Ischemic Pain in The Extremities and Raynaud's Phenomenon
Ischemic Pain in The Extremities and Raynaud's Phenomenon
Ischemic Pain in The Extremities and Raynaud's Phenomenon
n Abstract: Two important groups of disorders result from an establish a diagnosis as soon as possible in order to influ-ence
the evolution of the disease.
insufficient blood supply to the extremities: critical vascular
disease and the Raynaud’s phenomenon. The latter can be A sympathetic nerve block can be considered in patients with
subdivided into a primary and a secondary type. Crit-ical critical ischemic vascular disease after extensive conser-vative
ischemic disease is often caused by arteriosclerosis due to treatment, preferably in the context of a study (2B±). If this has
hypertension or diabetes. Primary Raynaud’s is idiopathic and insufficient effect, spinal cord stimulation can be considered in
will be diagnosed as such if underlying systemic pathol-ogy has a selected patient group (2B±). In view of the degree of
been excluded. Secondary Raynaud’s is often a manifestation invasiveness and the costs involved, this treat-ment should
of a systemic disease. It is essential to try to preferably be applied in the context of a study and with the use
of transcutaneous pO2 measurements.
In case of primary Raynaud’s, life style changes are the first
Address correspondence and reprint requests to: Maarten van Kleef, step. Sympathectomy can be considered as a treatment of
MD, PhD, FIPP, Department of Anesthesiology and Pain Management, Raynaud’s phenomenon (2C+), but only after multidisciplin-ary
Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht,
The Netherlands. E-mail: maarten.van.kleef@mumc.nl.
evaluation of the patient and in close consultation with the
DOI. 10.1111/j.1533-2500.2011.00460.x patient’s rheumatologist, vascular surgeon or inter-nist. n
;
One or more RCTs with methodological weaknesses, demonstrate effectiveness.
2B+ Benefits closely balanced with risk and burdens >
9
2B± Multiple RCTs, with methodological weaknesses, yield contradictory results
better or worse than the control treatment. Benefits closely balanced with risk and =
burdens, or uncertainty in the estimates of benefits, risk and burdens Considered, preferably
study-related
2C+ Effectiveness only demonstrated in observational studies. Given that there is ;
no conclusive evidence of the effect, benefits closely balanced with risk and burdens
0 There is no literature or there are case reports available, but these are insufficient to prove
Only study-related
effectiveness and/or safety. These treatments should only be applied in relation to studies
RCT of a good quality which does not exhibit any clinical effect. Given that there is
2A)
no positive clinical effect, risk and burdens outweigh the benefit >
discoloration of the distal parts of extremities, but it may II. TREATMENT OPTIONS
change to a dark blue, color. Also important is that there
are no arterial pulsations in the affected area. The A. II.A CONSERVATIVE MANAGEMENT FOR
extremity will feel colder and may show skin lesions that ISCHEMIC VASCULAR DISEASE
heal very poorly in a later stage. The distal peripheral parts Patients with pain due to a vascular disease initially receive
may show a tendency to necrosis. conservative and pharmacological therapy that aims at
General examination to evaluate the patient’s health treating the underlying cause. If the symptoms persist, it
(weight loss, malignancy) is relevant. The blood pressure may be decided to perform vascular surgery. The patient
should be measured and examination focusing on disorders group discussed in this chapter concerns inoperable,
of the connective tissues or on peripheral vascular disease vascular patients with pain at rest and/or ulcers (Fontaine
should be carried out. The hands and feet should be 11
III en IV) (Table 3).
inspected (wounds, ulcers); presence of dilated capillaries
in the nail bed is also important.
A. II.B INTERVENTIONAL MANAGEMENT FOR
ISCHEMIC VASCULAR DISEASE
I.C ADDITIONAL TESTS The treatment of these patients is aimed at pain reduc-tion
and cure of the ulcers in order to prevent amputa-tion. The
Additional laboratory testing (sedimentation, anti-bodies, literature mentions two methods:
renal function) focusing on autoimmune dis-orders can
1. Sympathectomy
best be performed by an internist/ rheumatologist.
2. Spinal cord stimulation
In case of critical ischemic vascular disease, the
imaging of the coronary arteries will be important, because Sympathectomy
it provides information about the prognosis and about
whether surgical intervention could be use-ful. Imaging is Sympathectomy primarily has a vasodilatatory effect on
less relevant in cases of Buerger’s dis-ease and Raynaud’s the collateral circulation resulting from a reduced
phenomenon; clinical and laboratory examination will sympathetic tone. Improved oxygenation of the tissues
provide sufficient infor-mation to make the diagnosis. leads to less tissue damage, which results in decreased pain
and increased healing of the ulcers. Pain reduction also
occurs due to the interruption of sympathetic nociceptive
Once the diagnosis has been established, the evo-lution
interaction.
can be followed by means of capillaroscopy, which
determines both the number of capillaries and the rate of Three randomized studies were reported in the litera-
12
red blood cell circulation. The determina- ture. Only Cross and Cotton found significant pain
tion of the transcutaneous oxygen saturation is also reduction in the group treated with chemical lumbar sym-
a parameter indicating the severity of the disease; pathectomy compared to the control group (bupivacaine
it can also be used to demonstrate improvement injection) (66.7% vs. 23.5%), but no changes in the ankle-
brachial index. The two other randomized controlled trials
in the microcirculation resulting from particular 13,14
treatments. (RCTs) did not show any objective advantages.
Over the years, however, several cohort studies have
been conducted examining the effect of sympathectomy,
I.D DIFFERENTIAL DIAGNOSIS
In cases of secondary Raynaud’s especially, it is impor- Table 3. Classification of Perfusion Disorders in Peri-pheral
Arterial Vascular Disease according to Fontaine
tant to demonstrate or exclude concomitant disorders.
Severe vascular disease may lead to organ damage.
Medicinal therapy is often indicated. The primary form
may resemble acrocyanosis (blue discoloration of the
nails) and primary livedo reticularis (red-blue dis-colored
skin in a reticular pattern); both are caused by reduced
perfusion of the skin and are enhanced by cold exposure
and emotional stress.
Stage I No symptoms (sufficient peripheral circulation)
Stage II Pain upon exertion, intermittent claudication
IIa ability to walk > 100 m
IIb ability to walk < 100 m
Stage III Pain at rest in the extremity concerned and
in the supine position due to a poor muscle
perfusion. The pain often temporarily
decreases if the leg is dependent
Stage IV Trophic disorders such as necrosis/gangrene
25. Ischemic Pain in the Extremities and Raynaud’s Phenomenon • 487
Sympathectomy 2B±
Spinal cord stimulation 2B±
488 • DEVULDER ET AL.
Technique Evaluation
Sympathectomy 2C+
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