Fluoroscopic Localization of L3 Sympathetic Ganglion Prior to Endoscopic Lumbar Sympathectomy

doi:10.21203/rs.3.rs-3201592/v1

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Fluoroscopic Localization of L3 Sympathetic Ganglion Prior to Endoscopic Lumbar Sympathectomy

https://doi.org/10.21203/rs.3.rs-3201592/v1

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Purpose: Plantar hyperhidrosis can cause a significant impact on an individual's quality of life. Surgical treatment of plantar hyperhidrosis involves blocking the lumbar sympathetic signals from reaching the plantar surface by placing a metal clip above the third lumbar ganglion. We hypothesize that by mapping the location of the third lumbar ganglion and correlating it with a fluoroscopic image of the lumbar spine will improve the level accuracy of lumbar sympathectomy.

METHODS: Ten human cadavers were dissected to define the locations of lumbar sympathetic ganglia, and fluoroscopic images of lumbar spine were obtained.

RESULTS: For the right L3 sympathetic ganglion most common locations corresponded with the upper 1/3 of the L3 vertebral body 36.4%, and the next most common location corresponded to the lower 1/3 of the L2 vertebral body 27.3%. The left L3 sympathetic ganglion the most common sites corresponded with the upper 1/3 of the L3 vertebral body 36.4% and the middle 1/3 of the L3 vertebral body 36.4%.

CONCLUSION: The L3 ganglion is consistently found next to either L2 or L3 vertebrae.

plantar hyperhidrosis

endoscopic lumbar sympathectomy

L3 ganglion

fluoroscopy

Plantar hyperhidrosis adversely affects an individual's quality of life and emotional well-being [1]. It is characterized by dysregulated non-temperature dependent eccrine sweat gland secretions on the plantar surface. Although the etiology of plantar hyperhidrosis is not completely elucidated, sympathetic nervous system anomaly is thought to play a key role [2]. Conservative management of plantar hyperhidrosis includes lifestyle modifications, topical aluminum chloride solution, iontophoresis, and botulinum toxin injection; these methods are not curative [3]. For a permanent relief, endoscopic lumbar sympathectomy (ELS) is done. ELS operation involves inserting an endoscope into the retroperitoneum, which is insufflated with carbon dioxide to make visualization possible [3]. The lumbar sympathetic trunk is exposed at the level of L2 and L3 vertebral bodies. A metal clip is placed above the L3 ganglion.

It is well known that imprecise endoscopic thoracic sympathectomy (ETS) for palmar hyperhidrosis causing near complete sympathetic innervation block to the palm will result in postoperative compensatory hyperhidrosis and sympathetic blockade to the heart. Similarly, imprecise endoscopic lumbar sympathectomy may also result in compensatory hyperhidrosis and ejaculation dysfunction. Therefore, knowing the precise intraoperative locations of lumbar ganglia will increase surgeon’s confidence in the ELS technical results and decrease complications. To better understand the lumbar sympathetic ganglia anatomy, we dissected human cadavers to outline the positions of L2 and L3 ganglia relative to their respective vertebrae and correlated the positions with x-ray images of the spine.

Ten human cadavers were obtained from the University of New England College of Osteopathic Medicine (UNECOM) donor lab and dissected in 2021, resulting in 20 lumbar sympathetic trunk dissections. The abdominal cavity on each cadaver was opened and the gastrointestinal tract and retroperitoneal structures were removed. For the dissection, the psoas major muscle was identified and removed from the vertebral column to expose the nerves of the lumbar plexus and sympathetic trunk. Rib 12 was palpated, and the subcostal nerve was found about 1 cm inferior to rib 12 for spatial recognition of the L1-L4 ganglia. The remaining lumbar ganglia were verified by tracing the communicating ramus from the ganglion to the ventral ramus Once the ganglia were dissected and found, metal wire was bent and placed over the borders of the ganglia and glued down. C-arm fluoroscopy was used to image the locations of the L1-L4 ganglia in the AP and Oblique views. Measurements of ganglion position were obtained relative to vertebral body position by analyzing the x-ray images with the aid of the HOROS DICOM open-source medical imaging viewer [4]. Using the imaging software, the position of a ganglion was recorded by dividing the vertebral body into an upper one-third, middle one-third, and lower one-third. The size of a lumbar ganglion and the distance between the ganglia were recorded.

In the 20 trunks dissected, 60 ganglia were found and the size of each ganglion and positions of the ganglia were recorded. An example of a typical x-ray image obtained is shown by Figure 1. The positions of L2 and L3 ganglion in relation to the L2 and L3 vertebrae are shown by Figure 2.

For the right L3 sympathetic ganglion most common locations corresponded with the upper 1/3 of the L3 vertebral body 36.4%, and the next most common location corresponded to the lower 1/3 of the L2 vertebral body 27.3%. The left L3 sympathetic ganglion the most common sites corresponded with the upper 1/3 of the L3 vertebral body 36.4% and the middle 1/3 of the L3 vertebral body 36.4%.

We have not been able to find, despite our best effort, any publication that fully describes the complete sympathetic nerve pathway to the plantar surface. It is well described in literature that cell bodies of sympathetic preganglionic neurons in the spinal cord are in the intermediolateral nuclei which extend from the thoracic segment 1 (T1) to lumbar segment 3 (L3) [5]. The sympathetic trunk which starts from the base of the skull to the coccyx runs parallel to the vertebral column with interspersed ganglion corresponding to each vertebra in the thoracic, lumbar, and sacral levels. It is also known that sympathetic innervation to the genital organs originates at the L1 and L2 ganglia. Hence, clipping the sympathetic output at the level between L1 and L2 ganglia would not be recommended. We also know that applying a metal clip between L2 and L3 ganglia cures plantar hyperhidrosis. Since there are no sympathetic preganglionic neurons that exit below the spinal cord L3 level, L3-5 ganglia must receive their signals from L1 and L2 ganglia. Based on these observations, we can conjecture that a substantial portion of sympathetic innervation to the plantar surface must arise from L1 and L2 ganglia.

There is considerable anatomical variability of the nervous system in the lumbosacral region. Fortunately, we found the level of the L3 ganglion is consistently found next to the upper two thirds of the L3 vertebra. Unlike thoracic ganglia, lumbar ganglia have a nodular appearance, and their location can be visually distinguished. If a ganglion nodule is visualized adjacent to the L3 vertebra, we can be confident that this represents the L3 ganglion. However, if ganglion nodule is not found adjacent to the L3 vertebra, the L3 ganglion should be sought near the L2 vertebra. If a nodule is found adjacent to the L3 vertebra, we can be certain that a metal clip is applied at the level of the intervertebral disc between L2 and L3 vertebrae, sympathetic signals coming from L1 and L2 will be blocked. Hence, prior to clipping the lumbar sympathetic trunk, C-arm fluoroscope should be used to visualize the L3 vertebra to ensure technical consistency. Since L2 ganglion can be found at the lower third of the L2 vertebra, the metal clip should be positioned well below the L2 ganglion to prevent injury to L2 ganglion.

ELS for plantar hyperhidrosis is seldom performed in pediatric patients due to the lack of requests from pediatric patients to treat the problem. Another reason stems from the lack of surgical experience and training gained by Pediatric Surgeons. The anatomy of the lumbar sympathetic system is viewed as highly variable and complicated. Although this is true, as our study shows, the position of target L3 lumbar ganglion is consistent, and this fact should provide encouragement to Pediatric Surgeons that surgical outcome will be successful with minimal complications. Combination ETS for palmar hyperhidrosis and ELS for plantar hyperhidrosis procedures have not been reported for pediatric patients. With greater experience, to spare the patients from multiple anesthesia, combination ETS and ELS could be considered in right patients.

The L3 ganglion is found next to the upper two thirds of the L3 vertebra or next to the lower one third of L2 vertebra.

Acknowledgement: None

Financial Disclosure: The authors have no financial relationships relevant to this article to disclose.

Conflict of Interest: The authors have no conflicts of interest relevant to this article to disclose.

Funding/Support: None

Vlahovic TC (2016) Plantar Hyperhidrosis: An Overview. Clin Podiatr Med Surg 33:441-451. doi: 10.1016/j.cpm.2016.02.010
Yoshida WB, Cataneo DC, Bomfim GAZ, Hasimoto E, Cataneo AJM (2010) Chemical lumbar sympathectomy in plantar hyperhidrosis. Clinical Autonomic Research 20: 113-115.
Rieger R, Pedevilla S, Pöchlauer S (2009) Endoscopic lumbar sympathectomy for plantar hyperhidrosis. British Journal of Surgery 96;1422–1428. doi.org/10.1002/bjs.6729.
https://medevel.com/horos-free-open-source-dicom-viewer-for-macosx-for-radiologists/
Terry L Powley (2012) Fundamental Neuroscience. 4th ed. Elsevier Science, New York

No competing interests reported.

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Fluoroscopic Localization of L3 Sympathetic Ganglion Prior to Endoscopic Lumbar Sympathectomy

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