6th Edition of Neurology World Conference 2026

Abstract

This article describes a multimodal outpatient protocol using a tunnelled epidural catheter as an analgesic alternative for severe chronic ischaemic lower-limb ulcers, illustrated by a representative case. The patient was a middle-aged man with Buerger’s disease, under multidisciplinary care since 2018, who presented to our Chronic Pain Unit in January 2024 with recurrent ischaemic ulcers deemed ineligible for revascularisation. Despite treatment with high-dose opioids and adjuvant analgesics, he continued to experience severe pain and progressive wound deterioration. After implementing the multimodal analgesic protocol for 17 weeks, wound resolution was achieved remaining ulcer-free, with marked improvement in pain and overall wellbeing. Background Locoregional anaesthetic techniques are nowadays widely use and have advanced significantly with the advent of ultrasonography for peripheral nerve blocks. Nevertheless, Central Neuraxial Blocks (CNBs) retain a vital role when applied judiciously for anaesthetic and analgesic purposes. These include spinal, epidural, combined spinal–epidural and caudal epidural techniques. When appropriately indicated, CNBs are considered safe and continue to represent the gold-standard in many areas, such as Obstetrics1,2 and Oncological Pain Therapy3–5 . Moreover, CNBs have been proposed as a valuable alternative for refractory non- oncological pain5,6 , such as associated with chronic ischaemic lower-limb ulcers arising from advanced peripheral vascular disease or vasospastic syndromes. These ulcers are frequently accompanied by severe rest pain and impaired wound healing and, in some cases, revascularisation is not feasible. When conventional systemic analgesia fails, our Pain Clinic developed a protocol revisiting a classical technique through prolonged epidural infusion via a tunnelled catheter, intended to modulate autonomic function, improve microvascular perfusion and achieve pain control, prior to more definitive treatments such as sympathectomy or implantable intrathecal pump6 . This report describes the practical application of our multimodal outpatient protocol, for several weeks, in a patient with refractory ischaemic ulcers with history of prior failure of varied high-dose systemic opioids and adjuvant analgesics. Conclusions This report describes a novel application of a classical anaesthetic technique in a non- oncological outpatient with severe chronic ischaemic ulcers who was unsuitable for revascularisation. With appropriate and rigorous follow-up, continuous epidural infusion via a tunnelled catheter, using the original technique described, provided effective analgesia and improved tolerance of wound care, and was associated with complete ulcer resolution without complications. Although there is limited literature on the use of continuous neuraxial techniques for chronic ischaemic pain, regional analgesic approaches have been reported in refractory cases. These findings support consideration of multimodal epidural analgesic protocols as a valuable therapeutic option in selected patients with refractory chronic limb ischaemia, particularly where revascularisation is not feasible and standard pharmacological management is insufficient.