Surgery for ischemic pain and Raynaud's' phenomenon in scleroderma: A description of treatment protocol and evaluation of results

Although the literature suggests that palmar sympathectomy (PS) with or wit hout vascular reconstruction may improve ischemic digital pain, fingertip u lceration, and cold intolerance in patients with scleroderma, the question regarding long-term efficacy still remains. This retrospective study of six patients (eight hands) operated on between 1995 and 1997 evaluates both ea rly (6 months) and long-term (average, 2.5 years) outcome after PS in combi nation with decompression arteriolysis of the radial and ulnar arteries pro ximal to the wrist. When preoperative digital blood flow was inadequate bas ed on noninvasive vascular studies and major inflow occlusion was present, vascular reconstruction was also performed when feasible. At early review, significant improvement in ischemic digital pain and moderate improvement i n cold intolerance resulted in eight hands, and at final follow-up, this wa s sustained in seven hands. Preoperatively, digital ulcerations were presen t in six hands. After digital debridement and/or amputation, all wounds hea led, but in one patient with bilateral disease who continued to smoke, ulce rations recurred without the need for subsequent surgery. Five of six patie nts were no longer dependent on narcotic analgesics. but use of vasodilator medication did not change. Five of six patients claimed significant improv ement in the quality of life after surgery and reported that they would und ergo the surgery again. PS in combination with radial and ulnar arteriolysi s appears to be efficacious at both early and long-term review. When major inflow occlusion exists and digital blood flow is compromised, vascular rec onstruction is recommended if possible. We review our treatment protocol in this complex population of patients. (C) 2001 Wiley-Liss, Inc.