Complete relief of a severe feet and hand necrotising Raynaud’s phenomenon with double cervical and dorsal spinal cord stimulation

Rationale of the study Several evidences suggest that spinal cord stimulation (SCS) can effectively treat vascular disorders. Raynaud’s phenomenon is a vaso- spastic condition affecting primarily the distal resistance vessels. Usually it is triggered by cold temperatures, or by emotions such as anxiety and stress. High levels of sympathetic activity seem to be related to Raynaud’s phenomenon as well as low levels of calcitonin gene-related peptide expression in the local sensory fibers. Methods We present a case of a severe necrotising Raynaud’s phenomenon involving one hand and feet refractory to conservative treatment successfully treated with cervical and dorsal SCS electrodes. Results A 37-year-old woman presented in November 2016 complaining of pain involving both feet and the V finger of the right hand; the diagno- sis was necrotising Raynaud’s phenomenon. The character of pain was tearing; touching objects or dresses led to an immediate increa- se in pain intensity, so that she even could not wear shoes, walk or take objects. The pain ratings were mean 8/10, maximum 10/10, and minimum 6/10 on the nominal analogue scale. Her pain did not respond to any kind of therapeutic manoeuvre or behavioural factors. She had been immediately treated with vasodilators iv, with scarce clinical response and increasing pain and necrosis. Indication of amputa- tion was therefore made. Before amputation, a trial of SCS was performed. A double octopolar SCS lead was implanted, one in cervical region (C3-C4), and one in the dorsal region (D8-D9), in a medial position in order to obtain an analgesic and vasodilator effect on both hand and feet. The patient referred in subsequent days a net improvement of symptoms, with a reduction of mean pain ratings until 2/10. Also perfusion in hand and feet significantly improved, so that necrosis completely reversed and amputation was no longer necessary. The system was therefore totally implanted. Conclusions It has been proposed that SCS increases cutaneous blood flow by antidromic activation of afferent fibers in the dorsal roots. Moreover it has a direct inhibitory effect on peripheral vasoconstriction that is maintained by efferent sympathetic activity including nicotinic transmis- sion in the ganglia and the postganglionic alpha-1-adrenergic receptors. Furthermore, it is believed that pain relief is mediated by sup- pression of nociceptive transmission via descending inhibitory pathways. This is the first case report, to our knowledge, in which a dou- ble cervical and thoracic lead was implanted. This approach was chosen in order to achieve a better pain control in the extremities and to program each side separately from the other. The present case once more highlights that epidural neurostimulation is a promising the- rapeutic option for severe Raynaud’s phenomenon.