Nocturnal neuropathic pain in diabetic patients may be caused by spinal stenosis

Background  Nocturnal exacerbation of neuropathic symptoms (NENS) is a recognized symptom of diabetic peripheral neuropathy (DPN). Symptoms are often worse in bed, may not be controlled with medication and disrupt sleep patterns. NENS can also be present in patients with spinal stenosis (SS), with or without concomitant peripheral neuropathy and may be related to sleep position. Extension position of the spine decreases the diameter of both the central canal and lateral recesses, which may compress or otherwise affect nerves controlling sensation from the feet and legs. Altering sleep position can reduce or eliminate symptoms. Modifications include sleeping in a recliner, with a pillow underneath the thighs if sleeping on the back, between the thighs if sleeping on the side, or under the stomach transversely if sleeping on the stomach. In addition, reducing nerve compression during the day by full‐time use of a wheeled walker set to induce lumbosacral flexion may reduce NENS. Methods and results  Retrospective patient review identified patients presenting with DPN including NENS, who noted alteration of NENS by changing body position, who also had walking and standing limitations consistent with SS. They underwent ‘positional testing’, involving modification of sleep position, and full‐time 3‐day use of a rollator walker, which may reduce symptoms of SS. Most reported good or excellent improvement of NENS. Conclusions  NENS, especially if affected by body position, or if accompanying a pattern of walking limitation improved with wheeled support, should lead to suspicion of SS. Positional testing should be considered in possible cases. Clinical use and further investigation are indicated.