Treatment of digit ulcers in a patient with Buerger's disease by using cervical spinal cord stimulation -a case report-
The 62-year-old male patient in this case report had a smoking history of more than 30 pack-years and a medical history of hypertension and diabetes. He had had a percutaneous coronary intervention 6 years previously due to angina and had noticed a cold and numbing sensation in the extremities of both hands for the previous 3 years. Two years previously, the patient's fourth finger on the left hand had experienced blue discoloration, with extreme pain of greater than 90/100 mm on the visual analogue scale (VAS), followed by ulceration. After a few tests at the orthopedic clinic, the patient had been diagnosed with Buerger's disease. He had been referred to the pain clinic for conservative treatment one year previously. On the patient's upper extremity angiography, greater than 80% stenosis was observed in the first and third finger artery in the area of radial artery and palmer arch, and greater than 90% stenosis was also observed in distal ulnar artery.\nAt the time of referral, the patient had been taking oxycodone 40 mg twice a day, as well as limaprost 5 µg and gabapentin 300 mg 3 times day. Even with an increase in opiate dose and several chest sympathetic block and stellate ganglion blocks, the analgesic effect was temporal. The pain and ulcers on the fingers worsened, and a finger amputation was planned as arterial bypass surgery was not a valid method for this patient. Although a number of treatments were tried, the patient complained about extreme pain, 90/100 mm on VAS, and there were severe gangrenous ulcers progressing on the fourth finger of the left hand and the index finger of the right hand. The patient was very much against the amputation even though he was under extreme pain and had been referred to the pain clinic several times. Hence, the decision was made to attempt spinal cord stimulation prior to amputation.\nThe blood pressure, heart rate, oxygen saturation, and electrocardiography were monitored, and, with the patient in the prone position, local anesthesia was performed at T2-3 intervertebral space. A 15-gauge Tuohy needle was used for the paramedian approach with a C-arm fluoroscopic image. After ensuring the needle was positioned in the epidural space, the guidewire was inserted for easy insertion of the electrode, and the electrode was positioned in the posterior epidural space using the C-arm fluoroscopic image. The guidewire was removed, and the octrode electrode lead (Advanced Neuromodulation System Inc, Plano, Texas, USA) was placed 2 mm left of the radiological center. The distal electrode was placed at the bottom of the cervical spine ().\nThe electrode was connected to the test stimulator, and the stimulation was profound in the areas with pain. After the test stimulation, the pain was reduced by 50%. During 1 week of test stimulation, the patient's pain was maintained to within 20-30/100 mm on VAS, and the use of opiate analgesics was decreased by 50%. Hence, the permanent spinal cord stimulation insertion procedure was carried out. The Genesis IPG (Advanced Neuromodulation System Inc, Plano, Texas, USA) was buried under the lower left-side clavicle, and stimulation was well controlled with 3-4+ electrode combination, 4.0 V amplitude, 240 msec pulse width, and 34 Hz frequency.\nAfter the spinal cord stimulation insertion, the ulcers on both hands began gradual recovery and were completely recovered after 6 months. The pain was maintained within 30/100 mm on VAS, and the use of opioid analgesics was decreased more than 50% compared with the pre-procedure stage ().