Summary SCS are used extensively in refractory peripheral artherosclerotic disease. The patient was a 50 year-old woman smoker affected by advanced Buerger’s disease with pain localized mostly in the distal extremities of lower limbs. Following the failure of different treatments we suggested performing SCS to obtain better pain control and better microcirculation. In 2009 the patient underwent SCS implantation and in May 2012, was found to have a decubitus ulcer in the area of the subcutaneous pocket. In October 2012 we implanted a high frequency SCS. We used a 10 cm VAS and ESAS (Edmonton Symptoms Assessment Scale) to evaluate difference in quality of life, sleep, disability, pain relief and Patient Global Impression Scale (PGIS) to compare the patient’s satisfaction between treatments. The patient reported a significant improvement in pain reduction with both types of stimulators (tonic and high frequency). The quality of life improved more with the high frequency stimulation and the patient considers high frequency stimulation more effective than tonic stimulation. Our case report suggests that high frequency SCS can be a useful therapy for ischemic pain control.
Riassunto La neurostimolazione midollare (SCS) è frequentemente usata per i disturbi vascolari periferici. Il dolore si associa alla sintomatologia vascolare e la risposta a vari tipi di terapie sono scarsi. La paziente con morbo di Buerger è stata sottoposta a un primo impianto nel 2009 per un dolore cronico severo localizzato principalmente agli arti inferiori. Nel maggio 2012 a seguito di un decubito e successiva infezione nella tasca dell’IPG abbiamo espiantato la batteria. Nei mesi precedenti la rimozione la paziente aveva lamentato una perdita di efficacia della stimolazione tonica per cui nell’ottobre 2012 è stato deciso di impiantare uno stimolatore ad alta frequenza. Entrambe le stimolazioni (tonica e alta frequenza) sono state efficaci sul dolore, ma la qualità di vita della paziente è stata maggiore con la stimolazione a alta frequenza grazie alla mancanza di parestesia. La nostra esperienza ci suggerisce che il trattamento dei disturbi vascolari periferici potrebbe essere un nuovo campo di applicazione per la stimolazione a alta frequenza.
Key wordsChronic pain, High Frequency stimulation, Tonic Stimulation, Buerger Disease (BD), Quality of life
Parole chiaveDolore cronico, stimolazione ad alta frequenza, stimolazione tonica, morbo di Buerger, qualità di vita
IntroductionBuerger’s disease (BD) (or thromboangiitis obliterans), is a nonarterosclerotic, segmental inflammatory disease of the small and the medium size arteries and veins of the extremities. It is associated with extreme pain, and despite various treatment methods, major limb amputation is carried out on 20 percent of patients, significantly affecting their quality of life. Pharmacologic and surgical therapies often fail to heal these patients. Combination drug therapy is effective for pain relief but it does not make a significant difference for ischemic ulcers, and vasculitis can continue to progress even after a revascularization surgical treatment. Both sympathectomy and sympathetic pharmacologic blockage do not always provide lasting results. They can be chosen to treat ischemic ulcers but do not cause a decrease in the limb amputation rate. Except for giving up smoking, no form of treatment has yet been shown to stop disease progression and prevent amputation.Spinal cord stimulators (SCS) are used extensively in refractory peripheral atherosclerotic disease. Experience in BD is limited but suggests that SCS have favourable effects on pain and healing of digital ulcers, comparable with those noted in other arteriopathies.1,2,3,4
Patients and methods The patient was a 50 year-old woman smoker affected by advanced BD with pain localized mostly in the distal extremities of lower limbs. She was previously treated with several pharmacologic and surgical therapies (six sympathectomies and surgical revascularization) without significant results as far as pain reduction was concerned. The patient's refusal to quit smoking led to a worsening of the disease and consequently of the necrotic lesions and, as a result, two toes in the right foot had to be amputated. Following the failure of these different treatments we suggested performing SCS to obtain better pain control and better microcirculation as well as preventing other potential amputations.A detailed informed consent was acquired from the patient. In 2009 she underwent SCS implantation. The procedure was performed by means of a percutaneous technique which involved the placement of an octopolar electrode connected to a subcutaneously implantable pulse generator. The stimulator was placed in the abdominal subcutaneous pocket and the whole affected limb and foot were targeted and covered completely with the paresthesia. In May 2012 the patient was found to have a decubitus ulcer in the area of the subcutaneous pocket. Surgical replacement of the subcutaneous pocket was performed and an antibiotic therapy was prescribed. Despite the specific antibiotic therapy for over a month, the removal of the battery was necessary due to persistent infection. In the months prior to the removal of the stimulator, the patient reported a decrease in the effectiveness of the tonic stimulation, therefore, having to perform a new implant we opted for a high frequency stimulator.In October 2012 we implanted a high frequency SCS with electrode tip inserted at the level of T8 vertebral body. We used a 10 cm VAS and ESAS (Edmonton Symptoms Assessment Scale) to evaluate difference in quality of life, sleep, disability, pain relief and Patient Global Impression Scale (PGIS) as well as to compare the patient’s satisfaction between treatments. Both procedures were performed in two sessions: trial and permanent implant.
Results The patient reported a significant improvement in pain reduction with both types of stimulators (tonic and high frequency) (Figure 1).
Although there is no significant difference between the two types of stimulators as far as pain reduction is concerned, the quality of life improved more with the high frequency stimulation (Figure 2). Using the Patient Global Impression Scale (PGIS) the patient considers high frequency stimulation more effective than tonic stimulation. The lack of paresthesia sensations allowed a better perception of general well-being, a better quality of sleep and more freedom of movement. The need for more frequent charging did not impact patient satisfaction.
DiscussionHigh frequency stimulation provided to be efficient in the treatment of low back pain and leg pain to more than 80 per cent of subjects.1,2,3,4
SCS is an accepted therapy for the treatment of chronic ischemic pain aimed at avoiding amputation in patients with severe non-revascularization peripheral occlusive arteriopathy, helping to improve skin microcirculation in the affected areas.2 Without paresthesia patients are able to accept SCS treatment with greater ease and experience significant improvements in disability and sleep quality.5
Conclusion In literature there aren't articles regarding the use of high frequency in peripheral vascular disorders. Our case report suggests that high frequency SCS can be a useful therapy for ischemic pain control. The noticeable decrease of VAS pain rating was associated with a better microcirculation and a consequent improvement in quality of life and reduced disability. This positive influence has been further proven by the absence of apparent new trophic lesions and the healing of ulcers despite continued tobacco use by the patient. The high frequency SCS system appears to be efficacious during one year follow-up, delivering substantial pain relief without perception of paresthesia. High frequency stimulation may offer a new opportunity in the field of pain treatment both for patients and physicians, but more data are needed.