Lumbar stenosis with neurogenic claudication – Symptoms, Diagnosis, Treatment, Precautions.

What is Lumbar Stenosis?

Lumbar spinal stenosis is a condition that occurs when the spinal canal (the hollow tube that holds and protects the entire spinal cord and its nerve roots), in the lumbar area, becomes narrow under the influence of aging, debris accumulation, arthritis, and so on. This narrowing of the spinal canal puts excessive pressure on nerves that run through the lower back and legs and impairs the motor function of the muscles that are connected to these nerves. For the sake of your information, the lumbar area (lower back) is made up of five vertebrae located between the ribs and the pelvis in the lower part of the spine. This area holds nerves that control the movement of the lower parts of the body, especially the legs.

Spinal stenosis can affect any part of your spine, but the lower back is the most common. It usually occurs due to degenerative conditions such as arthritis in people aged 60 or up, however, developmental factors may lead to lumbar stenosis in the younger patients. Medical evidence suggests that spinal stenosis can also be a congenital condition.

The narrowing of the spinal canal usually occurs gradually over a period of years or decades. With age, the spinal discs become less spongy, resulting in a loss of disc height and may result in the bulging of the hardened disc into the spinal canal. Ligaments surrounding the spinal cord may thicken and bone spurs may also occur. All of these factors may lead to central canal narrowing and may or may not cause symptoms. Some of the symptoms of this condition are numbness, weakness, or pain in the calves, legs, and buttocks, cramping in the calf, loss of normal bladder and bowel control, etc.

What is Neurogenic Claudication?

Neurogenic Claudication is also known as pseudo-claudication and can be defined by breaking the name into two parts:

The term “Neurogenic” refers to something that originates from the nervous system.

The term “Claudication” refers to leg pain, or more simply, weakness or impaired walking ability.

Neurogenic claudication is a condition that arises when nerves that run through the legs have an impaired transmission between the spinal cord and leg muscles. This usually occurs when nerves are pinched or compressed in the lumbar area of the spinal cord due to lumbar spinal stenosis. Resultantly, a person may feel pain, lethargy, or inability to walk correctly.

There is a difference between neurogenic claudication and vascular claudication, often referred to as claudication, which is caused by a reduction in blood flow to the leg muscles.

Lumbar Stenosis with Neurogenic Claudication:

Lumbar stenosis is the leading cause of neurogenic claudication. The two conditions are different in their origin, yet the damage that they do is collective. In fact, neurogenic claudication cannot exist in isolation with spinal stenosis.

Factors leading to Lumbar Spinal Stenosis with Neurogenic Claudication.

Degenerative changes such as degenerative disc disease and spinal osteoarthritis are among the most common causes of lumbar spinal stenosis. Lumbar spinal stenosis may also be acquired as a result of changes in the spine, such as excess scar tissue or bone formation, as a result of surgery. Other secondary causes include ankylosing spondylitis, space-occupying lesions, Paget’s disease, and rheumatoid arthritis. Achondroplasia, spina bifida and certain mucopolysaccharidoses are some less common causes of spinal canal stenosis which may be present at birth.

Neurogenic claudication may be caused by a variety of lower back disorders, such as spinal stenosis, spondylosis, infections, cancers, and herniated or ruptured discs. These conditions may cause the spinal cord to narrow, increasing pressure and causing damage to the spinal nerve roots, resulting in tingling, numbness, or weakness in the lower body.

Symptoms:

A person may experience several symptoms if he or she has both lumbar spinal stenosis and neurogenic claudication. Since the symptoms of lumbar spinal stenosis (LSS) are close to those of neurogenic claudication, the word “pseudo claudication” is often used to describe LSS symptoms. Pain, weakness, tingling, heaviness, fatigue, and/or paresthesias that reach into the lower extremities are some of the common symptoms. These symptoms may affect only one leg but they usually affect both legs. Leg pain is usually more serious than back pain in people who have both of their legs affected.

Low back pain is one of the first signs of stenosis. This can progress to claudication after a few months or years. The pain may be radicular and follow classic neurologic pathways. The spinal nerves or spinal cord become increasingly trapped in a smaller space inside the canal, resulting in this condition.

Although several patients with these conditions experience these common symptoms, people with extreme cases may experience rarer and more serious symptoms. Constant irritation, pain, or numbness are experienced in more severe cases. Patients’ mobility and function are affected as a result of the pain caused by excessive or continuous movements. Exercising and walking for long periods of time can cause pain, fatigue, numbness, and heaviness in the legs, lower back, and hips. Common tasks such as standing for long periods of time or lifting heavy items can become more difficult to complete.

Both of these conditions are classically differentiated by symptoms improving or worsening in response to certain activities and maneuvers. Standing, walking, and/or back extension can cause pain. Sitting and bending or leaning forward usually relieves the pain. Patients may also claim that their pain worsens when they walk downstairs and improves when they walk upstairs, ride a bike, or use a shopping cart.

In short, Claudication triggered by lumbar stenosis comes with the following most common symptoms:

• Constant leg pain and/or numbness while standing
• Increased leg pain and/or numbness while walking long distances or bending your spine backward.
• Impaired walking ability
• Difficulty in performing activities and other upright exercises

Diagnosis

Your doctor may inquire about your signs and symptoms, discuss your medical history and perform a physical examination to diagnose lumbar spinal stenosis with neurogenic claudication. To help pinpoint the cause of your signs and symptoms, he or she may order several imaging tests. These imaging tests may include:

X-rays:

Bony modifications, such as bone spurs, can be seen on X-rays of the spine, which may be narrowing the space inside the spinal canal. You are exposed to a small amount of radiation when you are getting an X-ray done.

CT or CT myelogram:

If you cannot have an MRI, your doctor can suggest a CT scan, which combines X-rays taken from a variety of angles to provide accurate cross-sectional images of your body. A CT scan is performed after a contrast dye is inserted in a CT myelogram. The dye will expose herniated discs, bone spurs, and tumors by outlining the spinal cord and nerves.

Magnetic resonance imaging (MRI):

Magnetic resonance imaging or an MRI produces cross-sectional images of the spine using a strong magnet and radio waves. Damage to your discs and ligaments, as well as the presence of tumors, can all be detected with this examination. Most importantly, it will reveal where the nerves in the spinal cord are being pressured.

Your doctor will have to differentiate this pain from vascular claudication since it imitates the true claudication of impaired circulation and blood flow caused by the narrowed blood vessels of peripheral vascular disease.

Treatment Options

Non-Surgical Treatments

In most cases, the treatment for lumbar spinal stenosis with neurogenic claudication begins with non-surgical treatments. For certain patients, a combination of time, medicine, posture management, stretching, and exercise may help with pain flare-ups. Weight loss, nicotine withdrawal, and bone-strengthening activities can also be recommended.

Medications:

Analgesics can be used to alleviate pain and anti-inflammatory medicines can be used to minimize swelling and pain. Most pain can be managed with over-the-counter drugs, but prescription medications can be recommended if the pain is serious or persistent.

Injections:

Epidural injections of cortisone (steroids) in the lumbar spine can also help relieve symptoms by reducing inflammation and swelling around the nerve tissue. These can be repeated up to three times per year. Each individual is affected differently by these injections.

Physical Therapy:

Early surgical treatment is common for LSS patients, but conservative treatment is also an option.  Not only because of the risks associated with surgery, but also because moderate symptoms of radicular pain can be alleviated with physical therapy. Physical therapy has been linked to a lower chance of patients needing surgery within a year. Only patients with symptoms should be treated. Physical therapy and/or prescribed exercises may aid in the stabilization and protection of the spine, as well as the build-up of endurance and flexibility. The patient will be able to resume a normal lifestyle and activities with the aid of physical therapy. Four to six weeks of counseling and therapy are usually recommended.

Spine Surgery

If non-surgical treatment (as discussed above) does not improve symptoms, a doctor will suggest surgery. There are many forms of spinal surgeries available, and a neurosurgeon may help decide which treatment is best for the patient depending on the situation.

The main aim of spine surgery is to remove any structures in the spinal canal or vertebral foramen that are compressing the nerves. The name of this procedure is known as lumbar decompression surgery (laminotomy, laminectomy, foraminotomy). This can be performed alone in some patients, but it must be combined with lumbar fusion in other patients.  The vertebrae can become unstable (spinal instability) if too much of the compressive structures need to be removed to free the nerve.

The vertebrae move abnormally as a result of this. If this happens, a spinal fusion may be performed to join the vertebrae and remove motion at that level. In order to properly support and repair the involved bone, metallic hardware can be installed in the vertebrae.

Many patients with lumbar spinal stenosis find that surgery relieves their leg symptoms of ambulatory pain, sciatica, and numbness. However, depending on the magnitude of the nerve compression and the amount of time the nerve has been compressed, surgery may not be able to alleviate some permanent damage. Back pain relief is less likely to be successful with surgery than symptoms associated with the legs.

If a patient meets the following criteria, he or she may be considered a candidate for surgery:

• Back and leg pain restricts daily activity and degrades one’s quality of life.
• Neurological deficits such as leg weakness, limb numbness and foot drop develop over time.
• Loss of normal bowel and/or bladder functions.
• Difficulty in standing and impaired walking ability.
• The use of medications and physical therapy is ineffective.
• The patient appears to be well.

The potential advantages of surgery should always be carefully measured against the complications of surgery and anesthesia. While a large percentage of patients with lumbar spinal stenosis who undergo surgery experience substantial pain relief, surgery does not guarantee that it will benefit all.

Spinal cord stimulator for neurogenic claudication:

A spinal cord stimulator is a device consisting of electrodes or thin wires and a small generator or battery pack. This device is inserted under your skin from where it sends a mild electric current to your spinal cord. When turned on, this device stimulates the nerves in the area where you are feeling pain. Pain is reduced since the electrical pulses change and block the pain signal from reaching your brain.

People suffering from neurogenic claudication can have this device implanted to minimize their pain and discomfort. Stimulation does not treat the underlying cause of pain. Rather, it aids the patients in pain management. Spinal cord stimulation is considered a success if the pain is reduced by at least half.

After a spinal cord stimulation surgery for neurogenic claudication, high rates of success and recovery have been recorded. The majority of patients say that the treatment is painless and worthwhile. When your chronic pain is managed properly, your incisional pain will also heal easily and quickly, and the patients will be able to resume a life of activity and comfort.

Risk factors associated with Lumbar Spinal Stenosis and Neurogenic Claudication

The major risk factors of lumbar spinal stenosis with neurogenic claudication are as follows:

• Aging, because is linked with the degeneration of the spine
• Other degenerative changes of the spine
• Obesity
• Family history
• Use of tobacco
• Work or exercises involving repetitive mechanical stress on the spine
• Injuries or deformities to the spine in the past
• Osteoporosis can cause compression fractures of the lumbar vertebrae, resulting in lumbar spinal stenosis.

Things that you can do to keep neurogenic claudication in check:

The best way to manage lumbar spinal stenosis with neurogenic claudication is to learn more about your condition, work closely with your doctors and medical team, and take an active part in the treatment of your condition.

You can’t really avoid lumbar spinal stenosis when it starts building because almost everyone has some kind of osteoarthritis of the spine by the age of 50. You can, however, be able to lower the risk. Here are a few ways to keep your spine in good shape:

Exercise regularly:

Exercise helps to keep your spine flexible by strengthening the muscles that support your lower back. Walking, swimming, cycling, and weight lifting are all excellent aerobic activities to keep your spine healthy. If you are living your life with lumbar canal stenosis and neurogenic claudication, you should avoid hoping that it will just go away. While spinal stenosis is a progressive condition, the right exercises may help alleviate symptoms. In addition to taking anti-inflammatory drugs, performing exercises recommended by your physiotherapist or chiropractor is important.

Maintain a good posture:

Learn how to lift heavy items safely. Similarly, sleep on a sturdy mattress and sit in a chair that supports your back’s natural curves.

Healthy weight management:

Excess weight puts more strain on your back and can contribute to the onset of lumbar spinal stenosis symptoms.

Sleep properly:

Sleep helps to alleviate or eliminate pain and/or numbness. It is also necessary as the body repairs itself while we sleep. Therefore it is imperative that you take a good night’s sleep regularly.

Lifestyle Changes

Maintain a healthy weight, practice good body mechanics, and get enough exercise to keep the lower back as healthy as possible.

Home Remedies:

Home remedies such as a heating pad, ice bag, massage, or a long, hot shower can be beneficial. Such remedies are good for temporary relief as it can reduce inflammation and give you symptomatic relief. Ask your doctor if you should take any dietary supplements, and talk about any alternative therapies or medications you’re considering.

Finally, unless the physical therapy choices have been exhausted, it’s normally better to place surgery on the back burner and focus on less invasive but equally successful physical therapy methods.

Conclusion

In conclusion, the outcomes for the patients suffering from this condition vary and are dependent on the seriousness and duration of symptoms at the time of treatment. In the end, a person’s prognosis is determined by how they react to treatment. The severity and cause of lumbar spinal stenosis, as well as the patient’s underlying medical condition, both influence the treatment response.