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

Copyright © 1999 EDIZIONI MINERVA MEDICA

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


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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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