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 has distinct features that differentiate it from vascular claudication:

• Posture-dependent symptoms: Worse when standing upright or with lumbar extension, relieved by sitting or leaning forward 1
• Primary symptoms: Leg pain, numbness, tingling, and occasionally weakness 1
• Activity pattern: Symptoms worsen with standing and walking, improve with rest in a flexed position 1
• Location: Often bilateral and may affect the buttocks, thighs, calves, or feet 1

Etiology

The primary cause of neurogenic claudication is lumbar spinal stenosis (LSS), which involves:

• Narrowing of the spinal canal that compresses the cauda equina and emerging nerve roots 1
• Often results from degenerative changes in the spine, including:
  • Disc bulging or herniation
  • Ligamentum flavum hypertrophy
  • Facet joint arthropathy
  • Osteophyte formation

Diagnosis

Diagnosis of neurogenic claudication relies on:

1. Clinical history:

   • Relationship of symptoms to posture and activity
   • Assessment of walking capacity and limitations
   • Identification of relieving factors (sitting, forward flexion) and aggravating factors (standing, walking) 1

2. Physical examination:

   • Neurological assessment
   • Lumbar range of motion
   • Straight leg raise test
   • Vascular assessment to rule out peripheral arterial disease 1

3. Imaging studies:

   • MRI is the gold standard for confirming lumbar spinal stenosis
   • CT myelography may be used when MRI is contraindicated
   • Plain radiographs may help identify degenerative changes 1

4. Differential diagnosis:

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

Management

Management follows a stepwise approach:

1. Non-surgical treatment (first-line approach):

   • Multimodal care with education, advice, and lifestyle changes
   • Manual therapy and exercise, particularly flexion-based exercises 1, 2
   • Trunk muscle stabilizing exercises 2
   • Limited evidence for pharmacological options 3

2. Interventional procedures:

   • Epidural steroid injections have shown mixed results, with some evidence suggesting limited effectiveness 4, 3
   • Minimally invasive lumbar decompression (MILD) and interspinous process spacers (IPS) show promising results but require more high-quality evidence 4

3. Surgical management:

   • Consider for patients with significant disability who have failed conservative management
   • Decompression at the most significant stenotic level is typically adequate 1, 5
   • Postoperative rehabilitation with supervised exercises and cognitive-behavioral therapy may be beneficial 3

Clinical Pearls and Pitfalls

• Key differential diagnosis: Always distinguish neurogenic claudication from vascular claudication, which is caused by peripheral arterial disease and not relieved by changes in posture 1
• Conservative approach: Recent evidence supports a multimodal approach including manual therapy and exercise as an effective treatment for neurogenic claudication 6
• Medication limitations: There is evidence against the routine use of NSAIDs, paracetamol, opioids, muscle relaxants, pregabalin, gabapentin, and epidural steroid injections for neurogenic claudication 3
• Natural history: Once established, symptoms of neurogenic claudication tend neither to improve nor deteriorate significantly without intervention 5