Abstract ID: A27
Abstract Title: Successful Use of Spinal Cord Stimulation in the Treatment of Severe Raynaud's Disease of the Hands
Poster Type: Poster
ABSTRACT BODY
Introduction
Raynaud’s Disease (RD) is a vasospastic disorder affecting the resistance vessels. As the ischemia becomes worse, this condition may progress to amputation of the affected digits.
The most common indication for spinal cord stimulation (SCS) in the USA is for painful neuropathies. SCS is also used to treat ischemic conditions. However, its use in RD is underreported. This case describes the use of cervical SCS to treat refractory digital ischemia in a patient with advanced RD.
Case Presentation
The Pain Service evaluated a 51 y/o female with a long history of RD. She complained of bilateral hand pain (8/10 VAS), cold intolerance, allodynia, hyperalgesia and symptoms of ischemia. She had had an amputation at the distal phalanx of her left index finger, as well as distal ulcerations of several of the digits, and dystrophic nails.
She had been a long-time smoker, but had stopped smoking several months earlier. Her pain was controlled poorly with methadone and gabapentin, and had not responded to other medications. She had scleroderma, fibromyalgia, and bilateral carpal tunnel syndrome.
The patient’s hands were pallid, and had multiple ulcers, dystrophic nails. She had allodynia, hyperalgesia, and hyperpathia of the digits only. Radial pulses were normal (Fig. 1).
After a successful trial, bilateral SCS leads (Medtronic Pisces Quad) were placed in the epidural space, with the 0 electrodes positioned at the C4 level (Fig. 2); the pulse generator (Medtronic Synergy) in the abdominal subcutaneous tissue.
1 ½ months after implantation, the patient had a completion amputation of the 2 distal phalanges of the left index finger due to a non-healing ulcer of the digit. Aside from that pre-existing ulcer, there was improvement in perfusion, as well as healing of other ulcers and nail dystrophy.
3 ½ months after the implant, her pain was 2/10, and had had no further surgical care. She was satisfied with her analgesia and function (Fig. 3). She continued on her medications due to pain from her other conditions, but had no further hospitalization.
10 months after implant, she had recurrent ischemia in the right distal index finger; her most serious area of ischemia. 1 year after implant, this distal phalanx was amputated. She has had no subsequent ischemia, nor recurrent pain. After this surgery, she decreased her oral analgesic medications, and continues to be active.
Discussion
Scleroderma & smoking predisposed this patient to vascular disease. However, treatment of the these had not improved her symptoms. Her RD had progressed to the point of serial amputation. SCS improved her pain control and circulation; to the extent minimal subsequent care has been required.
There has been controversy regarding the use of SCS in ischemic disease. However, there numbers of prospective studies, and a Cochrane Review, indicating the effectiveness of SCS in ischemia. However, these focus primarily on large vessel disease. While the mechanism of action of SCS in ischemic disease is uncertain, it affects vasoconstriction, and should be effective in RD.
The present case demonstrates effective use of cervical SCS in a case of severe RD, and represents an opportunity for an area of further study.
ATTACHED FILES
Reg Anesth Pain Med 2004; 29(2):A27