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Journal of Neurosurgical Sciences 1999 December;43(4):285-93

lingua: Inglese

Spi­nal ­cord stim­u­la­tion in crit­i­cal ­limb ische­mia of ­the low­er extrem­ities. ­Our expe­ri­ence

Petrakis I. E., Sciacca V.

1st Depart­ment of Gen­er­al Sur­gery, “Pol­i­clin­i­co Umber­to I”, Uni­ver­sity of ­Rome “La Sapien­za”, ­Rome


Back­ground. Spi­nal ­cord stim­u­la­tion (­SCS) ­improves micro­cir­cu­la­to­ry ­blood ­flow, ­relieves ischem­ic ­pain ­and reduc­es ampu­ta­tion ­rate in ­patients ­with ­severe periph­er­al arte­ri­al occlu­sive dis­ease. ­Aim: To eval­u­ate ­the spe­cif­ic prog­nos­tic param­e­ters in ­the pre­dic­tion of suc­cess­ful ­SCS ­and to per­form a ret­ro­spec­tive ­data anal­y­sis ­obtained dur­ing ­our ­patient fol­low-up.
Meth­ods. 150 ­patients (97 ­men, 53 wom­en; ­mean ­age: 68 ­years; ­range: 46-81) ­were sub­mit­ted to implan­ta­tion of a spi­nal ­cord electri­cal gen­er­a­tor ­for ­rest ­pain, ­and troph­ic ­lesions ­with ­dry gan­grene in ­severe low­er ­limb ische­mia, ­after ­failed con­ser­va­tive or sur­gi­cal treat­ment. ­The clin­i­cal stat­us ­was clas­si­fied as ­Fontaine’s ­stage ­III ­and IV ­and ­the ­main pathol­o­gy ­was essen­tial­ly ­due to ath­ero­scler­o­sis ­and dia­bet­ic vas­cu­lar dis­ease. In clin­i­cal con­trols, ped­al trans­cu­ta­ne­ous oxy­gen ten­sion (­TcPO2), ­ankle ­and ­toe pres­sure Dop­pler meas­ure­ments ­were util­ised to ­select ­and fol­low-up ­the ­patients.
­Results. ­After a ­mean fol­low-up of 71 ­months (range 24-138), ­pain ­relief >75% ­and ­limb sal­vage ­was ­achieved in 85 ­patients. In 28 ­patients ­was ­obtained a par­tial suc­cess ­with ­pain ­relief >50% ­and ­limb sal­vage ­for at ­least 6 ­months, ­while in 37 ­patients ­the meth­od ­failed or ­for tech­ni­cal prob­lems ­the ­device ­was ­removed, ­and ­the ­patients ­were ampu­tat­ed. ­TcPO2 ­was ­assessed on ­the dor­sum of ­the ­foot. Clin­i­cal improve­ment ­and ­SCS suc­cess ­was asso­dat­ed ­with ­the increas­ing of ­TcPO2, ­before ­and ­after implan­ta­tion (tem­po­rary peri­od). ­Limb sal­vage ­was ­achieved in ­the ­patients ­that pre­sent­ed sig­nif­i­cant ­TcPO2 chang­es with­in ­the ­first 2 ­weeks of ­the test­ing peri­od, indif­fer­ent ­from ­the ­stage of ­the dis­ease, ­and ­from ­the ­initial ­TcPO2 val­ue. ­After ­long-­term ­patient fol­low-up ­TcPO2 chang­es, ­from 22.6 to 43.1 ­mmHg in ­these ­with ­rest ­pain (p<0.01), ­from 16.2 to 36.1 ­mmHg (p<0.02) in ­those ­with troph­ic ­lesions <3 cm2, ­and ­from 12.4 to 28.1 in ­the ­patients ­with troph­ic ­lesions >3 cm2. A ­TcPO2 ­increase of ­more ­than 50% in ­the ­first 2 ­months ­after implan­ta­tion ­was pre­dic­tive of suc­cess, ­and ­was relat­ed ­with ­the pres­ence of ade­quate pares­the­sias in ­the pain­ful ­area dur­ing ­the ­trial peri­od. ­The sys­tol­ic ­ankle/bra­chi­al ­blood pres­sure ­index ­did ­not ­change ­under stim­u­la­tion.
Con­clu­sions. In ­patients ­with ­failed con­ser­va­tive ­and sur­gi­cal treat­ment ­for ­severe crit­i­cal low­er ­limb ische­mia, ­the ­SCS increas­es ­the ­skin ­blood ­flow, is asso­ciat­ed ­with a sig­nif­i­cant ­pain ­relief ­and ­could be prov­en an excel­lent alte­na­tive ther­a­py ­that ­improves ­the qual­ity of ­life. ­TcPO2 chang­es, with­in a ­test peri­od of 2 ­weeks, is a pre­dic­tive ­index of ther­a­py suc­cess ­and ­should be con­sid­ered ­before ­the ­final deci­sion in ­terms of ­cost ­effect, ­for ­the per­ma­nent implan­ta­tion.

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