Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 10  |  Issue : 1  |  Page : 293-296

Optimum target in percutaneous upper thoracic thermocoagulation in primary hyperhidrosis


Zagazig University Hospitals, Egypt

Date of Web Publication3-Aug-2018

Correspondence Address:
Osama Yehia A Khalifa
Department of Anesthesia, Zagazig Medical Faculty, Zagazig University, Zagazig 44519
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/asja.asja_73_16

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  Abstract 


Introduction Primary palmar hyperhidrosis is a disabling problem that affects young age groups and usually continues for years without an effective treatment. It is usually accompanied by plantar hyperhidrosis and to a lesser extent by axillary affection. We have tried to improve the efficacy of percutaneous radiofrequency ablation of upper thoracic sympathetic ganglia via imitating what thoracoscopic surgeons do in endoscopic thoracic sympathectomy.
Patients and methods A total of 40 patients with primary hyperhidrosis were randomly classified into two groups. Group Tb (n=20) underwent thermocoagulation of sympathetic chain on vertebral body. Group Th (n=20) underwent thermocoagulation of sympathetic chain on the head and neck of ribs. Hand temperature and dryness were followed up during the procedure and on the following intervals: 1 week, 1 month, 3 months, 6 months, 9 months, and 12 months after the procedure.
Results During the procedure, the hands of 50% of patients became warm and dry in group Tb and only 40% remained so till 12 months, whereas in group Th, the hands of 100% of the patients became warm and dry during the procedure till 12 months.
Conclusion Thermocoagulation of upper thoracic sympathetic chain on the head and neck of the second and third ribs is more effective than attacking the chain on vertebral bodies in patients with primary hyperhidrosis with no recorded complications.

Keywords: head and neck of ribs, primary hyperhidrosis, T2 and T3 sympathetic chain, thermocoagulation


How to cite this article:
Khalifa OY, Hegab AS. Optimum target in percutaneous upper thoracic thermocoagulation in primary hyperhidrosis. Ain-Shams J Anaesthesiol 2017;10:293-6

How to cite this URL:
Khalifa OY, Hegab AS. Optimum target in percutaneous upper thoracic thermocoagulation in primary hyperhidrosis. Ain-Shams J Anaesthesiol [serial online] 2017 [cited 2018 Nov 20];10:293-6. Available from: http://www.asja.eg.net/text.asp?2017/10/1/293/238482




  Introduction Top


Primary palmar hyperhidrosis occurs in 1–4.4% of the population of Fuzhou City of China and affects almost 7–8 million people in the USA [1],[2], with subsequent marked discomfort and psychological troubles to the patient. For years, we have been doing percutaneous thermocoagulation of T2 and T3 sympathetic ganglia on the body of T2 and T3 thoracic vertebra with unsatisfactory results. In such an approach, we follow the text books of pain interventions in which thermocoagulation of T2 and T3 thoracic ganglia is performed by targeting the posterior third of T2 and T3 vertebral body confirmed by anteroposterior and lateral fluoroscopic views and contrast injection. After negative sensory and motor stimulation, thermal lesion of the ganglia is done at 80°C for 90 s at two positions [3].

Success rate of endoscopic thoracic sympathectomy in primary palmar hyperhidrosis in which the sympathetic chain is attacked at the head and neck of the second and third ribs and not the vertebral body is 97.8% after 12 months [4].

To the best of our knowledge, there is no journal in pain medicine mentioning the performance of T2 and T3 thoracic sympathectomy via targeting the head of the second and third ribs. In this study, after reviewing of literature studies and discussion with some thoracoscopic surgeons, our objective was to compare between the efficacy of thermocoagulation at the vertebral body and at the head and neck of the ribs in the treatment of severe palmar hyperhidrosis.


  Patients and methods Top


Sample size was calculated by using Epi-Info program [Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, US]. At 80% power and 95% CI, α error 5%, β error 10%, and considering a previous study in which efficacy (regarding the primary outcome which is dryness of the hand) of thermocoagulation was 41% and efficacy of surgery was 86.7%, the estimated sample was 20 patients in each group. We added 10% (four patients) to compensate for drop out during the study as shown in the enrollment chart.

A total of 44 patients with primary palmar hyperhidrosis attending the pain clinic of Zagazig University hospitals were enrolled in the study; however, four patients were excluded as they did not meet the inclusion criteria. After obtaining the approval of institutional review board of Zagazig Medical Faculty, an informed consent was taken from patients or their guardians, and the patients were randomized in an allocation ratio of one to one between study groups. Randomization was electronically generated using random number tables from computer. The study was performed in Zagazig University hospitals in the period between May 2014 and April 2015. The first group was formed of 20 patients and named as group Tb, in which we did thermocoagulation of sympathetic ganglia on the body of T2 and T3 thoracic vertebra. The second group was also composed of 20 patients and was named Th, in which we did thermocoagulation of the sympathetic chain on the head and neck of the second and third ribs. All the patients had severe primary palmar hyperhidrosis with or without planter affection and sought nonsurgical treatment. We excluded cases less than 8 years old and previously failed cases either after percutaneous or surgical upper thoracic sympathetic neurolysis.

The procedure in group Tb

The patients lied prone and after sterilization of the area and draping, sedation was given using midazolam, ketamine, and propofol if needed. NeuroTherm RF curved tip needle of 20-G diameter (Morgan Automation Ltd, Liss, Hants, UK), 10 cm in length, and 10-mm active tip was used to attack the sympathetic ganglia at the junction between the anterior two-thirds and posterior one-third of the second and third vertebral bodies. After confirmation of the needle position via lateral and anteroposterior views ([Figure 1]), injection of nonionized radiopaque contrast material Iohexol 300 mg I/ml (Omnipaque, GE Healthcare Inc., Cork, Ireland), and negative sensory and motor stimulation on 50 Hz and greater than 0.7 V and 2 Hz and greater than 1.5 V, respectively, three thermal lesions were done on each body in the middle, upper, and lower areas. The same technique was repeated on the contralateral side.
Figure 1 AP view of targeting the T3 vertebral body.

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The procedure in group Th

The patient lied prone and was draped after sterilization of the area. C-arm was adjusted cephalocaudally and little laterally to obtain a clear view of the head and neck of the second and third ribs. We targeted the head and neck of the rib ([Figure 2] and [Figure 3]) and made thermal lesions after negative sensory and motor stimulation. The same needle was used in both groups and also the same radiofrequency generator (NeuroTherm) NT1100 generator. Thermal lesions in both groups were done at 80°C for 90 s.
Figure 2 Dead AP view of targeting the head of second rib.

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Figure 3 Oblique view of targeting the head of second rib.

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Hands’ temperature was monitored during the procedure; after making lesions, 3 ml of dexamethasone 1.6 mg/ml in normal saline was injected at each vertebral level. We did not inject local anesthetics to avoid sympathetic block that will increase hands’ temperature. Routine monitoring of pulse, blood pressure, and oxygen saturation was continuous during the procedure.

After the procedure, patients were followed up for dryness of hands and feet by a blinded member of pain clinic at 1-week, 1-month, 3-month, 6-month, and 12-month intervals.

Moreover, complications such as pain, pneumothorax, compensatory sweating, and over dryness were followed up during the same visit to pain clinic or via a telephone call.


  Results Top


Regarding demographic and clinical data, there was a nonsignificant difference between both groups ([Table 1]) regarding age and sex. Moreover, there was a nonsignificant difference between both groups in the site of affection with hyperhidrosis either palmar only or palmar and plantar.
Table 1 Demographic and clinical data

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Primary outcome results

[Table 2] showed the primary outcome results that denoted a significant difference between both groups during the procedures, with an increase in hand temperature of greater than or equal to 2°C in 18 of 20 patients in group Th, whereas this happened only in 10 of 20 patients in group Tb.
Table 2 Temperature rise and hand dryness during and after the procedure

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Dryness of the hands was present in 20 (100%) patients of group Th during all the follow-up intervals (1 week, 1 month, 3 months, 6 months, 9 months and 12 months), whereas in the group Tb, the efficacy of the technique was significantly lower than group Th at all the follow-up intervals. In group Tb, dryness of the hands was present in 10 (50%) patients at 1 week till 3 months. However, at the 6-month interval, the hands of two more patients became wet. Thus, only 40% of patients of group Tb continued with effective treatment till 12 months as shown in [Table 2].


  Discussion Top


Efficacy of thermocoagulation in Tb group is 40% after 6 months of intervention. This is comparable with Franco et al. [5] who made computed tomography-guided single lesion at the posterior third of T2 and T3 vertebral body and reported that the efficacy in palmar hyperhidrosis was 30.7%. Our results are little higher, which may be because we did multiple lesions on the vertebral bodies. This result is not concordant with the result of Purtuloglu et al. [6] who found that efficacy of thermocoagulation is 75%, but there are some differences between studies. First, they operated on T4 body rather than T2 and T3, and second, their sample size was nearly double compared with our sample size.

Regarding the results of thermocoagulation in group Th, the efficacy was 100% and in 18 cases, hands’ temperature increased more than 2°C after thermocoagulation of the sympathetic chain on the head and neck of the third rib. In 2 cases the temperature increased above 2°C after thermocoagulation of the chain on the head and neck of the second and third ribs. These results are concordant with the results of Chuang and Liu [7] as they found that percutaneous stereotactic thermocoagulation of upper thoracic ganglia and chain for palmar and craniofacial hyperhidrosis was successful in 99.5% of cases in a period from 2 to 59 months. This concordance may be because of targeting of the chain via a three-dimensional coordinate system, which was developed by the authors in a cadaveric study.

These results also agree with the findings of Wang et al. [8] who stated that ∼90% of T2 and T3 sympathetic trunks are located on the rib head and not on the vertebral body, so thermocoagulation at the rib head should be significantly more effective than thermocoagulation at the vertebral body.


  Conclusion Top


Thermocoagulation of upper thoracic sympathetic chain on the head and neck of the second and third ribs is more effective than attacking the chain on vertebral bodies in patients with primary hyperhidrosis with no recorded complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Li X, Chen R, Tu Y, Lin M, Lai FC, Li YP et al. Epidemiological survey of primary palmar hyperhidrosis in adolescent. Chin Med J 2007; 120:2215–2217.  Back to cited text no. 1
    
2.
Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol 2004; 5:241–248.  Back to cited text no. 2
    
3.
Raj P, Erdine S. Interventional pain procedures in the thoracic region. Chapter 14. In: Raj P, Erdine S, editors. Pain-relieving procedures the illustrated guide. Hoboken, New Jersey, USA: Willy-Blackwell; 2012. 244–249.  Back to cited text no. 3
    
4.
Rodríguez PM, Freixinet JL, Hussein M, Valencia JM, Gil RA, Herrero J et al. Side effects, complications and outcome of thoracoscopic sympathectomy for palmar and axillary hyperhidrosis in 406 patients. Eur J Cardiothorac Surg 2008; 34:514–519.  Back to cited text no. 4
    
5.
Franco CEG, Cajaraville JP, Grima FG, Espan A. Prospective study of percutaneous radiofrequency sympathicolysis in severe hyperhidrosis and facial blushing: efficacy and safety findings. Eur J Cardiothorac Surg 2011; 40:e146–e151.  Back to cited text no. 5
    
6.
Purtuloglua T, Atima A, Deniza S, Kavaklib K, Gurkokb ESS, Kurta E et al. Effect of radiofrequency ablation and comparison with surgical sympathectomy in palmar hyperhidrosis. Eur J Cardiothorac Surg 2013; 43:e151–e154.  Back to cited text no. 6
    
7.
Chuang K, Liu J. Long-term assessment of percutaneous stereotactic thermocoagulation of upper thoracic ganglionectomy and sympathectomy for palmar and craniofacial hyperhidrosis in 1742 cases. Neurosurgery 2002; 51:963–969; Discussion 969–970.  Back to cited text no. 7
    
8.
Wang YC, Sun MH, Lin CW, Chen YJ. Anatomical location of T2-3 sympathetic trunk and Kuntz nerve determined by transthoracic endoscopy. J Neurosurg 2002; 96(Suppl 1):68–72.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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