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neurogenic claudication

Managing Leg Dominant Pain

Managing Leg Dominant Pain

Teaser: 

Yoga Raja Rampersaud, MD, FRCSC,1 Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,2 Hamilton Hall, MD, FRCSC,3

1Associate Professor Department of Surgery, University of Toronto, Divisions of Orthopaedic and Neurosurgery, University Health Network Medical Director, Back and Neck Specialty Program, Altum Health, Immediate Past President Canadian Spine Society, Toronto, ON.
2Associate Professor, Department of Family and Community Medicine, University of Toronto, Medical Director, Sport CARE, Women’s College Hospital, Toronto, ON.
3Professor, Department of Surgery, University of Toronto; Medical Director, Canadian Back Institute; Executive Director, Canadian Spine Society, Toronto, ON.

CLINICAL TOOLS

Abstract: Leg dominant pain suggests direct nerve root involvement: radicular, not referred symptoms. Constant pain associated with positive neurological findings usually results from an acute disc herniation. Symptoms are the result of mechanical compression but principally reflect an inflammatory response, properly designated sciatica. Intermittent leg dominant pain triggered by activity in extension and relieved by rest in flexion probably represents neurogenic claudication: nerve root ischemia secondary to spinal stenosis. Except for acute cauda equina syndrome, acute sciatica is initially managed with scheduled rest, adequate medication, and time. Non-responsive cases may require surgery. Surgery also shows superior outcomes for disabling neurogenic claudication.
Key Words:leg dominant pain, sciatica, neurogenic claudication, cauda equina syndrome, surgery.

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True spine-generated, leg dominant pain is consistently reproduced by particular spinal movements or positions.
No imaging investigation is required for a patient presenting an unequivocal clinical picture and exhibiting steady predictable improvement.
Of the four back pain syndromes, only neurogenic claudication is consistently best treated by surgery.
In contrast to the back dominant cases, in sciatica there is a definite role for short-acting narcotics or psychotropic drugs for uncontrolled pain.
Criteria for Surgical Referral
Emergency Referral The symptoms of Cauda Equina Syndrome are: - Urinary retention followed by insensible urinary overflow. - Unrecognized fecal incontinence. - Loss or decrease in saddle/perineal sensation. Acute Cauda Equina Syndrome is a surgical emergency.
Consider Elective Referral Failure to respond to a trial of conservative care: - Unbearable constant leg dominant pain. - Worsening nerve irritation tests (SLR or femoral nerve stretch). - Expanding motor, sensory or reflex deficits. - Recurrent disabling sciatica. - Disabling neurogenic claudication.
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Lumbar Spinal Stenosis: Evidence for Treatment

Lumbar Spinal Stenosis: Evidence for Treatment

Teaser: 


David L. Snyder, PhD, Senior Research Analyst, Evidence-Based Practice Center, ECRI, Plymouth Meeting, PA, USA.
David Doggett, PhD, Senior Research Analyst, Evidence-Based Practice Center, ECRI, Plymouth Meeting, PA, USA.
Charles Turkelson, PhD, Chief Research Analyst and Director, Evidence-Based Practice Center, ECRI, Plymouth Meeting, PA, USA.

Degenerative lumbar spinal stenosis is a common problem among older adults. Stenotic compression of spinal nerves can result in low back pain, disabling leg pain, and greatly restricted walking capacity. Conservative therapies are usually prescribed for mild symptoms and surgery is prescribed for severe symptoms, while patients with moderate symptoms may not have an obvious treatment choice. The clinical evidence supporting these treatment options has been criticized because of problems with study design and quality that complicate their assessment. Despite the poor quality of most of the literature, recent studies provide better information and a means of starting to judge the effectiveness of treatment.

Key words: lumbar spinal stenosis, neurogenic claudication, conservative therapy, surgical intervention.