What is Neurogenic Claudication and How is it Treated?

There are five pairs of lumbar nerves on each side and each pair comes out of spinal canal through lumbar spinal foramina. There are 5 pairs of lumbar spinal foramina one on each side. Spinal cord gives out a pair of spinal nerve at each level in neck, thorax, lumbar and sacral segment. The nerve passes through spinal foramina and proceeds to peripheral organ and tissue. Spinal cord ends and splits into several nerves at the level of second lumbar vertebrae. The bundle of nerves within spinal canal below lumbar level 2 is known as cauda equina. Cauda equina is formed by 3 pairs of lumbar spinal nerve (third, fourth and fifth), 5 pair of sacral nerves, one coccygeal nerve and parasympathetic autonomic nerves. Neurogenic claudication is caused by irritation or pinch of the lower spinal cord or cauda equina. The term “neurogenic” means problem with nerves and word “claudication” is derived from Latin language, which means a limp.

• Most common cause of irritation or pinch is narrowing of the spinal canal.
• Narrowing of spinal canal is also known as spinal stenosis. Spinal stenosis is a condition caused by narrowing of the lumbar spinal canal.
• Mild to moderate narrowing of spinal canal causes irritation of spinal nerves resulting in symptoms like pain, tingling and numbness.
• Severe narrowing also causes muscle weakness, bladder and bowel incontinence in addition to above symptoms.¹
• Neurogenic claudication is thus characterized by pain, numbness, weakness, discomfort, urinary incontinence, bladder incontinence and muscle cramping in legs.
• Spinal stenosis is often observed in more than one level and narrowing may be unilateral or bilateral.
• The symptoms of neurogenic claudication are initiated and aggravated by walking or bending backwards.
• Symptoms associated with neurogenic claudication become less severe or relieved upon rest.

• Narrowing of spinal canal results in irritation, pinch or compression of spinal cord or cauda equina.
• Narrowing of spinal canal is either unilateral or bilateral.²
• The spinal cord lesion is observed between twelfth thoracic and first lumbar vertebrae, similarly cauda equina lesions are observed below second lumbar vertebrae.
• Spinal stenosis is a degenerative process and occurs gradually over a period of time as a person ages.
• Causes of spinal stenosis are as follows-
  • Hypertrophy or enlargement of vertebral body, pedicle and lamina
  • Large disc herniation or bulge
  • Hypertrophy of ligamentum flavum.

• Osteophytes are either solitary or multiple bony overgrowths that protrudes into spinal canal.³
• The osteophytes may have a sharp edge and often causes severe pinch or irritation of nerve.
• Osteophyte may develop in spinal canal or spinal foramina thus causing Neurogenic Claudication.

• Spondylolisthesis is caused by slippage of vertebral body over adjacent vertebrae.
• The slippage in to spinal canal causes narrowing of spinal canal resulting in spinal stenosis.⁴ Neurogenic Claudication occurs as a result of spinal stenosis.

• Facet joint enlargement and hypertrophy is observed in patient suffering with osteoarthritis.
• Enlarged facet joint causes narrowing of the spinal canal. The narrowing is often unilateral when unilateral facet joint is affected.

• Posterior spinal ligament runs on the posterior or back of vertebrae. Ossification of significant size protrudes into spinal canal and causes spinal canal narrowing⁵ which can cause neurogenic claudication.

• The primary or metastatic bone tumor localized over vertebral body, lamina and pedicle expands into spinal canal and causes narrowing of the spinal canal.⁶
• The tumor when occupies the space within spinal canal causes narrowing of the spinal canal resulting in spinal stenosis which in turn causes neurogenic claudication.

• Disc lies between upper and lower vertebrae. The disc degenerative disease is associated with hypertrophy of the vertebrae and narrowing of the disc, which often follows narrowing of spinal canal.⁷
• DDD is observed in elderly patient and results in narrowing of the disc.
• Severely narrowed disc also causes foraminal stenosis resulting in Neurogenic Claudication.

• Synovial ganglion cyst is observed in sacrum and lower lumbar vertebrae.
• The moderate to large size cyst causes spinal canal narrowing and stenosis resulting in neurogenic claudication.

Neurogenic Claudication occurs as a result of spinal stenosis. There are some risk factors, which increase the risk of degenerative process and hypertrophy of bone or ligament that can cause neurogenic claudication.

• Chronic Smoking- Smoking increases the degenerative process of the spine and cause neurogenic claudication.
• Obesity- Overweight causes additional strain and pressure on vertebrae, disc and ligaments resulting in osteophytes, degeneration and hypertrophy of the bone and ligaments which in turn can lead to neurogenic claudication.
• Inactive Life style- Living a sedentary life and not exercising causes osteoporosis and ligamental laxity resulting in neurogenic claudication.
• Heavy Weight Lifting- Inappropriate lifting of heavy objects can put undue strain on the spine resulting in subluxation, ligamental hypertrophy or osteophyte formation which can cause neurogenic claudication.

Patient suffering from neurogenic claudication commonly experiences symptoms in the calves; however, symptoms can also be felt in the thighs, hips, buttocks or feet.

• Patients suffering from neurogenic claudication would often have symptoms of feeling tired
• Generalized weakness is also one of the non specific symptom of neurogenic claudication.
• Loss of appetite

• Severe pain is felt in the lower back and legs in patients suffering from neurogenic claudication.
• Symptoms of pain associated with neurogenic claudication is spread along the dermatome of the spinal nerve depending on pinch or irritation of the spinal nerve.
• Burning and sharp pain associated with neurogenic claudication is triggered by flexion of the lower back. Pain is aggravated while walking up the hill with back in flex position.
• Pain in patients suffering from neurogenic claudication can start upon walking and bending backwards and gets relieved upon sitting or stooping.

• Irritation or pinch of the motor nerve causes muscle contractions resulting in muscles spasm and cramping in patients suffering from neurogenic claudication.
• The level of muscle cramp depends on the irritation or pinch of the segmental spinal nerve.

• In few cases patient suffering from neurogenic claudication feels continuous leg discomfort, which may or may not respond to pain medications.
• Leg discomfort may be less severe during extension of spinal cord.

• Pressure or pinch of lower spinal cord or cauda equina causes initial sensory symptoms like tingling in patients suffering from neurogenic claudication, which spreads along the dermatome supplied by the nerve.
• Tingling is felt as pins and needles along the dermatome of the nerve in one or both leg.
• Persistent pressure or irritation of spinal sensory nerve results in numbness.

• Cauda equina syndrome is a group of symptoms caused by pinch or pressure over cauda equina below second lumbar spinal segment.
• Symptoms are sensory (tingling, numbness), motor (muscle weakness) and autonomic (bladder and bowel incontinence).
• Sensory symptoms like tingling and numbness is caused by pinch or pressure over sensory nerve. Motor symptoms like muscle weakness is caused by motor nerve lesion and autonomic symptoms like bladder and bowel incontinence is caused by pressure or pinch of autonomic nerve.

• Muscle weakness follows pinch, pressure or compression of motor nerve and results in weakness of the muscle that receives motor nerve, which is pinched.
• Muscle tone depends on residual muscle contraction at rest, which is observed when motor nerve is injured.

• Muscle power is reduced when muscle is not functioning because of lack of impulses from non-functioning nerve, which is pinched. Muscle weakness or lower muscle power is observed when motor nerve is unable to send messages or impulses to muscles to contract.
• Severe motor nerve damage causes reduced muscle power.

• Muscle coordination depends on contraction and relaxation of several muscles in leg.
• The joint movement such as flexion, extension and rotation is accomplished with muscle coordination.
• Motor nerve lesion or damage results in paralysis of few or most muscles supplied by the nerve that is damaged.
• Coordination become abnormal or absent when muscle fails to contract or relax following motor nerve damage.

• Prolonged lack of use of muscle or failure to contract and relax frequently results in muscle atrophy or dead muscle fibers.
• The atrophied muscle when compared with normal muscle on opposite side shows a thinning of the muscles. The muscle mass is often decreased in size.
• Muscle atrophy is sign of severe motor nerve lesion or damage resulting in degeneration of muscle tissue.

• Joint stiffness is the late sign observed in patients suffering with neurogenic claudication.
• Paralysis of several group of muscles results in muscle weakness and atrophy. Muscle weakness and atrophy restricts voluntary joint movement. Restriction of joint movement eventually causes joint stiffness.

• Leg pain and muscle weakness become predominant following extension of lower back.
• The symptom becomes significant because spinal canal naturally narrows when the spine is extended.
• The opening of spinal canal further narrows with extension of lower back because of space being occupied by osteophytes, hypertrophied bones and ligament.
• Symptoms are observed during walking or standing for long periods of time and spread over one side or both side of lower back and leg.
• Discomfort is reduced when patient bends forward causing flexion of vertebral column. Flexion widens the spinal canal and causes relief from symptoms.

• Patient often has a tendency to lean over an object such as a shopping cart while walking.
• Forward leaning helps to temporarily alleviate symptoms.

• This type of neurogenic claudication is commonly seen in the leg muscles or buttocks and occurs as a result of decreased blood circulation to the affected region.
• Vascular neurogenic claudication usually occurs from atherosclerotic blockages of arterial or venous blood flow in lower leg.

• This type of neurogenic claudication occurs as a result of spinal stenosis which is a degenerative condition of the spine where the foramen through which the nerves exit gets narrowed resulting in compression on the spinal nerves.
• This spinal narrowing can occur from different causes such as herniated or bulging disc, bone spurs etc. Patient experiences localized pain particularly in the lower region of the spine, such as shooting pain down the legs.

X-Ray- X-ray of lower lumbar vertebrae is performed for following diseases which can be a cause for Neurogenic Claudication-

• Narrowing of spinal canal
• Narrowing spinal foramina
• Spondylolisthesis
• Subluxation of vertebrae
• Osteophytes

CT scan and MRI of the Spine- Shows much finer details and helps in diagnosis of following diseases which could be causing neurogenic claudication –

• Disc bulge or herniation
• Hypertrophy of ligamentum flavum
• Osteophytes
• Narrowing of spinal canal
• Narrowing of spinal foramina
• Spondylolisthesis
• Subluxation of vertebrae
• Vertebral tumor

Electromyogram (EMG)- ⁹

• Electromyogram study is performed to evaluate the motor nerve conduction and function of muscle contractions.
• F wave studies were performed following walking, the test was also known as motor stress test, which was specific for diagnosis of Neurogenic Claudication.⁹

• Rest is an important part of treatment protocol for Neurogenic claudication
• Heat therapy and Cold therapy are effective conservative treatment to reduce pain in patients suffering from neurogenic claudication.
• Aerobic exercises
• Chiropractic treatment
• Acupuncture

• NSAIDs like ibuprofen or naproxen can help relieve mild to moderate pain associated with neurogenic claudication.
• Opioids are effective in controlling more severe symptoms of pain in neurogenic claudication.
• Muscle Relaxants help in relaxing the stiff muscle.
• Antianxiety medications
• Antidepressants
• Oral Corticosteroids

• Lying down knee to chest exercises helps stretch the spine.
• Bridge pose exercise or pelvic tilts which are good strengthening exercises for low back.
• Squats

• Epidural steroid injection ¹¹
• Percutaneous adhenolysis ¹²

Surgery is often superior choice of treatment for Neurogenic Claudication.³

• Partial Fascectomy ¹³
• X-Stop ¹⁴
• Lumbar Decompression Surgery ¹⁴

References: