Jeffrey R. Carlson, MD, CPE
(Originally published in Hampton Roads Physicians’ Magazine)
When muscles don’t get enough blood flow due to obstructed arteries, cramping pain can result simply from walking or using one’s arms. Vascular claudication (VC) is a condition typically caused by peripheral artery disease and is a debilitating problem that worsens over time. Cardiologists consult with patients to determine if their claudication is caused by blood flow issues caused by cardiac insufficiency. If after rigorous examination and testing, they find no or little evidence of cardiac or vascular involvement, they suspect a spine related issue is at play and refer their patient to me for evaluation.
Neurogenic claudication or pseudo-claudication are terms that refer to claudication caused by nerve compression in the lumbar spine. Some of the symptoms are like VC, but many are different as you can see in the table below:
|Relief w/Leaning Forward (Shopping Cart Sign)||No||Yes|
|Pain Intensity||Intermittent/typically better at rest||May be constant|
|Dissipation of pain at rest||30 minutes||1-3 minutes|
|Difficulty with or Loss of Bladder/Bowel Control||No||Possible|
By doing a thorough physical examination, diagnostic imaging and asking specific questions designed to tease out these differences, I can make a diagnosis of neurogenic claudication caused by conditions such as spinal stenosis, a bulging or herniated disc, spondylolisthesis, degenerative disc disease or a combination of these.
Treatment usually starts conservatively, unless there are neurologic signs that are troubling, such as drop foot or loss of bowel or bladder control. I start with anti-inflammatory medications, physical therapy, and activity modification. If the nerve root(s) remain irritated after several weeks, I will order an epidural steroid injection to get the medication exactly at the pain generator. After the ESI, physical therapy tends to become more effective and less painful for the patient.
If this conservative treatment continues to provide little to no pain relief for the patient, surgery may be considered as an option. Depending on the mechanical issue, like a spondylolisthesis, a fusion may be needed for stability. I may need to clean out bone spurs and provide more space in the spinal canal to relieve pressure on the spinal cord and nerve roots by doing a laminectomy. Sometimes, I will have to perform several complex procedures to address multiple spinal issues, such as arthritis, a herniated disc and facet joint problems.
With today’s advanced technology, anesthesia and minimally invasive surgical techniques, spine surgery can mostly be done in an outpatient setting, so that the patient can go home the same day to recover in their own bed. With supportive in-home nursing and PT, I find that my surgical patients who had neurogenic claudication do very well in recovery. Nerve compression injury typically takes time to heal; however many patients recover with no lingering effects.