Does autonomic neuropathy influence spinal cord stimulation therapy success in diabetic patients with critical lower limb ischemia?

BACKGROUND Spinal cord stimulation (SCS) improves microcirculatory blood flow and reli eves diabetic neuropathic and ischemic pain, reducing the amputation rate i n patients with peripheral arterial occlusive disease (PAOD). The purpose o f this study was to evaluate whether the presence of autonomic neuropathy i n diabetic patients with PAOD influences the success of SCS therapy. METHODS Sixty consecutive diabetic: patients (15 with early and 13 with definite an d/or combined autonomic neuropathy) with an ankle/brachial systolic pressur e index (ABI) less than 0.20 +/- 0.08, underwent spinal cord stimulation af ter failed conservative or surgical treatment. The neuropathic status of th e patients was evaluated before implantation and pedal TcpO(2) measurements on the dorsum of the foot were performed. RESULTS Limb salvage and pain relief >75%, evaluated with the visual analogue scale , were achieved in 35 patients, whereas in 12 a partial success with pain r elief >50% and limb salvage for at least 6 months were obtained. In 13 pati ents the method failed and the ischemic limbs were amputated. Among the 28 diabetic patients with autonomic neuropathy the treatment failed or resulte d in only partial success in 25, whereas in all 32 patients without neuropa thy limb salvage and pain relief >75% were achieved (p < 0.0001). Partial s uccess in 10 patients with early neuropathy and in two with definite was ac hieved (p = 0.008), whereas in 11 patients with definite neuropathy and in two with early the method failed (p < 0.001). The stage of the neuropathy w as inversely related to the success of SCS therapy, independent of the stag e of the disease. The method's success was related to the presence of adequ ate paraesthesias and warm feeling in the painful area with size reduction of the trophic lesions. CONCLUSIONS Diabetic patients with peripheral arterial occlusive disease presenting wit h intractable pain may he successfully treated with spinal cord stimulation unless they have associated severe autonomic neuropathy. (C) 2000 by Elsev ier Science Inc.