title: Pain relief in complex regional pain syndrome due to spinal cord stimulation does not depend on vasodilation.
abstract: BACKGROUND
  Spinal cord stimulation (SCS) is known to relieve pain in patients with complex regional pain syndrome (CRPS) and, in general, to cause vasodilation. The vasodilatory effect of SCS is hypothesized to be secondary to inhibition of sympathetically mediated vasoconstriction, or through antidromic impulses resulting in release of vasoactive substances. The aim of the present study was to assess whether pain relief in CRPS after SCS is, in fact, dependent on vasodilation. In addition, we tried to determine which of the potential mechanisms may cause the vasodilatory effect that is generally found after SCS.
  
  
  METHODS
  Twenty-four of 36 patients with unilateral CRPS responded to the test of SCS. Twenty-two of these 24 responders (hand, n = 14; foot, n = 8) who had undergone previous sympathectomy were enrolled for the study. In addition, 20 control subjects (10 controls for each extremity) were studied. By means of laser Doppler flowmetry, the skin microcirculation of the patients was measured bilaterally while the SCS system was switched off and while it was activated. Control subjects (n = 20) were tested once only. The ratio of the rest flow at heart level and the dependent position was defined as the vasoconstriction index.
  
  
  RESULTS
  Both in affected hands and feet, patients were found to have lower vasoconstriction indices (P < 0.01) as compared with controls, indicating a decreased sympathetic tone. Applying SCS did not result in any microcirculatory change as compared with baseline or the contralateral clinically unaffected side.
  
  
  CONCLUSIONS
  The current study failed to show that SCS influences skin microcirculation in patients with CRPS and a low sympathetic tone. Therefore, we may conclude that pain relief in CRPS due to SCS is possible without vasodilation. Because sympathetic activity was greatly decreased in our patients, these results support the hypothesis that the vasodilation that is normally found with SCS is due to an inhibitory effect on sympathetically maintained vasoconstriction.
authors.affiliation: Department of Surgery of Maastricht University Hospital, Maastricht, The Netherlands. mkeml@shee.azm.nl
authors.forename: M A
authors.initials: MA
authors.lastname: Kemler
authors.forename: G A
authors.initials: GA
authors.lastname: Barendse
authors.forename: M
authors.initials: M
authors.lastname: van Kleef
authors.forename: M G
authors.initials: MG
authors.lastname: Egbrink
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D004599:Electric Stimulation Therapy; D005260:Female; D006801:Humans; D017078:Laser-Doppler Flowmetry; D008297:Male; D008833:Microcirculation; D008875:Middle Aged; D059408:Pain Management; D010147:Pain Measurement; D012019:Reflex Sympathetic Dystrophy / Q000628:therapy*; D012039:Regional Blood Flow; D012867:Skin / Q000098:blood supply; D013116:Spinal Cord / Q000098:blood supply / Q000503:physiopathology*; D013562:Sympathectomy; D014664:Vasodilation