Common iliac artery occlusion presenting with back and leg pain: case report and differential diagnosis considerations for neurogenic/vascular claudication

Figures & data

Figure 1. (a) Pain diagram at time of initial evaluation displaying severe back and leg pain pre-stent; (b) post-stent pain diagram with symptoms alleviation.

Figure 2. (a) Pre-stent angiogram showing 75% right common iliac artery occlusion; (b) post-stent angiogram associated with immediate relieve of back and leg pain.

Table 1. Examination findings associated with neurogenic and vascular claudication.

	Neurogenic claudication	Vascular claudication
Demographics
Age	>60 y/o	>60 y/o
Gender	Male > Female	Male > Female
Subjective
Symptom description	Vague pain, heaviness, fatigue, aching, cramping, burning, and/or paresthesia	Vague pain, cramping, tightness, and/or pressure
Symptom location	More often (B) lower extremity, less commonly low back and buttock(s)	(U) or (B) lower extremity, most commonly in the calf, less commonly low back and buttock
Symptom referral	Begins proximal and radiates distal with exacerbation	Remains localized to involved musculature
Aggravating activities	Positions or activities with lumbar spine extension, i.e. standing or walking	Aerobic activities involving repeated use of lower extremities, i.e. walking or cycling, independent of lumbar spine position
Relieving activities	Positions or activities with lumbar spine flexion, i.e. sitting, leaning forward, stooping, or squatting	Cessation of aerobic activities, independent of lumbar spine position
Time to relief	Prolonged (minutes)	Rapid (seconds–minutes)
Objective Testing
Skin	Normal	Hair loss and atrophy
Vascular Pulses ABI	Present and symmetrical >1.0	Diminished or absent. Often asymmetrical <0.9
Neurologic examination	Occasional/minimal findings	Rare
SLR/Slump tests	Negative	Negative
30-s Extension Test	Typical leg symptoms reproduced during active lumbar spine extension in standing for 30 s	No reproduction of symptoms during active lumbar spine extension in standing for 30 s
van Gelderen Bicycle Test	Symptom reproduction with lumbar extension. Symptom improvement with lumbar flexion	Symptom reproduction with spine in both lumbar extension and flexion
Treadmill Test	Symptoms worse during Stage 1 vs. Stage 2. Longer distance walked during Stage 2 vs. Stage 1	Symptom reproduction during both Stages. No difference in distance walked between Stages

(U) = Unilateral; (B) = Bilateral; ABI = Ankle-Brachial Index; SLR = Straight Leg Raise.

Figure 3. Clinical decision-making for differential diagnosis of neurogenic versus vascular claudication for patients with complaints of lower extremity pain and risk factors for peripheral vascular disease (ABI = Ankle-Brachial Index).