to result from nerve compression at the sciatic nerve by the piriformis muscle. It is a specific case of deep gluteal syndrome. The largest and most bulky nerve in the human body is the s ...
*
Muscle pain Myalgia or muscle pain is a painful sensation evolving from muscle tissue. It is a symptom of many diseases. The most common cause of acute myalgia is the overuse of a muscle or group of muscles; another likely cause is viral infection, espec ...
*
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 serious medical condition in which increased pressure within a Fascial compartment, body compartment compromises blood flow and tissue function, potentially leading to permanent damage if not promptly treated. There are ...
*
Peripheral neuropathy Peripheral neuropathy, often shortened to neuropathy, refers to damage or disease affecting the nerves. Damage to nerves may impair sensation, movement, gland function, and/or organ function depending on which nerve fibers are affected. Neuropa ...


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 aging process in which there are anatomic changes and possibly a loss of function of one or more intervertebral discs of the vertebral column, spine. DDD can take ...
(DDD) may trigger the
pathogenesis In pathology, 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 . Descript ...
of neurogenic claudication. When
intervertebral disc An intervertebral disc (British English), also spelled intervertebral disk (American English), lies between adjacent vertebrae in the vertebral column. Each disc forms a fibrocartilaginous joint (a symphysis), to allow slight movement of the ver ...
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 (also zygapophysial joints, zygapophyseal, apophyseal, or Z-joints) are a set of synovial joint, synovial, plane joints between the articular processes of two adjacent vertebrae. There are two facet joints in each functional s ...
s,
ligamentum flavum The ligamenta flava (: 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, and ensuring ...
, and intervertebral discs. These pathologic changes result in narrowing of the
vertebral canal In human anatomy, the spinal canal, vertebral canal or spinal cavity is an elongated body cavity enclosed within the dorsal bony arches of the vertebral column, which contains the spinal cord, spinal roots and dorsal root ganglia. It is a proc ...
and
neurovascular A neurovascular bundle is a structure that binds nerves and veins (and in some cases arteries and lymphatics) with connective tissue so that they travel in tandem through the body. Structure There are two types of neurovascular bundles: superfici ...
compression at the
lumbosacral Each vertebra (: vertebrae) is an irregular bone with a complex structure composed of bone and some hyaline cartilage, that make up the vertebral column or spine, of vertebrates. The proportions of the vertebrae differ according to their spinal ...
nerve root A nerve root () is the initial segment of a nerve leaving the central nervous system. Nerve roots can be classified as: * Cranial nerve roots: the initial or proximal segment of one of the twelve pairs of cranial nerves leaving the central nervous s ...
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 ...
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 enl ...
. 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 (proof theory) * Extension (predicate logic), the set of tuples of values that ...
when shifts in vertebral structures and
ligament A ligament is a type of fibrous connective tissue in the body that connects bones to other bones. It also connects flight feathers to bones, in dinosaurs and birds. All 30,000 species of amniotes (land animals with internal bones) have liga ...
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 neural foramen) (often abbreviated as IV foramen or IVF) is an opening between (the intervertebral notches of) two pedicles (one above and one below) of adjacent vertebra in the articulated spine. Each interve ...
, 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 ...
. The amount of narrowing may be 67% in compared to 9% in healthy spines.


Treatment

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 and 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 neuropathic pain and also for partial seizures of epilepsy. It is a commonly used medication for the treatment of neuropath ...
, and
methylcobalamin Methylcobalamin (mecobalamin, MeCbl, or MeB) is a cobalamin, a form of vitamin B12, vitamin B. It differs from cyanocobalamin in that the cyanide, cyano group at the cobalt is replaced with a methyl group. Methylcobalamin features an octahedral ...
. 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 and ventricular fibrillation. When used for local anae ...
and/or
steroids A steroid is an organic compound with four fused rings (designated A, B, C, and D) arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter mem ...
. 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 gut, belly, tummy, midriff, tucky, or stomach) is the front part of the torso between the thorax (chest) and pelvis in humans and in other vertebrates. The area occupied by the abdomen is called the abdominal ...
(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, also known as weight training or resistance training, is exercise designed to improve physical strength. It is often associated with the lifting of weights. It can also incorporate techniques such as bodyweight exercises (e ...
(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 a type of fibrous connective tissue in the body that connects bones to other bones. It also connects flight feathers to bones, in dinosaurs and birds. All 30,000 species of amniotes (land animals with internal bones) have liga ...
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 - Lying down on the back, bring one leg up and pull it towards the chest and hold for 30–45 seconds. * Posterior pelvic tilt (bridges) - Lying 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 (: pelves or pelvises) is the lower part of an Anatomy, anatomical Trunk (anatomy), trunk, between the human abdomen, abdomen and the thighs (sometimes also called pelvic region), together with its embedded skeleton (sometimes also c ...
, until the back is straight. Hold for 5–10 seconds and relax. * Neural Stretching of the legs - Lying 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 - Lying 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) - Lying 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 - Lying 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 lying 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, lie on the opposite side and repeat. * Abdominal draw-in (knee to chest) - Lying 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 ) is part of the biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. The five cardinal signs are heat, pain, redness, swelling, and loss of function (Latin ''calor'', '' ...
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 biosynthesis of prostanoids, including thromboxane and prostaglandins such a ...
activity, and reducing the production of
prostaglandin Prostaglandins (PG) are a group of physiology, physiologically active lipid compounds called eicosanoids that have diverse hormone-like effects in animals. Prostaglandins have been found in almost every Tissue (biology), tissue in humans and ot ...
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 Chemical synapse, synapse. The cell receiving the signal, or target cell, may be another neuron, but could also be a gland or muscle cell. Neurotra ...
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 Sheath ( ) is a lipid-rich material that in most vertebrates surrounds the axons of neurons to insulate them and increase the rate at which electrical impulses (called action potentials) pass along the axon. The myelinated axon can be lik ...
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 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 radiculopat ...
is considered the mainstay of surgical treatment. In this procedure, the
ligamentum flavum The ligamenta flava (: 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, and ensuring ...
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: People * Saa Emerson Lamina, Sierra Leonean politician * Tamba Lamina, Sierra Leonean politician and diplomat Science and technology * Planar lamina, a two-dimensional planar closed surface with mass and density, in mathem ...
. Laminectomy also involves partial or complete removal and sacrifice of the lamina, but in addition, facets 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, d ...
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 refers to the simultaneous presence of two or more medical conditions in a patient; often co-occurring (that is, concomitant or concurrent) with a primary condition. It originates from the Latin term (meaning "sickness" ...
. 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 medicine#Clinical practice, clinically it is measured by ...
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 Human life expectancy is a statistical measure of the estimate of the average remaining years of life at a given age. The most commonly used measure is ''life expectancy at birth'' (LEB, or in demographic notation ''e''0, where '' ...
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, a monoclonal
antibody An antibody (Ab) or immunoglobulin (Ig) is a large, Y-shaped protein belonging to the immunoglobulin superfamily which is used by the immune system to identify and neutralize antigens such as pathogenic bacteria, bacteria and viruses, includin ...
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 factor 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 ...
s (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 bloc (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 degeneration of the spinal column, which is the most common cause of spondylosis. The degener ...
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Spinal disease Spine or spinal may refer to: Science Biology * Spinal column, also known as the backbone * Dendritic spine, a small membranous protrusion from a neuron's dendrite * Thorns, spines, and prickles, needle-like structures in plants * Spine (zoolo ...
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Lumbar disc disease In tetrapod anatomy, lumbar is an adjective that means of or pertaining to the abdominal segment of the torso, between the diaphragm and the sacrum. Naming and location The lumbar region is sometimes referred to as the lower spine, or as an ar ...
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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 ...
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Orthopedic surgery Orthopedic surgery or orthopedics ( alternative spelling 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 specialty (medicine), medical specialty that focuses on the surgical treatment or rehabilitation of disorders which affect any portion of the nervous system ...


References

{{reflist Nerve, nerve root and plexus disorders