Dual-Lead Spinal Cord Stimulation for Refractory Diabetic Small Fiber Neuropathy With Erythromelalgia-Like Features:...

Small fiber neuropathy is a painful diabetes complication that may present with burning pain, dysesthesia, and autonomic features such as swelling, color changes, and hyperhidrosis. Some cases overlap with erythromelalgia, a rare condition marked by episodic erythema, temperature sensitivity, and vasomotor instability. Spinal cord stimulation has shown promise for refractory neuropathic pain, but evidence for its use for small fiber neuropathy and erythromelalgia is limited.

A 32-year-old man with longstanding Type 1 diabetes reported more than a decade of progressive neuropathic symptoms, including burning pain, temperature sensitivity, erythema, swelling, and hyperhidrosis affecting all extremities. Our exam found decreased temperature sensation in a "stocking-glove" distribution with autonomic dysfunction in the distal extremities. Electromyography showed no large fiber involvement, and an expanded autoimmune and genetic workup was unrevealing. Despite conservative therapies, he achieved only partial relief. He underwent a dual-lead spinal cord stimulation trial targeting the cervical and thoracic regions. He reported approximately 75%-80% pain relief, improved mobility, and resolution of his vasomotor symptoms.

This case illustrates the potential role of dual-lead spinal cord stimulation for treating refractory diabetic small fiber neuropathy with erythromelalgia-like features involving both the upper and lower extremities. Our patient reported significant improvements in pain and autonomic symptoms. These findings support considering targeted neuromodulation for patients who have medication-resistant small fiber neuropathy in multiple extremities.