There are three major clinical categories of intermittent claudication, namely neurogenic, spinal cord-derived, and vascular-derived, which are reviewed in the relevant literature with regard to their mechanisms of occurrence and clinical characteristics.
I. Intermittent claudication of neurogenic origin
The pain and numbness of the lower extremities when walking and the relief or disappearance of the above symptoms after rest are called neurogenic intermittent claudication.
1, lumbar spinal stenosis The lumbar spinal canal is narrowed in one or more places, and the compression of nerve roots or cauda equina causes a series of symptoms called lumbar spinal stenosis, and some people in China summarize its clinical characteristics as follows: intermittent claudication, many complaints but few signs, sometimes it is difficult to detect positive signs after rest, lumbar posterior extension restriction and pain.
The most common clinical manifestation in almost all patients is painful numbness of the lower limbs when walking or standing, and the symptoms can be relieved or disappear when resting or bending over. Most scholars believe that it is related to the following three factors: mechanical compression, impaired blood circulation, and inflammatory stimulation.
2, lumbar disc herniation Some patients can develop neurogenic intermittent claudication mechanism and intermittent claudication caused by lumbar spinal stenosis is basically the same, the difference is that the onset of lumbar scoliosis – restricted activity and neurogenic symptoms and signs are particularly obvious, the affected limb is cold, also known as cold sciatica, it is noted that some patients with lumbar disc herniation, the temperature of the affected limb becomes low to the distal end of the toes. The dorsalis pedis artery pulsation remains normal during examination.
3, lumbar intervertebral disc resorption disease, especially in the elderly due to degeneration and absorption of the nucleus pulposus proteoglycans and water loss, the nucleus pulposus dried up, narrowing of the intervertebral space and lumbar instability, degeneration and narrowing of the intervertebral space above and below the vertebral body end plate hyperplasia and sclerosis, followed by small joint synapse hyperplasia and hypertrophy of the ligamentum flavum triggering lumbar spinal canal and nerve root canal narrowing. Clinically, early lumbar and hip discomfort, gradually becomes lumbar pain and intermittent claudication.
4, lumbar vertebral posterior edge fracture lumbar vertebral body fracture for some reason into the spinal canal, compression and stimulation of nerve roots or (and) cauda equina appear similar to and heavier than the lumbar but canal stenosis or lumbar intervertebral disc herniation symptoms of back and leg pain *.
Intermittent claudication is particularly obvious.
5, pelvic outlet syndrome, called sciatic nerve pelvic outlet stenosis syndrome, the sciatic nerve pelvic outlet is a bony fibrous canal composed of multiple layers of muscle-ligament and connective tissue in the posterior pelvic wall, where soft tissue injury or lesion and pear-shaped muscle variation can cause sciatic nerve irritation or compression, resulting in a series of symptoms or intermittent claudication. On examination, there is significant pressure pain at the sciatic nerve outlet in the buttock and radiating pain in the posterior thigh, and passive internal rotation or resistance external rotation of the lower extremity can induce recurrence of symptoms. Straight leg raise test posterior thigh radiating pain, rarely crosses the N fossa.
6, common peroneal nerve entrapment syndrome A series of neurological symptoms caused by entrapment of the common peroneal nerve as it passes through the peroneal neck. Because the common peroneal nerve is relatively fixed and immobile at the neck of the fibula, its deep side is close to the upper end of the fibula and is confronted by the fibula, the superficial side is located under the skin without protection and is susceptible to compression and tension frictional injuries such as fractures, bone disease, osteomas, soft tissue cysts, plaster bandages and skin traction can compress the common peroneal nerve.
Intermittent claudication may occur depending on the degree of entrapment, such as increased pain in the lateral calf and dorsum of the foot during walking, which may be relieved after rest; mild entrapment of the common peroneal nerve is often graphically described as a fidgety calf, which can be considered based on history, signs and symptoms, as well as radiographic and electromyographic changes. This disease can be considered based on history, symptoms and signs, as well as radiographic and electromyographic changes.
The anatomical basis of this disease is the presence of the anterior crest of the inferior fibula and the compression of the superficial peroneal nerve by the deep fascia or the supraspinatus support band of the calf muscle.
The main clinical features of this disease are severe pain in the lower leg, anterior ankle and dorsum of the foot when walking and standing, and pain reduction or relief after stopping standing and walking and elevating the affected limb, as reported by Chengying Jiang. On physical examination, there are fixed pressure points on the lateral side of the lower and middle legs, and the skin of the dorsum of the foot and the front of the ankle feels allergic to the pain caused by the pulling of the superficial peroneal nerve branches at the site of penetration of the deep fascia when the ankle joint is strongly inwardly turned.
Electromyography suggests changes in the sensory latency of the superficial peroneal nerve.
Intermittent claudication of spinal cord origin
Due to the lesion of the spinal cord itself or due to the compression of the spinal cord by external factors, the weakness, sinking, numbness, soreness and swelling of the lower limbs are felt after walking for a certain time or distance, resulting in the inability to walk and recovery after a few moments of rest is called spinal cord-derived intermittent claudication.
1, endogenous lesions of the spinal cord previously mentioned neurogenic intermittent claudication is familiar to everyone, but intermittent claudication due to the spinal cord itself is less common, the first report of spinal cord-derived intermittent claudication in 2007, the etiology are spinal cord lesions themselves such as: spinal vascular lesions / spinal arteriovenous fistula and other vascular malformations. Some literature also refers to spinal cord hemangioma, spinal cord trapezoid hemangioma, spinal cord arteriovenous hemangioma, etc..
It is a lesion formed by congenital abnormal development of spinal cord blood vessels and is not essentially a tumor. The relationship between pathology and pathophysiological features and clinical symptoms is that most of the spinal cord vascular malformations contain arteriovenous short-circuiting forming direct shunts between the arteries and veins resulting in intermittent claudication of spinal origin in some patients due to spinal cord ischemia. When the lesion develops progressively, bleeding from the malformed vessels can cause damage to the spinal cord and nerve roots and cause paralysis.
2, Spinal cord-derived intermittent claudication due to exogenous compression of the spinal cord has been reported clinically very rarely. Kikuchi-Chen et al. reported spinal cord-derived intermittent claudication due to cervical or thoracic spinal cord compression caused by degenerative diseases, and conducted a systematic study and analysis of this group of cases, suggesting that the disease is caused by compression resulting in reduced arterial circulation of the spinal cord, venous stasis or venous congestion, or the combined effect of these two factors resulting in spinal cord ischemia.
Wang Shaobo et al. reported intermittent claudication of spinal cord origin due to compression of the spinal cord by degenerative diseases of the cervical and thoracic spine and applied the walking load test to this group of cases, i.e., after walking for a period of time or distance, there was a feeling of binding or weakness of the lower limbs that prevented walking, and the symptoms disappeared after resting for a certain period of time, at which time the cone bundle sign could appear on examination, and there was no cone bundle sign before walking or the cone bundle sign was more obvious and new cone bundle sign appeared. This is a positive walking test.
Intermittent claudication of vascular origin
The lower extremity ischemia is caused by the lesion of small and medium-sized blood vessels! When the patient walks for a certain time or distance, pain and numbness in the lower extremities occur. The pain is relieved after forcing the patient to stop and rest for a few moments! This is a typical symptom of chronic arterial insufficiency of the lower limbs. It is also the early stage of peripheral arterial lesions.
1, thrombo-occlusive vasculitis abbreviated as vasculitis, a common disease of vascular surgery, is an inflammatory and occlusive lesion involving blood vessels, especially the small and medium-sized arteries of the lower extremities, “mostly young and middle-aged men. The main symptoms in the early stage are pain and numbness in the affected limbs, coldness and abnormal sensation, and the above symptoms are aggravated after a long walk, and intermittent claudication gradually appears.
It is thought to be caused by a combination of factors: smoking, cold, skin mold infection, hormones, prostate dysfunction, genetic abnormalities or autoimmune dysfunction. Early suspected cases of this disease can be further diagnosed by Doppler ultrasound, limb hemogram, arteriography, infrared thermogram and other tests.
2, atherosclerotic occlusive lesions located in the lower limb arteries can also produce lower limb ischemic symptoms such as intermittent claudication, the main features of the disease: most of the elderly, hypertension, coronary arteriosclerosis and other diseases, the lesions mainly invade the larger or medium-sized arteries. e-ray film may show calcified spots in the arterial sites, “can also be used to Doppler ultrasound and other methods of examination to clarify the diagnosis.”
3, primary wandering thrombotic superficial phlebitis This disease can be complicated by chronic arterial insufficiency of the lower extremities at a certain stage of development with intermittent claudication, and it is noteworthy that about half of the patients with vasculitis can show clinical manifestations of wandering thrombotic superficial phlebitis in the early and middle stages”
4, periarteritis nodosa This disease mainly invades the small and medium-sized arteries, the lower extremities can appear similar to the ischemic symptoms of vasculitis, its clinical features: extensive lesions, often involving the kidneys, hearts and other internal organs! There may be subcutaneous nodules arranged along the arteries! Blood tests show hyperglobulinemia and biopsy of arterially arranged nodules can make a clear diagnosis.
5, diabetic foot disease Many people refer to the complication of diabetes mellitus with vascular and nerve damage to the foot as the diabetic foot. Some statistics show that about 50% of patients develop peripheral vascular disease within 10 years after the onset of diabetes. The mechanism of how diabetes mellitus causes vascular and neurological complications in the foot is unknown.
6, N artery “siege” syndrome is also known as N artery extrusion syndrome. It is also thought to be an important cause of intermittent claudication due to pain and discomfort in the calves of young people, which is rare and easily misdiagnosed! Intermittent claudication is the only symptom, and it is more common in men! It is thought that it may be related to muscular development.