CT-assisted thoracic sympathicolysis for therapy of primary hyperhidrosis palmaris-retrospective analysis of the influence of the amount and position of the sympathetic agent on the therapeutic outcome and side effects

Abstract

Purpose The objective of the present study was to evaluate the benefit of a thoracic, computed tomography-guided sympathicolysis (CTSy) in patients with primary, focal hyperhidrosis of the hands. In addition, the influence of the amount and distribution of the administered sympathicolytic agent was to be assessed. Patients and Methods Retrospectively, 78 patients [13 (16.7 %) men, mean age 31.2 ± 9 years and 65 (83.3 %) women, mean age 34.2 ± 12 years], who had been treated using CTSy, were included in the study. The indication for treatment was primary focal palmar hyperhidrosis grade II and grade III after exhaustion of all conservative treatment options and a continued high level of suffering. CTSy was performed after establishing the entry plane at the level of the intervertebral space T2 / T3 via a dorsolateral approach using a 22-G coaxial needle. On average 5 (2–10) ml of a sympathicolytic mixture (10 ml consisting of 8 ml 96 % alcohol, 1.6 ml 0.5 % Carbostesin and 0.4 ml 0.9 % NaCl solution, with added amounts of contrast medium) were instilled. The volume of distribution of the sympathicolytic agent was determined in craniocaudal direction using CT images. The patients evaluated their sense of discomfort preinterventionally, 2 days postinterventionally, and 6 and 12 months after the intervention, on the basis of a Dermatology life Quality Index (DLQI) as well as the side effects that occurred. Results The technical success rate of CTSy was 100 %. No major complications occurred. The interventions performed led to a significant reduction (p < 0.001) in the preinterventional sense of discomfort 2 days, 6 and 12 months after CTSy. As the most common side effect, compensatory sweating was reported by 16/78 (20.5 %) of the patients over the further course. In all of these patients, the volume of sympathicolytic agent administered was below 5 ml. In no case did the sympathicolytic agent extend caudally beyond the base plate of Th 3. No compensatory sweating of the back was observed in 5/78 (6.4 %) patients; here the sympathicolytic volume was above 5 ml and extended significantly caudally below the baseplate of T3.Transient miosis and ptosis was found in 8/78 (10.3 %) patients. In all of these patients, the volume of sympathicolytic agent administered was above 5 ml and it extended markedly cranially beyond the upper plate of T2. A mild to moderate recurrent sweating developed in 35/78 (44.9 %) patients, which was more marked if the volume of sympathicolytic administered was below 5 ml and slightly more pronounced on the left than on the right. Given a high level of satisfaction overall, 71/78 (91.0 %) patients said that they would undergo the intervention again. Conclusion For patients with primary, focal palmar hyperhidrosis CTSy represents a therapeutic option that offers good benefit and has few side effects. The amount and spatial distribution of the sympathicolytic agent has an influence on the therapeutic outcome and the side effects. Key Points: Citation Format

CT-guided Thoracic Sympathicolysis versus VATS Sympathectomy in the Therapeutic Concept for Severe Primary Palmar Hyperhidrosis

“…A comparatively caudal ablation or severance of the sympathetic trunk at the level of T3 instead of T2 appears to minimize the compensatory sweating. 8,9,14 As in our follow-up examinations, Kao et al 26 described a decline in compensatory sweating over time. Patients with persistent compensatory sweating that strongly impairs quality of life appear to benefit from a renewed operation with a multiple level diffuse sympathectomy, with few side effects.…”

“…27 Alternatively, CTSy would also be possible, whereby the sympathicolytic agent should then be applied as caudally of T3 as possible. 14 In our patient collective, there was a temporary miosis and ptosis with 9.1% in the CTSy and 7% in the VATS group, both values appear relatively high and can only be explained by an irritation that took place too far cranially. In the future, sympathicolysis or sympathectomy should be performed markedly caudally from Th 2.…”

“…Following thoracoscopic sympathectomy, Licht and Pilegaard 19 reported compensatory sweating in 89% of the patients operated on, whereby 35% displayed a severe form. Depending on the different technical methods used, the evaluation of differently weighted questionnaires, different lengths of follow-up period, the respective work setting of the patients, geographical position, ethnicity, and the season in question, distressing compensatory sweating of varying duration is found in just a few to as many as 90% of cases, 9,[12][13][14][19][20][21][22][23][24][25] so that a comparison between the studies is only possible to a limited degree. A comparatively caudal ablation or severance of the sympathetic trunk at the level of T3 instead of T2 appears to minimize the compensatory sweating.…”

“…The reason for the recurrent sweating appears to be an insufficient ablation or incomplete severance of the respective sympathetic trunk segment. 12,14,28 In addition, neural short circuits with variable contributions between the first to fourth intercostal nerves, which bridge the second and third sympathetic ganglia up to the brachial plexus, are of considerable importance. 29 Since these nerve tracts, as a result of their mean separation of > 7 mm from the sympathetic trunk, are in most cases impacted only peripherally or not at all by the sympathicolytic agent or sympathectomy, they may contribute to recurrent sweating.…”

“…10 In the meantime, CTSy also represents a safe, effective, and minimally invasive technique. [11][12][13][14] The objective of the present study was to compare the methods of CTSy and VATS with regard to their feasibility, the occurrence of minor and major complications, and the clinical outcome.…”