A Surgical Solution for Excessive Foot Sweating
A Lumbar sympathectomy is 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 located. At this point, it is either excised or clamped at the levels 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 by the doctor, a 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, the resulting discomfort can be brought down to a minimum. This enables the patient to leave the hospital later that day.
Many more cases must be done in order to establish a definitive pattern, which would allow us to do the majority of these 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 the nerve is damaged, the result can be some numbness in the inner thigh region. Fortunately, this is temporary.
The current success rate is approximately 97-98%. Possible side effects include bleeding, pain, discomfort.
Even though retrograde ejaculation has not been proven to be a problem in Lumbar Sympathectomy procedures, it is worth discussing.
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. The procedure would change from an endoscopically assisted Lumbar Sympathectomy, to an 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. The scarring is minimal as well.
It is important to keep in mind that this is a technical difficulty that can arise. Prior to the surgery, the patient is given the very clear choice to allow conversion from an endoscopically assisted to an open lumbar sympathectomy. The reason this is offered is to allow for more approaches to successfully complete the procedure.
The current method being used to perform ELS gives us better opportunities to examine the sympathetic chain. Obviously different centers use different approaches, but in comparing the methods, we found out that our current method gives an ability to examine the sympathetic chain over a longer segment. This enables us to make sure that all sympathetic fibers below the lumbar vertebra #2 are clamped for the best results.
It is a known fact that all sympathetic fibers below the lumbar vertebra #2 run to the feet. If the lumbar sympathectomy is done in a lower level (ie 3 or 4), one might miss some very fine fibers that run to the feet. This could result in a less successful outcome.
Clinical Results Thus Far (500 + Cases):
The clinical experience accumulated since 2008 shows that the lumbar sympathectomy is a very effective method for treating severe plantar (sweaty feet) hyperhidrosis. Most of our patients previously had ETS performed with zero results. As time goes by more people with primary plantar hyperhidrosis are having lumbar sympathectomy performed as well.
The success rate is about 97-98%, 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+ lumbar sympathectomy cases. Dr. Reisfeld continues to work hard to further develop and improve this procedure. No other surgeon comes close to this level of experience.
In ETS cases, at about 3 to 4 days after the lumbar sympathectomy, another bout of sweating occurs. As we learned from previous ETS cases, this is a short bout of sweating and it stops in a few hours or up to a day later. So far no increase in compensatory sweating has been noted after the lumbar sympathectomy procedure. Some patients will have an initial increase in their compensatory sweating, compared to what they had after the procedure.
The ELS procedure will cause fluctuation in the amount of compensatory sweating, but in the long run, these changes will go back to normal. This is why the time interval between ETS and ELS should be at least 6 months. On the other hand, patients who experience any level of compensatory sweating after an ETS procedure should expect that level to stay. Keep in mind ETS is a separate procedure from the lumbar sympathectomy. Learn more about ETS.
Some patients who previously had ETS done, and later underwent lumbar sympathectomy experience hand sweating. This a temporary occurrence and will resolve itself in a short time.
So far, information about compensatory sweating in patients who had only lumbar sympathectomy done is not yet available. This is due to the small number of cases where only the lumbar sympathectomy was performed. In the small amount of cases where only lumbar sympathectomy procedures were done, compensatory sweating was mild. It is still too premature to draw any definite conclusions.
In regards to the recurrence rate after an endoscopic lumbar sympathectomy, the numbers are not yet in. There are rare reports of some limited-partial recurrence. This can be the result of abnormal branches that are supplying the feet 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 in regards 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 in regards to the surgical treatment of plantar-feet hyperhidrosis. Across 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 about (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 The Lumbar Sympathectomy
Lumbar Sympathectomy is a procedure that used to be performed for patients with vascular insufficiency (blood supply problems – to lower legs). The idea was that by doing a sympathectomy, the vaso constrictive influence of the sympathetic chain on the blood vessels would be abolished. Therefore, the blood vessels would be open and provide a better blood supply to the legs.
This was done for many elderly patients with vascular insufficiency, but the results were poor. Lumbar sympathectomies are rarely done for this purpose in today’s medical world, and is being replaced by different medications. This is not to be confused with the lumbar sympathectomy procedure for excessive foot sweating.
Another condition for which Lumbar Sympathectomies are rarely done, is for complex regional pain syndrome or sympathetic neuralgia. Since this syndrome is not well understood, the results are inconclusive.
The Lumbar Sympathectomy procedure is, however, very effective in treating plantar hyperhidrosis. The same principal applies in cases of palmar hyperhidrosis, where a thoracic sympathectomy is very effective in treating excessive hand sweating. The current success rate is approximately at 97-98%.
Like in any other surgical procedure that tries to correct physiological – genetic problems with mechanical solutions, the issue of 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 that 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. This will make the endoscopic lumbar sympathectomy more difficult to perform. The option of an open procedure is always available, but extremely uncommon.
Does lumbar sympathectomy affect pregnancy?
So far there is no known connection between lumbar sympathectomy and the ability to become pregnant. On the contrary, Dr. Reisfeld’s female patients who had this procedure have become pregnant without any issues.
Will I get more hand sweating after doing the lumbar sympathectomy procedure for my sweaty feet?
No, but 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 performed for their excessive hand sweating. This is temporary.
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 done without any palmar hyperhidrosis associated with it.
The rest of the cases where the lumbar sympathectomy procedure was done after thoracic sympathectomy did not report this effect. The reason for this extreme dryness in a patient who only had plantar hyperhidrosis is unknown at this time. More cases will have to be done in order to understand this problem better.