今日の臨床サポート

間欠跛行

著者: 紺野愼一 福島県立医科大学 整形外科学講座

監修: 竹下克志 自治医科大学整形外科

著者校正/監修レビュー済:2022/02/16
参考ガイドライン:
  1. 日本整形外科学会日本脊椎脊髄病学会:腰部脊柱管狭窄症診療ガイドライン2021改定第2版
  1. 日本血管外科学会:下肢アテローム硬化性閉塞性動脈疾患に対する診療ガイドライン2015
患者向け説明資料

概要・推奨   

  1. 馬尾型もしくは混合型の腰部脊柱管狭窄(LSS)による間欠跛行患者にはリマプロスト投与を推奨する(推奨度2)
  1. 保存療法無効例のLSSによる間欠跛行患者では除圧術を推奨する(推奨度2)
  1. 末梢動脈疾患(PAD)の診断ではABIの使用を推奨する(推奨度1)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
紺野愼一 : 講演料(第一三共,ファイザー,エーザイ),奨学(奨励)寄付など(日本ストライカー)[2022年]
監修:竹下克志 : 講演料(第一三共,イーライリリー,ファイザー,エーザイ,塩野義)[2022年]

改訂のポイント:
  1. ガイドラインに基づき診察、診断、治療について改定を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. PADまたはLSSに伴う間欠跛行患者に対してまず行う治療は保存療法を推奨する(推奨度1)
  1. 手術は保存療法でも改善しない症例にのみ行うことを推奨する(推奨度1)
 
問診・診察のポイント  
 
  1. 腰部脊柱管狭窄の最大の特徴は、歩行に伴い症状は悪化するが、前屈や坐位で、症状が速やかに改善するという姿勢性因子を有することである。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

Shin-ichi Konno, Shin-ichi Kikuchi, Yasuhisa Tanaka, Ken Yamazaki, You-ichi Shimada, Hiroshi Takei, Toru Yokoyama, Masahiro Okada, Shou-ichi Kokubun
A diagnostic support tool for lumbar spinal stenosis: a self-administered, self-reported history questionnaire.
BMC Musculoskelet Disord. 2007 Oct 30;8:102. doi: 10.1186/1471-2474-8-102. Epub 2007 Oct 30.
Abstract/Text BACKGROUND: There is no validated gold-standard diagnostic support tool for LSS, and therefore an accurate diagnosis depends on clinical assessment. Assessment of the diagnostic value of the history of the patient requires an evaluation of the differences and overlap of symptoms of the radicular and cauda equina types; however, no tool is available for evaluation of the LSS category. We attempted to develop a self-administered, self-reported history questionnaire as a diagnostic support tool for LSS using a clinical epidemiological approach. The aim of the present study was to use this tool to assess the diagnostic value of the history of the patient for categorization of LSS.
METHODS: The initial derivation study included 137 patients with LSS and 97 with lumbar disc herniation who successfully recovered following surgical treatment. The LSS patients were categorized into radicular and cauda equina types based on history, physical examinations, and MRI. Predictive factors for overlapping symptoms between the two types and for cauda equina symptoms in LSS were derived by univariate analysis. A self-administered, self-reported history questionnaire (SSHQ) was developed based on these findings. A prospective derivation study was then performed in a series of 115 patients with LSS who completed the SSHQ before surgery. All these patients recovered following surgical treatment. The sensitivity of the SSHQ was calculated and clinical prediction rules for LSS were developed. A validation study was subsequently performed on 250 outpatients who complained of lower back pain with or without leg symptoms. The sensitivity and specificity of the SSHQ were calculated, and the test-retest reliability over two weeks was investigated in 217 patients whose symptoms remained unchanged.
RESULTS: The key predictive factors for overlapping symptoms between the two categories of LSS were age > 50, lower-extremity pain or numbness, increased pain when walking, increased pain when standing, and relief of symptoms on bending forward (odds ratio > or = 2, p < 0.05). The key predictive factors for cauda equina type symptoms were numbness around the buttocks, walking almost causes urination, a burning sensation around the buttocks, numbness in the soles of both feet, numbness in both legs, and numbness without pain (odds ratio > or = 2, p < 0.05). The sensitivity and specificity of the SSHQ were 84% and 78%, respectively, in the validation data set. The area under the receiver operating characteristic curve was 0.797 in the derivation set and 0.782 in the validation data set. In the test-retest analysis, the intraclass correlation coefficient for the first and second tests was 85%.
CONCLUSION: A new self-administered, self-reported history questionnaire was developed successfully as a diagnostic support tool for LSS.

PMID 17967201
Thom W Rooke, Alan T Hirsch, Sanjay Misra, Anton N Sidawy, Joshua A Beckman, Laura K Findeiss, Jafar Golzarian, Heather L Gornik, Jonathan L Halperin, Michael R Jaff, Gregory L Moneta, Jeffrey W Olin, James C Stanley, Christopher J White, John V White, R Eugene Zierler, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine, Society for Vascular Surgery
2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
J Am Coll Cardiol. 2011 Nov 1;58(19):2020-45. doi: 10.1016/j.jacc.2011.08.023. Epub 2011 Oct 6.
Abstract/Text
PMID 21963765
Ko Matsudaira, Atsushi Seichi, Junichi Kunogi, Takashi Yamazaki, Atsuki Kobayashi, Yorito Anamizu, Junji Kishimoto, Kazuto Hoshi, Katsushi Takeshita, Kozo Nakamura
The efficacy of prostaglandin E1 derivative in patients with lumbar spinal stenosis.
Spine (Phila Pa 1976). 2009 Jan 15;34(2):115-20. doi: 10.1097/BRS.0b013e31818f924d.
Abstract/Text STUDY DESIGN: Randomized controlled trial.
OBJECTIVE: To examine the effect of limaprost, an oral prostaglandin (PG) E1 derivative, on health-related quality of life (HRQOL) in patients with symptomatic lumbar spinal stenosis (LSS), compared to etodolac, a NSAID.
SUMMARY OF BACKGROUND DATA: Limaprost, an oral PGE1 derivative, was developed in Japan to treat numerous ischemic symptoms of thromboangiitis obliterans (TAO) and LSS. Previous studies have demonstrated the effectiveness of limaprost in the symptoms in patients with LSS. However, the evidence for effect on patient-reported outcomes, such as patient's HRQOL or satisfaction, is limited.
METHODS: This study was conducted at 4 study sites in Japan. Briefly, inclusion criteria were: age between 50 and 85 years; presence of both neurogenic intermittent claudication (NIC) and cauda equina symptoms (at least presence of bilateral numbness in the lower limbs); and MRI-confirmed central stenosis with acquired degenerative LSS. Limaprost (15 microg/d) or etodolac (400 mg/d) was administered for 8 weeks. The primary outcome was Short Form (SF)-36, and the secondary outcomes were the verbal rating scale of low back pain and leg numbness, walking distance, subjective improvement, and satisfaction.
RESULTS: A total of 79 participants were randomized (limaprost:etodolac = 39:40). Thirteen participants withdrew from the study (limaprost:etodolac = 5:8) and 66 completed the study (limaprost:etodolac = 34:32). Comparisons showed that limaprost resulted in significantly greater improvements in the SF-36 subscales of physical functioning, role physical, bodily pain, vitality, and mental health. Limaprost was also significantly better than etodolac for leg numbness, NIC distance, and subjective improvement and satisfaction. In the subgroup analysis stratified by symptom severity, limaprost seemed more effective for milder symptoms. No serious adverse effects were reported in either treatment group.
CONCLUSION: In this study, limaprost was found to be efficacious on most outcome measures, such as HRQOL, symptoms and subjective satisfaction, in LSS patents with cauda equina symptoms.

PMID 19112336
L Norgren, W R Hiatt, J A Dormandy, M R Nehler, K A Harris, F G R Fowkes, R B Rutherford, TASC II Working Group
Inter-society consensus for the management of peripheral arterial disease.
Int Angiol. 2007 Jun;26(2):81-157.
Abstract/Text
PMID 17489079
Shinichi Konno, Yasuaki Hayashino, Shunichi Fukuhara, Shinichi Kikuchi, Kiyoshi Kaneda, Atsushi Seichi, Kazuhiro Chiba, Kazuhiko Satomi, Kensei Nagata, Shinya Kawai
Development of a clinical diagnosis support tool to identify patients with lumbar spinal stenosis.
Eur Spine J. 2007 Nov;16(11):1951-7. doi: 10.1007/s00586-007-0402-2. Epub 2007 Jun 5.
Abstract/Text No clinical diagnostic support tool can help identify patients with LSS. Simple diagnostic tool may improve the accuracy of the diagnosis of LSS. The aim of this study was to develop a simple clinical diagnostic tool that may help physicians to diagnose LSS in patients with lower leg symptoms. Patients with pain or numbness of the lower legs were prospectively enrolled. The diagnosis of LSS by experienced orthopedic specialists was the outcome measure. Multivariable logistic regression analysis identified factors that predicted LSS; a simple clinical prediction rule was developed by assigning a risk score to each item based on the estimated beta-coefficients. From December 2002 to December 2004, 104 orthopedic physicians from 22 clinics and 50 hospitals evaluated 468 patients. Two items of physical examination, three items of patients' symptom, and five items of physical examination were included in the final scoring system as a result of multiple logistic regression analysis. The sum of the risk scores for each patient ranged from -2 to 16. The Hosmer-Lemeshow statistic was 11.30 (P = 0.1851); the area under the ROC curve was 0.918. The clinical diagnostic support tool had a sensitivity of 92.8% and a specificity of 72.0%. The prevalence of LSS was 6.3% in the bottom quartile of the risk score (-2 to 5) and 99.0% in the top quartile (12 to 16). We developed a simple clinical diagnostic support tool to identify patients with LSS. Further studies are needed to validate this tool in primary care settings.

PMID 17549525

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