Original ArticleUnilateral repetitive tibial nerve stimulation improves neurogenic claudication and bilateral F-wave conduction in central lumbar spinal stenosis
Introduction
Repetitive electrical nerve stimulation of the lower limb provides a beneficial effect on neurogenic claudication in patients with lumbar spinal stenosis (LSS). This type of neuromodulation has received little attention since originally described by Tamaki et al. (1986) [1] and confirmed by Takahashi et al. (1988) [2], despite its potential as a useful treatment option for LSS.
More recently (2014) [3], one study reconfirmed this stimulation-induced effect, showing in a series of LSS patients that repetitive tibial nerve stimulation at the ankle (RTNS) at the mild intensity of 5/s for 5 min doubled their maximal walking distances, at which point they could no longer continue walking due to an aggravation in leg symptoms (i.e., absolute claudication distance) [4]. The same study also revealed that conduction velocity of the tibial nerve F-wave significantly increased on the side receiving RTNS in LSS patients, but not in age- and sex-matched healthy subjects, suggesting an RTNS-induced improvement in motor nerve conduction in already impaired LSS patients.
To further clarify this neuromodulation, in the present exploratory study, we investigated whether the effects of RTNS applied to one leg in LSS patients occurred specifically in the stimulated nerve or more extensively in other unstimulated nerves, by conducting the electrophysiological study on both sides. Additionally, we compared the data for the two groups of central LSS patients; RTNS(+) group and RTNS(−) group. We also sought to determine whether RTNS affects the proximal motor segment, the distal motor segment, or both, by comparing the latency changes of F-wave vs M-wave induced by RTNS.
Section snippets
Patients
For our study, we selected a total of 26 LSS patients out of those who had been consecutively referred to Kochi Medical School for decompression surgery between October 2016 and March 2017. Our inclusion criteria comprised the following: (1) the presence of neurogenic claudication; (2) a claudication distance of less than 500 m; (3) radiologically-confirmed central LSS affecting both legs without radicular symptoms caused by lateral recess compression of an individual nerve root; and (4)
Results
The two groups showed no significant differences in age (p = 0.379), sex (p = 0.826), height (p = 0.304) or level of the most intense thecal sac compression (p = 1) (Table 1).
Discussion
Neurogenic claudication typically occurs in central LSS, which is classified radiographically as the stenosis located in the central canal with thecal sac compression tending to affect both legs [9]. Claudication symptoms may result from compression-induced focal nerve ischemia, as generally believed, because of its rapidly reversible nature. Various previous studies support this view. Cerebrospinal fluid pressure [10] or epidural pressure [11] measured in LSS patients increased while standing
Conflict of interest
The authors declare that they have no conflict of interest.
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