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Spinal cord stimulation in the treatment of chronic critical limb ischemia: Indications, clinical results and review of randomized studies

Die Rückenmarkstimulation in der Behandlung des austherapierten arteriellen Verschlußleidens: Indikationen, klinische Ergebnisse und Übersicht über randomisierte Studien

  • Main Topics: Spinal Cord Stimulation In The Treatment Of Chronic Critical Limb Ischemia And Angina Pectoris
  • Published:
Acta Chirurgica Austriaca Aims and scope Submit manuscript

Summary

Background: Despite the abundance of therapeutic options, there are still patients for whom conventional strategies of management have been exhausted. A possible alternative treatment for patients with non-reconstructable chronic critical limb ischemia is spinal cord stimulation.

Methods: In a review the technique of spinal cord stimulation, indications, results of clinical and randomized studies are analyzed.

Results: Spinal cord stimulation is effective in the treatment of ischemic pain in non-reconstructable patients. Significant pain relief (>75 %) is observed in 60 to 90 % of the patients. Moreover, ulcer healing was reported, suggesting an improvement of the nutritional skin blood flow. Microcirculatory parameters have shown significant improvement after stimulation as shown by the measurement of the red blood cell velocity, capillary density, measurement of the TcPO2 and laser Doppler fluxmetry. However, these studies were uncontrolled and there was an urgent need for randomized controlled trials. Reviewing the data of the randomized trials, we can make the following conclusions: stimulation is effective in the treatment for ischemic pain, pain relief seems largely to be secondary to an inhibition of the sympathetic activity and is assisted by improvement of the microcirculatory blood flow. The randomized studies were not able to show limb salvage. Patient selection based upon microcirculatory parameters helps identifying a subgroup of patients in whom stimulation can benefit as to limb salvage.

Conclusions: Spinal cord stimulation is an effective therapy in non-reconstructable patients with limb ischemia, providing significant pain relief, improving ulcer healing due to effects on the microcirculation. Effects on limb salvage are not observed.

Zusammenfassung

Grundlagen: Die vorliegende Arbeit soll einen Überblick über den gegenwärtigen Stand der epiduralen Rückenmarkstimulation in der Behandlung des austherapierten arteriellen Verschlußleidens im Stadium III und IV nachFontaine geben.

Methodik: Übersicht aus der Literatur über Indikation und Ergebnisse der klinisch und prospektiv randomisierten Studien.

Ergebnisse: Im Vordergrund steht der schmerzlindernde Effekt der Rückenmarkstimulation, wobei in 60 bis 90 % der Patienten eine signifikante Schmerzreduktion (>75 %) erreicht werden kann. Neben der Schmerzlinderung beobachteten verschiedene Autoren eine Heilung bzw. Rückbildung trophischer Störungen. Es gelang mittels videokapillar-mikroskopischer Untersuchungen, eine signifikante Zunahme der Anzahl perfundierter Hautkapillaren sowie Flußgeschwindigkeit der roten Blutzellen nachzuweisen. Zur Beurteilung des therapeutischen Effektes sind jedoch prospektiv randomisierte Studien notwendig. Die Ergebnisse der randomisierten Studien können wie folgt zusammengefaßt werden: Die Rückenmarkstimulation bewirkt eine signifikante Schmerzreduktion, die am ehesten durch eine verbesserte mikrozirkulatorische Hautdurchblutung zu erklären ist. Eine positive Auswirkung auf die Extremitätenerhaltung konnte nicht festgestellt werden. Mikrozirkulatorische Parameter ermöglichen eine Subgruppe zu selektionieren, bei welcher die Stimulation sinnvoll erscheint und die Extremitätenerhaltung positiv beeinflußt werden kann.

Schlußfolgerungen: Die Rückenmarkstimulation erweist sich als effektive Therapie des ischämischen Schmerzes. Bei erfüllten Indikationskriterien stellt sie ein wertvolles Behandlungsprinzip dar.

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Authors and Affiliations

  1. Department of Vascular Surgery, Marienhospital, Ruhr University of Bochum, Hölleskampring 40, D-44625, Herne, Germany

    L. G. Y. Claeys

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Correspondence to L. G. Y. Claeys.

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Claeys, L.G.Y. Spinal cord stimulation in the treatment of chronic critical limb ischemia: Indications, clinical results and review of randomized studies. Acta Chir. Austriaca 32, 52–57 (2000). https://doi.org/10.1007/BF02949229

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  • DOI: https://doi.org/10.1007/BF02949229

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