Operative anatomy of the lumbar sympathetic chain

Human lumbar sympathetic blockade: An anatomical study to address potential block failure

The lumbar sympathetic block is often used to treat complex regional pain syndrome, but it seems to have a high failure rate. This study seeks anatomical explanations for this apparent failure in order to refine our block procedure. Two simulated sympathetic trunk blocks were carried out on four fresh, cryopreserved unembalmed human cadavers under fluoroscopic control at the L2 vertebral body level, followed by two further simulated blocks at the L4 vertebral body level on the other side. Dye was injected, and the areas were dissected following a specific protocol. We then describe the anatomy and the spread of the dye compared to the spread of the contrast medium on fluoroscopy. The ganglia were differently located at different vertebral levels, and differed among the cadavers. Following this anatomical clarification, we now prefer to perform lumbar sympathetic blocks at the fourth lumbar vertebra level, using an extraforaminal approach at the caudal end of ​​the vertebra, avoiding the anterolateral margin of the vertebral body at the midpoint.

Retroperitoneoscopic lumbar sympathectomy for the treatment of primary plantar hyperhidrosis

Background

Primary plantar hyperhidrosis (PPH) is an idiopathic disease, characterized by excessive sweating of the feet. It leads to significant disturbance in private and professional daily lifestyle, due to excessive sweating. The aim of this study is to present the safety, efficacy and procedures of retroperitoneoscopic lumbar sympathectomy (RLS) for treatment of PPH.

Methods

RLS was performed 60 times in 30 patients (18 men, 12 women) with PPH in our institution from May 2019 to October 2020. All procedures were carried out by laparoscopy with retroperitoneal approach. Clinical data including patient demographics and perioperative, postoperative outcomes were evaluated. Recurrence of symptoms, and any adverse effects of surgery were evaluated after 7 to 30 days in outpatient clinic, and thereafter every 6 months.

Results

Mean age of patients was 33.6 (± standard deviation 10.8) years. Fourteen and fifteen patients were previously treated with medical therapy or endoscopic thoracic sympathectomy (ETS) respectively. Mean preoperative quality of life (QoL) score of patients was 91.8 (VERY BAD), but postoperative 12 months (QoL) score decreased to 29.1 (MUCH BETTER). There was no serious postoperative complication. During the mean 22 months of follow-up period, no compensatory sweating was observed.

Conclusions

RLS can be a safe and effective surgical treatment for severe PPH, especially for the patients with persistent plantar sweating even after conservative management and ETS. RLS also could be offered to surgeons who are familiar with retroperitoneal space anatomy as feasible surgical treatment for PPH.

Review: Pelvic nerves - from anatomy and physiology to clinical applications

A prerequisite for nerve-sparing pelvic surgery is a thorough understanding of the topographic anatomy of the fine and intricate pelvic nerve networks, and their connections to the central nervous system. Insights into the functions of pelvic nerves will help to interpret disease symptoms correctly and improve treatment. In this article, we review the anatomy and physiology of autonomic pelvic nerves, including their topography and putative functions. The aim is to achieve a better understanding of the mechanisms of pelvic pain and functional disorders, as well as improve their diagnosis and treatment. The information will also serve as a basis for counseling patients with chronic illnesses. A profound understanding of pelvic neuroanatomy will permit complex surgery in the pelvis without relevant nerve injury.

Severe Plantar Hyperhidrosis: An Effective Surgical Solution

Severe palmoplantar hyperhidrosis both affects activities of daily living and diminishes quality of life. This study evaluated overall safety and efficacy of endoscopic lumbar sympathectomy (ELS) using a clamping method in a large series of consecutive patients. Patient data were routinely entered into a prospectively designed database. Plantar sweating was graded as cured, improved, or unchanged. ELS (using 5-mm titanium clips) was performed in 154 patients, 68.2 per cent at the third lumbar vertebrae and 31.8 per cent at the fourth lumbar vertebrae. Follow-up averaged 15 months and ranged up to 4.7 years. Anhidrosis was achieved in 97.4 per cent of patients with the remainder reporting major reduction in symptoms. All patients were discharged home within 24 hours of surgery, requiring only oral analgesics, if any. There were two surgical complications (lymphatic leak and misidentification of genitofemoral nerve for sympathetic nerve). Six early patients required conversion to an open surgical procedure. Partial recurrence, usually mild, occurred in 4.5 per cent with 2.6 per cent requiring revision surgery. Severe plantar hyperhidrosis can be safely and effectively treated by endoscopic lumbar sympathectomy using the clamping method. It can be accomplished on an outpatient basis with low morbidity, complete resolution of symptoms, and a significant improvement in quality of life.

Relation of lumbar sympathetic chain to the open corridor of retroperitoneal oblique approach to lumbar spine: an MRI study

BACKGROUND

Retroperitoneal oblique approach to lumbar spine used surgical corridor between psoas muscle and aorta for exposure to anterior part of lumbar spine. Lumbar sympathetic chain (LSC) runs in the corridor to make it a structure at risk of injury.

RESEARCH QUESTION

Does LSC relationship with surgical corridor for minimally invasive retroperitoneal anterolateral oblique approach change in different intervertebral disc level?

METHODS

Left LSC was identified in axial magnetic resonance imaging images at L2-3, L3-4 and L4-5 intervertebral disc levels of 144 patients. Distances between LSC and left psoas muscle and aorta were recorded.

RESULTS

Mean age of the patients was 62.3 years. LSC was identifiable in 90.9% of levels. Distance between LSC and psoas muscle at L2-3, L3-4 and L4-5 was 4.0 mm, 4.7 mm and 5.2 mm. Statistical difference was found between L2-3 and L4-5 level (p = 0.006). Distance between LSC and aorta at each level was 12.4 mm, 12.3 mm and 10.6 mm without statistical difference. In non-scoliosis group distance between LSC and psoas muscle at each level was 3.1 mm, 3.3 mm and 4.0 mm. Statistical difference was found between L2-3 and L4-5 level (p = 0.012) and between L3-4 and L4-5 level (p = 0.041). Distance between LSC and aorta at each level was 11.9 mm, 11.4 mm and 10.2 mm. Statistical difference was found between L2-3 and L4-5 disc level (p = 0.039).

CONCLUSION

LSC moves away from psoas muscle and becomes closer to aorta in L4-5 disc level. These slides can be retrieved under Electronic Supplementary Material.

Morphometric anatomy of the lumbar sympathetic trunk with respect to the anterolateral approach to lumbar interbody fusion: a cadaver study

BACKGROUND

An approach to lateral lumbar interbody fusion (LLIF) utilizing an oblique corridor anterior to the psoas muscle was first described by Mayer in 1997 and subsequently by other authors. The only consistent structure of note in this corridor is the lumbar sympathetic trunk (LST), which at times must be mobilized in order to perform a discectomy and interbody fusion, thereby placing the LST at risk. This study was designed to describe the morphometric anatomy of the LST in relation to surgically relevant landmarks for the anterolateral approach to the lumbar spine at L3/L4 to L5/S1.

METHODS

Twenty-four embalmed cadavers (13 males, 11 females, age range, 50-89) were dissected to expose the LST. Bilateral measurements were recorded using a calliper under direct visualization, using the midsagittal plane of the lumbar spine as the reference landmark. The points were then marked with radio-opaque needles, and 14 cadavers were scanned with CT to validate the measurements.

RESULTS

Of 48 LSTs, there was minimal difference in the direction of its course between sides; 14/24 specimens had concordant directions. The majority (n=28) had a medial to lateral cephalocaudal course. If osteophytes were present at the L4/L5 level, the majority of LSTs (n=7, of 8) were displaced lateral to the osteophyte. At the L5/S1 level, half of the cases with osteophytes (n=3, of 6) stretched the LST over the top of the osteophyte. The LST was adherent to the L4/L5 disc space bilaterally in 93% of cases.

CONCLUSIONS

With the development of lumbar fusion techniques which utilize an oblique corridor and the retraction of psoas muscle, LST has become an important neural structure to define, protect and mobilize. In our morphometric analysis of 24 specimens, the position has been identified and quantified, and this paper notes variations, particularly distortions caused by degenerative processes. In this study, the LST ran in a medial to lateral direction from L3 to S1, and osteophytes typically displace and adhere to the LST.

Endoscopic lumbar sympathectomy for plantar hyperhidrosis

Background

The aim of this study was to evaluate the results of endoscopic lumbar sympathectomy for plantar hyperhidrosis.

Methods

A total of 178 endoscopic resections of the lower sympathetic lumbar trunk were carried out in 90 patients (59 men, 31 women) with severe plantar hyperhidrosis. The clinical results, including morbidity and satisfaction rates, were evaluated. Follow-up examination was carried out for all patients after a mean follow-up of 24 (range 3–45) months.

Results

All procedures were carried out endoscopically. There were no deaths and only three patients had a postoperative complication. All patients had evidence of postoperative sympathetic denervation of the feet. In 87 patients (97 per cent) hyperhidrosis was eliminated, but in three (3 per cent) it recurred. Compensatory sweating occurred in 40 patients (44 per cent), postsympathectomy neuralgia in 38 (42 per cent) and one man suffered temporary loss of ejaculation. A total of 86 patients (96 per cent) were very, or partly, satisfied with the result, and 83 (92 per cent) would have the procedure repeated if required.

Conclusion

Endoscopic lumbar sympathectomy was a safe and effective option for patients with severe plantar hyperhidrosis.

Retroperitoneoscopic lumbar sympathectomy for the treatment of plantar hyperhidrosis: technique and preliminary findings

BACKGROUND

Patients with plantar hyperhidrosis suffer physically and mentally from a disease that often cannot be treated sufficiently using conservative measures. This article reports the authors' experience with endoscopic lumbar sympathectomies for patients with plantar hyperhidrosis.

METHODS

Bilateral lumbar sympathectomy was performed for eight patients (3 women and 5 men). A retroperitoneoscopic surgical technique was used, during which the lower lumbar sympathetic trunk was resected after radiologic localization of the lumbar spine, with care taken to protect the cranial lumbar ganglia.

RESULTS

All 16 sympathectomies were conducted retroperitoneoscopically, with no intra- or postoperative complications. In all cases, pedal sweat secretion was completely suspended postoperatively. After a 3- to 8-month follow-up period, the anhidrosis persisted in all cases (100%). None of the patients experienced sexual dysfunction. Five patients (62%) reportedly experienced minor compensatory sweating of the torso, and four patients (50%) had postsympathectomy neuralgia. Seven of eight patients were very happy with the postoperative results and would agree to a repeat of the intervention any time.

CONCLUSIONS

Retroperitoneoscopic resection of the lower lumbar sympathetic trunk is a safe and effective procedure for obtaining suspension of excessive sweat secretion in patients with plantar hyperhidrosis that cannot be treated with conservative methods.

Thoracic, Lumbar, and Sacral Spine Anatomy for Endoscopic Surgery

WE DISCUSS THE anatomy of the thoracic, lumbar, and sacral levels of the spinal cord. Given the nature of endoscopic surgery, it is recommended that the surgeon have thorough knowledge not only of the bony architecture but also of important visceral and other soft tissue structures. It is essential to understand the normal anatomy to recognize the abnormal and anatomic variations. We present the so-called normal anatomic configurations and illustrate how these structures vary at the different levels of the spinal column.

Lumbar sympathetic ganglia in man: an electrophysiological study in vitro

A method has been developed for the removal, preservation and electrophysiological study 'in vitro' of sympathetic lumbar chains (L1-L3) from subjects undergoing lumbar ganglionectomy in the treatment of peripheral vascular diseases. Extracellular recordings from interganglionic trunks, and intracellular recordings from single sympathetic neurons, were performed. The extracellular experiments substantiated the concept, hitherto deduced from animal experiments, that the preganglionic fibres in the sympathetic lumbar chain are mainly of a descending nature. In fact, stimulation of the interganglionic trunk cranial to ganglia is always much more effective in driving ganglion neurons to fire than stimulation of the interganglionic trunk caudal to ganglia. The intracellular experiments produced a good definition of the main electrical characteristics of human sympathetic neurons. The results can be summarized as follows: the resting membrane potential ranged from 50 to 75 mV (63.4 +/- 9.2 mV; 21 neurons); action potential amplitude from 62 to 93 mV (74.3 +/- 8.1 mV; 27 neurons); membrane input resistance was 42.3 +/- 12.6 m omega (8 neurons) and total membrane capacitance 83.7 +/- 15.3 pF (8 neurons).

The identification of sympathetic segments

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