Sympathectomy and Neuromodulation in the Treatment of Critical Lower Limb Ischemia

Abstract

INTRODUCTION Critical lower limb ischemia is a widespread disease that occurs due to atherosclerotic lesions of the arteries with progressive narrowing of their lumen. Clinically critical ischemia is manifested by pain at rest, resistant to narcotic analgesics, and/or ulcerative necrotic process on the legs. In the absence of treatment, patients undergo amputation of the lower limb. Almost all patients die 10 years after amputation of the lower limb at the level of the thigh. Currently, there are following methods of treatment of critical ischemia: conservative therapy, direct revascularization, lumbar sympathectomy and neurostimulation.AIM OF STUDY To present the data of modern scientifi c literature on the use of lumbar sympathectomy and epidural spinal cord stimulation in the treatment of critical lower limb ischemia.MATERIAL AND METHODS This review presents the latest data obtained as a result of studying domestic and foreign literature on the treatment of critical lower limb ischemia with lumbar sympathectomy and epidural spinal cord stimulation. Currently, lumbar sympathectomy is performed by surgical (open, mini-access and endoscopic) and percutaneous (chemical or radiofrequency) methods. Percutaneous access is becoming widespread due to its minimally invasiveness, maximum accessibility, ease of performance and low cost. Epidural spinal cord stimulation is performed for resistant pain syndrome. The mechanism of action of spinal stimulation is to block the transmission of nerve impulses at the level of the gelatinous substance of the posterior horns of the spinal cord during stimulation of afferent fi bers of a larger diameter (type A-alpha and A-beta fi bers).CONCLUSION Spinal neurostimulation and lumbar sympathectomy are promising methods of treatment for critical lower limb ischemia in case of impossibility of direct revascularization. Lumbar sympathectomy can reduce the intensity of pain and improve the quality of life of patients. According to a number of studies, epidural spinal cord stimulation signifi cantly reduces the likelihood of amputation of the lower limb, and also reduces the intensity of pain in patients refractory to conservative therapy, as well as in those who are not indicated for direct revascularization of the arteries of the lower extremities. More large-scale studies are needed to determine the indications for the above methods.

Keywords

• lumbar sympathectomy
• critical lower limb ischemia
• spinal neurostimulation
• limb preservation
• chronic pain syndrome
• sympathetic ganglion