What is Neurogenic Claudication?
Written by Neil Badlani, M.D., Chief Medical Officer, North American Spine

Neurogenic claudication refers to the classic lumbar spinal stenosis symptom, which is a condition that leaves the spinal column narrow as a result of abnormal growths and structures, such as bone spurs from osteoarthritis. 

Symptoms of lumbar stenosis in the spine can occur when the nerves in the canals touch bone, or a ligament or disc that has been changed from spinal degeneration. In some cases, stenosis can be congenital, in which case the spinal canal was already naturally small, making it hard for the nerves that pass through them. Over time, this leads to the nerves becoming irritated, which causes the symptoms.

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More About Neurogenic Claudication

lumbar foraminotomy

Two Kinds of Claudication 

Intermittent neurogenic claudication is one of two kinds of cramping in the leg that you experience upon walking. Regardless of the type, it’s almost certainly going to derail your intentions to exercise as normal that day, but the type defines how the cramping occurs. 

In the case of neurogenic claudication, you are experiencing symptoms that arise due to pinched nerve, which is usually the result of lumbar spinal stenosis. This can happen because the lower back remains in an arched or extended position for too long. Combined with the narrow spine, either your neural foramina, the spinal canal, or both are inflamed to the point that sensitive nerves become compressed by the local bone or other abnormal growths. It is at this point when neurogenic claudication appears. 

There is also vascular claudication, which is an entirely different condition in which the blood vessels narrow so much that you are no longer getting a sufficient blood supply in the lower extremities. These symptoms are usually due as a result of peripheral vascular disease, and not because of a spinal issue. 

Neurogenic Claudication Syndrome 

Neurogenic claudication is not a single condition or disease, but is a collection of consistent symptoms that we do not fully understand, making it a syndrome. 

Symptoms of this syndrome are often related to poor posture, manifesting as muscle cramps in the leg or as pain in the power back. In conjunction with spinal stenosis, arching your back will put excessive pressure on the lumbosacral nerve roots or the horse’s tail–the cauda equina. This term refers to the bundle of nerves that exit the bottom of the spinal cord and apparently looks like the tail of a horse.

Neurogenic Claudication Symptoms

As previously mentioned, neurogenic claudication is a syndrome that is also a symptom of lumbar spinal stenosis. The term means painful or cramping legs as a result of a nerve problem, and as such it should not be mistaken from the vascular counterpart, which stems from an insufficient blood supply and not spinal nerve concerns. 

Symptoms of neurogenic claudication syndrome include:

Weakness, pain, or numbness in the buttocks and/or legs, and the pain is classically made worse by walking or simply standing; both of these activities increase the way the lumbar spine curves, which can cause the ligamentum flavum to get thicker, and can cause the spine canal to get narrower. Bending forward or sitting will relieve this pain, whereas vascular claudication only lessens by rest alone. Sitting helps because it stretches the ligament and straightens the spine.

How Neurogenic Claudication is Diagnosed?

To determine whether or not neurogenic claudication treatment is necessary, your doctor will conduct an interview to get an idea of your symptoms and medical history. Then, a physical exam and imaging tests may be needed. 

•  Physical Examination:

Patients suspected of having lumbar stenosis and neurogenic claudication will first undergo a physical check of the back. The doctor will take note of the curvature of the spine, as well as how flexible and mobile the spine is, and whether there are any neurologic changes during the exam, such as numbness when extending the spine, paresthesias, or pain in the leg. Additionally, it is necessary to check the skin for any signs of occult spinal dysraphism, which is a failure of the neural arches to close completely.

•  Neurologic Examination

Following the physical exam, a neurologic round may follow. Those who have idiopathic degenerative stenosis in the lumbar region might not notice any deficits when in a neutral or resting position. Depending on how chronic the caudal root compression is, there may be normal, poor, or completely absent deep tendon reflexes. Presence of pathologic reflexes or hyperactive deep tendon flexons tend to be absent unless injury has occurred. When walking, you may notice sensory deficits. All of this information is essential to an accurate diagnosis. 

 

Causes of Neurogenic Claudication

low back pain

In most cases, neurogenic claudication is the result of narrowing in the spinal canal in the lower back, which can be accompanied by back pain. This spinal stenosis is usually due to arthritic changes or natural wear and tear in the lower part of the spine. Some of the changes you may experience that lead to stenosis and thus neurogenic claudication are the thickening of ligaments, slipped or ruptured discs, and the growth of bone spurs, especially around the facet joints. Narrowing can apply pressure to the nerve roots that control lower body movement and sensation, and impingement leads to cramping, tingling, and pain. 

In most cases, you will notice worse pain when walking or standing, because a fully upright posture causes the canal to narrow naturally. When there is no room left to narrow, it puts that much more pressure on the roots of the nerves within. Flexing forward and sitting down both cause the canal to expand a little bit, which reduces the pressure and the pain associated with it. 

How is Neurogenic Claudication Treated?


Conservative Options

Conservative treatment options include nerve root blocks and steroid injections. These are designed to provide temporary relief (up to one year), and you may elect to have the procedure done multiple times. Other conservative strategies may include the placement of a spinal cord stimulator–or STIM–which is designed not to correct the underlying degeneration, but to lessen the pain the condition causes.

Decompression

Minimally invasive decompression surgery aims to relieve pressure on the nerves of the spine. This pressure is often caused by stenosis, bulging or herniated discs, and more. Relieving this pressure can be achieved by reducing or removing soft tissue (disc material or scar tissue) or bone (bone spurs, a section of the lamina or foramina) to decompress the affected nerve. When the compression is caused by soft tissue material, a surgical laser may be used to shrink the impinging material.

Fusion/Stabilization

Fusion surgeries are similar in goal–to remove damaged disc tissue and fuse the bones together–but differ in approach, including the use of specialized hardware to reinforce stability, and the location used to gain access to the spine. A related procedure is an artificial disc replacement, in which a damaged cervical disc is replaced with a synthetic disc, and the vertebrae are not fused.

How Much Does Treatment Cost?

Treatment cost depends on several factors, especially what insurance you have and how much of your deductible has been met. IN the last two years, 90% of our patients have paid less than $2000 out-of-pocket. Some have paid literally nothing, and other have paid much more than that. It depends. The good news is: our Patient Care Managers will handle as much as they can directly with your insurance company, and all your costs will be known up-front.

Important note: spine surgery often pays for itself within a year or two. Many people actually spend more money trying to live with the pain than they do getting the pain fixed. The following calculator is intended to give you a sense of what you spend on managing—rather than eradicating—your pain.

 

Calculate how much you've spent on back pain this year.
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This past year you have spent on your pain treatment:

Get surgery now. Getting surgery now is the smartest financial move. Over the last two years, the average North American Spine patient spent around $2,000 out-of-pocket for treatment. You’ve spent that much or more this year to manage your back pain than you could to fix it.

Get surgery soon. Over the last two years, the average North American Spine patient spent around $2,000 out-of-pocket for treatment. At your current rate, you will spend that much or more within the next two years. The sooner you get treatment, the sooner it will pay for itself.

Keep an eye on your spending. Currently, you are managing your pain efficiently from a financial perspective but over time, your expenses could add up. Surgery should be strongly considered if you start missing more work or spending more on treatment medication.

Great job! You are spending very little on your back pain. Keep it up!

Equipment Used to Diagnose and Treat Neurogenic Claudication

After physical and neurologic exams, the doctor may choose to conduct a number of imaging tests to try and determine the true cause of your neurogenic claudication. Some of the imaging exams that could be used include:

  • X-ray/Plain films: This is a test that produces images of the bones it captures; it does not generally produce images of soft tissue structures, such as ligaments, discs, spinal nerves, the spinal cord, cysts, vascular malformations, nor the majority of tumors. The purpose of the x-ray is to provide a sense of the bone anatomy and how the spine is curved and aligned within the body. Additionally, an x-ray can assess scoliosis, spinal slippage, spinal dislocation, and the overall balance of the spine. Finally, it is possible to assess specific situations related to the bones such as narrowing space in the discs, a fracture in the vertebral body, erosion, bone spurs, or collapse. With flexion/extension x-rays, doctors can see the spine in motion and may be able to see if there is something strange as you move. 
  • MRI: This is a diagnostic test that combines radio waves with large magnets to produce computer-generated images of high detail to examine the bones and soft tissues. This scan can reveal herniated discs or bulging discs that may be causing the claudication. 
  • CT Scan: If you’re unable to have an MRI, this diagnostic procedure combines x-rays with computers to create a more complex image than x-rays do.

How Does Neurogenic Claudication Compare to Similar Conditions?

This should not be confused with a similar but completely different condition called vascular claudication, which is related to blood circulation. The symptoms that manifest are similar in both conditions, but with the vascular counterpart, the pain arises because of leg arteries beginning to narrow, not because something is wrong with the nerve passageways. 

In the case of vascular claudication, your arteries have narrowed and are susceptible to further narrowing and hardening as fatty deposits, or plaque, start to stick to the arterial walls. The hardening of arteries is known as atherosclerosis, and the reduced blood supply to that region is called peripheral arterial disease. Vascular claudication pain can disappear once you stand up, which gives the affected region a fresh supply of blood. 

On the other hand, neurogenic claudication symptoms are not so simple to get rid of, as they require a bit more effort in terms of treatment, like medication or physical therapy. In some cases, you may be able to reduce the symptoms of neurogenic claudication by sitting or bending at the waist forward to alleviate pressure placed on the nerves. 

Neurogenic claudication occurs over a long period of time due to aging, especially as the spinal discs get naturally weaker and end up compressing the nerves around them. Likewise, vascular claudication takes a while to develop, but the related arterial hardening can get bad early on in life when consuming a diet simultaneously too high in both fats and sugar.

Analogy: Blow-Out vs Flat Tire

A bulging disc is like a flat tire, a slipped disc is like a blowout. When you have a flat tire, the wheel’s material loses its shape, but it stays more or less together. In a blowout, the inside of the wheel becomes exposed to the outside.

Both conditions can cause pain, and both should be professionally evaluated. And don’t forget: a bulging disc (flat tire) can progress to become a slipped disc (blowout).

Blow-Out

Blow-Out = Instant Rupture

Flat Tire

Flat Tire = Slow Leak

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