This patient came into the practice with a 3 week history of worsening low back and leg pain. He had suffered previously with back pain episodes over the past 20 years but nothing that had involved pain into the legs. This episode had started the morning after an enthusiastic game of tennis. Since then it had been getting progressively worse, was effecting his walking, starting to wake him at night and caused a lot of stiffness first thing in the morning.
The leg pain was provoked when walking for more than 150 yards (140 meters) making it very difficult to carry out his normally active daily routine. The leg pain would ease within minutes of sitting down and leaning forward, but prolonged sitting would worsen his back symptoms. This would continue through out the day.
The physical exam found weakness in both legs, with pain being provoked at the base of his back. The right leg was the worst effected. Vibration sensation in the legs were reduced equally on both sides and the right foot was not as sensitive as the left to pin prick testing. The right patella tendon reflex was absent. General muscle weakness existed around the pelvis. Other findings were unremarkable.
When considering any case with a sudden change or worsening to a longstanding problem it is important to determine why that is, or if it is actually something new but masquerading as an old problem. The main priority here was to understand his difficulty walking and if those new leg symptoms related to the low back.
The history gave vital clues as to not only the source of the problem but the structures that could be involved. The physical examination was then used to test this.
One thing that stood out from the history was the clockwork way that the leg pain would come on with walking a set distance, and how it was then relieved by sitting down and leaning forward. This suggested a condition called neurogenic claudication.
Neurogenic claudication is a common symptom of longterm low back problems. It is seen where gradual or sudden changes cause narrowing of the structures around the spinal nerves. Neurogenic means that the problem originates with a problem at a nerve, and claudication, from the Latin for limp, because the patient feels a painful cramping or weakness in the legs. It is thought to be caused by reduction of blood supply to the nerves that exit from the spine. Nerves like all tissues off the body need the nutrients that are provided by the blood to work. If this supply is reduced or stopped it can cause lots of different and often painful sensations. Compression of these blood vessels can be caused by structures such as arthritic spinal joints, calcified spinal ligaments, scar tissue and bulging or herniated discs.
Neurogenic claudication can effect one or both legs causing calf, buttock, or thigh discomfort, pain or weakness. In some patients with severe compression it is not intermittent but painfully persistent. The pain is classically relieved by a change in position particularly bending forward at the waist.People with intermittent symptoms have less disability in climbing steps, pushing carts and cycling.
In order to treat it correctly it is important to determine what structures are causing the problem. An MRI is a type of diagnostic imaging that gives this information; it provides details about the bones and the soft tissues like discs, muscles and nerves.
The MRI results showed a broad bulge of the L4/L5 disc and its encroachment into the exit points of the spinal nerves at that level. This meant, as was suspected, the leg symptoms were related to a worsening of the longterm low back problem. This gave the working diagnosis of an “Intermittent neurogenic claudication secondary to an L4/L5 disc protrusion”.
Disc protrusions/bulges can be the result of longterm degenerative changes, particularly common at the base of the spine. Where episodes of recurrent low back pain exist it is a common to see discs becoming progressively damaged with each episode.
The disc protrusion here was causing problems for the legs only when walking for a set distance. So with each step, the pressure would cause the bulge to obstruct the blood vessels to the nerves. As a point of interest, most MRI scans at the moment are ones where the patient is laying down. The next generation of MRI scans are called “Standing MRI” where as the name suggests the patient is able to stand, but also sit or hold different positions to reproduce symptoms that are not necessarily present when laying flat. This next generation of MRI scans will be much more specific at pinpointing the extent of disc bulges in different positions.
The first objective of treatment was to reduce the pain and stiffness at the base of the spine. This is done using very specific spinal adjustments and soft tissue techniques to loosen the structures around the injured area to reduce the physical tension. Understanding the body’s response to an injury like this helps to guide treatment. The body has what is known as the “pain spasm pain” cycle when nerves are damaged. This means with each sensation of pain the response is a spasm, which unfortunately causes more pain. The use of ice is very helpful in dealing with this, as it reduces down unwanted nerve discharges and helps with the inflammation in the damaged area.
Inflammation is the body’s response to injury (see my post on Hot Vs. Cold), it follows a common pattern. It causes joints to be more stiff first thing in the morning and then as the day progresses (with gentle movement) the stiffness will ease to a point. The effects of inflammation are most notable with less activity. This is one of the reasons why bed rest is not recommended. Interestingly sleep has an effect on how the body regulates its inflammatory response to damage; as you sleep the hormones in the body that keep inflammation under control are less effective and swelling becomes much more pronounced.
Simple changes to daily routine are also an important part of treatment; in particular the length of time spent sitting at his desk. Even though sitting relieved his leg symptoms, it aggravated his low back, a true Catch 22. The solution here is to use active sitting techniques; this limits total sitting time to less than half an hour before getting up and moving around briefly (not to the point of provoking the leg pain) as well as using air cushions where possible. Incorporating a gentle low back stretch routine across the day further benefits recovery. It is important also to stop over enthusiastic activity (running, tennis etc) where the likelihood is to antagonise the problem further rather than help.
The outcome at the four week review for this case was very positive. The patient is able to walk now without bringing on the leg pain and his low back is no longer tender when sitting. His routine of active sitting and self stretches have continued as a long term strategy to strengthen his low back and core muscles. He is now being encouraged to swim to further the improvement.