Dual Aetiology of Lower Limb Claudication: A Rare Case of Coexisting Lumbar Facet Joint Synovial Cyst and Critical Lower Limb Arterial Stenoses

Lower limb claudication is a common symptom with diverse aetiologies, most frequently neurogenic or vascular in origin. Identifying and discerning between these causes is essential, especially in patients with cardiovascular risk factors, as misdiagnosis may lead to suboptimal treatment. Dual pathology, though rare, can pose a significant diagnostic challenge. We report a case of a 60-year-old male farmer with a history of coronary artery disease who presented with progressive bilateral lower limb claudication and lumbosacral back pain. MRI spine revealed a right L4-L5 facet joint synovial cyst causing central spinal canal stenosis, while CT angiography demonstrated bilateral critical femoral artery stenoses. He underwent a percutaneous CT-guided facet joint synovial cyst rupture, which provided partial symptom relief, mainly from neurogenic claudication. Despite this, he still experienced persistent exertional claudication. He subsequently underwent staged endovascular revascularisation of the femoral arteries under Interventional Radiology, resulting in complete resolution of symptoms. At the three-month follow-up, he remained asymptomatic and had returned to his baseline physical function. This case highlights the diagnostic challenges associated with claudication when neurogenic and vascular features overlap and demonstrates that although the coexistence of neurogenic and vascular claudication is uncommon, it should be considered in patients presenting with atypical or refractory symptoms. In this particular case, a sequential percutaneous approach, addressing the spinal pathology first, followed by vascular insufficiency, resulted in excellent functional outcomes. These findings emphasise the importance of thorough clinical assessment and appropriate imaging in identifying the aetiology, thus preventing misdiagnosis. In addition, it also demonstrates that staged, minimally invasive radiological interventions can obviate the need for open surgery whilst still achieving complete symptom resolution and restoration of function.