neurogenic claudication

Neurogenic claudication commonly describes pain, weakness, fatigue, tingling, heaviness and paresthesias that extend into the lower extremities. These symptoms may involve only one leg, but they usually involve both. Leg pain is usually more significant than back pain in individuals who have both.{{cite journal | vauthors = Genevay S, Atlas SJ | title = Lumbar spinal stenosis | journal = Best Practice & Research. Clinical Rheumatology | volume = 24 | issue = 2 | pages = 253–65 | date = April 2010 | pmid = 20227646 | pmc = 2841052 | doi = 10.1016/j.berh.2009.11.001 }} {{Abbr|NC|neurogenic claudication}} is classically distinguished by symptoms improving or worsening with certain activities and manoeuvres. Pain may occur with walking, standing, and back extension. Sitting and bending or leaning forward tend to provide relief. Patients may also report that pain is worse while walking down stairs and improved while walking up stairs or using a bicycle or shopping cart. A positive "shopping cart sign" refers to the worsening of pain with spinal extension and improvement with spinal flexion.

Whilst these common symptoms are usually present in many patients with {{Abbr|NC|neurogenic claudication}}, rarer and more serious symptoms can occur in severe cases of {{Abbr|NC|neurogenic claudication}}. In extreme cases of {{Abbr|NC|neurogenic claudication}} constant discomfort, pain or numbness is experienced. This results in patients to have decreased mobility and function as excessive or constant movements cause pain. Exercise and prolonged walking often become difficult and are triggers of pain, tiredness, numbness and heaviness in the legs, lower back and hips.{{cite journal | vauthors = Ammendolia C, Schneider M, Williams K, Zickmund S, Hamm M, Stuber K, Tomkins-Lane C, Rampersaud YR | display-authors = 6 | title = The physical and psychological impact of neurogenic claudication: the patients' perspectives | journal = The Journal of the Canadian Chiropractic Association | volume = 61 | issue = 1 | pages = 18–31 | date = March 2017 | pmid = 28413220 | pmc = 5381486 }} Common tasks such as standing upright for an extended duration or picking up heavy objects may become increasingly difficult to perform. In addition, patients with severe {{Abbr|NC|neurogenic claudication}} may experience difficulties sleeping as lying down on their back causes discomfort and pain. In very extreme cases, bowel or bladder dysfunction can occur. However, this is a consequence of the underlying cause of {{Abbr|NC|neurogenic claudication}} rather than the condition itself. As most causes of {{Abbr|NC|neurogenic claudication}} involve increased pressure or damage to the nerves in the lower spine, damage and pressure on the nerves that extend to the bowel or bladder may occur, leading to bowel or bladder dysfunction.{{cite journal | vauthors = Watanabe K, Sekiguchi M, Yonemoto K, Nikaido T, Kato K, Otani K, Yabuki S, Kakuma T, Kikuchi SI, Konno SI | display-authors = 6 | title = Bowel/bladder dysfunction and numbness in the sole of the both feet in lumbar spinal stenosis - A multicenter cross-sectional study | journal = Journal of Orthopaedic Science | volume = 22 | issue = 4 | pages = 647–651 | date = July 2017 | pmid = 28551282 | doi = 10.1016/j.jos.2017.04.006 | doi-access = free }}

On physical examination, patients with {{Abbr|NC|neurogenic claudication}} have normal peripheral pulses. The neurologic exam, straight leg raise, and femoral nerve stretch are typically normal. Abnormal signs may be revealed if the patient is observed walking until they exhibit {{Abbr|NC|neurogenic claudication}}. For example, a positive "stoop test" is observed if bending forward or stooping while walking relieves symptoms. Occasionally, patients may have other signs such as sensory loss or gait changes.

Neurogenic claudication is the fundamental clinical feature of lumbar spinal stenosis, which may be congenital or acquired. As a result of {{Abbr|LSS|lumbar spinal stenosis}}, the spinal canal in the lumbar spine narrows, causing damage and arthritic changes in the spine. These changes, such as bulging disks, thickening of ligaments and overgrowth of bone spurs, lead to pressure and potentially damage to the spinal nerve roots. The compression of the spinal nerve roots that control movements and sensations in the lower body subsequently causes the symptoms of {{Abbr|NC|neurogenic claudication}}. The causes of {{Abbr|LSS|lumbar spinal stenosis}} are most commonly acquired and include degenerative changes such as degenerative disc disease and spinal osteoarthritis. {{Abbr|LSS|lumbar spinal stenosis}} may also be acquired from changes due to spinal surgery such as excess scar tissue or bone formation. Other secondary causes include space-occupying lesions, ankylosing spondylitis, rheumatoid arthritis, and Paget's disease. Less commonly, the cause of spinal stenosis may be present at birth as seen in achondroplasia, spina bifida, and certain mucopolysaccharidoses.{{Citation|last1=Munakomi|first1=Sunil|title=Spinal Stenosis And Neurogenic Claudication|date=2020|url=http://www.ncbi.nlm.nih.gov/books/NBK430872/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=28613622|access-date=2020-11-20|last2=Foris|first2=Lisa A.|last3=Varacallo|first3=Matthew}} In addition to spinal stenosis, other lower back conditions such as spondylosis, tumors, infections and herniated or ruptured discs can cause {{Abbr|NC|neurogenic claudication}}. These conditions contribute to the potential narrowing of the spinal cord, increasing pressure and inducing damage on the spinal nerve roots, thus, causing paing, tingling or weakness in the lower body.

Risk factors for {{Abbr|LSS|lumbar spinal stenosis}} include:{{cite journal | vauthors = Bagley C, MacAllister M, Dosselman L, Moreno J, Aoun SG, El Ahmadieh TY | title = Current concepts and recent advances in understanding and managing lumbar spine stenosis | journal = F1000Research | volume = 8 | pages = 137 | date = 2019-01-31 | pmid = 30774933 | pmc = 6357993 | doi = 10.12688/f1000research.16082.1 | doi-access = free }}

• Age
• Degenerative changes of the spine
• Obesity
• Family history of spinal stenosis
• Tobacco use
• Occupation involving repetitive mechanical stress on the spine
• Past deformities or injuries to the spine

File:SPINAL_STENOSIS.JPG

Neurogenic claudication is one subtype of the clinical syndrome of lumbar spinal stenosis (LSS). No gold standard diagnostic criteria currently exist, but evaluation and diagnosis is generally based on the patient history, physical exam, and medical imaging. The accuracy of a diagnosis of {{Abbr|NC|neurogenic claudication}} increases with each additional suggestive clinical finding. Therefore, a combination of signs and symptoms may be more helpful in diagnosing NC than any single feature of the history or physical exam. These signs and symptoms include pain triggered by standing, pain relieved by sitting, symptoms above the knees, and a positive "shopping cart sign".

Specific questions that may aid diagnosis include:

• "Does the patient have leg or buttock pain while walking?"
• "Does the patient flex forward to relieve symptoms?"
• "Does patient feel relief when using a shopping cart or bicycle?"
• "Does the patient have motor or sensory disturbance while walking?"
• "Are the pulses in the foot present and symmetric?"
• "Does the patient have lower extremity weakness?"
• "Does the patient have low back pain?"

The physical exam may include observation, evaluation of pulses in the foot, lumbar spine range of motion, and components of a neurological exam.

Helpful imaging may include x-rays, CT, CT myelogram, and magnetic resonance imaging (MRI), but MRI is preferred. Abnormal MRI findings may be present in two-thirds of asymptomatic individuals, and imaging findings of spinal stenosis do not correlate well with symptom severity. Therefore, imaging findings must be considered in the context of a patient's history and physical exam when seeking a diagnosis. The evidence for using objective imaging findings to define {{Abbr|NC|neurogenic claudication}} has been conflicting.

Neurogenic claudication must be differentiated from other causes of leg pain, which may be present in a number of conditions involving the spine and musculoskeletal system. The differential diagnosis for {{Abbr|NC|neurogenic claudication}} includes:

• Vascular claudication
• Lumbosacral radicular pain secondary to lumbar disc herniation
• Referred pain from spinal structures, hip or sacroiliac joint, myofascia, or viscera
• Trochanteric bursitis
• Piriformis syndrome
• Muscle pain
• Vertebral compression fracture
• Compartment syndrome
• Peripheral neuropathy

Both neurogenic claudication and vascular claudication manifest as leg pain with walking, but several key features help distinguish between these conditions. In contrast to {{Abbr|NC|neurogenic claudication}}, vascular claudication does not vary with changes in posture. Patients with vascular claudication may experience relief with standing, which may provoke symptoms in {{Abbr|NC|neurogenic claudication}}. The walking distance necessary to produce pain in vascular claudication is more consistent than in neurogenic claudication.

File:Spinal_Stenosis.png

Degenerative disc disease (DDD) may trigger the pathogenesis of neurogenic claudication.{{Cite journal |last1=Guha |first1=Daipayan |last2=Heary |first2=Robert F. |last3=Shamji |first3=Mohammed F. |date=October 2015 |title=Iatrogenic spondylolisthesis following laminectomy for degenerative lumbar stenosis: systematic review and current concepts |url=https://pubmed.ncbi.nlm.nih.gov/26424349/ |journal=Neurosurgical Focus |volume=39 |issue=4 |pages=E9 |doi=10.3171/2015.7.FOCUS15259 |issn=1092-0684 |pmid=26424349}} When intervertebral discs degenerate and change shape in {{Abbr|DDD|degenerative disc disease}}, the normal movements of the spine are interrupted. This results in spinal instability and more degenerative changes in spinal structures including facet joints, ligamentum flavum, and intervertebral discs. These pathologic changes result in narrowing of the vertebral canal and neurovascular compression at the lumbosacral nerve roots.{{cite journal | vauthors = Ammendolia C, Stuber K, Tomkins-Lane C, Schneider M, Rampersaud YR, Furlan AD, Kennedy CA | title = What interventions improve walking ability in neurogenic claudication with lumbar spinal stenosis? A systematic review | journal = European Spine Journal | volume = 23 | issue = 6 | pages = 1282–301 | date = June 2014 | pmid = 24633719 | doi = 10.1007/s00586-014-3262-6 | s2cid = 12962371 }} The compression of these spinal nerve roots that control sensation and movement in the lower body results in the tingling, pain and weakness {{Abbr|NC|neurogenic claudication}} patients often experience. However, because the severity of symptoms does not correlate well with the degree of stenosis and nerve root compression, a clear understanding of the specific pathogenesis remains challenging.

It is currently unknown which exact cellular mechanisms within the body causes the pain of {{Abbr|NC|neurogenic claudication}} as a response to the compression of spinal nerves. The two main proposed mechanisms agree that neurovascular compression plays a role. The ischemic theory proposes that poor blood supply to the spinal nerve roots results in {{Abbr|NC|neurogenic claudication}}. In contrast, the venous stasis theory proposes that a combination of low oxygen levels and metabolite buildup are responsible due to venous backup at the cauda equina. Pain with walking may be partially explained by the corresponding increase in nerve root oxygen requirements.

These changes in blood flow may occur during back extension when shifts in vertebral structures and ligaments narrow the spinal canal and compress the neurovasculature. Compared to a neutral position, extended spines exhibit 15% less cross-sectional area of the intervertebral foramina, and nerve root compression is present one-third of the time. These dynamic changes in the shape of the spinal canal are more pronounced in individuals with spinal stenosis. The amount of narrowing may be 67% in {{Abbr|LSS|lumbar spinal stenosis}} compared to 9% in healthy spines.

{{See also|Lumbar spinal stenosis#Management}}

File:Blausen 0354 EpiduralSteroidInjection.png

Treatment options for {{Abbr|NC|neurogenic claudication}} aim to cure the underlying cause of the condition, such as lumbar spinal stenosis (LSS) or other degenerative spinal diseases. Decreased walking and lower body motor ability due to {{Abbr|NC|neurogenic claudication}} is the primary disabling feature of LSS. Constant discomfort and pain in the lower extremities and an inability to sleep and lying down are also disabling features of {{Abbr|NC|neurogenic claudication}} that affect a patient's quality of life. Therefore, the target of most treatments is to solve these complications. Currently, several treatment options are available to patients, and they can be grouped broadly into nonsurgical and surgical options. Nonsurgical treatments include medications, physical therapy, and spinal injections. Medication options for neurogenic claudication have included non-steroidal anti-inflammatory drugs (NSAIDs), prostaglandin-based drugs, gabapentin, and methylcobalamin. However, the quality of evidence supporting their use is not high enough for specific recommendations. Physical therapy is commonly prescribed to patients, but the quality of evidence supporting its use for neurogenic claudication is also low. One quarter of all epidural injections are administered to treat symptoms of {{Abbr|LSS|lumbar spinal stenosis}}. Preparations may contain lidocaine and/or steroids. They may be considered for short-term pain relief or to delay surgery, but their benefit is considered small.

Patients that experience light to mild symptoms are commonly treated through physical therapy, which involves stretching and strengthening the lower back, abdominal (core) and leg muscles.{{cite journal | vauthors = Ammendolia C, Stuber K, de Bruin LK, Furlan AD, Kennedy CA, Rampersaud YR, Steenstra IA, Pennick V | display-authors = 6 | title = Nonoperative treatment of lumbar spinal stenosis with neurogenic claudication: a systematic review | journal = Spine | volume = 37 | issue = 10 | pages = E609-16 | date = May 2012 | pmid = 22158059 | doi = 10.1097/BRS.0b013e318240d57d | s2cid = 34821901 }} Common stretches used include the knee to chest stretch, posterior pelvic tilt, neural stretching of the legs, hip-flexor stretch and lower trunk rotation.{{cite journal | vauthors = Markman JD, Gewandter JS, Frazer ME, Pittman C, Cai X, Patel KV, Jahromi BS, Dworkin RH, Burke LB, Farrar JT | display-authors = 6 | title = Evaluation of outcome measures for neurogenic claudication: A patient-centered approach | journal = Neurology | volume = 85 | issue = 14 | pages = 1250–6 | date = October 2015 | pmid = 26354988 | pmc = 4607594 | doi = 10.1212/WNL.0000000000002000 }} In conjunction with these stretches, various strengthening exercises are often implemented, targeting the core, lower back and hip muscles. Common exercises include bridges, bird to dog, tabletop leg press, clamshell and knees to chest. “Lumbar/Core Strength and Stability Exercises”, Princeton University Athletic Medicine, accessed 2 October 2020, https://uhs.princeton.edu/sites/uhs/files/documents/Lumbar.pdf . Depending on the age, mobility and physical health of patients, a combination of easier and more difficult exercises should be prescribed to suit the patient's needs. More difficult exercises may include the incorporation of resistance training (weights), gym equipment and more explosive movements. Other exercises such as cycling (stationary), swimming and water-based activities have also been found to strengthen and improve overall stability and strength in the core, lower back and hips. Ultimately, the aim of physical therapy is to loosen and relax the tight muscles and ligaments that contribute to the symptoms, and to strengthen those muscles to prevent further reocurrences of the condition. However, studies have found conflicting conclusions in regards to the effectiveness of physical therapy as a treatment option for {{Abbr|NC|neurogenic claudication}} patients.{{cite journal | vauthors = Schneider MJ, Ammendolia C, Murphy DR, Glick RM, Hile E, Tudorascu DL, Morton SC, Smith C, Patterson CG, Piva SR | display-authors = 6 | title = Comparative Clinical Effectiveness of Nonsurgical Treatment Methods in Patients With Lumbar Spinal Stenosis: A Randomized Clinical Trial | journal = JAMA Network Open | volume = 2 | issue = 1 | pages = e186828 | date = January 2019 | pmid = 30646197 | pmc = 6324321 | doi = 10.1001/jamanetworkopen.2018.6828 }} Thus, the low quality of evidence supporting its use has prompted further research into physical therapy as a treatment option for {{Abbr|NC|neurogenic claudication}} to be necessary.{{cite journal | vauthors = Sahin F, Yilmaz F, Kotevoglu N, Kuran B | title = The efficacy of physical therapy and physical therapy plus calcitonin in the treatment of lumbar spinal stenosis | journal = Yonsei Medical Journal | volume = 50 | issue = 5 | pages = 683–8 | date = October 2009 | pmid = 19881973 | pmc = 2768244 | doi = 10.3349/ymj.2009.50.5.683 }}{{cite journal | vauthors = Macedo LG, Hum A, Kuleba L, Mo J, Truong L, Yeung M, Battié MC | title = Physical therapy interventions for degenerative lumbar spinal stenosis: a systematic review | journal = Physical Therapy | volume = 93 | issue = 12 | pages = 1646–60 | date = December 2013 | pmid = 23886845 | pmc = 3870489 | doi = 10.2522/ptj.20120379 }}

Common stretching exercises used to relieve pain and treat {{Abbr|NC|neurogenic claudication}} include:

• Knee to chest stretch - Lying down on the back, bring one leg up and pull it towards the chest and hold for 30–45 seconds.
• Posterior pelvic tilt (bridges) - Lying on the back, bend both legs and place your feet on the floor. Raise stomach from the ground, lifting the back and pelvis, until the back is straight. Hold for 5–10 seconds and relax.
• Neural Stretching of the legs - Lying on the back, bring one leg up with a stretching band until a stretch is felt in the legs. Ensure your legs are straight. Once the stretch is felt, hold for 30–45 seconds and relax.
• Hip-flexor stretch - To stretch the right hip-flexor, bring the left leg forward, and kneel on the right knee. Push the pelvis forward (lean forward), whilst keeping the upper body straight. Hold the position for 30–45 seconds and relax. To stretch the left hip-flexor, bring swap the positions of the legs.
• Lower trunk rotation - Lying down on the back, bring both knees towards your chest whilst keeping the back flat on the floor. Rotate the bent legs from the left to right side and vice versa whilst keeping back flat on the ground.

Common strengthening exercises used to treat and prevent future reocurrences of {{Abbr|NC|neurogenic claudication}} include:

• Posterior pelvic tilt (bridges) - Lying on the back, bend both legs and place your feet on the floor. Raise stomach from the ground, lifting the back and pelvis, until the back is straight. Hold for 5–10 seconds and relax.
• Quadruped opposite arm/leg (bird to dog) - On all fours (knees on ground and arms against floor supporting upper body) straighten one knee whilst straightening the opposite side arm and hold for 3 seconds and repeat for the other arm/leg pair.
• Tabletop leg press press - Lying on the back, bring both knees towards the chest and then straighten both legs (such that legs are hanging in the air), whilst keeping the back flat on the ground.
• Clamshell - Whilst lying on the side with knees bent inwards, bring the top knee up (whilst keeping leg bent) and hold for 3 seconds. To exercise the opposite leg, lie on the opposite side and repeat.
• Abdominal draw-in (knee to chest) - Lying flat on the back, bend both legs and bring knees towards the chest without lifting the back from the ground and then straighten legs again. For a more difficult version of the exercise, keep one leg bent and feet on the ground and bring the other leg towards the chest.

Medications such as NSAIDs, prostaglandin-based drugs, gabapentin, methylcobalamin and epidural steroid injections are often used in conjunction with physical therapy to treat patients with mild or moderate symptoms of {{Abbr|NC|neurogenic claudication}}. The main goal of these medications is to reduce pain and provide temporary relief for {{Abbr|NC|neurogenic claudication}} patients. NSAIDs and prostaglandin-based medications control inflammation at sites of nerve damage or pressure by inhibiting cyclooxygenase activity, and reducing the production of prostaglandins, a key contributor of inflammation.{{cite journal | vauthors = Kuritzky L, Samraj GP | title = Nonsteroidal anti-inflammatory drugs in the treatment of low back pain | journal = Journal of Pain Research | volume = 5 | pages = 579–90 | date = 2012-11-28 | pmid = 23271922 | pmc = 3526867 | doi = 10.2147/JPR.S6775 | doi-access = free }}{{cite journal | vauthors = Ricciotti E, FitzGerald GA | title = Prostaglandins and inflammation | journal = Arteriosclerosis, Thrombosis, and Vascular Biology | volume = 31 | issue = 5 | pages = 986–1000 | date = May 2011 | pmid = 21508345 | pmc = 3081099 | doi = 10.1161/ATVBAHA.110.207449 }} By reducing inflammation, less pressure is put on the nerve roots, decreasing pain, and providing relief for {{Abbr|NC|neurogenic claudication}} patients.{{cite book | vauthors = Pahwa R, Goyal A, Bansal P, Jialal I | chapter = Chronic Inflammation|date=2020|url=http://www.ncbi.nlm.nih.gov/books/NBK493173/| title =StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=29630225|access-date=2020-11-15 }} Gabapentin aims to reduce pain and provide relief by altering the normal functioning of neurotransmitters that induce a sensation of pain and discomfort.{{Cite book| vauthors = Narain T, Adcock L |url=http://www.ncbi.nlm.nih.gov/books/NBK531934/|title=Gabapentin for Adults with Neuropathic Pain: A Review of the Clinical Effectiveness |date=2018|publisher=Canadian Agency for Drugs and Technologies in Health|series=CADTH Rapid Response Reports|location=Ottawa (ON)|pmid=30325622}} However, the exact mechanism of Gabapentin’s functioning in the body is not completely understood and current knowledge is based on experimental studies that target the nervous system.{{cite book | vauthors = Yasaei R, Katta S, Saadabadi A | chapter =Gabapentin|date=2020|url=http://www.ncbi.nlm.nih.gov/books/NBK493228/| title = StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=29630280|access-date=2020-11-15 }}  Methylcobalamin is another medication that targets the nervous system to reduce pain and provide {{Abbr|NC|neurogenic claudication}} patients with temporary pain-relief. The drug produces myelin to cover and protect nerves from damage, preventing pain induced from damaged nerve roots, as described in some cases of {{Abbr|NC|neurogenic claudication}}.{{cite journal | vauthors = Zhang M, Han W, Hu S, Xu H | title = Methylcobalamin: a potential vitamin of pain killer | journal = Neural Plasticity | volume = 2013 | pages = 424651 | date = 2013 | pmid = 24455309 | pmc = 3888748 | doi = 10.1155/2013/424651 | doi-access = free }} Epidural steroid injections are the main epidural injections prescribed to treat {{Abbr|NC|neurogenic claudication}}. They inhibit the inflammatory cascade signalling to reduce inflammation at sites of spinal nerve damage or pressure.  Consequently, they reduce pain and provide relief to individuals with {{Abbr|NC|neurogenic claudication}}.{{cite journal | vauthors = Leem JG | title = Epidural steroid injection: a need for a new clinical practice guideline | journal = The Korean Journal of Pain | volume = 27 | issue = 3 | pages = 197–9 | date = July 2014 | pmid = 25031804 | pmc = 4099231 | doi = 10.3344/kjp.2014.27.3.197 }}{{cite journal | vauthors = King W, Miller DC, Smith CC | title = Systemic Effects of Epidural Corticosteroid Injection | journal = Pain Medicine | volume = 19 | issue = 2 | pages = 404–405 | date = February 2018 | pmid = 29016932 | doi = 10.1093/pm/pnx173 | doi-access = free }} Whilst the use of medications is common among {{Abbr|NC|neurogenic claudication}} patients that experience frequent or constant pain, their effectiveness has yielded mixed results in studies.{{cite journal | vauthors = Comer CM, Redmond AC, Bird HA, Conaghan PG | title = Assessment and management of neurogenic claudication associated with lumbar spinal stenosis in a UK primary care musculoskeletal service: a survey of current practice among physiotherapists | journal = BMC Musculoskeletal Disorders | volume = 10 | issue = 1 | pages = 121 | date = October 2009 | pmid = 19796387 | pmc = 2762954 | doi = 10.1186/1471-2474-10-121 | doi-access = free }} Further research into their viability as a medication for {{Abbr|NC|neurogenic claudication}} is necessary to allow doctors to provide better care and treatment options for {{Abbr|NC|neurogenic claudication}} patients.{{cite journal | vauthors = Ammendolia C, Côté P, Southerst D, Schneider M, Budgell B, Bombardier C, Hawker G, Rampersaud YR | display-authors = 6 | title = Comprehensive Nonsurgical Treatment Versus Self-directed Care to Improve Walking Ability in Lumbar Spinal Stenosis: A Randomized Trial | journal = Archives of Physical Medicine and Rehabilitation | volume = 99 | issue = 12 | pages = 2408–2419.e2 | date = December 2018 | pmid = 29935152 | doi = 10.1016/j.apmr.2018.05.014 | s2cid = 49396022 }}

Depending on the cause and severity of the condition, surgical options for {{Abbr|NC|neurogenic claudication}} vary. Symptoms of {{Abbr|LSS|lumbar spinal stenosis}}, including {{Abbr|NC|neurogenic claudication}}, are the most common reason patients 65 and older undergo spinal surgery. Surgery is generally reserved for patients whose symptoms do not improve with nonsurgical treatments, and the main objective of surgery is to relieve pressure on the spinal nerve roots and recover normal mobility and quality of life. Lower spinal decompression is considered the mainstay of surgical treatment. In this procedure, the ligamentum flavum is first removed, followed by the removal of the superior facet osteophyte in the spinal canal, and then the decompression of the spinal nerve root. Another surgical method of decompression is the Fenestration method, which involves creating a small window in the spinal canal and then decompressing the nerves. Alternative surgical options include the use of interspinous process spacers, minimally invasive lumbar decompression (MILD) procedure, laminectomy, microdiscectomy and placement of a spinal cord stimulator. The MILD procedure aims to relieve spinal cord compression by percutaneous removal of portions of the ligamentum flavum and lamina. Laminectomy also involves partial or complete removal and sacrifice of the lamina, but in addition, facets in one or more segments of the spinal cord are usually sacrificed as well. Microdiscectomy is another surgical alternative which uses small incisions, and a miniature camera for viewing, to enter the spinal cord and release pressure on the nerve roots. Laminoplasty and spinal fusion surgeries are other alternative surgical procedures that can be performed. However, they are relatively new methods which still require more research and advancements in order for it to be safely performed with minimal risks.{{Cite web|title=Neel Anand, MD - Professor of Orthopaedic Surgery Director of Spine Trauma|url=https://www.spineuniverse.com/author/2433/anand|access-date=2020-11-14|website=SpineUniverse|language=en}}

The use of interspinous spacers is associated with increased costs and rates of reoperation, while evidence comparing effectiveness of the MILD procedure to spinal decompression is insufficient. The effectiveness of laminectomy, microdiscectomy, laminoplasty and spinal fusion surgeries as an alternative to spinal decompression has also been heavily debated, with studies showing conflicting results.{{cite journal | vauthors = Bydon M, Macki M, Abt NB, Sciubba DM, Wolinsky JP, Witham TF, Gokaslan ZL, Bydon A | display-authors = 6 | title = Clinical and surgical outcomes after lumbar laminectomy: An analysis of 500 patients | journal = Surgical Neurology International | volume = 6 | issue = Suppl 4 | pages = S190-3 | date = 2015-05-07 | pmid = 26005583 | pmc = 4431053 | doi = 10.4103/2152-7806.156578 | doi-access = free }}{{Cite journal| vauthors = Mohamed A, El Sisi YB, Al Emam SE, Hussen MA, Saif DS |date=2020-07-13|title=Evaluating the outcome of classic laminectomy surgery alone versus laminectomy with fixation surgery in patients with lumbar canal stenosis regarding improvement of pain and function |journal=Egyptian Journal of Neurosurgery|volume=35|issue=1|pages=19|doi=10.1186/s41984-020-00087-6|s2cid=220507514|issn=2520-8225|doi-access=free}} While studies show that surgery improves walking ability, minimizes constant pain and improves quality of life, comparisons between the efficacy of surgical and nonsurgical treatment of {{Abbr|LSS|lumbar spinal stenosis}} have yielded mixed results.

Individuals with {{Abbr|LSS|lumbar spinal stenosis}} may be asymptomatic for many years before developing symptoms such as {{Abbr|NC|neurogenic claudication}}. However, most {{Abbr|LSS|lumbar spinal stenosis}} patients that present with {{Abbr|NC|neurogenic claudication}} often seek medical help and treatment due to the condition causing pain and affecting their quality of life. Consequently, the prognosis of untreated {{Abbr|LSS|lumbar spinal stenosis}} and {{Abbr|NC|neurogenic claudication}} has not been well reported and is unknown. Based on the physiological cause of {{Abbr|NC|neurogenic claudication}}, it is projected that the symptoms of NC can worsen over time, with roughly one-third of patients showing signs of improvement with time.

For {{Abbr|NC|neurogenic claudication}} patients that develop worse symptoms over time, severe consequences can occur. Over time, untreated {{Abbr|NC|neurogenic claudication}} and {{Abbr|LSS|lumbar spinal stenosis}} can lead to chronic pain and muscle weakness. In severe cases, caudea equina syndrome can develop, disrupting sensory and motor function in the lower body and bladder. Consequently, disability in the lower extremities may develop over time in individuals with untreated {{Abbr|NC|neurogenic claudication}} and {{Abbr|LSS|lumbar spinal stenosis}}. Whilst some patients may recover and improve their {{Abbr|NC|neurogenic claudication}} condition over time, without the help of medical treatment or interventions, this is only prevalent in individuals with light or very mild symptoms of {{Abbr|NC|neurogenic claudication}}. In most scenarios, the prognosis of {{Abbr|NC|neurogenic claudication}} can lead to potential disability, muscle weakness or constant pain in the lower body.

{{Abbr|NC|neurogenic claudication}} is a noncommunicable condition and thus, does not pose any community risks in terms of infectiousness. Rather, NC is associated with increasing age and mostly affects individuals over the age of 60. Age is a major contributing factor to the onset of {{Abbr|NC|neurogenic claudication}} due to spinal degenerative changes that are brought by aging and the weakening of bones and ligaments in the lumbar area. {{Abbr|NC|neurogenic claudication}} is also more likely present in individuals with other spinal comorbidities. A history of spinal injuries or deformities is also a contributing factor to the increased likelihood of the onset of {{Abbr|NC|neurogenic claudication}}.{{cite journal | vauthors = Maeda T, Hashizume H, Yoshimura N, Oka H, Ishimoto Y, Nagata K, Takami M, Tsutsui S, Iwasaki H, Minamide A, Nakagawa Y, Yukawa Y, Muraki S, Tanaka S, Yamada H, Yoshida M | display-authors = 6 | title = Factors associated with lumbar spinal stenosis in a large-scale, population-based cohort: The Wakayama Spine Study | journal = PLOS ONE | volume = 13 | issue = 7 | pages = e0200208 | date = 2018-07-18 | pmid = 30020970 | pmc = 6051614 | doi = 10.1371/journal.pone.0200208 | bibcode = 2018PLoSO..1300208M | doi-access = free }} Other factors such as exercise and bone density have also been found to be associated with {{Abbr|NC|neurogenic claudication}}. Increased exercise activity in the form of strength training has also been found to increase bone density, muscle strength and thus, decrease the likelihood of {{Abbr|NC|neurogenic claudication}} as aging occurs.{{cite journal | vauthors = Sigmundsson FG, Kang XP, Jönsson B, Strömqvist B | title = Prognostic factors in lumbar spinal stenosis surgery | journal = Acta Orthopaedica | volume = 83 | issue = 5 | pages = 536–42 | date = October 2012 | pmid = 23083437 | pmc = 3488183 | doi = 10.3109/17453674.2012.733915 }}

One of the main causes of {{Abbr|NC|neurogenic claudication}} is the onset of lumbar spinal stenosis in elderly patients. Relative to their respective age groups, 16% of individuals aged less than 40 experience lumbar spinal stenosis whilst 38.8% of individuals aged over 60 experience lumbar spinal stenosis.{{cite journal | vauthors = Costandi S, Chopko B, Mekhail M, Dews T, Mekhail N | title = Lumbar spinal stenosis: therapeutic options review | journal = Pain Practice | volume = 15 | issue = 1 | pages = 68–81 | date = January 2015 | pmid = 24725422 | doi = 10.1111/papr.12188 | s2cid = 206246340 | doi-access = free }}{{cite journal | vauthors = Kalichman L, Cole R, Kim DH, Li L, Suri P, Guermazi A, Hunter DJ | title = Spinal stenosis prevalence and association with symptoms: the Framingham Study | journal = The Spine Journal | volume = 9 | issue = 7 | pages = 545–50 | date = July 2009 | pmid = 19398386 | pmc = 3775665 | doi = 10.1016/j.spinee.2009.03.005 }} Between the ages of 60 and 69, the prevalence of lumbar spinal stenosis relative to this population group is 47.2%. Data obtained from medical practitioners suggest that the incidence of lumbar spinal stenosis is 5 cases per 100 000. This increased prevalence of lumbar spinal stenosis as a consequence of aging, heavily contributes to the epidemiology and acquiring of {{Abbr|NC|neurogenic claudication}}. Among individuals with spinal stenosis, {{Abbr|NC|neurogenic claudication}} is present in greater than 90% of patients and present in almost half of patients that present with low back pain, with over 200,000 people being affected in the United States. The prevalence of {{Abbr|NC|neurogenic claudication}} and spinal stenosis in elderly men is also evident, with studies finding that roughly 1 in 10 elderly men experience leg pain in combination with low back pain (symptoms of {{Abbr|NC|neurogenic claudication}}) and this incidence rate is also doubled in retirement communities. As the global life expectancy increases, the impact of spinal disease symptoms such as {{Abbr|NC|neurogenic claudication}} is likely to increase.

Current treatment options for {{Abbr|NC|neurogenic claudication}} are not diverse and lack extensive and detailed research to support their effectiveness, resulting in patients having to choose from a small pool of treatment options, some of which may not be effective. This lack of evidence to support the effectiveness of treatment options for {{Abbr|NC|neurogenic claudication}} is especially prevalent in nonsurgical treatments, such as physical therapy and medications. Among surgical interventions for {{Abbr|NC|neurogenic claudication}}, current research into improving methods of surgery to minimize post-surgery complication and to improve quality of life have also been of concern.{{cite journal | vauthors = Machado GC, Ferreira PH, Harris IA, Pinheiro MB, Koes BW, van Tulder M, Rzewuska M, Maher CG, Ferreira ML | display-authors = 6 | title = Effectiveness of surgery for lumbar spinal stenosis: a systematic review and meta-analysis | journal = PLOS ONE | volume = 10 | issue = 3 | pages = e0122800 | date = 2015-03-30 | pmid = 25822730 | pmc = 4378944 | doi = 10.1371/journal.pone.0122800 | bibcode = 2015PLoSO..1022800M | doi-access = free }}{{cite journal | vauthors = Anderson DB, Ferreira ML, Harris IA, Davis GA, Stanford R, Beard D, Li Q, Jan S, Mobbs RJ, Maher CG, Yong R, Zammit T, Latimer J, Buchbinder R | display-authors = 6 | title = SUcceSS, SUrgery for Spinal Stenosis: protocol of a randomised, placebo-controlled trial | journal = BMJ Open | volume = 9 | issue = 2 | pages = e024944 | date = February 2019 | pmid = 30765407 | doi = 10.1136/bmjopen-2018-024944 | pmc = 6398750 }}

Studies have found that physical therapies such as stretches and strengthening exercises have yielded mixed results in terms of its effectiveness in treating {{Abbr|NC|neurogenic claudication}}. Reports have shown that physical therapy does aid in treating {{Abbr|NC|neurogenic claudication}} in patients with light to mild symptoms,{{cite journal | vauthors = Wise J | title = Physical therapy is as effective as surgery for lumbar spinal stenosis, study finds | journal = BMJ | volume = 350 | pages = h1827 | date = April 2015 | pmid = 25852064 | doi = 10.1136/bmj.h1827 | s2cid = 206904981 }} whilst others have shown the contrary. It has also been found that patients with more severe symptoms of {{Abbr|NC|neurogenic claudication}} find less long-term success in treating the condition through physical therapy. Thus, doctors have concluded that further research into the effectiveness of physical therapy as a treatment option for {{Abbr|NC|neurogenic claudication}} is necessary. With more detailed research, doctors will then be able to suggest the best treatment options for their patients, to help them recover from the condition.

Medications commonly prescribed to {{Abbr|NC|neurogenic claudication}} patients are generally steroids, pain relievers or anti-inflammatories that aim to reduce pain and provide pain-relief. However, studies have found that these medications only provide temporary relief for patients, and do not provide a permanent solution, with symptoms often reoccurring several months following the disuse of medications.{{cite journal | vauthors = Haddadi K, Asadian L, Isazade A | title = Effects of Nasal Calcitonin vs. Oral Gabapentin on Pain and Symptoms of Lumbar Spinal Stenosis: A Clinical Trial Study | journal = Clinical Medicine Insights. Arthritis and Musculoskeletal Disorders | volume = 9 | pages = 133–8 | date = 2016-01-01 | pmid = 27398032 | pmc = 4934406 | doi = 10.4137/CMAMD.S39938 }} Hence, doctors have reported that it is important to research possible medications that can provide long term relief or a permanent solution for patients. Currently, Tanezumab, a monoclonal antibody that suppresses nerve activity, has been in development for use in patents with back pain, such as {{Abbr|NC|neurogenic claudication}}.{{cite journal | vauthors = Webb MP, Helander EM, Menard BL, Urman RD, Kaye AD | title = Tanezumab: a selective humanized mAb for chronic lower back pain | journal = Therapeutics and Clinical Risk Management | volume = 14 | pages = 361–367 | date = 2018-02-21 | pmid = 29503555 | pmc = 5825994 | doi = 10.2147/TCRM.S144125 | doi-access = free }} The drug functions by selectively targeting and inhibiting nerve growth factors (NGF) in the body. By blocking NGF in the body, Tanezumab aims to prevent pain signals produced in the body from reaching the brain, thus reducing pain and providing relief for patients.{{cite journal | vauthors = Nair AS | title = Tanezumab: Finally a Monoclonal Antibody for Pain Relief | journal = Indian Journal of Palliative Care | volume = 24 | issue = 3 | pages = 384–385 | date = 2018 | pmid = 30111960 | pmc = 6069623 |doi = 10.4103/IJPC.IJPC_208_17 |doi-broken-date = 1 November 2024 |doi-access=free}} Whilst positive results have been shown in several studies, further research is still necessary for its safe and effective use.{{cite journal | vauthors = Patel MK, Kaye AD, Urman RD | title = Tanezumab: Therapy targeting nerve growth factor in pain pathogenesis | journal = Journal of Anaesthesiology Clinical Pharmacology | volume = 34 | issue = 1 | pages = 111–116 | date = 2018-01-01 | pmid = 29643634 | doi = 10.4103/joacp.JOACP_389_15 | pmc = 5885425 | doi-access = free }}

Whilst surgical procedures exist to treat {{Abbr|NC|neurogenic claudication}}, current methods involve partial or complete removal of the lamina and segments of the spinal cord, leading to poor stability. Hence, orthopedic surgeons and neurosurgeons have been developing and researching other surgical techniques that reduce this side effect. Haruo Tsuji, in 1990, introduced a procedure known as laminoplastie en bloc (expansive laminoplasty) as an alternative to laminectomy and since then, variations and further developments have been made on that procedure, with developments still being currently.{{cite journal | vauthors = Tsuji H, Itoh T, Sekido H, Yamada H, Katoh Y, Makiyama N, Yamagami T | title = Expansive laminoplasty for lumbar spinal stenosis | journal = International Orthopaedics | volume = 14 | issue = 3 | pages = 309–14 | date = 1990 | pmid = 2279841 | doi = 10.1007/BF00178765 | s2cid = 39499491 }} This procedure involves a reconstruction of the vertebral lamina such that it creates a hinge on one side, allowing for decreased pressure on spinal nerve roots.{{cite journal | vauthors = Yang YM, Yoo WK, Bashir S, Oh JK, Kwak YH, Kim SW | title = Spinal Cord Changes After Laminoplasty in Cervical Compressive Myelopathy: A Diffusion Tensor Imaging Study | language = en | journal = Frontiers in Neurology | volume = 9 | pages = 696 | date = 2018 | pmid = 30210428 | doi = 10.3389/fneur.2018.00696 | pmc = 6124480 | doi-access = free }} Advances in this procedure involve finding ways to access the spinal cord with minimal incisions and to more effectively create hinges that replicate normal functioning of the spine.{{cite journal | vauthors = Fehlings MG, Ahuja CS, Mroz T, Hsu W, Harrop J | title = Future Advances in Spine Surgery: The AOSpine North America Perspective | journal = Neurosurgery | volume = 80 | issue = 3S | pages = S1–S8 | date = March 2017 | pmid = 28350952 | doi = 10.1093/neuros/nyw112 | s2cid = 25153345 | doi-access = free }}{{cite journal | vauthors = Hirano Y, Ohara Y, Mizuno J, Itoh Y | title = History and Evolution of Laminoplasty | language = en | journal = Neurosurgery Clinics of North America | volume = 29 | issue = 1 | pages = 107–113 | date = January 2018 | pmid = 29173422 | doi = 10.1016/j.nec.2017.09.019 }} In addition to laminoplasty, spinal fusion surgeries have also been of growing interest to orthopedic surgeons and neurosurgeons.{{cite journal | vauthors = Proietti L, Scaramuzzo L, Schiro' GR, Sessa S, Logroscino CA | title = Complications in lumbar spine surgery: A retrospective analysis | journal = Indian Journal of Orthopaedics | volume = 47 | issue = 4 | pages = 340–5 | date = July 2013 | pmid = 23960276 | pmc = 3745686 | doi = 10.4103/0019-5413.114909 | doi-access = free }} This process involves connecting two vertebrae of the bones together to reduce pain or correct any spinal deformities.{{cite journal | vauthors = Daniels CJ, Wakefield PJ, Bub GA, Toombs JD | title = A Narrative Review of Lumbar Fusion Surgery With Relevance to Chiropractic Practice | journal = Journal of Chiropractic Medicine | volume = 15 | issue = 4 | pages = 259–271 | date = December 2016 | pmid = 27857634 | pmc = 5106443 | doi = 10.1016/j.jcm.2016.08.007 }} As such this form of surgery has the potential to treat the underlying cause of {{Abbr|NC|neurogenic claudication}}. However, these types of surgeries are difficult and dangerous to perform due to the sensitive nature of the spinal area. Additionally, these techniques are relatively new and thus, more research and advances in its methodology is still required for it to be considered a reliable and viable option to treat {{Abbr|NC|neurogenic claudication}} patients.{{cite journal | vauthors = Harris IA, Traeger A, Stanford R, Maher CG, Buchbinder R | title = Lumbar spine fusion: what is the evidence? | journal = Internal Medicine Journal | volume = 48 | issue = 12 | pages = 1430–1434 | date = December 2018 | pmid = 30517997 | doi = 10.1111/imj.14120 | s2cid = 54524476 | doi-access = free | hdl = 1959.4/unsworks_75083 | hdl-access = free }}{{cite journal | vauthors = Dhillon KS | title = Spinal Fusion for Chronic Low Back Pain: A 'Magic Bullet' or Wishful Thinking? | journal = Malaysian Orthopaedic Journal | volume = 10 | issue = 1 | pages = 61–68 | date = March 2016 | pmid = 28435551 | pmc = 5333707 }}

• Lumbar spinal stenosis
• Spondylosis
• Spinal disease
• Lumbar disc disease
• Claudication
• Orthopedic surgery
• Neurosurgery

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Category:Nerve, nerve root and plexus disorders