The reliability of differentiating neurogenic claudication from vascular claudication based on symptomatic presentation

Abstract

Background: Intermittent claudication can be neurogenic or vascular. Physicians use a profile based on symptom attributes to differentiate the 2 types of claudication, and this guides their investigations for diagnosis of the underlying pathology. We evaluated the validity of these symptom attributes in differentiating neurogenic from vascular claudication. Methods:Patients with a diagnosis of lumbar spinal stenosis (LSS) or peripheral vascular disease (PVD) who reported claudication answered 14 questions characterizing their symptoms. We determined the sensitivity, specificity and positive and negative likelihood ratios (PLR and NLR) for neurogenic and vascular claudication for each symptom attribute. Results:We studied 53 patients. The most sensitive symptom attribute to rule out LSS was the absence of "triggering of pain with standing alone" (sensitivity 0.97, NLR 0.050). Pain alleviators and symptom location data showed a weak clinical significance for LSS and PVD. Constellation of symptoms yielded the strongest associations: patients with a positive shopping cart sign whose symptoms were located above the knees, triggered with standing alone and relieved with sitting had a strong likelihood of neurogenic claudication (PLR 13). Patients with symptoms in the calf that were relieved with standing alone had a strong likelihood of vascular claudication (PLR 20.0). Conclusion:The classic symptom attributes used to differentiate neurogenic from vascular claudication are at best weakly valid independently. However, certain constellation of symptoms are much more indicative of etiology. These results can guide general practitioners in their evaluation of and investigation for claudication.Contexte : La claudication intermittente peut avoir une étiologie neurogène ou vasculaire. Les médecins utilisent un profil fondé sur les particularités des symptômes pour distinguer l'une de l'autre et ceci oriente leur choix des méthodes de diagnostic de la pathologie sous-jacente. Nous avons évalué la validité de ces particularités des symptômes utilisées pour distinguer la claudication d'origine neurogène de la claudication d'origine vasculaire. Méthodes :Des patients atteints d'une sténose spinale lombaire (SSL) ou d'une maladie vasculaire périphérique (MVP) avérées qui se plaignaient de claudication ont répondu à 14 questions afin de caractériser leurs symptômes. Nous avons déterminé la sensibilité, la spécificité et les rapports de probabilité positifs et négatifs (RPP et RPN) à l'égard de la claudication neurogène ou vasculaire pour chacune des particularités des symptômes.Résultats : Notre étude a regroupé 53 patients. La particularité des symptômes dotée de la sensibilité la plus élevée pour ce qui est d'écarter le diagnostic de SSL a été l'absence de « déclenchement de la douleur à la simple station debout » (sensibilité 0,97; RPN 0,050). Les données sur ce qui soulageait la douleur et sur la localisation des symptômes ont eu une faible portée clinique en ce qui a trait à la SSL et à la MVP. La présence d'une constellati...

Management of lumbar spinal stenosis

“…Conversely, the alleviation of symptoms with standing (stopping walking but remaining upright) and symptoms located below the knees provided strong evidence for vascular claudication (likelihood ratio of 20). 27 The symptoms of LSS can have a substantial impact on mobility, functional autonomy, and performance (physical activity in daily life). Most people with symptomatic LSS have limited walking capacity; they may require walking aids and may even avoid walking altogether.…”

Run-Off Computed Tomography Angiography (CTA) for Discriminating the Underlying Causes of Intermittent Claudication

“…Patients were allocated to one of three categories based on the imaging finding best explaining symptoms of IC: 1 = vascular pathology (VASC), 2 = musculoskeletal (MSK) pathology or 3 = combined vascular and MSK pathology (COMB). Regarding MSK IC, we classified the following findings as possibly causing IC-like symptoms: absolute spinal stenosis (defined as a combination of bilateral facet arthrosis, disk bulging or herniation and hypertrophy of the ligamentum flavum causing narrowing of the sagittal diameter of the spinal canal), intervertebral disk herniation, vertebral body fracture, and severe joint diseases (coxarthrosis, gonarthrosis, chondrocalcinosis) [ 17 – 20 ].…”

Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management

“…In patients with vascular claudication, symptoms typically are relieved with standing alone and may be located below the knees. 15 Patients with vascular claudication may have diminished pulses, skin discoloration, and loss of extremity hair. Vascular studies, including the ankle-brachial index, duplex ultrasonography, and magnetic resonance angiography, can help rule out peripheral vascular diseases.…”