Spinal Cord Stimulation for Intractable Chronic Limb Ischemia: A Narrative Review

Abstract

Critical limb ischemia (CLI) is the most severe form of peripheral arterial disease, significantly impacting quality of life, morbidity and mortality. Common complications include severe limb pain, walking difficulties, ulcerations and limb amputations. For cases of CLI where surgical or endovascular reconstruction is not possible or fails, spinal cord stimulation (SCS) may be a treatment option. Currently, SCS is primarily prescribed as a symptomatic treatment for painful symptoms. It is used to treat intractable pain arising from various disorders, such as neuropathic pain secondary to persistent spinal pain syndrome (PSPS) and painful diabetic neuropathy. Data regarding the effect of SCS in treating CLI are varied, with the mechanism of action of vasodilatation in the peripheral microcirculatory system not yet fully understood. This review focuses on the surgical technique, new modalities of SCS, the mechanisms of action of SCS in vascular diseases and the parameters for selecting CLI patients, along with the clinical outcomes and complications. SCS is a safe and effective surgical option in selected patients with CLI, where surgical or endovascular revascularization is not feasible.

Keywords: clinical outcomes; intractable critical limb ischemia (ICLI); neuropathic pain; new SCS modalities; peripheral arterial disease (PAD); spinal cord stimulation (SCS).

Figure 1

Flowchart of study selection process for SCS research. This flowchart illustrates the systematic selection process for clinical trials and case series assessing the efficacy of SCS in treating CLTI. From an initial pool of 423 records obtained from electronic databases and reference lists, 330 records were excluded because of irrelevance or lack of pertinence. The remaining 93 full-text articles were evaluated, leading to the exclusion of 76 articles due to reviews and subset studies. Finally, 17 clinical trials and case series were assessed for eligibility, with 12 studies focusing on tonic SCS and 5 exploring new wave modalities.

Figure 2

(A) Lumbar spinal X-ray, antero-posterior view: the Tuohy needle is advanced under fluoroscopy through the fascia toward the interlaminar space. (B) Fluoroscopic lateral view of the lumbar spine showing the tip of the needle entering the epidural space and being moved upward. (C) Antero–posterior fluoroscopic image of the two electrodes at T7 level. The figure was created by the authors.