ENDOSCOPIC LUMBAR SYMPATHECTOMY (ELS)

Hyperhidrosis

Hyperhidrosis Forum

Lumbar sympathectomy history

The lumbar sympathectomy was first described by Julio Diez of Argentina in 1924 (to treat gangrene and other lower limb problems), followed very shortly by Royle in Australia in 1925 (to treat spastic paralysis) and Adson in the US in 1925 (to treat Raynaud's Syndrome). Historically, lumbar sympathectomy was primarily performed on patients with lower leg ischemic (blood circulation) problems and neuralgia. Its use for most of these problems has decreased since 1960, due to the availability of superior and safer arterial reconstruction techniques.

Many surgeons also found that patients with plantar (feet) hyperhidrosis saw good results in having their feet sweating stop completely after an open lumbar sympathectomy. However, side effects such as retrograde ejaculation and general pain/neuralgia led to most surgeons around the world not recommending the procedure for hyperhidrosis of the feet. Even after the procedure started being performed endoscopically, the side effects remained significant. At the time, the second lumbar ganglion (L-2) was destroyed by being cut or cauterized or resected.

Present state of lumbar sympathectomy

Since the mid-2000s, lumbar sympathectomy has witnessed a resurgence in popularity for treating plantar hyperhidrosis. Just like with ETS surgery, clamping replaced cutting or cauterizing or resection (of the lumbar chain instead of the thoracic chain in this case), and clamping of L-3 or L-4 instead of L-2 became the treatment of choice for feet sweating ELS surgery (for hand sweating, ETS surgeons switched from T-2 to T-3 and/or T-4).

The resurgence in lumbar sympathectomy started in Brazil and Europe (specifically, Austria and France). In the US, only one surgeon currently performs lumbar sympathectomies with any kind of regularity.

Important published studies on lumbar sympathectomy for feet sweating

Because there have been very few surgeons around the world who have been performing lumbar sympathectomy with any significant frequency to treat feet sweating, it is easy to find and list below virtually all studies on the subject that have been published in recent years. Note that doctors who have published a few papers over the years are typically including some of the same patients in each paper, so there is some double and triple counting. It should also be noted that numerous doctors in China and India likely perform ELS to treat feet sweating (and some have youtube videos on it), but there is very little publicly available information from these doctors in the form of published studies in reputable western journals.

April 2015 -- Dr. Rieger and other Austrian doctors' summary of 52 lumbar sympathectomy patients (31 male, 21 female).

August 2013 -- Dr. Reisfeld from the US and his summary of 154 lumbar sympathectomy patients (around two-thirds were clamped at L-3, and one-third at L-4). Interesting that he admits "misidentification of genitofemoral nerve for sympathetic nerve" in one instance.

August 2012 -- Student Diana Seaders' excellent literary review of nine case studies/published reports related to ELS from 2001-2011.

January 2012 -- Dr. Rieger's summary of 154 lumbar sympathectomy patients (spanning December 2004 through August 2011).

June 2011 -- Dr. Li and other Taiwanese doctors summary of just 1 procedure (and it might have been their first one), but worth checking if they have done any more thereafter.

September 2010 -- Dr. Rieger from Austria and several Brazilian doctors' summary of 130 lumbar sympathectomy patients (8 male, 122 female). All 130 patients also had prior ETS surgery to treat excessive hand sweating.

February 2010 -- Dr. Coelho and other Brazilian doctors' summary of 5 lumbar sympathectomy patients (all female).

January 2010 -- Dr. Stefaniak and other Polish doctors' summary of 12 lumbar sympathectomy patients (2 male, 10 female) operated upon between 2008 and 2009 using a posterior approach.

December 2009 -- Dr. Rieger and other Austrian doctors' summary of 90 lumbar sympathectomy patients (59 male, 31 female).

December 2009 -- an interesting fully available report of a chemical lumbar sympathectomy to treat one person's feet sweating.

July 2008 -- South Korean experiences with chemical lumbar sympathectomy block (CLSB) for feet sweating on 69 patients.

April 2008 -- Dr. Loureiro and other Brazilian doctors' summary of 31 lumbar sympathectomy patients (all female).

January 2007 -- Dr. Rieger and other Austrian doctors' summary of 8 lumbar sympathectomy patients (5 male, 3 female).

November 2001 -- Dr. Tseng from Taiwan published a very interesting report on 1 right side only lumbar sympathectomy female patient who saw both feet stop sweating despite only being operated upon on the right side! Too bad this has not been tried en masse since then.

Important lumbar sympathectomy related links

Dr. Tarfusser's page on lumbar sympathectomy.

Dr. Tarfusser's page on lumbar sympathectomy intra-operative images.

Dr. Reisfeld's page on lumbar sympathectomy.

Dr. Reisfeld's page on side effects from lumbar sympathectomy.

Dr. Noel Perin at New York Unversity and his minimally invasive “Tubular Retractor” lumbar sympathectomy.

Updates

January 2012: At the end of December 2011, someone named Chris e-mailed me and wanted to urgently talk on the phone about Hidrex and Idromed (and also advise me about lumbar sympathectomy that he already had). I called that person, and he told me that he had lumbar sympathectomy 1.5 years ago, and the results were excellent for 1.5 years with no side effects. However, recently, the sweating had returned to almost original levels in his right foot, and 10 percent of original levels in his left foot. This person got operated on by Dr. Reisfeld, but was not keen to pay around $13k a second time for a repeat procedure and was thus curious about iontophoresis. If he calls or e-mails me again, I will update this interesting case. This person's health insurance provided almost no reimbursement for his surgery. So if you do end up going to Dr. Reisfeld, I would recommend asking for a free or highly discounted procedure in case of symptom recurrence within a few years. Edit: See Chris's post.

April 2013: Forum member "slovenec" just had an ELS in Italy with Dr. Tarfusser. So far a success. See his thread updates.

November 2013: I contacted Dr. Tarfusser about his experiences with lumbar sympathectomy to date and he sent me a very detailed response for which I am grateful (although he did not respond to my question about symptom recurrence rates). Some highlights -- In Europe, apart from Dr. Tarfusser, Dr. Schick in Germany and Dr. Rieger in Austria are the only other surgeons who currently perform ELS. In Brazil, "a group in Sao Paolo" performs ELS. In Argentina, Dr. Garcia-Morato (who assisted/trained under Dr. Tarfusser with one ELS procedure some time ago) might have started offering ELS. And of course Dr. Reisfeld offers the procedure in the US. (I should note here that there are numerous videos on youtube of surgeon's performing lumbar sympathectomy so in all likelihood there are a lot of them out there. However, if I was getting ELS, I would pick one of the very select few in the world who have performed more than 100 ELS surgeries to treat hyperhidrosis). Finally, here is an interesting paragraph from Dr. Tarfusser's e-mail that I will paste rather than try to summarize:

"In summary, for the time being, there are only a handful surgeons with experience in ELS. This may be due to ELS being a more difficult operation than ETS, with a longer learning curve for the surgeon. Another explanation may be that the retroperitoneal space is a domain of urologists, and general surgeons usually have no or almost nil experience with endoscopy in this part of the body (even less thoracic surgeons). Only specifically interested surgeons or urologists (like me) do normally venture in this field. Therefore, I guess that this technique will not gain the same spreading as ETS. And it is probably better to concentrate the experience to only a few centers, because the number of patients with extreme suffering from plantar HH is much lower than for hand sweating, If many hospitals would offer this surgery, there is a risk that some colleagues would end up with an yearly operation frequency in the single digit range. I am afraid that this would generate higher complication rates and maybe an increasing number of patients who should never have been operated (as we unfortunately have been observing for ETS)."

My Recommendations

The above study results sound very promising, although most of the patients surveyed got the surgery done recently and cannot discuss long-term satisfaction rates. The main negative seem to be that some people get a recurrence in feet sweating after a year or two, typically in just one foot. A Around 20-40 percent of patients seem to develop compensatory sweating, although most seem to find it preferable to their prior excessive feet sweating. There are some cases of other significant side effects, but most seem temporary, including neuralgia/pain; at least one case of the dreaded retrograde ejaculation problem in one of the studies; and a temporary increase in hand sweating for some patients. In some tough cases, a surgeon may need to do a more intensive open sympathectomy during the middle of the operation rather than the safer endoscopic one.

My already significant feet sweating increased after my ETS surgery that successfully cured my hand sweating, but I prefer to stick with iontophoresis (or nothing when busy/travelling) for now rather than undergo a lumbar sympathectomy. Because my feet do not sweat when I am asleep and because I can wear socks for most of the rest of the day (in case the feet start dripping -- which is usually half my waking time, and often less in winter), I can cope with the problem a lot better than I could with the excessive sweaty hands problem. I would also most definitely rather have sweaty feet than risk some kind of sexual dysfunction or lower feet pain side effect in the long run. I feel like there will be a better solution within the next decade, just like the laser sweat ablation and miraDry procedures for curing armpit sweating, that have become popular since 2009.