Surgical Solution for Excessive Foot Sweating
Lumbar sympathectomy is being done under general anesthesia. It involves 3 small cuts for the endoscopic approach into the retro-peritoneal area. Once the surgeon is there a space is developed and the sympathetic chain at the lumbar region is visualized. Once it is visualized it is either excised or clamped at the level L3-L4. This particular procedure is done on both sides. The operation takes about an hour to perform and in contrast to the endoscopic thoracic sympathectomy the patient should stay over at the hospital for one day.
As more experience is gained even lumbar sympathectomy can be performed on an outpatient basis. In a typical case like this if the operation starts early in the morning, and the anatomical relations are displayed easily and nicely, the resultant pain and discomfort can be brought down to a minimum enabling a patient like this to leave the hospital in the late afternoon. Many more cases will have to be done in order to establish a definite pattern which would allow us to do the majority of the cases on an outpatient basis. There are a few sensory nerves located close to the lumbar sympathetic chain. It is very important to avoid them but even if such nerve is damaged the result can be some numbness in inner thigh region that usually of a temporary basis.
The current success rate is approximately at 97%. The possible side effects and complications include bleeding, pain, discomfort, and in the male population, the issue of retrograde ejaculation should be discussed in detail with the surgeon. Even though retrograde ejaculation has not been proven to be a problem in Lumbar Sympathectomy this particular issue is the responsibility of the surgeon and the patient to discuss. Even though in the clinical experience it was not proven to be a problem there is always a possibility and the security of sperm donation for future use if the retrograde ejaculation becomes a permanent problem.
Potential patients for Lumbar Sympathectomy should be aware of the fact that sometimes, in very rare cases, due to technical difficulties there might be a need to change the operation from endoscopically assisted Lumbar Sympathectomy to open Lumbar Sympathectomy. This will involve incisions on both sides measuring about two inches in size. The added discomfort or pain is very well tolerated by patients in situations where the operation had to be converted to open Lumbar Sympathectomy. The scarring is minimal and also is in an area that is very well accepted.
It is important to keep in mind this is a technical difficulty in doing the procedure and not a complication. Prior to the surgery the patient is given the very clear choice to allow conversion from endoscopically assisted to an open lumbar sympathectomy. The reason this is offered is to allow for more approaches to successfully complete the procedure.
As more experience is gained the current method being used to perform ELS gives us a better ability to examine the sympathetic chain compared to other methods used. Obviously different centers using different approaches but in comparing the methods we found out that our current method gives an ability to examine the sympathetic chain over longer segment thus making sure that all sympathetic fibers below lumbar vertebra #2 are being clamped so as to get total sweat cessation in the feet. It is a known fact that all sympathetic fibers below lumbar vertebra #2 are running to the feet. If it happens that the lumbar sympathectomy was done in a somewhat lower level (ie 3 or 4) one might miss some very fine fibers that run to the feet leaving a possibility for incomplete and successful procedure.
Clinical Results Thus Far (500 + Cases):
The clinical experience accumulated since about 2008 shows that lumbar sympathectomy is a very effective method with regard to severe plantar (sweaty feet) hyperhidrosis. Most of our patients previously had ETS with no relief for their excessive foot sweating. As time goes by more people with primary plantar hyperhidrosis are having lumbar sympathectomy as well. The success rate is about 97% and side effects such as increased compensatory sweating, pain, discomfort and scars are minimal. Retrograde ejaculation (male patients),sexual dysfunction or hypotension has not occurred in any of Dr. Reisfeld’s 500 plus lumbar sympathectomy cases so far. Dr. Reisfeld continues to work hard to further develop and improve this procedure. No other surgeon comes close to this level of experience.
Of interest is the fact that similar to the ETS cases at about 3 to 4 days after the lumbar sympathectomy another bout of sweating occurs. As we learned from the ETS cases this is a short bout of sweating and it stops a few hours to a day later. So far no increase in compensatory sweating have been noted after the lumbar sympathectomy procedure. Some patients will have an initial increase in the compensatory sweating compared to what they had after having the ETS procedure. The ELS procedure will cause fluctuation in the amount of compensatory sweating but on a long run these changes will go back to the compensatory sweating levels that were obtained after ETS. That is the reason why the time interval between ETS and ELS should be at least 6 months. On the other hand patients who experience whatever level of compensatory sweating after ETS should expect that level to stay. Keep in mind ETS is a separate procedure from lumbar sympathectomy. Learn more about ETS.
Another point of clinical interest is the fact that in those patients who had previous ETS and later on underwent lumbar sympathectomy there is at times (in a small percentage of cases) slight temporary recurrence with their hand sweating that with time will go disappear.
So far the information about compensatory sweating and patients who had only lumbar sympathectomy is not yet available due to the small number of cases of lumbar sympathectomy only. In the small amount of cases where only lumbar sympathectomy was done compensatory sweating was mild however it is still too premature to draw any definite conclusions.
With recurrence rate after endoscopic lumbar sympathectomy, the numbers are not yet in. There are rare reports of some limited-partial recurrence in one aspect or another of the foot surface which can be the result of abnormal branches that are supplying the feet area with sympathetic innervation. Again those observations were made in a very small number of cases and more time will be needed to define the exact reason for this limited recurrence.
In 2013 Dr. Reisfeld published another important study with regard to the treatment of severe plantar hyperhidrosis. Dr. Reisfeld is proud to be one of the few surgeons who has invested his time and effort to study and advance this subject. View this study.
In a paper published in December 2009 there is a description with results with regard to the surgical treatment of plantar-feet hyperhidrosis. Basically in about 90 patients the procedure had a high success rate and overall satisfaction. For a brief summary of this paper see -> Endoscopic lumbar sympathectomy for plantar hyperhidrosis.
In a separate study (Endoscopic sympathectomy for palmar and plantar hyperhidrosis: results in 107 patients) published in 2000 French surgeons performed 78 lumbar sympathectomies. Their results are similar to those published in the previous paper as well as by Dr. Reisfeld in his published/peer reviewed paper on ELS. The French authors performed ELS only on women.
The History of Lumbar Sympathectomy
Lumbar Sympathectomy used to be performed for patients with vascular insufficiency (blood supply problems – to lower legs). The idea was that by doing sympathectomy the vaso constrictive influence of the sympathetic chain of the blood vessels will be abolished and hence the blood vessels will be open and providing a better blood supply to the legs. This was done for many elderly patients, with specifically vascular insufficiency, but the results were poor. Lumbar Sympathectomy done for those patients is rarely done now and is being replaced by different medications. This is not to be confused with lumbar sympathectomy for excessive foot sweating.
Another indication which Lumbar Sympathectomy is rarely done for is for complex regional pain syndrome or sympathetic neuralgia. Since this syndrome is not well understood obviously the results are very inconclusive.
Lumbar Sympathectomy is however very effective in treating plantar hyperhidrosis and the same principal applies here as in the cases palmar hyperhidrosis where thoracic sympathectomy is a very effective modality in treating excessive hand sweating. The current success rate is approximately at 97%.
Like in any other surgical procedure that tries to correct physiological – genetic problems with mechanical solutions the issue recurrence will always be a possibility. Even though the possibility is extremely low it can happen. There are two main factors that typically contribute to this; The inexperience of the surgeon and the fact some anatomical variations can exist (everyone’s body is different). The surgeon of choice should have extensive experience and knowledge.
When does conversion from an endoscopic lumbar sympathectomy to open lumbar sympathectomy happen?
Overweight patients or those patients who had previous operations performed in the vicinity of the lumbar region (such as c-section, hysterectomy, kidney operation) can create scar tissue that will make the endoscopic lumbar sympathectomy more difficult to perform. The option of an open procedure is always available extremely uncommon.
Does lumbar sympathectomy affect pregnancy?
So far there is no known connection between lumbar sympathectomy and the ability to conceive. On the contrary, Dr. Reisfeld’s female patients who had this procedure have become pregnant without any issue.
Will I get more hand sweating after doing the lumbar sympathectomy procedure for my sweaty feet?
Basically the answer is no, there are some instances in which patients describe a temporary increase in their hand sweating after their lumbar sympathectomy. Those patients already had the thoracic sympathectomy for their excessive hand sweating. This temporary and short increase is unexplained so far.
Could my feet become too dry after lumbar sympathectomy?
There has been one case where a patient was complaining that her feet after the lumbar sympathectomy were very dry to the level of discomfort. This particular patient had only plantar hyperhidrosis without any palmar hyperhidrosis associated with it. The rest of the cases were the lumbar sympathectomy was done after thoracic sympathectomy this side effect has not been reported. The reason for this extreme dryness in a patient who only had plantar hyperhidrosis is unknown at this time and more cases will have to be done in order to understand this problem better.