To observe the clinical effect of combined CT-guided thoracic and lumbar sympathetic nerve block in the treatment of hand and foot hyperhidrosis. Methods Twenty-three patients with hand and foot hyperhidrosis treated with CT-guided percutaneous thoracic and lumbar sympathetic nerve block at our hospital between January 2013 and December 2014 were treated with CT-guided puncture through the T3/4 and L2/3 intervertebral spaces until the needle tip reached above the costal tuberosity of T4, anterolateral to the L3 vertebral body and anterior to the psoas major muscle.
The thoracic and lumbar sympathetic parasympathetic nerves were injected with 2 ml and 3 ml of 1% lidocaine containing the contrast agent iodophoresis respectively, and the injected solution in the thoracic and lumbar segments was observed to be distributed in front of the small head of the T4 ribs and between the lumbaris major muscle and the vertebral body, and the patient’s finger and toe terminal perfusion index rose more than 5 times and the temperature of the hands and feet rose more than 3℃, then the thoracic and lumbar segments were injected with 3 ml and 5 ml of anhydrous alcohol containing the contrast agent iodophoresis at each puncture point The CT scan was repeated and 3D reconstruction was performed to observe the distribution of the drug. Results CT could precisely guide the puncture needle to reach the target site, and the end perfusion index of fingers and toes and the temperature rise of palms and feet of both hands increased by 7.36±1.57 times, 6.99±1.43 times and 5.04±0.97℃, 4.86±0.88℃ on average after 5 min of injection of local anesthetic, respectively; the excellent efficacy rate of patients after injection of anhydrous alcohol was 86.96%, and the recurrence rate within 1 year was 13.04%, and no related complications occurred.
Conclusion CT-guided combined thoracic and lumbar sympathetic nerve block technique can effectively treat hyperhidrosis of the hands and feet.
Hyperhidrosis of the hands and feet is the main manifestation of primary hyperhidrosis, and although it has little effect on the physical health of patients, it often has a significant negative impact on the quality of life and psychological health of patients. In this paper, CT-guided combined thoracic and lumbar sympathetic nerve block was used to treat hand and foot hyperhidrosis with good results, which are reported below.
1. Clinical data and methods
1.1 Subjects: 23 patients who came to our hospital between January 2013 and December 2014, met the diagnostic criteria for primary hyperhidrosis, had excessive sweating of the hands and feet as the main manifestation, had a severity grading (HDSS) of grade 3-4, and agreed to receive CT-guided combined thoracic and lumbar sympathetic nerve block treatment: the ratio of male to female was 11/12, aged 16 to 45 years, with an average of 22.8±4.2 years old. All patients were discussed and approved by the hospital ethics committee and obtained informed consent from patients and their families before treatment, and were checked for no contraindications to puncture such as infection, bleeding tendency, no bradycardia, and no history of alcohol allergy.
1.2 Treatment method: The patient’s family and himself were informed in detail about the operation procedure, expected effect and possible complications of CT-guided combined thoracic and lumbar sympathetic nerve block treatment technique.
The patient was placed prone on the CT table with thin pillows under the chest and waist, and the patient’s blood pressure (NIBP), heart rate (HR), electrocardiogram (ECG), finger pulse oxygen saturation (SPO2), terminal perfusion index (PI) of fingers and toes, and palmar temperature (T) of both hands and feet were monitored and recorded before the CT-guided combined thoracic and lumbar sympathetic nerve block operation: the thoracic and lumbar dorsum were exposed, and the skin was placed on T3 and L2 The best puncture level for thoracic and lumbar sympathetic block is selected, the best puncture path is designed at the selected level, the depth and angle of needle entry are measured, the puncture point is marked on the corresponding skin, and the puncture point is marked with post-lidocaine local anesthesia under the guidance of the CT-positioned puncture guide. After local anesthesia with posterior lidocaine, the needle was inserted according to the designed puncture path under the guidance of the CT localization puncture guide until the tip of the needle reached above the costal tuberosity of T4, the anterolateral aspect of the L3 vertebral body and the anterior aspect of the psoas major.
The thoracic and lumbar sympathetic nerves were injected with 2 ml and 3 ml of 1% lidocaine containing the contrast agent iodophoresis, respectively, and the CT scan observed that the drug injected in the thoracic and lumbar segments was distributed between the anterior aspect of the small head of the T4 ribs on both sides, the lumbaris major muscle on both sides and the L2 (and/or L3) vertebrae, and the perfusion index of the patient’s finger and toe endings rose by more than 5 times and the temperature of the palms of the hands and feet rose by more than 3℃ at each puncture point in the thoracic and lumbar segments. 3ml and 5ml of anhydrous alcohol containing contrast agent iodophoresis, and again CT scan and three-dimensional reconstruction to observe the distribution of the drug, and see that the drug covers the small head of T3 and T4 ribs and the anterolateral side of L2 and L3 vertebrae respectively then the operation is finished. Patients were followed up for efficacy and complications on the second day, first week, 1st, 3rd, 6th, 9th, and 12th month after surgery, respectively.
1.3 Efficacy criteria: The postoperative efficacy criteria were classified as grade III: excellent: sweating of both hands and feet completely disappeared after surgery; good: sweating of one of the hands and feet remained as before or slightly decreased after surgery, while the other three limbs did not sweat at all; invalid: sweating of both hands and feet was the same as before surgery after surgery. If the postoperative efficacy was excellent or good, the postoperative relapse was considered if sweating reappeared at the original sweating site or increased to the preoperative level after several months.
1.4 Statistical analysis: HR, SBP, DBP, SPO2, PI, T and other measures of the patients before and after the obtained drug injection were statistically analyzed by SPSS10.0, and P<0.05< span=""> was considered statistically significant.
2 , Results
A total of 92 thoracic and lumbar sympathetic percutaneous puncture operations were performed in 23 patients, and all were punctured to each target site under the guidance of CT localization puncture guide. The PI of both fingers and toes started to rise 1 min after injection of local anesthetic, and the temperature of both palms and feet rose significantly after 5 min: the PI of fingers and toes rose 7.36±1.57 times and 6.99±1.43 times on average; the temperature of both palms and feet rose 5.04±0.97℃ and 4.86±0.88℃ on average, and there was no significant change in HR and BP, and the specific changes of each index were shown in Table 1. After the operation, the patients felt that their extremities changed from moist and cold to dry and warm. The number of patients who were followed up for 3, 6 and 12 months was 23, 17, 13 and 9, respectively, with 86.96% of excellent results and 13.04% of recurrence rate within one year. The average time of block operation was 49 min, with 4-8 intraoperative CT scans and 30-60 msv of X-ray exposure.
3. Discussion
Hornberger et al. defined the diagnostic criteria for primary hyperhidrosis as “unexplained locally visible sweating lasting more than 6 months with at least two of the following.
(i) symmetry of the sweating area;
(ii) Significant impact on the patient’s life;
(iii) Sweating more frequently than once a week;
④The onset of hyperhidrosis was before 25 years of age;
⑤ Family history;
⑥No night sweats.” In our clinical work, we found that hyperhidrosis of the hands and feet accounted for more than 65% of patients with primary hyperhidrosis. All 23 patients in our group met this diagnostic criterion, and all of them had a hyperhidrosis degree grading (HDSS) of grade 3 or higher (excessive sweating that is almost or completely intolerable and seriously affects the patient’s daily life). Although hyperhidrosis of the hands and feet does not affect the physical health of the patients, it brings serious problems to the work, study and social life of the patients, and some of them have low self-esteem resulting in autism, depression and social difficulties, and therefore have a strong desire for treatment.
It has been proven that primary hyperhidrosis is caused by excessive activity of the sympathetic chain, which governs the secretion of the sweat glands. The current causative treatment is mostly focused on the inhibition of sympathetic nerve activity, and “thoracoscopic thoracic sympathetic nerve chain dissection” has become the “gold standard” for the treatment of hand sweating, but the procedure needs to be done under general anesthesia, which is costly and traumatic. The chance of compensatory hyperhidrosis after the procedure is as high as 85%, and 15% of them have severe compensatory hyperhidrosis, which is not easily accepted by patients. Although endoscopic lumbar sympathetic chain dissection has been reported for the treatment of foot sweating, it has not been performed on a large scale in clinical practice because the operation is more tedious than thoracoscopic thoracic sympathetic chain dissection.
In recent years, with the financial support of Jiaxing Science and Technology Bureau, Zhejiang Provincial Department of Health and Zhejiang Provincial Department of Science and Technology, our group has devoted to the research and development of more minimally invasive techniques for the treatment of hyperhidrosis, especially the effectiveness and safety of “CT-guided percutaneous thoracic and lumbar sympathetic chain modulation technique” for the treatment of hyperhidrosis. We have accumulated rich clinical experience in the treatment of hand sweating, head sweating, axillary sweating, perineal hypohidrosis and compensatory hyperhidrosis, and found that the peripheral perfusion index (PI) of the fingers (toes) can be a more sensitive index than palm temperature (T) for predicting the efficacy of treatment. In addition, we designed and produced the “CT positioning puncture guide” in clinical work, which greatly improved the accuracy of puncture and reduced the pain and X-ray exposure of patients.
Since 2010, we have completed 459 cases of sympathetic nerve block treatment for patients with hyperhidrosis. For patients with hyperhidrosis of the hands and feet, we mostly perform thoracic sympathetic block first and then lumbar sympathetic block after some time for separate treatment, although we have also achieved good results, but it takes a long time and consumes more time for patients to seek medical treatment.
Subsequently, we carefully selected 23 patients with primary hyperhidrosis of hands and feet for “CT-guided combined thoracic and lumbar sympathetic nerve block treatment” on the basis of the previous study, and found that the excellent rate of this technique for treating hand and foot hyperhidrosis was 86.96%, and the recurrence rate was only 13.04% within one year. In addition, this technique does not require thoracoscopic or other endoscopic surgery under general anesthesia, but only requires two fine needles from the back of the chest and the back of the waist to cure hand and foot hyperhidrosis at the same time, which is almost non-invasive and can be an ideal method for treating primary hand and foot hyperhidrosis.