CASE STUDY AND QUESTIONS: To be completed by the 6 th September

Week 7: Case Study Tim

45-year-old male
Tim a 45- year-old male presents to your office suffering low back and left leg pain.
The back pain was felt centrally and was intermittent.

History of Presenting Complaint

The symptoms occur with fast walking for more than 15 minutes, prolonged standing,
and occur occasionally at night. The leg pain is posterior and is described as an
ache rather than a sharp pain. The leg pain generally starts just after the onset of
the back pain. Walking, sitting or flexing the trunk eased the pain, usually in about
15 minutes.
The pain in the low back and leg have been present for about 3 years. There is no
known cause or onset. The symptoms are progressively getting worse particularly
over the last 4 months. He had tried various medications and chiropractic treatment
all without relief. He had been well previously with no signs or symptoms of arthritis
and there was no history of trauma. His past medical history was unremarkable.
Physical Examination

The patient appeared fit. His pulses of the lower limb were normal. The lumbar
spine was hypolordotic. The patient is thin. All lumbar movements were generally
stiff with little extension occurring in the spine. Most of trunk extension was the
result of hip flexion. Flexion was better but he was only able to reach to his knees.
Lateral flexion was restricted by 40% in both directions with a slight ache in the lower
back on left lateral flexion (right lateral flexion was painless). Rotation to the left was
restricted by 60% with low back pain. Right rotation was only slightly restricted
(30%) and painless. None of the movements reproduced the pain in the left leg.
SLR, Nachlas and Ely’s were negative. There were no neurological deficits.
Palpation to the lumbar spine was painless but restricted in all lumbar segments.
Compression and distraction testing were negative or unremarkable.

Questions:
1. Do you think this patient has vascular or neurogenic claudication/ Explain your
answer.

The term neurogenic claudication is applied to the diagnosis for those people
with such lower extremity pain who have no ischaemia to the leg muscles but
rather who suffer from compression of the cauda equina in the lumbar spine
resulting in a neurological basis of this malady.
Based on the presentation of back pain that is alleviated in flexion and
extension aggravating the pain, the pulses being normal, pain that can come
on with rest. SLR maybe positive I am favoring neurogenic claudication. (see
table)

DIFFERENTIAL DIAGNOSTIC POINTS OF

INTERMITTENT CLAUDICATION

FINDING VASCULAR NEUROGENIC

CLAUDICATION CLAUDICATION
Arterial Pulses in the lower Absent Present
limb
The pain in the legs is Walking but not postural Walking and postural
induced by: change. change.
Flexion alleviates, extension
aggravates

The pain in the legs is Rest Forward flexion, squat.

relieved by:

The pain in the legs is
accompanied by LBP,
buttock and thigh pain:
The type of Pain is:
No low back and leg pain.
Typically presents with calf
pain
Cramping
Common
Sharp/shooting
Pins and needles, sensory
disturbances (subjective
and/or objective)

The pain comes on at rest: No Yes and No (depending on

position)

There is sensory loss No Yes or No

The SLR test is: Negative Maybe positive

 Arterial Murmur Present (likely) Not present
Plain film x-ray findings: Arteriosclerosis Spondyloarthrosis.
Plaquing.

2. Run through the GORPOMNICS physical examination that would eliminate

and/or confirm whether this patient is suffering from vascular claudication or
neurogenic claudication.

GORP in standing, sitting, supine and prone according to relevant part of

mnemonic. ROM is diagnostic for vascular verse neurogenic where flexion
alleviates neurogenic and extension aggravates. Rotation and lateral flexion –
side where IVF is decreased may reproduce the pain in neurogenic. Tests:
refer to table for tutors (vascular verses neurogenic). Plus other diagnostic
tests are any test that decreases the IVF (for neurogenic claudication). This
includes homer pheasant which involves creep. Kemps can be positive
because it reduces the IVF.

Back pain common with neurogenic, proximal pain, decreased sensory/ motor
findings
Xray hypertrophic changes with neurogenic claudication
Xray show arteriosclerosis in vascular claudication
CT and MRI examine soft tissue encroachment

SMR exam, vascular exam of peripheral pulses and heart auscultation

SLR and variations of

3. Refer to the diagram below. Does this represent central stenosis or lateral
recess stenosis? Would there be neurological signs present? Explain your
answers.
- Both
- Hypertrophied ligamentum flavum would cause central canal stenosis
- Degenerative IVF would cause lateral recess stenosis
- Myelopathy would be present due to central canal stenosis
- Radiculopathy would be present due to lateral recess stenosis
 http://ddjointpain.weebly.com/neurogenic-claudication.html

Test For Case 7 indicate the likely outcome for the

following tests. Indicate whether it is likely to
be a true positive, false positive, true
negative, false negative
Squat test TP
Lumbar Kemps test TP
Lumbar Vertical compression
test
 Slump test
Djerine’s triad (Valsalva,
cough, sneeze)
Flip or Bechterew’s test TP
Straight leg raising test (SLR) TP
Well straight leg raising test TP
(WSLR)
Bilateral straight leg raising
test
Braggard’s test TP
Bonnet’s test
Bowstring’s test TP
Kernig’s/Brudzinski’s test
Milgram’s test
Nachlas test (prone knee
bending
Ely’s test
Stoop Test TP
Lumbar springing test TP
Trendelenburg’s test TP
Patrick Fabere test
Sign of the Buttock
Bicycle test TP
Belt test or supported Adam’s
Ober’s test

From the ‘likely diagnosis’ for Cases 7, complete the following table:

General questions on Vascular and Intermittent claudication

1.From the information in the above case history and physical examination, what is
the most likely diagnosis?
2. Which of the following tests/assessments typically differentiates between
neurogenic claudication and vascular intermittent claudication?

Spinal stenosis typically occurs in patients whose lumbar spines are:

True spinal stenosis implies constriction of the spinal canal by bony or soft
tissue intrusions. Incidence 5/1000 over 65 yrs – 35% of chronic low back pain
are related to this disorder. Male > female
Commonly L5 (75%), L4 (15%).
Risk factors: advanced age, previous spine trauma or surgery
Spondylolisthesis, scoliosis

Spinal Stenosis leads to compression of the contents of the canal, capable of

causing neural compression.
Irritation of the cauda equina by disc protrusion or a narrowed canal creates a
relative ischaemia of the involved nerve roots. This results in hypoxia which is
further aggravated by exercise and the increased oxygen consumption in the
activated nerves.

3. Dynamic lateral recess stenosis more typically occurs in:

DYNAMIC: This is caused by increased intersegmental motion secondary

to the unstable phase of degeneration. It may be recurrent and relieved by
conservative treatment.

5. The most common causes of developmental or acquired spinal stenosis are:

ACQUIRED: Due to degenerative disc disease, ligamentum flavum

hypertrophy, trauma, post surgical scarring, ossification of the posterior
longitudinal ligament, osteoarthritis, or spondylolisthesis. This is seldom
prevalent before the age of 50

6. Which of the following enables the clinician to differentiate between an

intervertebral disc herniation and spinal stenosis.

7. Fixed central stenosis is usually associated with:

FIXED STENOSIS: This term is used when spinal degeneration has reached
stabilisation, or it can applied during the unstable phase if the stenosis is so
severe that it is unable to be relieved by a change in vertebral position.
8. Dynamic lateral recess stenosis may be associated with:

The most common cause of Lateral Recess Stenosis is Facet hypertrophy or

degenerative changes of the articular processes and posterolateral disc
herniation. Uncinate hypertrophy of the cervical spine may also be considered
a cause.

9. A congenitally small spinal canal:

Eisenstein’s method
No single measurement should be less than 15 mm (though some have
suggested a 14 mm minimum. 12 mm is considered relative stenosis
10 mm is considered absolute stenosis. The interpedicular distance,
considered subnormal if < 18 mm

10. The pain from lateral recess stenosis is usually

1. Pain in the back with either claudication or sciatic type pain in the legs.
2. Pain on standing with relief by lying down but often by sitting down.
3. Cramping and pain in the calves on walking for short distances.
Decreasing ability to walk noted over the past 2 years. If walking is
continued, paraesthesia and numbness in one or both legs becomes
unbearable. Gait becomes unsteady.
4. Walking up hill is easier than walking down hill
5. Riding a bike can be done with ease, often for long distances
6. Hyperextension of the low back is impossible because of pain.
7. Circulation in the legs is normal
8. The patient is usually (but by no means invariably) past 5 and may be either
male or female.
9. The pain may be unilateral or bilateral, or more severe in one leg than the
other.
10. The pain is relieved by flexion of the lumbar spine and aggravated by
extension
11. Weinstein states that the most classic finding of narrow lumbar canal to be
aggravation of the pain in the lower extremities following exaggerated
lordosis of the lumbar spine.
12. The patient will tend to have a bent forward posture as to relieve the
pressure on the stenotic area.
13. Since the recess contains the nerve root, the symptoms in any spinal area
will be radicular in nature. The symptoms are characteristically intermittent
in nature.

A patient presents with neurogenic claudication. An x-ray is taken of L5-S2 shown

below. Discuss the mechanism by which this person may have a diagnosis of
neurogenic claudication.

http://headbacktohealth.com/Retrolisthesis.html

Eisenstein’s method
No single measurement should be less than 15 mm (though some have
suggested a 14 mm minimum. 12 mm is considered relative stenosis
10 mm is considered absolute stenosis. The interpedicular distance,
considered subnormal if < 18 mm

References
Souza T: Differential Diagnosis and Management for the Chiropractor:
Protocols and algorithms, Jones and Bartlett Learning, 2016

Yochum T.R. Rowe L.J. (2004) Essentials of Skeletal Radiology 1st. Ed.
Williams and Wilkins, Baltimore, USA

General questions on Vascular and Intermittent claudication

4. From the information in the above case history and physical examination, what is
the most likely diagnosis?
a Vascular intermittent claudication
b Neurogenic claudication (dynamic lateral recess stenosis)
c Neurogenic claudication (central spinal recess stenosis)
d Intervertebral disc prolapse at L5- S1
e Left sacro-iliac ligament sprain.

3. Which of the following tests/assessments typically differentiates between

neurogenic claudication and vascular intermittent claudication
a Active lumbar range of motion.
b SLR
c Compression and distraction testing
d Assessing the dorsalis pedis and posterior tibial pulses of the lower
limb.
e ‘a’ and ‘d’

4. Spinal stenosis typically occurs in patients whose lumbar spines are:

a. Hyperlordotic
b. Hyolordotic
c. Scoliotic (normal lumbar sagittal curve)
d. Normal lumbar sagittal curve
e. All the above

5. Dynamic lateral recess stenosis more typically occurs in:

a. Men age between 15 and 35 years of age
b. Men and women between 30-55 years of age
c. Women between 45 and 60 years of age
d. Women between 15 and 35 years of age
e. Men over 60 years of age.

6. The most common causes of developmental or acquired spinal stenosis are:

a. Hypertrophy of the facet joints
b. Hypertrophy of the ligamentum flavum
c. Isthmic Spondylolisthesis
d. ‘a’ and ‘b’ only
e. ‘a’, ‘b’ and ‘c’

11. Which of the following enables the clinician to differentiate between an

intervertebral disc herniation and spinal stenosis.
 a. Arterial pulses of the lower limb
b. SLR (straight leg raising test)
c. Lumbar range of motion (particularly flexion and extension)
d. Compression and distraction testing
e. Palpation of the affected segments.

12. Fixed central stenosis is usually associated with:

a. Neurological signs and symptoms
b. Unilateral leg pain and back pain
c. Dural signs
d. Spondylosis
e. ‘a’, ‘c’ and ‘d’

13. Dynamic lateral recess stenosis may be associated with:

a. traction spurs
b. claw spurs
c. annular tearing
d. retrolisthesis
e. all of the above.

14. A congenitally small spinal canal:

a. Invariably causes symptoms associated with spinal stenosis
b. May predispose to spinal stenosis i.e. It is clinically silent.
c. Usually only affects (compresses) the nerve root
d. Usually only affects (compresses) the spinal cord.
e. ‘b’ and ‘c’

15. The pain from lateral recess stenosis is usually:

a. Referred
b. Radicular (following a dermatomal pattern)
c. Associated with pins and needles in the lower extremities bilaterally.
d. Felt in both legs in a dermatomal pattern
e. Felt in the central low back.

Study Guide Questions: 7.4

The questions for this week will focus on Vital Signs assessment.

Answer the following questions on this topic:

Q1. Name the 4 measurements which comprise the ‘vital signs’ temperature, radial
pulse, respiration, blood pressure
Q2. State if the following are True or False:

a. Body temperature is usually lower early in the morning, compared to the

evening T
b. Using a tympanic membrane thermometer is preferable to other methods in a
child with a suspected ear infection. F
c. When measuring pulse and respiratory rate, it is best to count for 15 seconds
then multiply by 4. T
d. The pulse rate is usually higher in a newborn than in a child. T
e. The most common cause of an irregularly irregular pulse is atrial fibrillation. T
f. A pulse which is very strong and forceful is usually denoted as 1+ F
g. The average respiratory rate generally increases from birth to adulthood. F
h. The average blood pressure generally increases from birth to adulthood T

Q3. When taking the pulse, the 3 major measurements you need to do are
rate, rhythm and volume

Q4. The level of blood pressure is determined by cardiac output, blood volume and
Peripheral vascular resistance

Q5. The apparatus used to measure blood pressure is called a

sphygmomanometer

Q6. What are the 8 domains that are considered and assessed when conducting a
Mental State Exam?

Appearance

Behaviour

Speech and Language

Mood and Affect (Feelings)

Thought Content

Thinking (Perception)

Cognition

Insight and Judgement