Low back pain due to arterial obstruction.

There are enough commonly known causes of backache to torment, as well as to test the skill of, the practising physician. In addition to the more recognised causes. backache from vascular obstruction must be considered. The following observations support this fact. The term claudication properly means limp. and in some instances there may be no pain but only weakness of the legs with disturbance of gait. “ Intermittent claudication “ has generally been applied to the cramp-like pain in the calf brought on by exertion and relieved by rest. This symptom, as a rule, is so typical in the lower extremities that when such information is obtained the diagnosis of arterial obstruction may readily be made. Even in the absence of the more frequent discomfort in the legs. such pain may be located in the muscles of the low back and gluteal regions. Because the pain in the low back may be the predominant. or at times the only, symptom of arterial obstruction, the actual etiology may be overlooked and the back pain attributed to some local disease of the musculo-skeletal system. Such observations have been made before in isolated cases. Homans (1939) stated that the discomfort of peripheral vascular disease could at times simulate “ sciatic neuritis.” Leriche (1940) described the syndrome that now bears his name, and in a more complete account (Leriche and Morel 1948) he emphasised that thrombotic obliteration of the aortic bifurcation does not necessarily cause a typical cramp-like calf pain, but that more frequently the patient complains of easy fatiguability in the lower extremities. Although none of the four patients that he reported had associated low backache, one had symptoms typical of “sciatica.” Leriche mentioned other signs and symptoms, such as impotentia erigendi. pallor of the legs and feet when standing, and global atrophy of both lower extremities, and these symptoms have often been regarded as an essential feature of aortic or iliac obstruction. Subsequent workers (Morel 1943; Kramer, Perilstein and de Medeiros 1958) have found that any or all of these additional signs may be lacking and that the only symptom may be that of pain or weakness in the legs. Other observers (Ortner and Griswold 1950; Samuels 1950; Goodwin and Petrie 1951; Kekwick, McDonald and Semple 1952; LeFevre, Phalen and deWolfe 1953; deWolfe, LeFevre, Humphries, Shaw and Phalen 1954; and Phalen 1955) have reported cases of cramp-like suffering in the low back associated with similar pain in the gluteal muscles and in the muscles of the thighs and calves after exertion. Pain localised exclusively in the back. however, has not received adequate attention. The present study was prompted by the investigation of several patients with aorto-iliac obstruction who appeared with low back pain as the initial symptom. Sixty patients, fifty-two men and eight women, were seen at the Johns Hopkins Hospital in a period of six and a quarter years, between June 1952 and September 1958. The diagnosis of aorto-iliac obstruction was proven in each case either by aortograph, operation, or both. Analysis of these cases showed that thirteen of the sixty patients had low back pain, with or without “sciatica.” as a prominent symptom. In two instances the low back pain was attributed to a previous injury to the back, and in one other instance to a urinary tract infection. Ten patients had been