49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

Use of Spinal Cord Stimulation for the Treatment of Refractory Vasospastic Angina: Case Report

Nikita Patole¹, Boshra Louka MD FACC FSCAI² , Rano Faltas MD¹

iSpine Clinics Maple Grove, Minnesota¹, Interventional Cardiology, Willis Knighton Medical Center, Shreveport, Louisiana²

Introduction

Long-acting nitroglycerins¹ and Calcium channel blockers²
Ranolazine- sodium channel inhibitor
Percutaneous revascularizations/surgical options for vasospastic angina are limited given absence of focal mechanical obstructive lesions.

Spinal cord stimulation at the T1 to T2 level has been effective and more commonly used for management of refractory angina pectoris

One other documented use of spinal cord stimulation for vasospastic angina in a 73 year old patient³.

Patient: 46 year old Female

Angina pectoris presenting for several months limiting her independence as well as activities of daily living.
The patient sought treatment in Emergency Departments several times within the span of 6 months.
The patient was evaluated by cardiology

Angiogram showed widely patent coronary arteries and exercise electrocardiogram was normal.
Angiogram and response of coronary vasoconstriction to intracoronary acetylcholine led to the diagnosis of vasospastic angina without atherosclerotic coronary artery disease.

Enhanced External Counterpulsation (EECP) therapy for two months with benefit but not resolution of her symptoms.
Medication therapy: several opioids, NSAIDs, muscle relaxants, neuropathic medications, Low Dose Naltrexone, and a ketamine compound cream. Only Nitroglycerin 0.4MG, in combination with a calcium channel antagonist (Cardizem, Diltiazem), partially relieved her symptoms.

Neuromodulation Treatment

Implantation of a spinal cord stimulator was proposed
The patient saw 100% relief of symptoms after a five-day trial
Baseline pain was a 9/10 prior to the trial and a 0/10 during the trial.
Procedure: Under fluoroscopy guidance, two eight contact Octrode spinal cord stimulator leads were placed using a 14-gauge Touhy needle to advance into the epidural space up to the T1-T2 level. The leads were tunneled to the generator located in a newly created lateral pocket where a Proclaim XR 5 IPG was placed.
Patient was seen in follow up one week, two weeks, and three weeks post-implant without complications.

90% relief of her vasospastic angina after programming of the device settings
Complete resolution of symptoms during activities of daily living, improvement in walking short distances, and carrying objects.
Functional disability as measured with a Low Back Oswestry Disability Index was 72 prior to the implant and decreased to 56 after the implant.
The patient is currently two years post implant and continues to receive 90% relief.

Figure 1. SCS Implantation Fluoroscopic Images

Discussion

This case demonstrates the successful use of neuromodulation for refractory vasospastic angina.
In the previous use of spinal cord stimulation for ischemic angina pectoris, it has been effective in providing an antianginal effect without reduction of myocardial infarction warning symptoms⁴.
Neuromodulation treats neuropathic anginal pain by inducing paresthesia of the heart and chest region and suppressing the hyperexcitatory responses of spinothalamic tract cells thereby providing an analgesic effect⁵.
A randomized controlled trial would be required to confirm the efficacy of this treatment for vasospastic angina.

References

Parker JD, Parker JO. Nitrate therapy for stable angina pectoris. N Engl J Med. 1998 Feb 19;338(8):520-31. doi: 10.1056/NEJM199802193380807. PMID: 9468470.
Krikler DM. Calcium antagonists for chronic stable angina pectoris. Am J Cardiol. 1987 Jan 30;59(3):95B-100B. doi: 10.1016/0002-9149(87)90088-9. PMID: 2880496.
Kinfe TM, Pintea B. The Usefulness of Spinal Cord Stimulation for Chronic Pain Due to Combined Vasospastic Prinzmetal Angina and Diabetic Neuropathic Pain of the Lower Limbs. J Neurol Surg A Cent Eur Neurosurg. 2016 Mar;77(2):176-8. doi: 10.1055/s-0034-1543960. Epub 2015 Aug 3. PMID: 26238940.
Eliasson T, Jern S, Augustinsson LE, Mannheimer C. Safety aspects of spinal cord stimulation in severe angina pectoris. Coron Artery Dis. 1994 Oct;5(10):845-50. PMID: 7866604.
Linderoth B, Foreman RD. Physiology of spinal cord stimulation: review and update. Neuromodulation. 1999 Jul;2(3):150-64. doi: 10.1046/j.1525-1403.1999.00150.x. PMID: 22151202.

CASE REPORT: USE OF SPINAL CORD STIMULATION FOR THE TREATMENT OF REFRACTORY VASOSPASTIC ANGINA