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Spinal causes of leg pain
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Problems originating from the spine are an important, yet at times complex, cause of pain in the leg. Important causes are:
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nerve root (radicular) pain from direct pressure, esp. sciatica (L4–S3)
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referred pain from:
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spinal canal stenosis causing claudication
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Vascular causes of leg pain
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Occlusive arterial disease
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Acute lower limb ischaemia
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Sudden occlusion whether by embolism or thrombosis is a dramatic event which requires immediate diagnosis and management to save the limb.
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Signs and symptoms—the 6 Ps
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Pain
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Pulselessness
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Pallor
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Paralysis
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Paraesthesia or numbness
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‘Perishing’ cold
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Management of acute ischaemia
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Golden rules: Occlusion is usually reversible if treated within 4 h (i.e. limb salvage). It is often irreversible if treated after 6 h (i.e. limb amputation).
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Intravenous heparin (immediately) 5000 U
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Emergency embolectomy (ideally within 4 h) or
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Arterial bypass if acute thrombosis in chronically diseased artery or
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Stenting of vessels (a modern option)
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Amputation (early) if irreversible ischaemic changes
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Lifelong anticoagulation with warfarin will be needed.
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Chronic lower limb ischaemia
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Chronic ischaemia caused by gradual arterial occlusion can manifest as intermittent claudication or rest pain in the foot.
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General measures (if applicable): control obesity, diabetes, hypertension, hyperlipidaemia, cardiac failure.
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Achieve ideal weight.
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Absolutely no smoking (the risk factor).
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Exercise: daily graduated exercise to the level of pain. Approx. 50% will improve with walking so advise as much walking as possible.
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Try to keep legs warm and dry.
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Maintain optimal foot care (podiatry).
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Drug therapy: aspirin 150 mg daily.
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Note: Vasodilators and sympathectomy are of little value. ∼1/3 progress, while the rest regress or don't change.
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When to refer to a vascular surgeon
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‘Unstable’ claudication of recent onset; deteriorating
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Severe claudication—unable to maintain lifestyle
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Rest pain
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‘Tissue loss’ in feet (e.g. heel cracks, ulcers on or between toes, dry gangrenous patches, infection)
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Varicose veins and pain
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They may be painless even if large and tortuous. Pain is a feature where there are incompetent perforating veins running from the posterior tibial vein to the surface through the soleus muscle.
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Severe cases lead to the lower leg venous hypertension syndrome characterised by pain worse after standing, cramps in the leg at night, irritation and pigmentation of the skin, swelling of the ankles and loss of skin features such as hair.
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Keep off legs as much as possible.
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Sit with legs on a footstool.
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Use supportive stockings or tights (apply in morning before standing out of bed).
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Avoid scratching itching skin over veins.
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Compression sclerotherapy
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Surgical ligation and stripping
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Superficial thrombophlebitis
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The objective is to prevent propagation of the thrombus by uniform pressure over the vein.
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Cover whole tender cord with a thin foam pad.
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Apply a firm elastic bandage (preferable to crepe) from foot to thigh (well above cord).
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Leave pad and bandage on for 7–10 d.
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Bed rest with leg elevated is recommended.
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Prescribe an NSAID esp. if a complication of IV infusion (e.g. indomethacin or diclofenac (ο) 75 mg bd) or diclofenac 1% gel topically tds for 14 d.
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If spontaneous, consider an LMWH SC daily for 4 wks.
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If the problem is above the knee, ligation of the vein at the saphenofemoral junction may be necessary.
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Deep venous thrombosis (DVT)
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DVT may be asymptomatic but usually causes tenderness in the calf. One or more of the following features may be present (refer to Wells’ diagnostic algorithm: www.mdcalc.com wells-criteria-for-dvt).
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Ache or tightness in calf
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Acute diffuse leg swelling
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Pitting oedema
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Tender ‘doughy’ consistency to palpation
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Increased warmth (may be low-grade fever)
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Pain on extension of foot
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Tenderness (gently squeeze calves)
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Duplex US: accurate for above-knee thrombosis; improving for distal calf (repeat in 1 wk if initial test normal)
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Contrast venography, esp. if ultrasound −ve
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MRI is very accurate
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D dimer test (consider in certain cases): where probability of DVT is low, a normal D dimer usu. excludes diagnosis
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Coagulation disorder screen ?thrombophilia
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Prevention (cases at risk):
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early and frequent mobilisation/exercises
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elastic or graded compression stockings
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physiotherapy
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pneumatic compression
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electrical calf muscle stimulation during surgery
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surgery: unfractionated heparin 5000 U (SC) bd or tds (LMW heparin for orthopaedic surgery)
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long flights/sitting: LMWH prior to flying and on arrival
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Admit to hospital (usu. 5–7 days) but can treat as an outpatient.
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Collect blood for APTT, INR and platelet count (check kidney function).
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One-way-stretch elastic bandages (both legs to above knees) or class II graded compression stocking to affected leg, esp. if swelling
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LMW heparin e.g. enoxaparin SC daily or
Unfractionated heparin 330 U/kg, SC loading then 250 U/kg SC bd or
5000 U statim bolus IV then infusion in IV saline or
Fondaparinux SC according to weight
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Oral anticoagulant (warfarin) for 6 mths (monitor with INR)
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Mobilisation upon resolution of pain, tenderness and swelling
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Surgery is necessary in extensive and embolising cases.
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Cellulitis and erysipelas of legs
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Rest in bed
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Elevate limb (in and out of bed)
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Aspirin for pain and fever
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Search for evidence of diabetes
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Streptococcus pyogenes (the common cause):
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Severe: di (flu)cloxacillin (child: 50 mg/kg up to) 2 g IV, 6 hrly
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Less severe: procaine penicillin 1 g IM 12 hrly or phenoxymethyl penicillin 500 mg (o) 6 hrly
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If penicillin sensitive: clindomycin 450 mg (o) 8 hrly
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Severe, may be life-threatening: di(flu)cloxacillin 2 g IV 6 hrly
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Less severe: di(flu)cloxacillin 500 mg (o) 6 hrly or cephalexin 500 mg (o) 6 hrly if penicillin sensitive
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Osteomyelitis and septic arthritis
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Sepsis may occur in major joints such as the hip and knee. Osteomyelitis usually occurs in long bones, e.g. the tibia. Presents with pain, fever, malaise and unwillingness to move the affected part. The primary site, such as a wound or skin abscess, is often not found. Perform joint aspiration and blood culture + imaging. Oganisms—S. aureus, E. coli, Kingella, Pseudomonas, others. Usually treated with IV di(flu)cloxacillin.