Spinal cord stimulation in treatment of patients with critical lower limb ischemia

Abstract

<p>Critical limb ischemia (CLI) is a state of substantial reduction of blood flow in the extremities, mostly due to severe obstruction of the arteries. In lower limbs, it produces severe pain after even a short distance walk (intermittent claudication) and/or skin ulcers or sores. Surgical revascularization is a “golden standard” in CLI therapy, but it is contraindicated or not accessible for a large proportion of patients, while the medical prognosis is poor for conservative therapy. This situation stimulated the development of alternative approaches, including spinal cord stimulation (SCS) and various methods of “indirect” revascularization. In this paper, the authors give a short description of the latest approaches and a detailed review of the SCS method, while paying special attention to the studies that demonstrate not only a palliative effect of SCS (pain reduction), but also clinically significant changes in the indicators of lower limb muscles blood supply. CLI is characterized with a "vicious circle": pain causes reduced mobility and changes in the preferred limb position, which in turn lead to edema triggering an increase of ischemia and further elevation of pain. The clinical effects of SCS in CLI patients are related both with pain relief leading to a break of this vicious circle, and with the direct vasodilatory effects of the stimulation itself. There are several possible biological mechanisms of these actions, but most probably the therapeutic actions of SCS arise from their combination. Examination of different opinions about the appropriateness of spinal cord stimulation in patients with CLI, including those related to the economic efficiency of the method, leads to the conclusion that the evidence on these issues is currently insufficient. The reviewed data demonstrate the need for further development of the CLI treatment methods and high urgency of this problem.</p><p>Received 6 April 2017. Accepted 23 April 2017.</p><p><strong>Funding:</strong> The study did not have sponsorship.<br /><strong>Conflict of interest:</strong> The authors declare no conflict of interest.</p>

High-Frequency versus Low-Frequency Spinal Cord Stimulation in Treatment of Chronic Limb-Threatening Ischemia: Short-Term Results of a Randomized Trial

“…Our study confirms the efficacy of SCS in patients with CLTI non-eligible for revascularization surgery, which corresponds with the results of trials [4,14,15,21,22]. The current research aimed to establish is there any reasonable advantage of higher frequency SCS on clinical outcomes in this type of patients.…”

“…The sample size was calculated based on previously published studies (Liu et al [14]) and our own HF-SCS experience. According to Liu study mean treatment effect (visual analog scale score at 12 months) for LF-SCS was 2.35 (±0.62) and for our HF-SCS series was 1.85 (±0.3).…”

“…There is substantial evidence supporting the efficacy and safety of the conventional SCS for ischemic pain relief [4,6,9,14,15], but there are no publications regarding the HF-SCS application for ischemic conditions. In accordance with our previous experience, we suggested that HF-SCS provides more improvement in peripheral tissue perfusion and better pain relief.…”

Sympathectomy and Neuromodulation in the Treatment of Critical Lower Limb Ischemia

“…Критическая ишемия нижних конечностей (КИНК)это заболевание, характеризующееся декомпенсацией хронической артериальной недостаточности нижних конечностей (НК) [1,2]. Ведущими клиническими признаками КИНК представляются болевой синдром (БС) в покое, некупируемый опиоидными анальгетиками, и/или язвенно-некротический процесс НК, продолжающийся более 2 недель [3].…”

“…Ведущими клиническими признаками КИНК представляются болевой синдром (БС) в покое, некупируемый опиоидными анальгетиками, и/или язвенно-некротический процесс НК, продолжающийся более 2 недель [3]. Распространенность КИНК в США и странах Западной Европы набирает 50-100 случаев заболевания на 100 000 человек в год [1]. В США ежегодно госпитализируется более 400 000 больных с хроническими облитерирующими заболеваниями артерий НК (ХОЗАНК).…”