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Practicing Citations
SOurce 1.

Answers to module 7 questions
The media is a copy of an X-Ray and CT scan of a patient with neurogenic claudication. It shows the compression of the spine from a side view and through a CT shows cross sections of the spine (viewed from above) at different sites of neurogenic claudication. It is not my own work. The file I have chosen is a JPEG file. The licence I have chosen is a creative commons 1.0 licence. The category I will add the media or photo to would be in the diagnostic section of the article Neurogenic Claudication. I would describe the file as an "Neurogenic Claudication X-Ray and CT" or "Lumbar Spinal Stenosis X-Ray and CT".

Neurogenic Claudication final draft
The predominant symptoms of NC involve one or both legs and usually presents as some combination of tingling, cramping discomfort, pain, numbness, or weakness in the lower back, calves, glutes, and/or thighs and is precipitated by walking and prolonged standing. However, the symptoms vary depending on the severity and cause of the condition. Lighter symptoms include pain or heaviness in the legs, hips, glutes and lower back, post-exercise.[6][8] Mild to severe symptoms include prolonged constant pain, tiredness and discomfort in the lower half of the body.[6][8] In severe cases, impaired motor function and ability in the lower body can be observed, and bowel or bladder dysfunction may be present.[6][8] Classically, the symptoms and pain of NC are relieved by a change in position or flexion of the waist.[9] Therefore, patients with NC have less disability in climbing steps, pushing carts, and cycling. [1]

Treatment options for NC depends on the severity and cause of the condition, and may be nonsurgical or surgical. Nonsurgical interventions include drugs, physical therapy, and spinal injections.[10] Spinal decompression is the main surgical intervention and is the most common back surgery in patients over 65.[1] Other forms of surgical procedures include: laminectomy, microdiscectomy and laminoplasty.[8][11] Patients with minor symptoms are usually advised to undergo physical therapy, such as stretching and strengthening exercises. In patients with more severe symptoms, medications such as pain relievers and steroids are prescribed in conjunction with physical therapy. Surgical treatments are predominantly used to relieve pressure on the spinal nerve roots and are used when nonsurgical interventions are ineffective or show no effective progress. [1][11]

Signs and Symptoms
Whilst these common symptoms are usually present in many patients with NC, rarer and more serious symptoms can occur in severe cases of NC. In extreme cases of NC constant discomfort, pain or numbness is experienced. This results in patients to have decreased mobility and function as excessive or constant movements cause pain. Exercise and prolonged walking often become difficult and are triggers of pain, tiredness, numbness and heaviness in the legs, lower back and hips.[13] Common tasks such as standing upright for an extended duration or picking up heavy objects may become increasingly difficult to perform.[6][13] In addition, patients with severe NC may experience difficulties sleeping as lying down on their back causes discomfort and pain.[8][13] In very extreme cases, bowel or bladder dysfunction can occur. However, this is a consequence of the underlying cause of NC rather than the condition itself. As most causes of NC involve increased pressure or damage to the nerves in the lower spine, damage and pressure on the nerves that extend to the bowel or bladder may occur, leading to bowel or bladder dysfunction.[14]

Treatment
Physical Therapy Patients that experience light to mild symptoms are commonly treated through physical therapy, which involves stretching and strengthening the lower back, abdominal (core) and leg muscles.[18] Common stretches used include the knee to chest stretch, posterior pelvic tilt, neural stretching of the legs, hip-flexor stretch and lower trunk rotation.[18][19] In conjunction with these stretches, various strengthening exercises are often implemented, targeting the core, lower back and hip muscles. Common exercises include bridges, bird to dog, tabletop leg press, clamshell and knees to chest.[19][20] Depending on the age, mobility and physical health of patients, a combination of easier and more difficult exercises should be prescribed to suit the patient's needs. More difficult exercises may include the incorporation of resistance training (weights), gym equipment and more explosive movements. Other exercises such as cycling (stationary), swimming and water-based activities have also been found to strengthen and improve overall stability and strength in the core, lower back and hips.[19] Ultimately, the aim of physical therapy is to loosen and relax the tight muscles and ligaments that contribute to the symptoms, and to strengthen those muscles to prevent further reocurrences of the condition. However, studies have found conflicting conclusions in regards to the effectiveness of physical therapy as a treatment option for NC patients.[10][21] Thus, the low quality of evidence supporting its use has prompted further research into physical therapy as a treatment option for NC to be necessary. [10][21][22][23]

Stretching Exercises Common stretching exercises used to relieve pain and treat NC include: [20]

Knee to chest stretch - Laying down on the back, bring one leg up and pull it towards the chest and hold for 30-45 seconds. Posterior pelvic tilt (bridges) - Laying on the back, bend both legs and place your feet on the floor. Raise stomach from the ground, lifting the back and pelvis, until the back is straight. Hold for 5-10 seconds and relax. Neural Stretching of the legs - Laying on the back, bring one leg up with a stretching band until a stretch is felt in the legs. Ensure your legs are straight. Once the stretch is felt, hold for 30-45 seconds and relax. Hip-flexor stretch - To stretch the right hip-flexor, bring the left leg forward, and kneel on the right knee. Push the pelvis forward (lean forward), whilst keeping the upper body straight. Hold the position for 30-45 seconds and relax. To stretch the left hip-flexor, bring swap the positions of the legs. Lower trunk rotation - Laying down on the back, bring both knees towards your chest whilst keeping the back flat on the floor. Rotate the bent legs from the left to right side and vice versa whilst keeping back flat on the ground. Strengthening Exercises Common strengthening exercises used to treat and prevent future reocurrences of NC include: [19][20]

Posterior pelvic tilt (bridges) - Laying on the back, bend both legs and place your feet on the floor. Raise stomach from the ground, lifting the back and pelvis, until the back is straight. Hold for 5-10 seconds and relax. Quadruped opposite arm/leg (bird to dog) - On all fours (knees on ground and arms against floor supporting upper body) straighten one knee whilst straightening the opposite side arm and hold for 3 seconds and repeat for the other arm/leg pair. Tabletop leg press press - Laying on the back, bring both knees towards the chest and then straighten both legs (such that legs are hanging in the air), whilst keeping the back flat on the ground. Clamshell - Whilst laying on the side with knees bent inwards, bring the top knee up (whilst keeping leg bent) and hold for 3 seconds. To exercise the opposite leg, lay on the opposite side and repeat. Abdominal draw-in (knee to chest ) - Laying flat on the back, bend both legs and bring knees towards the chest without lifting the back from the ground and then straighten legs again. For a more difficult version of the exercise, keep one leg bent and feet on the ground and bring the other leg towards the chest. Medications Medications such as NSAIDs, prostaglandin-based drugs, gabapentin, methylcobalamin and epidural steroid injections are often used in conjunction with physical therapy to treat patients with mild or moderate symptoms of NC.[15] The main goal of these medications is to reduce pain and provide temporary relief for NC patients. NSAIDs and prostaglandin-based medications control inflammation at sites of nerve damage or pressure by inhibiting cyclooxygenase activity, and reducing the production of prostaglandins, a key contributor of inflammation.[24][25] By reducing inflammation, less pressure is put on the nerve roots, decreasing pain, and providing relief for NC patients.[26] Gabapentin aims to reduce pain and provide relief by altering the normal functioning of neurotransmitters that induce a sensation of pain and discomfort.[27] However, the exact mechanism of Gabapentin’s functioning in the body is not completely understood and current knowledge is based off experimental studies that target the nervous system.[28] Methylcobalamin is another medication that targets the nervous system to reduce pain and provide NC patients with temporary pain-relief. The drug produces myelin to cover and protect nerves from damage, preventing pain induced from damaged nerve roots, as described in some cases of NC.[29] Epidural steroid injections are the main epidural injections prescribed to treat NC. They inhibit the inflammatory cascade signalling to reduce inflammation at sites of spinal nerve damage or pressure. Consequently, they reduce pain and provide relief to individuals with NC.[30][31] Whilst the use of medications is common among NC patients that experience frequent or constant pain, their effectiveness has yielded mixed results in studies.[27][32] Further research into their viability as a medication for NC is necessary to allow doctors to provide better care and treatment options for NC patients.[33]

Surgical Interventions Depending on the cause and severity of the condition, surgical options for NC vary. Symptoms of LSS, including NC, are the most common reason patients 65 and older undergo spinal surgery. Surgery is generally reserved for patients whose symptoms do not improve with nonsurgical treatments, and the main objective of surgery is to relieve pressure on the spinal nerve roots and recover normal mobility and quality of life.[10] Lower Spinal Decompression is considered the mainstay of surgical treatment.[2] In this procedure, the ligamentum flavum is first removed, followed by the removal of the superior facet osteophyte in the spinal canal, and then the decompression of the spinal nerve root.[5][11] Another surgical method of decompression is the Fenestration method, which involves creating a small window in the spinal canal and then decompressing the nerves.[8] Alternative surgical options include the use of interspinous process spacers, minimally invasive lumbar decompression (MILD) procedure, laminectomy, microdiscectomy and placement of a spinal cord stimulator. The MILD procedure aims to relieve spinal cord compression by percutaneous removal of portions of the ligamentum flavum and lamina.[10] Laminectomy also involves partial or complete removal and sacrifice of the lamina, but in addition, facets in one or more segments of the spinal cord are usually sacrificed as well.[8][11] Microdiscectomy is another surgical alternative which uses small incisions, and a miniature camera for viewing, to enter the spinal cord and release pressure on the nerve roots.[5][8] Laminoplasty and spinal fusion surgeries are other alternative surgical procedures that can be performed. However, they are relatively new methods which still require more research and advancements in order for it to be safely performed with minimal risks.[11][34]

Prognosis
Individuals with LSS may be asymptomatic for many years before developing symptoms such as NC.[1] However, most LSS patients that present with NC often seek medical help and treatment due to the condition causing pain and affecting their quality of life.[13] Consequently, the prognosis of untreated LSS and NC has not been well reported and is unknown. Based off the physiological cause of NC, it is projected that the symptoms of NC can worsen over time, with roughly one-third of patients showing signs of improvement with time.[7]

For NC patients that develop worse symptoms over time, severe consequences can occur. Over time, untreated NC and LSS can lead to chronic pain and muscle weakness.[13] In severe cases, caudea equina syndrome can develop, disrupting sensory and motor function in the lower body and bladder.[15] Consequently, disability in the lower extremities may develop over time in individuals with untreated NC and LSS.[15] Whilst some patients may recover and improve their NC condition over time, without the help of medical treatment or interventions, this is only prevalent in individuals with light or very mild symptoms of NC. In most scenarios, the prognosis of NC can lead to potential disability, muscle weakness or constant pain in the lower body.[13][15]

Epidemiology
NC is a noncommunicable condition and thus, does not pose any community risks in terms of infectiousness. Rather, NC is associated with increasing age and mostly affects individuals over the age of 60. Age is a major contributing factor to the onset of NC due to spinal degenerative changes that are brought by aging and the weakening of bones and ligaments in the lumbar area.[6] NC is also more likely present in individuals with other spinal comorbidities.[1] A history of spinal injuries or deformities is also a contributing factor to the increased likelihood of the onset of NC.[37] Other factors such as exercise and bone density have also been found to be associated with NC. Increased exercise activity in the form of strength training has also been found to increase bone density, muscle strength and thus, decrease the likelihood of NC as aging occurs.[38]

One of the main causes of NC is the onset of LSS in elderly patients. Relative to their respective age groups, 16% of individuals aged less than 40 experience LSS whilst 38.8% of individuals aged over 60 experience LSS.[39][40] Between the ages of 60 and 69, the prevalence of LSS relative to this population group is 47.2%.[39] Data obtained from medical practitioners suggest that the incidence of LSS is 5 cases per 100 000.[40] This increased prevalence of LSS as a consequence of aging, heavily contributes to the epidemiology and acquiring of NC. Among individuals with spinal stenosis, NC is present in greater than 90% of patients and present in almost half of patients that present with low back pain, with over 200,000 people being affected in the United States.[2][1][7] The prevalence of NC and spinal stenosis in elderly men is also evident, with studies finding that roughly 1 in 10 elderly men experience leg pain in combination with low back pain (symptoms of NC) and this incidence rate is also doubled in retirement communities.[9] As the global life expectancy increases, the impact of spinal disease symptoms such as NC is likely to increase.[15]

Current Research
Current treatment options for NC are not diverse and lack extensive and detailed research to support their effectiveness, resulting in patients having to choose from a small pool of treatment options, some of which may not be effective.[10] This lack of evidence to support the effectiveness of treatment options for NC is especially prevalent in nonsurgical treatments, such as physical therapy and medications.[21][32] Among surgical interventions for NC, current research into improving methods of surgery to minimize post-surgery complication and to improve quality of life have also been of concern.[41][42]

Physical Therapy Studies have found that physical therapies such as stretches and strengthening exercises have yielded mixed results in terms of its effectiveness in treating NC. Reports have shown that physical therapy does aid in treating NC in patients with light to mild symptoms,[21][43] whilst others have shown the contrary.[10][22] It has also been found that patients with more severe symptoms of NC find less long-term success in treating the condition through physical therapy. Thus, doctors have concluded that further research into the effectiveness of physical therapy as a treatment option for NC is necessary. With more detailed research, doctors will then be able to suggest the best treatment options for their patients, to help them recover from the condition. [21][22][23]

Medications Medications commonly prescribed to NC patients are generally steroids, pain relievers or anti-inflammatories that aim to reduce pain and provide pain-relief. However, studies have found that these medications only provide temporary relief for patients, and do not provide a permanent solution, with symptoms often reoccurring several months following the disuse of medications.[18][44] Hence, doctors have reported that it is important to research possible medications that can provide long term relief or a permanent solution for patients.[19][44] Currently, Tanezumab, a monoclonal antibody that suppresses nerve activity, has been in development for use in patents with back pain, such as NC.[45] The drug functions by selectively targeting and inhibiting Nerve Growth Factors (NGF) in the body. By blocking NGF in the body, Tanezumab aims to prevent pain signals produced in the body from reaching the brain, thus, reducing pain and providing relief for patients.[46] Whilst positive results have been shown in several studies, further research is still necessary for its safe and effective use.[45][47]

Surgical Procedures Whilst surgical procedures exist to treat NC, current methods involve partial or complete removal of the lamina and segments of the spinal cord, leading to poor stability.[15] Hence, orthopedic surgeons and neurosurgeons have been developing and researching other surgical techniques that reduce this side effect. Haruo Tsuji, in 1990, introduced a procedure known as Laminoplastie En-block expansive Laminoplasty as an alternative to laminectomy and since then, variations and further developments have been made on that procedure, with developments still being currently.[48] This procedure involves a reconstruction of the vertebral lamina such that it creates a hinge on one side, allowing for decreased pressure on spinal nerve roots.[49] Advances in this procedure involve finding ways to access the spinal cord with minimal incisions and to more effectively create hinges that replicate normal functioning of the spine.[50][51] In addition to Laminoplasty, spinal fusion surgeries have also been of growing interest to orthopedic surgeons and neurosurgeons.[52] This process involves connecting two vertebrae of the bones together to reduce pain or correct any spinal deformities.[53] As such this form of surgery has the potential to treat the underlying cause of NC. However, these types of surgeries are difficult and dangerous to perform due to the sensitive nature of the spinal area. Additionally, these techniques are relatively new and thus, more research and advances in its methodology is still required for it to be considered a reliable and viable option to treat NC patients.[54][55]