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Background
Intermittent Neurogenic Claudication (INC) is a complex of symptoms first described by Van Gelderen in 1948 and in 1950 by the Dutch neurosurgeon Verbiest, therefore formerly known as the Verbiest syndrome [1-4]. The characteristic symptom is described as leg pain (frequently in both legs) which can be exacerbated with prolonged walking or lumbar extension. Others, like Evans, describe a cramp, tightness or discomfort of the legs after walking which diminish after a short period of sitting or bending forward [1]. Apart from the leg pain, associated low back pain may occur [5].
Since the description of neurogenic claudication by Verbiest, explanation of the symptoms has been disputed. Verbiest stated in 1954:“In the writer’s humble opinion the ligamentum flavum is most unlikely to contact any spinal root unless this root is distorted from its regular path”[4]. Evans showed in 1964 a cerebral spinal fluid stop at the low lumbar levels narrowing of the canal by degenerative facet arthrosis resulting in nerve root compression. INC is often seen in patients with lumbar degenerative spinal stenosis [4]. Due to this arthrosis of the facet joints, lumbar nerve root compression will develop. Arnoldi described multiple types of lumbar spinal stenosis. His article published in 1975 was actually a summarization of a symposium on this subject [4,6]. Presently, his classification is still widely used. Like in any acquired disease, INC is usually seen in the elderly [1].
The best treatment of NIC due to lumbal stenosis remains controversial [5,7]. Nonoperative therapy like epidural steroid injections, nonsteroidal anti- inflammatory medication, analgesics, physical therapy, and spinal manipulation, is frequently performed [8]. A 2005 Cochrane review found that the paucity and heterogeneity of evidence limited conclusions regarding surgical efficacy for spinal stenosis [7,9-12]. Indeed, Weinstein et al published in his article the results of a randomized cohort study with relatively poor results in the non-operative group [13-15]. Despite the high level of crossovers in their study, the treatment effect was favouring surgery on the SF-36 scale for bodily pain. Also Malmivaara et al showed a better recovery after surgery versus conservative treatment with a difference of improvement of 11.3 on the ODI disability scale [16]. Furthermore Turner et al published in their attempted meta-analysis a success rate (good to fair outcome) of 64% after surgical bony decompression in patients with INC [17].
Felix: Design and protocol
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