What is neurogenic claudication?

Neurogenic Claudication

Neurogenic claudication is a clinical syndrome characterized by leg pain, numbness, and weakness that occurs with walking or standing and is relieved by sitting or spinal flexion, associated with lumbar spinal stenosis. 1

Clinical Presentation

Neurogenic claudication presents with distinct features that differentiate it from vascular claudication:

• Symptoms:

  • Leg pain, numbness, tingling, and occasionally weakness
  • Bilateral symptoms in most cases
  • Pain distribution may be diffuse rather than following a specific dermatome
  • Symptoms worsen with standing and walking
  • Key distinguishing feature: Relief with sitting or forward flexion of the spine 1

• Posture-dependent nature:

  • Symptoms are worse when standing upright or with lumbar extension
  • Symptoms are relieved by sitting or leaning forward (e.g., pushing a shopping cart)
  • Walking uphill is often better tolerated than walking downhill (opposite of vascular claudication) 1, 2

Pathophysiology

Neurogenic claudication is primarily caused by lumbar spinal stenosis (LSS), which involves:

• Narrowing of the spinal canal that compresses the cauda equina and emerging nerve roots 1
• Typically results from degenerative changes in the lumbar spine, including:
  • Disc herniation or bulging
  • Facet joint hypertrophy
  • Ligamentum flavum hypertrophy
  • Degenerative spondylolisthesis 3, 2

The mechanism involves:

• Venous pooling in the cauda equina between levels of stenosis
• Failure of arterial vasodilation of congested nerve roots during exercise
• Compression worsens with extension of the spine (standing/walking) 2

Differential Diagnosis

It's crucial to distinguish neurogenic claudication from other conditions:

1. Vascular claudication:

   • Pain is reproducibly precipitated by similar amounts of exercise
   • Promptly relieved by rest (not position)
   • Associated with diminished pulses, trophic changes 1

2. Other causes of pseudoclaudication:

   • Chronic compartment syndrome
   • Osteoarthritis
   • Inflammatory muscle diseases
   • Venous obstructive disease 1

Diagnostic Approach

1. Clinical history:

   • Determine relationship of symptoms to posture and activity
   • Assess walking capacity and limitations
   • Identify relieving and aggravating factors 1

2. Physical examination:

   • Neurological assessment including muscle strength, reflexes, and sensation
   • Lumbar range of motion
   • Straight leg raise test
   • Vascular assessment to rule out peripheral arterial disease 1

3. Imaging:

   • MRI is the gold standard for confirming lumbar spinal stenosis
   • CT myelography if MRI is contraindicated
   • Plain radiographs may show degenerative changes but are insufficient for diagnosis 3, 4

4. Rule out vascular causes:

   • Ankle-brachial index (ABI) to exclude peripheral arterial disease
   • If ABI is ≤0.9, vascular claudication should be considered 1, 5

Management

The management of neurogenic claudication should follow a stepwise approach:

1. First-line treatment (non-surgical):

   • Multimodal care with education, manual therapy and exercise:

     • Flexion-based exercises (avoid extension)
     • Trunk muscle stabilization exercises
     • Home exercise program 4, 6, 7

   • Pharmacological options (limited evidence):

     • Serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants may be considered 4
     • Not recommended: NSAIDs, paracetamol, opioids, muscle relaxants, pregabalin, gabapentin 4

2. Interventional options:

   • Epidural steroid injections are not recommended based on high-quality evidence 4, 7
   • Minimally invasive lumbar decompression (MILD) procedure and interspinous process spacers show promise but require more evidence 3

3. Surgical management:

   • Consider for patients with significant disability who have failed conservative management
   • Decompression at the most significant stenotic level is typically adequate 2
   • Postoperative rehabilitation with supervised exercises and cognitive-behavioral therapy is beneficial 4

Prognosis

Once established, symptoms of neurogenic claudication tend to neither improve nor deteriorate significantly without intervention 2. The condition primarily affects quality of life through limited mobility rather than causing progressive neurological deterioration.

Clinical Pearls

• The hallmark of neurogenic claudication is positional relief (sitting or leaning forward)
• Patients often report they can walk longer distances when pushing a shopping cart (forward flexion)
• Bicycle riding is often better tolerated than walking due to the flexed spine position
• Multiple level involvement is common in lumbar spinal stenosis
• Conservative management should be tried before considering surgical intervention