Surgery for ischemic pain and Raynaud's' phenomenon in scleroderma: a description of treatment protocol and evaluation of results.
Although the literature suggests that palmar sympathectomy (PS) with or without vascular reconstruction may improve ischemic digital pain, fingertip ulceration, and cold intolerance in patients with scleroderma, the question regarding long-term efficacy still remains. This retrospective study of six patients (eight hands) operated on between 1995 and 1997 evaluates both early (6 months) and long-term (average, 2.5 years) outcome after PS in combination with decompression arteriolysis of the radial and ulnar arteries proximal to the wrist. When preoperative digital blood flow was inadequate based on noninvasive vascular studies and major inflow occlusion was present, vascular reconstruction was also performed when feasible. At early review, significant improvement in ischemic digital pain and moderate improvement in cold intolerance resulted in eight hands, and at final follow-up, this was sustained in seven hands. Preoperatively, digital ulcerations were present in six hands. After digital debridement and/or amputation, all wounds healed, but in one patient with bilateral disease who continued to smoke, ulcerations recurred without the need for subsequent surgery. Five of six patients were no longer dependent on narcotic analgesics, but use of vasodilator medication did not change. Five of six patients claimed significant improvement in the quality of life after surgery and reported that they would undergo the surgery again. PS in combination with radial and ulnar arteriolysis appears to be efficacious at both early and long-term review. When major inflow occlusion exists and digital blood flow is compromised, vascular reconstruction is recommended if possible. We review our treatment protocol in this complex population of patients.