A 63-year-old woman comes to the office due to several months of bilateral leg pain, predominantly in her calves and thighs when she walks. After a block or two, she experiences numbness in both calves and thighs that progresses to pain and weakness with continued walking. The patient's symptoms worsen when she walks downhill, and the pain and numbness quickly subside with rest. Her symptoms often occur at the grocery store, but are relieved when she leans over a cart. She also has lower back pain. The patient has no bladder and/or bowel symptoms, chest pain, chest pressure, dyspnea, or edema.
The patient's medical problems include hypertension, gastroesophageal reflux disease, hyperlipidemia, and degenerative joint disease. She also has a history of coronary artery disease with stent placement in her right coronary artery 2 years ago. Her medications include atorvastatin, metoprolol, aspirin, clopidogrel, lisinopril, and omeprazole.
The patient's blood pressure is 130/80 mm Hg and pulse is 72/min. A bruit is heard over the right carotid artery. There are no abdominal or femoral bruits. Her femoral, popliteal, and dorsalis pedal pulses are normal and symmetric. There are no trophic changes of the skin or nails in the feet. Straight leg raising test is negative. The patient can walk on her heels and toes. There are no lower extremity sensory deficits. Lower extremity deep-tendon reflexes are 2+ and symmetric. Perineal sensation is normal.
Which of the following would establish the correct diagnosis?

Question

A 63-year-old woman comes to the office due to several months of bilateral leg pain, predominantly in her calves and thighs when she walks.  After a block or two, she experiences numbness in both calves and thighs that progresses to pain and weakness with continued walking.  The patient's symptoms worsen when she walks downhill, and the pain and numbness quickly subside with rest.  Her symptoms often occur at the grocery store, but are relieved when she leans over a cart.  She also has lower back pain.  The patient has no bladder and/or bowel symptoms, chest pain, chest pressure, dyspnea, or edema.
The patient's medical problems include hypertension, gastroesophageal reflux disease, hyperlipidemia, and degenerative joint disease.  She also has a history of coronary artery disease with stent placement in her right coronary artery 2 years ago.  Her medications include atorvastatin, metoprolol, aspirin, clopidogrel, lisinopril, and omeprazole.
The patient's blood pressure is 130/80 mm Hg and pulse is 72/min.  A bruit is heard over the right carotid artery.  There are no abdominal or femoral bruits.  Her femoral, popliteal, and dorsalis pedal pulses are normal and symmetric.  There are no trophic changes of the skin or nails in the feet.  Straight leg raising test is negative.  The patient can walk on her heels and toes.  There are no lower extremity sensory deficits.  Lower extremity deep-tendon reflexes are 2+ and symmetric.  Perineal sensation is normal.
Which of the following would establish the correct diagnosis?

Quizplus · Accepted Answer

11ec193a_9912_8d82_853d_9553b67658b3_MD0002_00 This patient's clinical presentation is most consistent with lumbar spinal stenosis, which occurs most commonly in adults age >60 due to degenerative spondylosis. Patients typically present with a syndrome of bilateral pain (pseudoclaudication) that is worsened when walking with the spine extended (eg, downhill more than uphill) or with prolonged periods of standing upright. Both activities decrease the diameter of the spinal canal and cause mechanical and/or ischemic disruption of nerve root function. Symptoms are usually relieved with rest or bending forward while walking (eg, leaning over a cart) as these maneuvers increase the diameter of the spinal canal. Pseudoclaudication may resemble vascular claudication, but the lower extremity pulses are usually normal. Lower extremity neurologic examination may also be normal, although objective weakness may be seen in advanced disease. Lumbar MRI is the preferred test as it best visualizes the soft tissues and neural structures (eg, conus medullaris, spinal nerve roots). (Choice A) Although abdominal aortic aneurysm (AAA) and occlusive peripheral vascular disease can co-exist, most AAAs remain asymptomatic until they rupture. It would be unlikely for this patient's symptoms to be caused by an AAA. (Choice B) Reduced ankle-brachial index (ABI) indicates vascular claudication due to extensive atherosclerotic vascular disease. Lower extremity pulses are usually diminished. However, ABI is usually normal in lumbar stenosis. (Choice C) Bone scan is useful to diagnose metastatic lesions but would be unlikely to be diagnostic in this patient who has no point tenderness of her back, no history of cancer, and no evidence of cauda equina syndrome. (Choice E) Nerve conduction studies are diagnostic for peripheral neuropathy, but this patient's symptoms do not suggest this condition. Educational objective: Lumbar spinal stenosis produces lower extremity symptoms exacerbated by walking downhill and relieved with rest and bending forward; these symptoms are known as pseudoclaudication and may be similar to vascular claudication. MRI of the lumbar spine is the preferred diagnostic test. __________ References: Lumbar spinal stenosis (http://www.ncbi.nlm.nih.gov/pubmed/20227646)

A 63-Year-Old Woman Comes to the Office Due to Several