A 49-yr old man was referred by primary care for evaluation of low back pain. The patient reported chronic mild axial lumbar region pain with a more recent onset of left gluteal/hip and thigh region pain, with the latter being more bothersome. This newer pain was described as a “fatigue” sensation that only occurred after walking for approximately 15 mins and promptly resolved with rest. He denied any radiation of this pain to the distal lower limb or any lower limb neurologic symptoms. His medical history was significant for hypercholesterolemia, hypertension, and a 70–pack year smoking history.
Lumbar examination was benign, with no tenderness and full pain-free range of motion. Lower limb neurologic examination result was normal as well. Vascular examination was notable for an absent left pedal pulse and reproduction of the patient’s typical left gluteal/hip region symptoms after ambulating 10 mins. Lumbar radiographs demonstrated degenerative disc changes at L4–5 and L5–S1.
The patient was referred for Ankle-Brachial Index measurements. Results revealed moderately severe left peripheral arterial disease (Ankle-Brachial Index: left, 0.62; right, 0.91). Vascular surgery was consulted and a computed tomography angiogram (Fig. 1) demonstrated occlusion of the entire left external iliac artery. One month later, the patient underwent left ileofemoral bypass, which resulted in the complete resolution of his left gluteal/hip region claudication symptoms. Follow-up Ankle-Brachial Index measurement 3 days after surgery showed marked improvement (left, 1.02; right, 1.10).
Low back pain remains one of the most common reasons for physician visits in the United States.1 A single specific etiologic diagnosis is infrequently identified in most low back pain patients.2 Although the differential for low back pain is quite broad, physicians must remain cognizant of less common but treatable causes of regional low back pain. This case highlights the importance of paying close attention to the salient aspects of a patient’s history. In this patient with multiple cardiovascular risk factors, the recent onset of new proximal limb symptoms was exacerbated by exertion and was alleviated with rest, and an absent lower limb pulse on examination all pointed to vascular claudication as the etiology for his pain.
Peripheral arterial disease typically presents with posterior distal leg pain. However, this patient’s symptoms were more consistent with proximal vessel peripheral arterial disease, and this suspicion was confirmed with the Ankle-Brachial Index measurement and computed tomography angiogram. Complete and successful resolution of his symptoms with a vascular bypass procedure further confirmed this diagnosis.
1. Walker BF: The prevalence of low back pain: a systematic review of the literature from 1966–1998. J Spinal Disord
2000; 13: 205–17
2. Deyo RA, Kent D: What can the history and physical examination tell us about low back pain? JAMA
1999; 268: 760–5