From the Guidelines
Neurogenic claudication is a specific type of pain caused by compression of the spinal nerves in the lower back, typically resulting from lumbar spinal stenosis, and is characterized by symptoms of leg pain and occasionally weakness on walking or standing, relieved by sitting or spinal flexion, as defined by the American College of Physicians and the American Pain Society 1.
Definition and Causes
Neurogenic claudication presents as pain, tingling, numbness, or weakness that starts in the lower back and radiates down the buttocks and legs, particularly when standing or walking for extended periods. This condition occurs when the spinal canal narrows due to age-related degenerative changes, herniated discs, bone spurs, or thickened ligaments, all of which can compress the spinal nerves.
Diagnosis and Treatment
Treatment typically begins with conservative approaches such as physical therapy, pain medications like NSAIDs, epidural steroid injections, and posture modifications. For severe cases that don't respond to conservative treatment, surgical decompression may be necessary to create more space for the nerves. The pain mechanism involves both mechanical compression and inflammatory processes affecting the nerve roots, which explains why both anti-inflammatory medications and physical interventions that alter spinal positioning can provide relief, as suggested by the guidelines from the American College of Physicians and the American Pain Society 1.
Key Considerations
- Neurogenic claudication is distinct from vascular claudication and is relieved by sitting or leaning forward, which increases the space in the spinal canal and reduces pressure on the nerves.
- The condition is associated with spinal stenosis, and its symptoms can be similar to those of radiculopathy or sciatica, but the key distinguishing feature is the relief of symptoms with sitting or spinal flexion.
- Conservative management is the first line of treatment, with surgical intervention considered for cases that do not respond to conservative measures, as outlined in the guidelines 1.
From the Research
Definition and Prevalence of Neurogenic Claudication
- Neurogenic claudication (NC) is a condition characterized by pain, numbness, or weakness in the legs, calves, or buttocks that occurs when walking or standing, and is often associated with lumbar spinal stenosis (LSS) 2, 3, 4, 5.
- LSS is a degenerative spinal condition that affects nearly 50% of patients presenting with lower back pain, and its occurrence is associated with advanced age 6.
- NC can significantly impact functional ability, quality of life, and independence in the elderly 5.
Symptoms and Diagnosis of Neurogenic Claudication
- The symptoms of NC can include pain, numbness, or weakness in the legs, calves, or buttocks, and can be challenging to identify due to the wide variety of presentation subtleties and common comorbidities such as degenerative disc disease 6.
- Recent developments in imaging techniques can be useful in accurately identifying the precise location of the spinal compression 6.
- A systematic review of the evidence for the effectiveness of nonoperative treatment of LSS with NC found that there is very low-quality evidence from six trials that calcitonin is no better than placebo or paracetamol, regardless of mode of administration or outcome assessed 4, 5.
Treatment Options for Neurogenic Claudication
- Treatment options for NC can range from conservative to surgical, with the latter being reserved for when patients have neurological compromise or conservative measures have failed 6.
- A clinical practice guideline for the nonsurgical management of patients with LSS causing NC recommends that clinicians and patients may initially select multimodal care nonpharmacological therapies, including education, advice, and lifestyle changes, behavioral change techniques, home exercise, manual therapy, and/or rehabilitation 2.
- There is moderate-quality evidence that a multimodal approach which includes manual therapy and exercise, with or without education, is an effective treatment for NC, and that epidural steroids are not effective for the management of LSS with NC 3.