Spinal cord stimulation utilization to treat the microcirculatory vascular insufficiency and ulcers associated with scleroderma: a case report and review of the literature.

OBJECTIVE: To report a case of scleroderma with associated Raynaud's phenomenon and its successful treatment with spinal cord stimulation. To demonstrate the use of transcutaneous oxygen pressure monitoring to guide the progression from trial to implantation and to assess post-implantation microcirculatory recovery. DESIGN: Case report and literature review. PATIENT: A 51-year-old female with scleroderma, associated Raynaud's phenomenon, and a non-healing 3.7-cm lower extremity ischemic ulcer. Ankle-brachial indexes demonstrated normal macrocirculation, but transcutaneous oxygen pressures demonstrated significant microcirculatory insufficiency. INTERVENTION: Treatment was a spinal cord stimulator implantation after a successful trial. Transcutaneous oxygen pressures were interpreted during the trial and post-implantation stages. Results. Based on a 5-day trial that documented improvements in transcutaneous oxygen pressures and pain relief, the patient underwent implantation. At 4 months, the ischemic ulcer had healed. The patient had significant improvement in pain control and reduced Raynaud's phenomenon signs and symptoms. At 18 months, the patient continued to have improvement with no associated complications. A literature review demonstrated only four published reports, including a total of 18 patients, on spinal cord stimulator treatment for scleroderma and associated Raynaud's phenomenon. CONCLUSIONS: We report the healing of a greater than 3-cm ischemic ulcer in an individual with normal macrocirculation but severe microcirculatory insufficiency from scleroderma. Improvements in microcirculation correlated with wound healing. Spinal cord stimulation may be considered for select individuals with microcirculatory reserves that can be modulated with treatment.

The utilization of transcutaneous oxygen pressures to guide decision-making for spinal cord stimulation implantation for inoperable peripheral vascular disease: a report of two cases.

Spinal cord stimulation (SCS) may be helpful in treating pain and vascular insufficiency associated with inoperable peripheral vascular disease (PVD). Often decision-making regarding progression from trial to implantation is based on subjective measures. Transcutaneous oxygen pressure, a measure of microcirculation and tissue perfusion, provides information on changes that may occur in PVD patients that undergo SCS trials and may provide predictive information for patient outcomes. This article reports on 2 patients with severe PVD in which transcutaneous oxygen pressures were measured during the trial phase, guided progression to implantation, and were followed in the postoperative period. Transcutaneous oxygen pressure values continued to improve following permanent implantation. We provide a review on transcutaneous oxygen pressure monitoring, along with emphasis on the technical aspects of transcutaneous oxygen pressure monitoring and its incorporation into practice. The decision to implant a SCS should be based on not only subjective measures of improvement, but also objective measures of improvement in transcutaneous oxygen pressure. Additional research is warranted to develop transcutaneous oxygen pressure predictive indices to assist in the selection of patients for progression to permanent implantation.