NEW BAY CONTRIBUTOR Iona Collins MBBS, BMedSci(Hons), MRCS, FRCS(Orth),
Consultant Spinal Surgeon and founder of the new website www.fixmyspine.co.uk asks the question:
Then you’re not alone.
Many people suffer with their legs, which can stop them going out for that refreshing coastal walk, or even from nipping out to the corner shop to pick up your copy of the BAY magazine. It’s quite debilitating.
Limited walking distance due to tired legs is typically described as claudication, which derives from the Latin word claudus, meaning “lame”. In medical terms, claudication relates to limited walking distance due to either a circulation/vascular problem (vascular claudication) or a spinal problem (neurogenic claudication). It’s possible that both problems can co-exist, of course, but vascular claudication pain tends to ease when you stand still, allowing the circulation to wash away the build up of lactic acid which has built up in the muscles through walking. On the other hand, neurogenic claudication tends to ease when you sit down, leaning forward to create a little more space for the compressed nerves in the spine.
With neurogenic claudication, the walking distance can be improved by commandeering a shopping trolley when picking up the groceries. The act of leaning forward can considerably improve the walking stamina and delay that increasing feel-ing of leg heaviness, like wading in mud. Some people experience sciatica symptoms which quickly resolve after a few minutes of sitting down, so that they look for benches to rest on when walking from point A to point B.
Neurogenic claudication is due to a condition called spinal stenosis (“stenos” is Greek for “narrow”). Nobody knows for sure why some people develop narrowing in the spine, but the condition usually evolves over a number of years, with symptoms gradually developing over time.
A health professional can help to diagnose spinal stenosis, matching the symptoms of neurogenic claudication and examination findings which tend to be fairly innocuous, with the MRI appearance of a narrowed spinal canal. Getting the right information together in order to suspect spinal stenosis isn’t as easy as it sounds. Health professionals tend to take a history and examine people differently, so a group of researchers organised a huge survey of 279 different health professionals from 29 different countries to find out if they could agree on questions which were most likely to point to the diagnosis of spinal stenosis. 80% of them agreed on the following:
- Leg or buttock pain when walking
- Bending forward to relieve symptoms
- Feel better when using a shopping trolley or a push bike
- Weakness, heaviness, numbness, tingling in legs when walking (motor or sensory disturbance
- Equal and normal pulses in the feet
- Weak legs
- Low back pain
These 7 questions were found to be so useful that the paper reporting these findings in August 2016 was awarded a prize by the International Society for the Study of the Lumbar Spine (ISSLS).
When a health professional suspects neurogenic claudication (symptom), the diagnosis of spinal stenosis is made by MRI.
There is evidence to show that doing exercise such as aquatic walking ie. walking in a swimming pool helps to improve the symptoms of spinal stenosis.
- Lose some weight
Weight loss may also help to improve symptoms of neurogenic claudication, with some researchers suggesting that the act of offloading the weight on the spine by leaning on a shopping trolley is the reason why people can walk for longer with spinal stenosis. There is also an association between body mass index, or BMI, and the development of symptoms in association with spinal stenosis.
- Spinal surgery?
When exercise and walking aids, such as a rollator, don’t go far enough to improve the symptoms of spinal stenosis, then surgery can be considered. The commonest operation for spinal stenosis is called a lumbar decompression operation and it is one of the commonest procedures performed by spinal surgeons. This is hardly surprising, when researchers estimate that 9% of the population over 65 years old has spinal stenosis on MRI.
The British Association of Spinal Surgeons has produced useful information about both spinal stenosis and lumbar decompression surgery, with the website details cited in the references at the end of this article. In essence, a lumbar decompression operation involves removing excess tissue which is causing the narrowing in the spinal canal, to allow more room for the spinal nerves. Spinal surgery is not risk-free, however, with surgeons typically quoting an estimated risk of around 1:1000 that the operation may result in permanent paralysis.
Although surgery has a high chance of improving the symptoms of neurogenic claudication, the evidence is not as convincing as perhaps we would like it to be. In 2016, a Cochrane review of published evidence showed a preference for surgery over non-operative treatment, but the authors raised concern over the lack of strong evidence to support surgery. On the other hand, the authors reported the complications recorded in the study such as wound infection, but there were no reported complications in association with treatment that did not involve surgery. The authors recommended caution when recommending surgery due to their findings.
In summary, if you can’t walk as far as you would like to, due to your back and legs becoming painful, heavy and weak, then you may have symptoms of claudication. It’s worth seeing your GP in order to establish a firm diagnosis and then you can try getting your weight into the normal range for your height e.g. around ten stones if you are 5 foot six inches tall and exercise more. If this doesn’t help, sometimes, a spinal decompression operation can help to improve your symptoms.
References supporting this article and further reading (most of these are free downloads online)
- The reliability of differentiating neurogenic claudication from vascular claudication based on symptomatic presentation. Nadeau et al, J Can Chir Vol 56 no 6, December 2013.
- Lumbar spinal stenosis. Genevay et al. Best Pract Res Clin Rheumatol. 2010 April; 24(2):253-265.
- The effects of aquatic walking and jogging program on physical function and fall efficacy in patients with degenerative lumbar spinal stenosis. Lee et al, Journal of Exercise Rehabilitation 2015;11(5):272-275.
- Gait analysis does not correlate with clinical and MR imaging parameters in patients with symptomatic lumbar spinal stenosis. Zeifang et al. BMC Musculoskeletal disorders 2008, 9:89.
- Loading is more effective than posture in lumbar spinal stenosis: a study with a treadmill equipment. Oguz et al. Eur Spine J 2007; 16:913-918.
- Spinal stenosis British Association of Spinal Surgeons website www.spinesurgeons.ac.uk/patients/patient-information/spinal-stenosis accessed July 24th 2016.
- Lumbar decompression surgery. British Association of Spinal Surgeons website www.spinesurgeons.ac.uk/
patients/patient-information/lumbar-discectomy-and-decompression accessed July 24th 2016.
- Surgical versus non-surgical treatment for lumbar spinal stenosis (Review). Zaina et al. Cochrane Database of Systematic Reviews 2016, issue 1.
- SPINE Volume 41, Number 15, pp 1239–1246ISSLS Prize Winner: Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis results of an International Delphi Study. Christy Tomkins-Lane et al.
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