Lumbar Sympathectomy: Treatment, Effects & Risks

Lumbar sympathectomy is a form of surgical nerve block. It is used to treat hyperhidrosis or pain.

What is lumbar sympathectomy?

Lumbar sympathectomy is when certain ganglia of the sympathetic nervous system in the lumbar region are cut during a surgical procedure. The transection may be partial or complete. The sympathetic nervous system is part of the autonomic nervous system and is the counterpart of the parasympathetic nervous system. It fulfills the task of regulating metabolism, heart and circulation. In addition, it ensures a higher performance capacity of the body. Another function of the sympathetic nervous system is to stimulate perspiration. In the case of lumbar sympathectomy, there is an option to block the sympathetic nerve, which leads to the reduction of excessive sweating. Similarly, lumbar sympathetic nerve block is suitable for the treatment of chronic pain conditions. Both open and endoscopic lumbar sympathectomy are available.

Function, effect, and goals

Unlike endoscopic thoracic sympathectomy (ETS), which is performed to treat sweating of the face and hands, lumbar sympathetic blockade is used to treat plantar hyperhidrosis of the feet. While thoracic sympathectomy involves transection or partial removal of the limiting cord in the thoracic region, endoscopic lumbar sympathectomy (ELS) involves the procedure in the lumbar spine region. In both procedures, a minimally invasive approach is possible with the help of a special endoscope. However, a surgical sympathectomy is only performed if all other therapy options do not lead to the hoped-for effect. By blocking the sympathetic nervous system in the lumbar region, pain can also be treated effectively. This is especially true for pain conditions in the lower limbs. In this case, the pain is either significantly alleviated or even completely eliminated. In pain treatment, the nerves can be influenced by administering an active substance (sympatholytic agent). The surgeon administers the drug into the adjacent vein, which results in improved blood flow to the muscles and other body structures. This results in a reduction of pain. Even a long-term effect is possible, provided that several sessions are performed. The control of the surgical procedure takes place under ultrasound or X-ray supervision. In this way, the surgeon can insert a long needle into the area surrounding the sympathetic border cord and anesthetize it with it. The main indications for thoracic sympathectomy, in addition to plantar hyperhydrosis, are pain due to circulatory disorders, nervous disorders, and a complex regional pain syndrome. For effective treatment of plantar hyperdhidrosis, it is necessary to eliminate or at least reduce the sweating that occurs on the feet. For this purpose, the surgeon cuts the sympathetic boundary cord, which is located at the level of the lumbar spine. Its course extends from the major blood vessels such as the aorta to the anterior lumbar spine. Because the sympathetic nerve is difficult to access, extensive open surgery was required in earlier years. The patient’s recovery period lasted several weeks. For several years, however, the gentle endoscopic lumbar sympathectomy has been one of the common surgical procedures, which involves video endoscopy. Access is gained on both sides through three smaller skin incisions in the lateral region of the umbilical level. After the blockade of the sympathetic nerve, the patient only needs to stay in the hospital for 24 hours. The postoperative recovery period is now also limited to a few days. However, the surgeon’s experience plays a decisive role in the success of the operation. In principle, endoscopic lumbar sympathectomy is performed nowadays. In contrast, open surgery is only used in exceptional cases. Because this procedure is an exceedingly complicated operation, it is performed only in a few specialized centers.

Risks, side effects, and hazards

Endoscopic lumbar sympathectomy can sometimes lead to undesirable side effects and complications.Similar to endoscopic thoracic sympathectomy, compensatory sweating is possible following surgery. However, the extent of this side effect is much less pronounced in most patients. Some patients, which primarily include people who have already undergone thoracic surgery, barely feel this effect. Another possible side effect is an increase in peripheral blood flow in the feet. This is manifested by feet that are too dry and too warm. Occasionally, the feet swell, but this is only temporary. The complication of retrograde ejaculation in men, in which the seminal fluid no longer empties to the outside, has become rather rare. It is primarily seen after open sympathectomies. However, the introduction of the more precise endoscopic lumbar sympathectomy has significantly reduced this unpleasant side effect. Occasionally, anatomic problems occur during the procedure. For example, scarred tissue due to inflammation, bleeding, or obstructed vision sometimes prevents access to the sympathetic nerve. In such cases, the physician aborts the operation or alternatively selects an open approach. In principle, the interruption of the sympathetic nerve leads to a significant improvement in hyperhidrosis of the feet. Thus, the success rate is about 99 percent. In some cases, however, the ganglionic chain cannot be passed at all, which is due to inflammatory processes or adhesions formed after previous interventions. In addition, the patient’s anatomy may vary. Because of this, the surgeon often must proceed on an individual basis.