Neurogenic Intermittent Claudication

Neurogenic intermittent claudication is a pathognomonic symptom that suggests the presence of spinal stenosis before additional examination methods. It is characterized by pain when walking, which regresses when sitting down or bending the body forward. After that, a person can again walk a certain distance until painful sensations appear. In a sitting position, the patient can perform any work (exercise bike, driving a car) without pain. The intensity of neurogenic intermittent claudication is estimated in the distance (meters) that a person can walk before the onset of pain.

To stop neurogenic lameness, a person usually needs not only to stop walking but at the same time take a specific posture: with a slight bending of the legs in the hip and knee joints and bending the body forward. In this position, the lumbar spine is straightened, the distance between the posterior structures of the vertebra, the root increases, when the pressure stops, the spring expands, the pressure disappears, the thread is free, and it falls out. Neurogenic claudication often occurs in men over 40 years old, in women over 50 years old. But it may be earlier, depending on the reasons that caused the compression of the nervous tissue. Usually, the development of the disease is imprinted by the patient’s lifestyle: work, nutrition, excess weight, injuries, etc.

According to different researchers, the motor variant of intermittent neurogenic claudication occurs in 20% – 40% of cases. Usually, movement disorders in the legs are combined with reflex pain syndromes: soreness along the back, front, lateral surfaces of the thighs, lower legs, numbness of the same areas with spread to the foot.

Types and Causes of Neurogenic Intermittent Claudication

Types

The types of intermittent neurogenic claudication are divided into neurogenic and vascular.

1. Neurogenic (due to compression, circulatory failure occurs, and if compression occurs chronically, atrophy of the nervous tissue occurs)
2. Vascular (the most common cause of obliterating endarteritis and atherosclerosis)

But there are other, more rare causes from different branches of medicine that need excluding if the symptoms do not correspond to the two above: genetic diseases (dysmetabolic), traumatological (damage to the bursa, piriformis hypertrophy, etc.), neurological, psychogenic, etc.

Neurogenic intermittent claudication can be both unilateral (most often with damage to one root, for example, lateral hernia) and bilateral (due to stenosis of the spinal canal, central hernia). Or the onset of the disease is unilateral, followed by spread to the other side with or without the addition of pain, numbness, other unpleasant sensations, and dysfunctions of the pelvic organs.

Prerequisites

• spinal stenosis (congenital / acquired, fixed / dynamic, monosegmental / polysegmental);
• displacement of the vertebrae relative to each other (between them and the compression of the roots occurs);
• the presence of bone growths;
• overgrowth of joints;
• consolidation of ligaments;
• deposits in the bundles of calcium salts;
• intervertebral hernia;
• an increase in the size of the yellow ligament;
• varicose veins of the spine.

Causes

Factors of neurogenic intermittent claudication are:

1. Initial factors are:

• based on the periodic arising cessation of blood flow or its significant weakening to the spinal cord or its lumbosacral roots due to increased needs for movements with a simultaneously impaired vascular supply of the roots (with age, the lumen of the arteries becomes smaller, their elasticity and strength decrease) as a result of their compression surrounding tissues;
• spasm of the arteries;
• stagnation of blood in the venous system of the spine;
• the pressure increase of the cerebrospinal fluid (from the side of the spinal cord and its roots) in the vertebral or radicular canal.

2. Producing factors are: 

• not always, especially at the onset of the disease, the patient experiences pain and weakness in the lower extremities; 
• most often, they are caused by a specific position of the body, for example, when moving to an upright position with the extension of the trunk while walking and standing;
• reverse movement achieves pain relief: flexion of the spine – straightening the lordosis, tilting – to the healthy side, and stopping – to rest.

Diagnostics and Treatment of Neurogenic Claudication

Diagnostics

The syndrome of intermittent neurogenic claudication is presented clinically. With the help of instrumental examination methods, the cause is established, the location of the lesion and its compliance with the clinical picture is determined, and indications for conservative or surgical treatment methods are established.

Instrumental methods, the use of which is mandatory in the diagnosis of neurogenic intermittent claudication are:

• X-ray of the lumbar spine in two projections and functional positions;
• computed tomography of the level of stenosis;
• myelography of the lumbar spine;
• magnetic resonance imaging of the lumbar spine.

Additional research methods are:

• selective angiography;
• venography;
• ENMG;
• bicycle test (a patient with neurogenic claudication can engage in much longer than with vascular pathology).

Conservative Treatment

1. Conservative treatment includes:

• taking non-steroidal anti-inflammatory drugs during an exacerbation;
• drugs that relieve swelling and tonic vessels;
• implanted nerve stimulators;
• physiotherapy treatment;
• physiotherapy exercises;
• vertiflex procedure, if necessary.

The patient’s stopping of heavy physical activity is important, taking medications according to the doctor’s prescription.

Usually, conservative treatment is carried out in patients with mild to moderate intermittent neurogenic claudication syndrome for 1-3 months. With the ineffectiveness of conservative treatment, gross changes according to CT and MRI, and with the consent of the patient, surgical treatment is carried out.

2. Surgical treatment. Preparation for surgical treatment is performed according to the protocols.

The operation is performed under endotracheal anesthesia. The planned operation determines the position of the patient on the operating table. The type of operation is determined for each patient individually, depending on the cause of the pathology.

• The primary purpose of the operation is decompression of neural structures (mechanically removing the structure compressing the nerve tissue), which is well defined by MRI examination.
• The second stage is the stabilization of the spine with a metal structure.
• When the hernia is completely removed, a metal or polymer cage is placed.

Hopefully, all this information was useful for you. Take care of yourself.

FAQs

• How are nerve stimulators with neurogenic intermittent claudication implanted?

The implant consists of a central abutment with two wing-shaped branches. When it is precisely inserted between the two vertebrae, the physician will open these wings. In each wing, a recess holds the spinous processes of the vertebrae above and below the device. Once the implant is in place, it gently separates the two bones, which widens the spinal canal and relieves pressure on the nerves. The nerves are no longer pinched and the symptoms of lumbar spinal stenosis are reduced.

• Can spinal stenosis be treated without surgery?

In the initial stages of the degenerative cascade, the symptoms of spinal stenosis may not bother at all. However, if the situation worsens, then it is no longer possible to cure the disease without surgery. Removal of stenosis is possible only by surgery.

• What is the Vertiflex procedure?

The procedure involves the use of an implant, which is currently the only FDA-approved interspinous spacer on the market. This is an evidence-based procedure and is one of the most advanced life-enhancing procedures for those suffering from lumbar spinal stenosis. For 5 years, this method has helped patients get rid of leg pain in 75% of cases.

• Do you need a Vertiflex procedure?

To understand this, ask yourself these questions:

1. Are you experiencing cramps, numbness, pain, or tingling in your legs, calves, or seat?
2. Is it aching, dull pain spreading from back to legs?
3. Do you feel better when you are sitting, bending forward, lying on your back, or sitting with your legs up?

If your answer is “yes”, you need this procedure.