Palmar hyperhidrosis CT guided chemical percutaneous thoracic sympathectomy Oepartmrril of r)iagiiostic Radiology. Rambam Medical Center, Fiiculty of Mediciiic. Technion-lsraclInstitute ofTechnology. Haifa. Israel. aod ' I>epartnien~~ifUiogiiostic Radiology. Centie Hospitaliei. I.uxembourg
Summary
-
~
-
.
.. .
Palmar hyperhidrosis or excessive sweating of the hands causes, to those affected. eniotional and physical disturbance and irnpediment in professional and social life. The caiise is unkriowii. Sweat glands are innervated by the syrnpathic chain of the autonomous nervous System. The Center of sympathic regulatiori of the upper extremities is located between the Segments of D.2-D.9 of the spinal cord. Accepted treatment consists of surgery aimed to excise the tliird thoracic sympathic ganglion. Besides the surgical procediire a s such, and its complicatians, there a r e complications inherent to the excision of the ganglion. These are Horner's syndrome, compensatory sweating in other parts of the body. and recurrence of sweating. CT guided chemical percutaneoiis thoracic syrnpathectomy presents an alternative, which in the event of failure does not prevent ensuing surgery. 'rhe preliminary experierice with this procedure in 50 patients is presented and discussed.
Key words
tlyperhidrose der Handflächen verursacht psycho-physische Hemmungen und wirkt sich sowohl im privaten als auch im Berui'sleben ungunstig aus. Die llrsache ist unbekannt. Die Schweißdriisen werden von der Sympathikuskette des autonomen Nervensystenis gesteuert. Das Zentrum der Sympathikusregulierung der oberen Extremitäten liegt zwischen den Segmenten D2 bis D9 des Rückenmarks. Die allgemein akzeptierte Behandlung besteht in einem Versuch einer Exzision des 3. thorakalen sympathischen Ganglions. Abgesehen vom chirurgischen Vorgehen selbst und dessen Komplikationen entstehen außerdem weitere Komplikationen durch die Exzision des Ganglions, U. a. das Hornersche Syndrom, kompensatorische Schweißabsonderungen ari anderen Körperstellen, und Wiederkehr der Schweißanfalle. Eine Alternative besteht in CTgeführter chemischer perkutaner thorakaler Syrnpathektoinie; bleibt diese erfolglos, so kann dennoch chirurgisch vorgegangen werden. Vorläufige Erfahrungen mit dieser Methode a n 50 Patienten werden mitgeteilt und diskutiert.
Hyperhidrose der Handflächen - Sympathektomie - Chemische perkutane Sympathektomie
.P
Palmar hyperhidrosis (PH) i. e. excessive sweatirig of the hands is a n emotionally, socially arid professionally disabling condition. The accepted treatment is the surgical intervention: tlioracic syrnpathectomy. Recently we introduced computed tomography giiided chemical percutarieous tlioracic sympatectomy (PTS); the purpose of this paper is to report on our preliminary experience with this inethod.
This study group includes 50 patieiits (1 1 men. 39 womeii) who ~iiiderwentPTS in the time period hetweeri
Fortschr. Röntgeristr. 1 53.4 (1 990) 400-403 O CinorgThicme Verlag Stuttgart. New York
P
Schlüsselwörter
.
Palmar hyperhidrosis . . Sympathec:torny Chemical sympathectomy percutaneous ....~
Hyperhidrose der HandnächenCT-geführte chemische perkutane thorakale Sympathektomie . - -
December 1987 and Decerner 1989. The first three patients underwent the procedure in December 1987: nine consecutive patierits in March 1988. These 1 2 patients were treated in collaboration with Prof. Robert Llondelinger; the remaining 38 patients from Septernher 1988 o n , by us. Thc youngest patient was 17 years old. the oldest 44 years. Thirty-one patients were in the agc group or 17-30 years. 19 patients between 31 -45 years. All had a Iiistory ol'rnore or Iess excessive sweating ol'the hands. exacerbated in sorne to drippirig of sweat nininly in surnmer time or hy emotional Stress. In all of thern concomitaiit sweating of the feet, sometirnes i n the axillary region, was present too. Two of thc patients were siblings. two others were lnother and daughter. 111 12 patiants familiar cumulation of PH was elucidated involving parents, sihlings or cousiris. Twenty-nine were of Ashkenazi origin. 2 1 of Sephardi origin.
Heruntergeladen von: NYU. Urheberrechtlich geschützt.
-.
Palmar hyperhidrosis ---
rslroiiiitics nt thr
.
...
.
~
.-
. .. ...
--.--- .-
. ... .
F o r t s c h ~Rör~tgenstr.153,4
. .. .
401 P
Eacli patit:iit iiiidnrwcnt tho procccl~ircTor bo1.h samc scssion
Tlic patient is positioncd prone on Lhe cornpiitcd tornography table. ns cornlortably as possible, with tho hands above the hcad. A scout view of the thorax is obtained and the third dorsal vertebra is localised (Fig. I). At this level 0.5 Cm thick slices at 0.5 cm incrc!rncirits a r e performed to choose Llie trajectory of nccdlc placemeiitat a plane frce ol'the transverse proccss and above or below the intervertebral forainen. Thc cntraricct point, laterally to the spinous process. is markod ori the skin. After strrile draping arid local anacsthnsia, a 10 cin long 22 gaugc spinal rieeclle is advanccd cautiously along a n angled trajeclory; bOd~ the ta.rgct point is lhe lateral aspect O f thc: verLebral (Iyig. 2- 3). The advancement of the needle is carefully monitored by frequent. repcat CT scan to avoid violation of the pleura and to ensure proper positioning of thc nccdle tip. h h e n this point is reached 0.5-1.0 ccrn dili~tedcontrast material is injected to observe its distributiori and diff~ision(Fig. 4). If no backflow into thc spirial caiial can be scen and ailer ensuring by suction that the needle tip is not inside a blood vessel, one proceeds with sJow injection of srnall increments of' pheriol l'Sterop(Bruxellcs) phcnol 400 mgr. glyccrin 1.5 gr, aqua ad 5 mll.
Fig. 1 Scout view.Thebody of thethirddorsal vertebraisat the height of the medial end oftheclavicles(arrow).
Fig. 2
Tlie patient reports ori progressive warming up of Lhe hand procccding I'rorn Lhe ringertips proximally, accompanied by asensatio~iofdryness. Dilatation of superficial veins at the dorsal aspect of thc hand occurs either before or at the time of the hand warming up: pupillary reaction to light excitation is rnonitored during the whole injection. 'l'he arnount of phttriol used is individual. When the patient reports a s a t i s f a c ~ o feeling r~ of dryness of' the hand the injection is stopped. The Same proccdure is performed for the other limb(Fig. 5). The procedure Tor both hands can be perforined in an average time of 90- 1 20'.
Fig. 3
At the cnd of the procedure the patient stays in the department for 2-3 hours in a sitting position, arid is thereafter rctiirned to the surgical ward iintil the next day. Blood prcssure is monitored. 1,ight aniilgesics can be adrniriistered i i i the event of pain.
Ir] one patient we performed thci procedure twicc at a diiTerent linie interva.1, without success. All the rernaining 49 patients, i. c. 98 extreinilies, reported iiriinediaie results nlready on the examination table.
Fig. 2 and 3 The needle ic advanced step by step toward the lateral aspect of the 3rdvertebral body with close monitoring by repeat CTscans.
Heruntergeladen von: NYU. Urheberrechtlich geschützt.
A short anamnesis is obtained as to the onsrt. duration and scverity of PI-l as well a.s general Iiealth coiidition of thc prospective patient. Dctailed explanation is given to thc patierit coiicerning thc esseritials of the procedure and the steps involved, about possible early and lato complications, and rate 0fsuc:c:ess. Chest X-ray, ECG arid blood pressiire valiics are requested. as wcll a s a written corisent.
402 Fortschr. Höntgenslr 15.3.4
--
- --
-
.
.
Olga L?. ildler ct al. -~
.
Swcnt forrnatiori by Llie sweat glands plays aii iinporlant rolc i n ttie ll~erriialregulation of tho body and assures moisturi! to Lhe skin. Increascd ~ ~ ( i i l t i roccurs ig at changc oi'inner or outcr ternpcraiiiro or i i i a slate of anxicty, pain or anger (7. 1 4 . 17). Thc: iiioisture of thc skin is f~~rriislied by the apocrinct sweal glands. rather niirneroiis i r i distribution at thc: paliiiar arid volar aspcci. ol'the haiids and feet, axillary region and facc. Thoir liiric:lioii begins uIren.dy at birlli: tlieir nunibcr stays iiriclianged ailcl constant duriiig lifetinie.
Fig. 4 Contrast material injection shows its dispersion along theveriebral body and forward.
Fig. 5 The procedure 1s repeated on the left side. Widening of right paraveriebral space following phenol injection can be appreciated
In 1 1 patients 2-3 mm ptosis OS one eyelid was observed at the end of the procedurc. In 7 patients, chest or back pain necessitated adrninistralion of peroral analgesics. Eight patients bcgan cornplaining 2-3 days afler Lhe procedure about pain, burning and disturbing Sensations in onc lirnb, wliich later on disappeared after medical trcat,rnent. Sweating recurrcd alter 4 months to a previous slale in 5 patients; to a Iesser degree in 4 patients. Cornpensatory swcating of the back or chest occrrrrcd in 4 patients. Permanent success, i. c. dry tiands, was obsr:rved for 2 years in 3 paticnts, for 20 inonths in 20 palienls, and for 1 2 rnonths in 19 patients. 'l'he last paticnts r '/IZ and are well in thc rncanhave had a follow-up f i ~ only time. The ptosis of thc cyclid disappeared in the course of halfa year in 3 pationts oul of 1 1 . 'l'he remainder (all of tliern worncn) conceal il by make-up and arc. still happy to havc dry harids at lhe price of this minor cosrnc:tic: defect.
Thr: produclioii of sweat is iindcr rolleclory control ol'thc sympalliic systeni. which on thci otlier Iiarid is regulatcd by the lieat centre in thc hypothalainus (3.6. 14). I;ibrcs l'roni ~ h hypothalamiis e dr!sc:r:nd Llirough the brain storn 10 Llie spinal cord and synapse wilh the neurons ot'tlie syiiipathic chain in thci niiddle Part of the gray rnat,tor ot'lhe cord. which cstcnds belween DI-L,?. Prcganglionar white syinpathic fibres leave the cord to roach tlie sympathic ganglions siLuaLed along both sidcs of lhe verlebi-al column. Thr: ganglions contain thc ccll bodies of the post ganglionic: fibre ( 2 . 7 . 8 ) . The prcganglionic Tibres o f a given scgrnent of the spinal cord miiy synapse iii a ganglion situaled a l the heigth of thc: sarrie segrnent. but they rnay pass Lhrough them usiially ~o liiglier levels. Postganglionic gray fibres partly joiii lhe spinal nervcs, partly accoinpany the vesscls. There are variants in which Lhe syriapsis orthe prcganglionar fibres with thr' poslgariglioiiar fibres is locatcd oulside the ganglion (1 2. 1 4 , 18).The synipathic inncirvalioii of lhe upper extrerriilies is located in thc cord a l the level D.2--D.9. The rnain ganglion rcsponsible Tor lhe syrnpathic inriervalioi~ofthe uppcr cstremilies is D.2-D.3. Hypcrhidrosis is a pathologic statt! cliaracterised by excessivc sweatiiig. It may bc prirnarily of unknown origin; the sweat glands and tlieir synipathic innervat,iori arc: riormal (3), possibly Lhere is sorne hypcract.ivity ol' ttie Iiypothalamic therrrial ceiitie or a congcnilal defect in the cortical ccntrci ofthe hands and fect. Sccoridary Iiyperhidrosis may bo due lo lesion of thc ncrvous systern in a central. pcripheral or regional locatiori; sysleriiic diseases likc hypr:rthyroidism. obcsity, rneriopause can exhi bit. cscr:ssive swealing (1, 6, 14). PH is a disturbing phcnornonon in every clay life, frorn sirnple actions like hand shaking, writing or any other func:lion linked to the hand, thus it causes a ieeling of crnotional and social disabling arid evnn invalidity in profossiorial life. Interestingly. PH is ralher cornmon in Jcws. rnore in those originating fror11 North Africa, Ycrnctn, tlie Balkans. ancl in .lapanese. Often farnily history cari be eslablished. Because of thc discornli~rlcaused by P H , rnariy lrealrnent forms havc bcen lried. Conservative treatment aiins to local applicalion of substances containing alurninium salts and ottier coinponents sealing off tht? oullet of the swoat glaiids. Their effect is ternporary bul lliey may causc? ari iriflarnmatory reaction. Trial ol'peroral anticholinergic drug also leads to iinploasaril side effects and is therel'ore not in wiclesprcad usc: (6). Tho accepled and eficacioiis trcatnierit is the surgical onH, corisisling of escision of thc upper thoracic syrnpat,hicganglia. 'l'here are four rnain ar:c:ess roules to the syrnpalliic gaiiglionar chain: t.he subclavicular. transaxil-
Heruntergeladen von: NYU. Urheberrechtlich geschützt.
--
References .. .. ..
lar, anterior o r posterior thoiacic route, according to ttie
-
skill of Lhe surgeon ( 1 , 2, 8, Y). 'l'he succcss rate is Iiigli.
Compuled loinography giiided clierriical percutaneous thoracic syinpathectomy presenls a n attractive alternative t« surgery (16). Chcrnical synipathicolysis is a known procedure. applied to block pain transmission (1 0, 1 1, 13): coeliac ganglion block in patients with pancreas carcirioriia. lumbar block in advanced periphcral vascular disease, mainly Ruerger's disease. to alleviatc: pair1 (4. 15). In 1387 Dondclinger reported for the lirst lime C1' guided percutaneous thoracic sympathicolysis in 12 patients, thc niajority Sor Raynaud's diseaso and iri 3 out of 1 2 for PH (5). It is a n ambulatory procedure a n d leaves no scars; cornplicatioris connectcd to l h e surgical procedure like piieumothorax, pleural fluid rormation, lcsion oiblood vessels o r nervc d o not occur d u e to thc rnerits ofexact needle localisatiori by C l ' guidancc. Complications of the proccdure like Horner's syndrome o r cornpensatory swcating a r e tlie sarne as with surgery. As to the results: f'urther follow-up is neccssary to assess whether ccssatiori o f s w e a t ing is perrnancnl. PTS does not excliid(: ensuing surgical intervcntion. T h e procedure shoiild b e performed by cxpcrienced interventional radiologisls.
Acknowledgement Tho authors wisli to express thcir Special gratitude to Prof. Roh~rtDotidslinger who initinted thom in perforniing thc proccdure.
/\dar, R., A. Ki~rclrin.A. Zweig, M . Moses: Palninr hypcrhydI-osis and its surgical treatrneiit: a raport on 100 rases. Aiin. Surg. 186 (1 977) 34 .40 ' Atkinsotz, L.: Upper dorsal sympath~ctoiny.4fed. .J. Aust. 1 11975) 267 270 .' Uohtz. L). I
Summary
-
~
-
.
.. .
Palmar hyperhidrosis or excessive sweating of the hands causes, to those affected. eniotional and physical disturbance and irnpediment in professional and social life. The caiise is unkriowii. Sweat glands are innervated by the syrnpathic chain of the autonomous nervous System. The Center of sympathic regulatiori of the upper extremities is located between the Segments of D.2-D.9 of the spinal cord. Accepted treatment consists of surgery aimed to excise the tliird thoracic sympathic ganglion. Besides the surgical procediire a s such, and its complicatians, there a r e complications inherent to the excision of the ganglion. These are Horner's syndrome, compensatory sweating in other parts of the body. and recurrence of sweating. CT guided chemical percutaneoiis thoracic syrnpathectomy presents an alternative, which in the event of failure does not prevent ensuing surgery. 'rhe preliminary experierice with this procedure in 50 patients is presented and discussed.
Key words
tlyperhidrose der Handflächen verursacht psycho-physische Hemmungen und wirkt sich sowohl im privaten als auch im Berui'sleben ungunstig aus. Die llrsache ist unbekannt. Die Schweißdriisen werden von der Sympathikuskette des autonomen Nervensystenis gesteuert. Das Zentrum der Sympathikusregulierung der oberen Extremitäten liegt zwischen den Segmenten D2 bis D9 des Rückenmarks. Die allgemein akzeptierte Behandlung besteht in einem Versuch einer Exzision des 3. thorakalen sympathischen Ganglions. Abgesehen vom chirurgischen Vorgehen selbst und dessen Komplikationen entstehen außerdem weitere Komplikationen durch die Exzision des Ganglions, U. a. das Hornersche Syndrom, kompensatorische Schweißabsonderungen ari anderen Körperstellen, und Wiederkehr der Schweißanfalle. Eine Alternative besteht in CTgeführter chemischer perkutaner thorakaler Syrnpathektoinie; bleibt diese erfolglos, so kann dennoch chirurgisch vorgegangen werden. Vorläufige Erfahrungen mit dieser Methode a n 50 Patienten werden mitgeteilt und diskutiert.
Hyperhidrose der Handflächen - Sympathektomie - Chemische perkutane Sympathektomie
.P
Palmar hyperhidrosis (PH) i. e. excessive sweatirig of the hands is a n emotionally, socially arid professionally disabling condition. The accepted treatment is the surgical intervention: tlioracic syrnpathectomy. Recently we introduced computed tomography giiided chemical percutarieous tlioracic sympatectomy (PTS); the purpose of this paper is to report on our preliminary experience with this inethod.
This study group includes 50 patieiits (1 1 men. 39 womeii) who ~iiiderwentPTS in the time period hetweeri
Fortschr. Röntgeristr. 1 53.4 (1 990) 400-403 O CinorgThicme Verlag Stuttgart. New York
P
Schlüsselwörter
.
Palmar hyperhidrosis . . Sympathec:torny Chemical sympathectomy percutaneous ....~
Hyperhidrose der HandnächenCT-geführte chemische perkutane thorakale Sympathektomie . - -
December 1987 and Decerner 1989. The first three patients underwent the procedure in December 1987: nine consecutive patierits in March 1988. These 1 2 patients were treated in collaboration with Prof. Robert Llondelinger; the remaining 38 patients from Septernher 1988 o n , by us. Thc youngest patient was 17 years old. the oldest 44 years. Thirty-one patients were in the agc group or 17-30 years. 19 patients between 31 -45 years. All had a Iiistory ol'rnore or Iess excessive sweating ol'the hands. exacerbated in sorne to drippirig of sweat nininly in surnmer time or hy emotional Stress. In all of thern concomitaiit sweating of the feet, sometirnes i n the axillary region, was present too. Two of thc patients were siblings. two others were lnother and daughter. 111 12 patiants familiar cumulation of PH was elucidated involving parents, sihlings or cousiris. Twenty-nine were of Ashkenazi origin. 2 1 of Sephardi origin.
Heruntergeladen von: NYU. Urheberrechtlich geschützt.
-.
Palmar hyperhidrosis ---
rslroiiiitics nt thr
.
...
.
~
.-
. .. ...
--.--- .-
. ... .
F o r t s c h ~Rör~tgenstr.153,4
. .. .
401 P
Eacli patit:iit iiiidnrwcnt tho procccl~ircTor bo1.h samc scssion
Tlic patient is positioncd prone on Lhe cornpiitcd tornography table. ns cornlortably as possible, with tho hands above the hcad. A scout view of the thorax is obtained and the third dorsal vertebra is localised (Fig. I). At this level 0.5 Cm thick slices at 0.5 cm incrc!rncirits a r e performed to choose Llie trajectory of nccdlc placemeiitat a plane frce ol'the transverse proccss and above or below the intervertebral forainen. Thc cntraricct point, laterally to the spinous process. is markod ori the skin. After strrile draping arid local anacsthnsia, a 10 cin long 22 gaugc spinal rieeclle is advanccd cautiously along a n angled trajeclory; bOd~ the ta.rgct point is lhe lateral aspect O f thc: verLebral (Iyig. 2- 3). The advancement of the needle is carefully monitored by frequent. repcat CT scan to avoid violation of the pleura and to ensure proper positioning of thc nccdle tip. h h e n this point is reached 0.5-1.0 ccrn dili~tedcontrast material is injected to observe its distributiori and diff~ision(Fig. 4). If no backflow into thc spirial caiial can be scen and ailer ensuring by suction that the needle tip is not inside a blood vessel, one proceeds with sJow injection of srnall increments of' pheriol l'Sterop(Bruxellcs) phcnol 400 mgr. glyccrin 1.5 gr, aqua ad 5 mll.
Fig. 1 Scout view.Thebody of thethirddorsal vertebraisat the height of the medial end oftheclavicles(arrow).
Fig. 2
Tlie patient reports ori progressive warming up of Lhe hand procccding I'rorn Lhe ringertips proximally, accompanied by asensatio~iofdryness. Dilatation of superficial veins at the dorsal aspect of thc hand occurs either before or at the time of the hand warming up: pupillary reaction to light excitation is rnonitored during the whole injection. 'l'he arnount of phttriol used is individual. When the patient reports a s a t i s f a c ~ o feeling r~ of dryness of' the hand the injection is stopped. The Same proccdure is performed for the other limb(Fig. 5). The procedure Tor both hands can be perforined in an average time of 90- 1 20'.
Fig. 3
At the cnd of the procedure the patient stays in the department for 2-3 hours in a sitting position, arid is thereafter rctiirned to the surgical ward iintil the next day. Blood prcssure is monitored. 1,ight aniilgesics can be adrniriistered i i i the event of pain.
Ir] one patient we performed thci procedure twicc at a diiTerent linie interva.1, without success. All the rernaining 49 patients, i. c. 98 extreinilies, reported iiriinediaie results nlready on the examination table.
Fig. 2 and 3 The needle ic advanced step by step toward the lateral aspect of the 3rdvertebral body with close monitoring by repeat CTscans.
Heruntergeladen von: NYU. Urheberrechtlich geschützt.
A short anamnesis is obtained as to the onsrt. duration and scverity of PI-l as well a.s general Iiealth coiidition of thc prospective patient. Dctailed explanation is given to thc patierit coiicerning thc esseritials of the procedure and the steps involved, about possible early and lato complications, and rate 0fsuc:c:ess. Chest X-ray, ECG arid blood pressiire valiics are requested. as wcll a s a written corisent.
402 Fortschr. Höntgenslr 15.3.4
--
- --
-
.
.
Olga L?. ildler ct al. -~
.
Swcnt forrnatiori by Llie sweat glands plays aii iinporlant rolc i n ttie ll~erriialregulation of tho body and assures moisturi! to Lhe skin. Increascd ~ ~ ( i i l t i roccurs ig at changc oi'inner or outcr ternpcraiiiro or i i i a slate of anxicty, pain or anger (7. 1 4 . 17). Thc: iiioisture of thc skin is f~~rriislied by the apocrinct sweal glands. rather niirneroiis i r i distribution at thc: paliiiar arid volar aspcci. ol'the haiids and feet, axillary region and facc. Thoir liiric:lioii begins uIren.dy at birlli: tlieir nunibcr stays iiriclianged ailcl constant duriiig lifetinie.
Fig. 4 Contrast material injection shows its dispersion along theveriebral body and forward.
Fig. 5 The procedure 1s repeated on the left side. Widening of right paraveriebral space following phenol injection can be appreciated
In 1 1 patients 2-3 mm ptosis OS one eyelid was observed at the end of the procedurc. In 7 patients, chest or back pain necessitated adrninistralion of peroral analgesics. Eight patients bcgan cornplaining 2-3 days afler Lhe procedure about pain, burning and disturbing Sensations in onc lirnb, wliich later on disappeared after medical trcat,rnent. Sweating recurrcd alter 4 months to a previous slale in 5 patients; to a Iesser degree in 4 patients. Cornpensatory swcating of the back or chest occrrrrcd in 4 patients. Permanent success, i. c. dry tiands, was obsr:rved for 2 years in 3 paticnts, for 20 inonths in 20 palienls, and for 1 2 rnonths in 19 patients. 'l'he last paticnts r '/IZ and are well in thc rncanhave had a follow-up f i ~ only time. The ptosis of thc cyclid disappeared in the course of halfa year in 3 pationts oul of 1 1 . 'l'he remainder (all of tliern worncn) conceal il by make-up and arc. still happy to havc dry harids at lhe price of this minor cosrnc:tic: defect.
Thr: produclioii of sweat is iindcr rolleclory control ol'thc sympalliic systeni. which on thci otlier Iiarid is regulatcd by the lieat centre in thc hypothalainus (3.6. 14). I;ibrcs l'roni ~ h hypothalamiis e dr!sc:r:nd Llirough the brain storn 10 Llie spinal cord and synapse wilh the neurons ot'tlie syiiipathic chain in thci niiddle Part of the gray rnat,tor ot'lhe cord. which cstcnds belween DI-L,?. Prcganglionar white syinpathic fibres leave the cord to roach tlie sympathic ganglions siLuaLed along both sidcs of lhe verlebi-al column. Thr: ganglions contain thc ccll bodies of the post ganglionic: fibre ( 2 . 7 . 8 ) . The prcganglionic Tibres o f a given scgrnent of the spinal cord miiy synapse iii a ganglion situaled a l the heigth of thc: sarrie segrnent. but they rnay pass Lhrough them usiially ~o liiglier levels. Postganglionic gray fibres partly joiii lhe spinal nervcs, partly accoinpany the vesscls. There are variants in which Lhe syriapsis orthe prcganglionar fibres with thr' poslgariglioiiar fibres is locatcd oulside the ganglion (1 2. 1 4 , 18).The synipathic inncirvalioii of lhe upper extrerriilies is located in thc cord a l the level D.2--D.9. The rnain ganglion rcsponsible Tor lhe syrnpathic inriervalioi~ofthe uppcr cstremilies is D.2-D.3. Hypcrhidrosis is a pathologic statt! cliaracterised by excessivc sweatiiig. It may bc prirnarily of unknown origin; the sweat glands and tlieir synipathic innervat,iori arc: riormal (3), possibly Lhere is sorne hypcract.ivity ol' ttie Iiypothalamic therrrial ceiitie or a congcnilal defect in the cortical ccntrci ofthe hands and fect. Sccoridary Iiyperhidrosis may bo due lo lesion of thc ncrvous systern in a central. pcripheral or regional locatiori; sysleriiic diseases likc hypr:rthyroidism. obcsity, rneriopause can exhi bit. cscr:ssive swealing (1, 6, 14). PH is a disturbing phcnornonon in every clay life, frorn sirnple actions like hand shaking, writing or any other func:lion linked to the hand, thus it causes a ieeling of crnotional and social disabling arid evnn invalidity in profossiorial life. Interestingly. PH is ralher cornmon in Jcws. rnore in those originating fror11 North Africa, Ycrnctn, tlie Balkans. ancl in .lapanese. Often farnily history cari be eslablished. Because of thc discornli~rlcaused by P H , rnariy lrealrnent forms havc bcen lried. Conservative treatment aiins to local applicalion of substances containing alurninium salts and ottier coinponents sealing off tht? oullet of the swoat glaiids. Their effect is ternporary bul lliey may causc? ari iriflarnmatory reaction. Trial ol'peroral anticholinergic drug also leads to iinploasaril side effects and is therel'ore not in wiclesprcad usc: (6). Tho accepled and eficacioiis trcatnierit is the surgical onH, corisisling of escision of thc upper thoracic syrnpat,hicganglia. 'l'here are four rnain ar:c:ess roules to the syrnpalliic gaiiglionar chain: t.he subclavicular. transaxil-
Heruntergeladen von: NYU. Urheberrechtlich geschützt.
--
References .. .. ..
lar, anterior o r posterior thoiacic route, according to ttie
-
skill of Lhe surgeon ( 1 , 2, 8, Y). 'l'he succcss rate is Iiigli.
Compuled loinography giiided clierriical percutaneous thoracic syinpathectomy presenls a n attractive alternative t« surgery (16). Chcrnical synipathicolysis is a known procedure. applied to block pain transmission (1 0, 1 1, 13): coeliac ganglion block in patients with pancreas carcirioriia. lumbar block in advanced periphcral vascular disease, mainly Ruerger's disease. to alleviatc: pair1 (4. 15). In 1387 Dondclinger reported for the lirst lime C1' guided percutaneous thoracic sympathicolysis in 12 patients, thc niajority Sor Raynaud's diseaso and iri 3 out of 1 2 for PH (5). It is a n ambulatory procedure a n d leaves no scars; cornplicatioris connectcd to l h e surgical procedure like piieumothorax, pleural fluid rormation, lcsion oiblood vessels o r nervc d o not occur d u e to thc rnerits ofexact needle localisatiori by C l ' guidancc. Complications of the proccdure like Horner's syndrome o r cornpensatory swcating a r e tlie sarne as with surgery. As to the results: f'urther follow-up is neccssary to assess whether ccssatiori o f s w e a t ing is perrnancnl. PTS does not excliid(: ensuing surgical intervcntion. T h e procedure shoiild b e performed by cxpcrienced interventional radiologisls.
Acknowledgement Tho authors wisli to express thcir Special gratitude to Prof. Roh~rtDotidslinger who initinted thom in perforniing thc proccdure.
/\dar, R., A. Ki~rclrin.A. Zweig, M . Moses: Palninr hypcrhydI-osis and its surgical treatrneiit: a raport on 100 rases. Aiin. Surg. 186 (1 977) 34 .40 ' Atkinsotz, L.: Upper dorsal sympath~ctoiny.4fed. .J. Aust. 1 11975) 267 270 .' Uohtz. L). I
