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Wednesday, August 20, 2014
Spine and Back Health
Neuropathy vs Claudication
In November of `09 I started chemo and radiation for endometrial cancer 99.9% removed with a TAH , but a residual tiny pinhead spot on the suture line of the cervix remained. PET, CA125, etc. were all totally negative. As a result I have continued to have feet and leg pain that is so severe in the evenings with toe swelling. I take Indocet daily. It is fine in the mornings, but evenings are brutal at times. I had spinal stenosis and lumbar disc surgery a year ago that was totally successful and no subsequent problems except the usual limitations. I am 70. In Jan., as a result of chemo, I started with neuropathy and the treatments were stopped after 4 (instead of 6). After Brachytherapy in Feb., back pain began. Both of these have subsequently eased with the exception of the feet pain which persists. The Indocet is usually only 2 in the evening when the symptoms progress to the worst; occasionally I need 4 total; rarely during the day. Walking when the weather isn`t so hot is about 2-3 miles 2-3 times per week with daily dog walks in between. It is hilly where I live. I have never been able to ride a bike because of calf pain and leg pain. I walked 90 miles in the Alps 3 years ago and until Sept., was an active ER nurse. My lifestyle has not been sedentary with heavy gardening for 50 years. My question is: Is this neuropathy or claudication?. My toes swell by the end of the day; I always have some sensation of numbness as well as super sensitivity of my feet. I can no longer wear sandals. It seems as though the more swollen my feet are, the more pain. Would diuretics help? I am on Crestor for choleterol; my blood pressure is wonderful and I have not taken any antihypertensive since starting treatment. I have never smoked or imbibed in alcohol. Could this be a combination of both? Would the Rebuilder help. I do not want to have to take indocet forever, and am not sure that this condition with time will ease. I realize you cannot recommend treatment, but I do need help trying to figure out just what this is. Perhaps a Doppler study would answer the question. Thank you for your time.
Hello, thank you for your question. The most likely differential diagnosis here is between true vascular claudication, neurogenic claudication, or neuropathy, as you have suggested. A quick examination of the pulses, temperature, and skin color of your feet ought to suggest for or against vascular claudication, but if the examination is inconclusive a test called an ABI (ankle-brachial index) is a quick and simple way to assess the blood flow to the feet – it’s based on comparing blood pressures taken with cuffs on the legs versus the arms. Pretty harmless test.
If the question is spinal stenosis and neurogenic claudication versus neuropathy, an EMG study ought to help with that. Usually EMGs are normal in patients with claudication, but should be blatantly abnormal if neuropathy is present. Of course, it’s not always so cut-and-dried, and you must work with your doctor to get to the bottom of things. This doesn’t sound typical of claudication to me, but naturally I can’t diagnose you this way. Good luck.
David J Hart, MD
Associate Professor of Neurosurgery
School of Medicine
Case Western Reserve University