Poster 85: Severe aortoiliac occlusive disease presenting as suspected symptomatic high lumbar stenosis: a report of 2 cases

Abstract

Setting: Outpatient physiatric spine center. Patients: 2 patients with the chief complaint of proximal thigh pain. Case Descriptions: 2 middle-aged female smokers were referred by their primary care physician with bilateral thigh pain that had persisted for several years. Each presented with a lumbar magnetic resonance imaging, which demonstrated upper lumbar stenosis. In each case, bilateral and circumferential thigh pain was described, which prohibited the patient from ambulating extended distances and was relieved through quiet standing. A detailed history and radiographic review were not convincing for a corroborative radicular stressor. Each patient was neurologically intact and had diminished lower-extremity pulses. Segmental arterial Doppler studies were performed. Assessment/Results: In each case, a markedly diminished ankle-brachial index was observed. Although a focal drop in pressure was not observed between lower-limb segments, a significant reduction was appreciated when comparing the high thigh to brachial pressure measurements. Computed tomography (CT) angiograms confirmed severe aortoiliac atherosclerotic disease. Each patient was treated with an antiplatelet agent prior to further considering aortofemoral bypass. One patient’s carotid Doppler image revealed severe bilateral occlusion that led to a prompt endarterectomy. Discussion: Neurogenic claudication can present with proximal and anterior lower-extremity pain arising from a high lumbar and stenotic radicular stressor. Vascular claudication most commonly arises from atherosclerosis obliterans, and smoking remains a primary risk factor. Isolated proximal limb pain with ambulation, Leriche’s syndrome, can arise from aortoiliac occlusive disease. Conclusions: Spine practitioners are often consulted to determine if a patient’s limb complaints are arising from a spinal pain generator. These atypical cases highlight a less common pain distribution in the vascular patient, the symptomatic overlap between neurogenic and vascular claudication, and the challenges that arise when evaluating the patient with combined disease.