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What is intermittent claudication

  Intermittent claudication refers to the patient’s backache or pain when starting to walk, or after walking for a certain distance, accompanied by unilateral or bilateral lower extremity pain or numbness, resulting in claudication; but after sitting and resting for a period of time, the symptoms gradually eased After walking for a while, the above process and symptoms of pain, numbness and weakness reappeared. Because of the intermittent period, medically called intermittent claudication. In severe cases, both lower limbs are weak and cannot walk on the ground.
  There are many diseases that cause intermittent claudication, mainly caused by three types of reasons. Among them, intermittent claudication (neurogenic) and vascular claudication caused by lumbar spinal stenosis are more common clinically, and intermittent claudication of spinal cord origin is less common. See, the latter is mostly caused by spinal cord lesions and exogenous spinal cord compression factors.
neurogenic intermittent claudication

  Lumbar spinal stenosis due to various causes (commonly, spondylolisthesis, etc.) can cause intermittent claudication of cauda equina origin (neurogenic). After the patient walks a certain distance (tens of meters to hundreds of meters), there will be backache or pain, accompanied by unilateral or bilateral lower limb pain or numbness, resulting in limp; squat or sit for a period of time (5-15 minutes), the symptoms gradually eased or disappeared, and the patient could continue to walk again, but the distance was shorter than the previous walking distance.
  The appearance of neurogenic intermittent claudication is mainly due to the obvious pathological stenosis of the lumbar spinal canal, due to the increased pressure load on the vertebral body and nerve roots when standing upright, and the contraction of lower limb muscles during walking. Promoting the physiological congestion of the nerve root blood vessels of the corresponding spinal ganglion in the spinal canal, followed by venous blood stasis in the spinal canal and traction of the nerve root, the microcirculation of the corresponding part is blocked, and ischemic radiculitis occurs, resulting in low back and leg pain, lower extremity pain Symptoms such as numbness and weakness. When the patient squatted down, sat down or rested on his back, the pressure load on the nerve roots was reduced, and the ischemic state of the spinal cord and nerve roots was improved, so the symptoms were also relieved; when walking again, the above symptoms appeared again; Symptoms are relieved again: This cycle repeats and alternates, forming intermittent claudication. It is one of the main clinical features of lumbar spinal stenosis.
Vasogenic intermittent claudication

  In patients with lower extremity vascular disease (lower extremity arteriosclerosis obliterans and thromboangiitis obliterans), the legs will be heaviness, weakness, numbness, chills, and pain after lower extremity activities, and the affected limbs are not as light as the healthy side when walking Flexible and can be relieved after rest. This is mainly due to the sclerosis and plaque of the blood vessel wall in the lower extremities, the lumen is gradually narrowed, the patency of the pipeline is affected, and the blood flow to the lower extremities is reduced. When the stenosis is to a certain extent or even completely blocked, the blood supply to the lower extremities cannot meet the needs of activities, and ischemia and hypoxia will occur after lower extremity activities, resulting in intermittent claudication. It is mainly caused by the stenosis of the large arteries leading to the obstruction of blood supply to the lower extremities.
  Clinical manifestations of lower extremity arteriosclerosis obliterans
  1. Mild complaining stage (first stage). The skin temperature of the affected extremity is decreased, cold, or mild numbness, easy to fatigue after activity, and the extremity is prone to tinea pedis infection and is difficult to control.
  2. Intermittent claudication (Phase II). Intermittent claudication of the lower leg is the most common symptom of ischemic lesions of the lower extremity. It is characterized by pain in the lower extremity after walking about hundreds of meters to tens of meters, usually manifested as soreness of the calf muscles, but also pain in other parts of the lower extremity. Continue to walk, but the pain can recur as you continue to move. With the aggravation of the lesion, the walking distance for pain is getting shorter and shorter, from a few hundred meters to the last ten meters, or even a few meters, which requires timely treatment.
  3. Resting pain period (third period). Patients still have lower extremity pain even when they are not exercising, especially when they fall asleep at night, which makes the patient sleepless and nervous. Occurs mostly at night, often waking up in pain during sleep, sitting with knees tucked. At this stage, patients must pay close attention to active treatment, otherwise they will enter the advanced stage of the disease.
  4. Tissue necrosis stage (fourth stage). Limb ulcers and gangrene develop. Even if a little skin is broken on the feet, it is not easy to heal, and the lower limbs gradually become necrotic, and eventually they can only be amputated, which is serious and even life-threatening.
  Vasogenic claudication can also be seen in venous lesions
  Vasogenic claudication is not exclusive to arterial lesions and can also be seen in venous lesions. Venous claudication occurs in patients with chronic venous insufficiency. The main symptoms of the patients are the heaviness and soreness of the lower extremities, accompanied by edema of the lower extremities. Some patients have dilation and tortuosity of the superficial veins of the lower extremities.
  Arterial ischemic claudication is seen in lower extremity arteriosclerosis obliterans or thromboangiitis obliterans. The former is more common in the elderly and the latter is more common in young men. From the course of the disease, the symptoms of intermittent claudication caused by untreated arterial ischemia were gradually aggravated, and the walking distance of patients gradually shortened. Patients with arteriosclerosis are often accompanied by cerebral ischemia or myocardial ischemia, and a considerable number of patients are accompanied by diabetes, hyperlipidemia, and hypertension. Thromboangiitis obliterans usually has a history of migratory phlebitis. Patients with arterial claudication often need to stop walking after symptoms appear and take a short rest before continuing to walk. Smoking, diabetes, hypertension, and dyslipidemia are all predisposing factors for the disease.

spinal cord-derived intermittent claudication

  The pathogenic causes are mostly caused by lesions of the spinal cord itself and exogenous compression of the spinal cord, such as acquired or congenital cervical spinal stenosis caused by various reasons (such as severe ossification of the posterior longitudinal ligament); compression by tumors or space-occupying lesions in the cervical spinal canal ; Severe syringomyelia; Short neck deformity caused by fusion of the upper cervical vertebrae, often combined with occipital neck deformity, and neurological symptoms often appear in the early stage, mainly manifested as spinal cord compression caused by occipital and cervical instability. There are two main reasons: (1) spinal cord arterial blood supply disorder, which leads to spinal cord ischemia due to decreased spinal artery circulation; (2) spinal cord venous return disorder causes venous congestion and congestion, leading to spinal cord ischemia. If the above two factors coexist, the result will aggravate spinal cord ischemia.
  Typical clinical manifestations of spinal cord-derived intermittent claudication
  1. After walking for a period of time or a certain distance, lower extremity weakness, numbness, heaviness (the patient complains of not being able to drag the legs), chest and abdomen girdle, drunken gait, etc., resulting in inability of the lower extremities walk.
  2. Accompanied by positive pathological signs (Babinkis’s sign, Oppenham’s sign, Gordon’s sign, ankle clonus), hyperreflexia of knee tendon, and high muscle tone of both lower extremities.
  3. Symptoms are relieved when the patient sits down or rests in bed.
  4. There are different degrees of spinal cord compression on imaging.
Differentiation of neurogenic and vascular intermittent claudication

  1. The pulse of the dorsal artery in neural intermittent claudication is good, and the pulse of the dorsal artery in vascular intermittent claudication is weakened or disappeared.
  2. Neurological intermittent claudication may have segmental sensory disturbances in the lower extremities, and vascular intermittent claudication is a sock-type sensory disturbance.
  3. The walking distance of neurological intermittent claudication gradually shortened with the prolongation of the disease course, but the vascular intermittent claudication was not obvious.
  4. Arteriography can be performed when necessary, the arteries are good in neural intermittent claudication, and the stenotic area of ​​the arterial lumen can be displayed in vascular intermittent claudication.

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