What Is Neurogenic Claudication?
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.
Description of Neurogenic Claudication and Spinal Stenosis
- 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.
What Causes Neurogenic Claudication?
Neurogenic Claudication Caused Due To Spinal Stenosis-
- 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.
Neurogenic Claudication Caused Due To Osteophytes Within Spinal Canal- 3
- 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.
Neurogenic Claudication Caused Due To Spondylolisthesis 4
- 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.
Neurogenic Claudication Caused Due To Facet Joint Hypertrophy
- 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.
Neurogenic Claudication Caused Due To Ossification of Posterior Spinal Ligament-
- 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.
Neurogenic Claudication Caused Due To Vertebral Column Bone Tumor-
- 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.
Neurogenic Claudication Caused Due To Degenerative Disc Disease (DDD)-
- 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.
Neurogenic Claudication Caused By Midline Synovial Ganglion Cyst-8
- 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.
What Are The Risk Factors Of 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.
What Are The Symptoms of 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.
Non-specific Symptoms of Neurogenic Claudication –
- 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
Specific Symptoms of Neurogenic Claudication
Symptoms of Pain in Neurogenic Claudication –
- 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.
Symptoms of Leg Cramps in Neurogenic Claudication –
- 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.
Symptoms of Leg Discomfort in Neurogenic Claudication –
- 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.
Symptoms of Tingling and Numbness in Neurogenic Claudication –
- 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-
- 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.
What Are The Signs of Neurogenic Claudication?
Muscle Weakness as a Sign of Neurogenic Claudication
- 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.
Reduced Muscle Power as a Sign of Neurogenic Claudication –
- 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.
Lack of Muscle Coordination as a Sign of Neurogenic Claudication-
- 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.
Muscle Atrophy as a Sign of Neurogenic Claudication
- 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.
Signs of Joint Stiffness in Neurogenic Claudication
- 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.
Pain with Extension and Flexion as a Sign of Neurogenic Claudication
- 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.
Patients Lean Forward-
- Patient often has a tendency to lean over an object such as a shopping cart while walking.
- Forward leaning helps to temporarily alleviate symptoms.
What Are The Different Types of Neurogenic Claudication?
The Different Types of Neurogenic Claudication are:
Vascular Neurogenic Claudication:
- 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.
Spinal Neurogenic Claudication:
- 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.
Investigations to Diagnose Neurogenic Claudication
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
- Subluxation of vertebrae
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
- Narrowing of spinal canal
- Narrowing of spinal foramina
- 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
What is the Treatment for Neurogenic Claudication?
Conservative Treatment for Neurogenic Claudication- 10
- 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
Specific Treatment for Neurogenic Claudication Includes-
Medications to Treat Neurogenic Claudication
- 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
- Oral Corticosteroids
Physical Therapy for Neurogenic Claudication
Some of the physical therapy exercises that can help patient suffering from Neurogenic Claudication would include:
- Lying down knee to chest exercises helps stretch the spine.
- Bridge pose exercise or pelvic tilts which are good strengthening exercises for low back.
Interventional Pain Therapy for Neurogenic Claudication
- Epidural steroid injection 11
- Percutaneous adhenolysis 12
Surgery for Neurogenic Claudication
Surgery is often superior choice of treatment for Neurogenic Claudication.3
- Partial Fascectomy 13
- X-Stop 14
- Lumbar Decompression Surgery 14
1. Lumbar spinal stenosis, cauda equina syndrome, and multiple lumbosacral radiculopathies.
Storm PB1, Chou D, Tamargo RJ.
Phys Med Rehabil Clin N Am. 2002 Aug;13(3):713-33,
2. Correlation of lateral stenosis in MRI with symptoms, walking capacity and EMG findings in patients with surgically confirmed lateral lumbar spinal canal stenosis.
Kuittinen P1, Sipola P, Aalto TJ, Määttä S, Parviainen A, Saari T, Sinikallio S, Savolainen S, Turunen V, Kröger H, Airaksinen O, Leinonen V.
BMC Musculoskelet Disord. 2014 Jul 23;15:247. doi: 10.1186/1471-2474-15-247.
3. J Am Acad Orthop Surg. 2012 Aug;20(8):527-35. doi: 10.5435/JAAOS-20-08-527.
Degenerative lumbar spinal stenosis: evaluation and management.
Issack PS1, Cunningham ME, Pumberger M, Hughes AP, Cammisa FP Jr.
4. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 10: lumbar fusion for stenosis without spondylolisthesis.
Resnick DK1, Watters WC 3rd, Mummaneni PV, Dailey AT, Choudhri TF, Eck JC, Sharan A, Groff MW, Wang JC, Ghogawala Z, Dhall SS, Kaiser MG.
J. Neurosurg Spine. 2014 Jul;21(1):62-6.
5. Ossification of the posterior longitudinal ligament.
Wennekes MJ, Anten HW, Korten JJ.
Clin Neurol Neurosurg. 1985;87(4):297-302.
6. Neurogenic claudication due to narrowing of the lumbar canal by extradural metastatic tumor.
Martin NA, Gutin PH, Newman AB, Pickett JB.
Neurosurgery. 1981 Oct;9(4):436-9.
7. Characteristics of Postural Sway during Quiet Standing Before and After the Occurrence of Neurogenic Intermittent Claudication in Female Patients with Degenerative Lumbar Spinal Canal Stenosis.
Sasaki K1, Senda M, Katayama Y, Ota H, Matsuyama Y.
J Phys Ther Sci. 2013 Jun;25(6):675-8. doi: 10.1589/jpts.25.675. Epub 2013 Jul 23.
8. Midline synovial and ganglion cysts causing neurogenic claudication.
Pindrik J, Macki M, Bydon M, Maleki Z, Bydon A.
World J Clin Cases. 2013 Dec 16;1(9):285-9.
9. F wave studies of neurogenic intermittent claudication in lumbar spinal stenosis.
Bal S1, Celiker R, Palaoglu S, Cila A.
Am J Phys Med Rehabil. 2006 Feb;85(2):135-40.
10. What interventions improve walking ability in neurogenic claudication with lumbar spinal stenosis? A systematic review.
Ammendolia C1, Stuber K, Tomkins-Lane C, Schneider M, Rampersaud YR, Furlan AD, Kennedy CA.
Eur Spine J. 2014 Jun;23(6):1282-301.
11. Correlation between severity of lumbar spinal stenosis and lumbar epidural steroid injection.
Park CH1, Lee SH.
Pain Med. 2014 Apr;15(4):556-61.
12. Effectiveness of percutaneous transforaminal adhesiolysis in patients with lumbar neuroforaminal spinal stenosis.
Park CH1, Lee SH.
Pain Physician. 2013 Jan;16(1):E37-43.
13. Partial facetectomy for lumbar foraminal stenosis.
Kang K1, Rodriguez-Olaverri JC1, Schwab F2, Hashem J1, Razi A1, Farcy JP1.
Adv Orthop. 2014;2014:534658.
14. X-stop versus decompressive surgery for lumbar neurogenic intermittent claudication: randomized controlled trial with 2-year follow-up.
Strömqvist BH1, Berg S, Gerdhem P, Johnsson R, Möller A, Sahlstrand T, Soliman A, Tullberg T.
Spine (Phila Pa 1976). 2013 Aug 1;38(17):1436-42. doi: 10.1097/BRS.0b013e31828ba413.