Epidural spinal cord electrical stimulation in diabetic critical lower limb ischemia

Spinal cord stimulation (SCS) has been suggested to improve microcirculator y blood flow to relieve ischemic pain and to reduce amputation rate in pati ents with peripheral arterial occlusive disease (PAOD). The aim of this stu dy was to evaluate the specific prognostic parameters in the prediction of successful SCS, in diabetic patients, performing a retrospective data analy sis. To perform this evaluation, 64 diabetic patients (39 men, 25 women; me an age, 69 years) classified as Fontaine's stage III and IV, with PAOD, wer e treated with SCS for rest pain and trophic lesions with dry gangrene, aft er failed conservative or surgical treatment. In clinical controls, pedal t ranscutaneous oxygen tension (TcPO2), ankle/brachial blood pressure index ( ABI), and toe pressure Doppler measurements were utilized to select and fol lowup the patients. After 58 months of follow-up (range, 20-128 months), pa in relief greater than 75% and limb salvage were achieved in 38 diabetic pa tients. A partial success was obtained in nine patients with pain relief gr eater than 50% and limb salvage for at least 6 months. The method failed in 17 patients or the device was removed due to technical problems, and the l imb was amputated in these patients. TcPO2 was assessed on the dorsum of th e foot. Clinical improvement and SCS success were associated with increase of TcPO2, before and after implantation. Limb salvage was achieved in the p atients who had significant TcPO2 increase within the 2 weeks of the testin g period, independently of the stage of the disease. A TcPO2 increase of mo re than 50% in the first 2 months after implantation was predictive of succ ess, and was related to the presence of adequate paresthesias in the painfu l area during the trial period. TcPO2 significantly increased after long-te rm follow-up in all patients with limb salvage from 22.1 to 43.1 mm Hg in t he rest pain patients, from 15.8 to 36.4 mm Hg in those with trophic lesion s of less than 3 cm(2), and from 12.1 to 28.1 in those with trophic lesions of greater than 3 cm(2) (p < 0.01). ABI did not changed under stimulation. In diabetic patients with PAOD, the SCS increases the skin blood flow, is associated with significant pain relief, and could be proven an excellent a lternative therapy, improving the life quality. Significant TcPO2 increase within the 2-week test period, is a predictive index of therapy success and should be considered before the final decision in terms of cost effectiven ess, before the permanent implantation. (C) 2000 Elsevier Science Inc.