Management of vasospastic disorders with botulinum toxin A

BACKGROUND: Surgical digital artery sympathectomy is indicated when medical management has failed to control rest pain, impending infarction of digits, or healing of ischemic ulcerations caused by profound vasospasm that is associated with other systemic diseases. After digital artery sympathectomy, recurrence or persistence of vasospasm may compromise hand function and ultimately result in amputation of all or portions of both lower and upper extremities. METHODS: The authors present a case series of 11 patients with vasospasm producing intractable rest pain, digital ulcerations, and digit infarctions that failed aggressive medical therapy and that were then treated by perivascular injections of botulinum toxin A (Botox). Before Botox injection, the level of pain, cutaneous temperatures, color, and ulcerations and infarctions were documented RESULTS: The authors' longest follow-up was 30 months. All patients reported highly significant pain reduction, 10 of 10 to 0 to 2 of 10, within 24 to 48 hours after injection, persisting for months after the injection. Nine of 11 patients with nonhealing ulcers spontaneously healed small ulcers and areas of infarction after surgical debridement. Two cases required small skin grafts. Nine of 11 patients reported decreased severity and frequency of vasospastic episodes. CONCLUSIONS: Hand injection of botulinum toxin A appears to be an effective treatment for intractable digital ulcerations and rest pain in patients with severe vasospastic disorders. Because of the complexity of surgical digital artery sympathectomy along with its associated high risk of persistent symptoms, the authors conclude that the therapeutic use of botulinum toxin A injections represents an attractive alternative therapy.