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An Arterial Pulse Examination Is Not Sufficient for Diagnosis of Peripheral Arterial Disease in Lumbar Spinal Canal Stenosis: A Prospective Multicenter Study

Imagama, Shiro MD*; Matsuyama, Yukihiro MD*; Sakai, Yoshihito MD*; Ito, Zenya MD*; Wakao, Norimitsu MD*; Deguchi, Masao MD; Hachiya, Yudo MD; Osawa, Yoshimitsu MD§; Yoshihara, Hisatake MD; Kamiya, Mitsuhiro MD**; Kanemura, Tokumi MD††; Kato, Fumihiko MD‡‡; Yukawa, Yasutsugu MD‡‡; Yoshida, Toru MD§§; Harada, Atsushi MD¶¶; Kawakami, Noriaki MD***; Suzuki, Kazuhiro MD†††; Matsubara, Yuji MD‡‡‡; Goto, Manabu MD§§§; Sato, Koji MD¶¶¶; Ito, Shigehiko MD****; Maruyama, Koji MD††††; Yanase, Makoto MD‡‡‡‡; Ishida, Yoshihiro MD§§§§; Kuno, Naoto MD¶¶¶¶; Hasegawa, Takao MD*****; Ishiguro, Naoki MD*

doi: 10.1097/BRS.0b013e3181ebd86f
Clinical Case Series

Study Design. Prospective, multicenter study.

Objective. To conduct peripheral arterial disease (PAD) screening on intermittent claudication (IC) in patients with lumbar spinal canal stenosis (LSCS) to examine the relationships among combined LSCS and PAD, symptoms, and physical findings.

Summary of Background Data. IC occurs due to two underlying diseases, LSCS and PAD, and has an increasing prevalence with the aging of society. Reliable diagnosis of PAD is critical for appropriate conservative management of IC patients with LSCS in an Orthopedic Surgery Outpatient Department (OSOPD).

Methods. PAD tests were prospectively conducted in 201 patients with IC and LSCS who initially visited an OSOPD at a hospital affiliated with the Nogoya Spine Group. Occurrence of PAD as a complication was assessed using ankle brachial pressure index (ABI) and toe brachial pressure index (TBI) tests. PAD was diagnosed in patients with ABI ≤ 0.9 or TBI ≤ 0.6, and the relationship of the occurrence of PAD with symptoms and physical findings such as abnormal arterial pulses was investigated.

Results. Combined LSCS and PAD was found in 52 patients (26%), with 45 cases (22%) diagnosed on the basis of TBI test in patients with a normal ABI. Of the patients with PAD, many suffered from risk factors for PAD, with a significantly higher frequency of PAD in patients with hyperlipidemia (P < 0.05). PAD also occurred significantly more frequently in patients with abnormal pulses in the popliteal (P < 0.05), posterior tibial (P < 0.0001), and dorsal pedis (P < 0.0001) arteries; however, the sensitivity of these tests for PAD diagnosis was relatively low, at 34%, 60% and 68%, respectively.

Conclusion. The results of the prospective study define the rate of occurrence of combined LSCS and PAD using ABI and TBI tests for the first time, and the findings suggest that screening for PAD should be conducted in LSCS patients. ABI and TBI tests are necessary for PAD screening in outpatients, whereas observation of the arterial pulse in the lower extremities is necessary but not sufficient for PAD diagnosis.

Peripheral arterial disease tests (ankle brachial pressure index and toe brachial pressure index) were conducted prospectively in 201 outpatients with lumbar spinal canal stenosis. Combined lumbar spinal canal stenosis and peripheral arterial disease was found in 52 cases (26%), with 45 of these diagnosed only by the toe brachial pressure index test. Ankle brachial pressure index and toe brachial pressure index tests are necessary because examination of the arterial pulse is not su. cient for the diagnosis of peripheral arterial disease.

* Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan.

Department of Orthopaedic Surgery, Nagano Red Cross Hospital, Wakasato, Nagano, Japan.

Hachiya Orthopaedic Hospital, Chikusa-ku, Nagoya, Japan.

§ Department of Orthopaedic Surgery, Nagoya First Red Cross Hospital, Nakamura-ku, Nagoya, Japan.

Department of Orthopaedic Surgery, Toyohashi Municipal Hospital, Aotake-cho, Toyohashi, Japan.

** Department of Orthopaedic Surgery, Aichi Medical University, Nagakute-cho, Aichi-gun, Japan.

†† Department of Orthopaedic Surgery, Konan Kosei Hospital, Nobaku-cho, Konan, Aichi, Japan.

‡‡ Department of Orthopaedic Surgery, Chubu Rosai Hospital, Minato-ku, Nagoya, Japan.

§§ Yoshida Orthopaedic Hospital, Toyota, Aichi, Japan.

¶¶ National Center for Geriatrics and Gerontology, Obu, Aichi, Japan.

*** Department of Orthopaedic Surgery, Meijo Hospital, Naka-ku, Nagoya, Japan.

††† Department of Orthopaedic Surgery, Anjo Kosei Hospital, Anjo-cho, Anjo, Aichi, Japan.

‡‡‡ Department of Orthopaedic Surgery, Kariya-Toyota General Hospital, Sumiyoshi-cho, Kariya, Aichi, Japan.

§§§ Goto Hospital and Spine Center, Sakuragi-dori, Toyokawa, Aichi, Japan.

¶¶¶ Department of Orthopaedic Surgery, Nagoya 2nd Red Cross Hospital, Showa-ku, Nagoya, Japan.

**** Department of Orthopaedic Surgery, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan.

†††† Department of Orthopaedic Surgery, Nakatsugawa municipal Hospital, Nakatsugawa, Gifu, Japan.

‡‡‡‡ Department of Orthopaedic Surgery, Nagoya Kyoritsu Hospital, Nakagawa-ku, Nagoya, Japan.

§§§§ Department of Orthopaedic Surgery, Handa Municipal Hospital, Toyo-cho, Handa, Aichi, Japan.

¶¶¶¶ Department of Orthopaedic Surgery, Tokoname Municipal Hospital, Koie-honmachi, Tokoname, Aichi, Japan.

***** Department of Orthopaedic Surgery, Tokai-Kinen Hospital, Hazama-cho, Kasugai, Aichi, Japan.

Address correspondence and reprint requests to Shiro Imagama, MD, Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai, Showa-ku, Nagoya, 466-8550, Japan, E-mail: Imagama@med.nagoya-u.ac.jp

The authors thank all the staff of Nagoya Spine Group for allowing me to study their patients.

Acknowledgement date: March 17, 2010. Acceptance date: May 24, 2010.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

This article is designed and submitted acting on guideline of institutional review board of Nagoya University Graduate School of Medicine and all patients have signed consent forms for this study.

© 2011 Lippincott Williams & Wilkins, Inc.