37M With Symptoms of BackPain Followed by Limb Claudication Pain

 

23-12-2024

This is an Online E Log Book to discuss our patient's de-identified health data shared after taking his signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

OPD 37M with symptoms of sudden back pain after lifting heavy weights 6 months back followed by limb claudication pain after walking 100 mts since last 6 months. @PPM3 has asked interns to perform the 6minute walk test to check if it's a vasculogenic or neurogenic claudication by replicating the pain during his 6 minute walk and seeing what happens after termination of the test, if the pain subsides even with standing or he has to sit and hopefully take a deidentified 1 minute video of the 6MWT outcomes evaluable at the last minute and share here. A corporate hospital did his CT angiography of lower limbs and found some vascular occlusions they wanted to balloon but we don't think they are the cause of his current symptoms.

PPM 1 - OPD patient previously shared above:

After 2 and 1/2 minutes of the 6MWT the patient started having pain as seen in this video captured by our intern

https://youtu.be/1ntMgcPbN5Y?feature=shared

 and for the first assessment we made him stand as there's this text book buzz that vasculogenic claudication can reduce simply without any further change in posture just by reducing the muscular demand for blood supply. His pain reduced just 60-70% and then our intern made him walk again following which the pain recurred and then made him sit this time following which he also squatted and his pain got relieved 100%!

He also mentions that he felt like fecal incontinence during the pain.

As this is favoring more of a lumbar canal stenosis we are getting his Lumbo sacral MRI inspite of the vascular priors gleaned by the previous evaluators elsewhere.

PPM 2 - 

PPM 2 - Useful resource for claudication. Source Paul Brazis.

PPM 1 - We tested his climbing abilities on our ramp and in less than one minute he developed the pain again and climbing down relieved the pain!

PPM 2 - Neurogenic vs vascular?

PPM 1 - 👍

PPM 2 - What is the problem? - Claudication

Where is the problem? - Neurological (needs clinical localisation) vs vascular (risk factors + clinical assessment for vascular insufficiency)

Why is there a problem?

What is the etiological agent and natural history of his life that led to his problem?

Medicine is very simple isn't it @PPM1 sir 😅

PPM 1 - 👍

Very simple if only one can have data capture robots or IOT gathering event data for all citizens in real time!

👆@PPM4 if the lumbar canal stenosis causing neurogenic claudication hypothesis here draws a blind end structurally on the MRI and we are left with this CT angiography offered arterial blockages alone to explain his symptoms would you like to balloon and stent these peripheral vessel occlusions? What would be your cost estimate?

16-01-2025

PPM 1 - Reviewed this patient of neurogenic vs vascular claudication pain in the OPD now!

His diagnostic uncertainty was compounded by the clinico radioligic dys correlation that mandated further testing!

PPM 1 - This is his current MRI done in view of a clinical diagnosis of neurogenic claudication contrary to the angiography that was done elsewhere with a clinical impression of vasculopathy that was perhaps coincidentally vindicated on testing.