Thoracoscopic sympathectomy for hyperhidrosis: analysis of 642 procedures with special attention to Horner's syndrome and compensatory hyperhidrosis.

BACKGROUND: Hyperhidrosis (HH) profoundly affects a patient's well-being. OBJECTIVE: We report indications and outcomes of 322 patients treated for HH via thoracoscopic sympathectomy or sympathotomy at the Barrow Neurological Institute. METHODS: A prospectively maintained database of all patients who underwent sympathectomy or sympathotomy between 1996 and 2008 was examined. Additional follow-up was obtained in clinic, by phone, or by written questionnaire. RESULTS: A total of 322 patients (218 female patients) had thoracoscopic treatment (mean age 27.6 years; range, 10-60 years). Mean follow-up was 8 months. Presentations included HH of the palms (43 patients, 13.4%), axillae (13 patients, 4.0%), craniofacial region (4 patients, 1.2%), or some combination (262 patients, 81.4%). Sympathectomy and sympathotomy were equally effective in relieving HH. Palmar HH resolved in 99.7% of patients. Axillary or craniofacial HH resolved or improved in 89.1% and 100% of cases, respectively. Hospital stay averaged 0.5 days. Ablating the sympathetic chain at T5 increased the incidence of severe compensatory sweating (P = .0078). Sympathectomy was associated with a significantly higher incidence of Horner's syndrome compared with sympathotomy (5% vs 0.9%, P = .0319). Patients reported satisfaction and willingness to undergo the procedure again in 98.1% of cases. CONCLUSION: Thoracoscopic sympathectomy is effective and safe treatment for severe palmar, axillary, and craniofacial HH. Ablating the T5 ganglion tends to increase the severity of compensatory sweating. Sympathectomy led to a higher incidence of ipsilateral Horner's syndrome compared with sympathotomy.

Bone dowels in anterior lumbar interbody fusion.

Since the Food and Drug Administration approved the Babgy-Kuslich BAK cage for anterior lumbar interbody fusion (ALIF), various threaded interbody fusion devices have been introduced. Bone dowels offer several theoretical advantages over cages with regard to stress shielding; the purpose of this study was to assess the efficacy of bone dowels in interbody fusion. All patients undergoing ALIF performed by the senior author between 1998 and 2001 were retrospectively reviewed. Patients' preoperative and postoperative neurologic status, functional status, and both back and radicular pain were assessed according to a previously published outcome measure. Between 1998 and 2000, 23 patients underwent ALIF with cortical femoral allograft bone dowels. One patient underwent simultaneous bone dowel and titanium cage placements and was therefore excluded from further analysis. The 22 remaining patients underwent a total of 33 fused segments; of these, 21 patients were available for follow-up. Mean clinical follow-up was 30.6 months. Mean imaging follow-up was 21 months. There were 5 instances of radiographic nonunion (3 symptomatic and 2 asymptomatic). The incidence of technical failures and complications related to the bone dowels was 17%. Bone dowels failed and caused symptoms only in patients with a stand-alone ALIF. There were no clinical failures in patients treated with supplemental anterior or posterior spinal fixation. These data demonstrate that marginal fusion rates and functional success rates can be achieved using stand-alone bone dowels for ALIF. The clinical success and fusion rates are significantly higher if ALIF dowels are shielded from stress with rigid spinal instrumentation.

Surgical management of giant herniated thoracic discs: analysis of 20 cases.

OBJECT: The authors evaluated the clinical and surgical outcomes obtained in patients with giant herniated thoracic discs (HTDs), defined as occupying more than 40% of the spinal canal. Surgery-related considerations and functional outcomes in patients with small- and medium-sized HTDs were compared. METHODS: The authors reviewed 140 cases of surgically treated HTDs, 20 (14%) of which were giant. Before and after surgery, all patients underwent computerized tomography myelography, magnetic resonance imaging, or both. Functional outcomes were assessed using the Frankel grading system preoperatively, immediately after surgery, and at long-term follow-up examination. The results observed in patients with giant HTDs were compared with those with small- and medium-sized HTDs. The mean overall follow-up period was 2.6 years. Sixty-six patients (47%) presented with myelopathy, including 19 (95%) with a giant HTD. Of the latter, 16 (80%) underwent anterior, eight thoracoscopic, and eight open thoracotomy approaches. Four patients (20%) with laterally oriented giant HTDs within the spinal canal underwent surgery via a posterolateral approach. Based on analysis of long-term follow-up data, 53% of patients with giant HTDs improved neurologically by one Frankel grade. Progression of myelopathy was arrested in 42%, and in 5% the Frankel grade worsened by one. In patients with small- and medium-sized HTDs, the Frankel grade improved by one in 77%, stabilized in 23%, and worsened in 0%. Patients with giant HTDs who underwent thoracoscopic surgery had worse short- and long-term functional outcomes than those in whom open thoracotomy was performed. CONCLUSIONS: Patients with giant HTDs presented more frequently with myelopathy and experienced worse functional outcomes than those with smaller HTDs. Based on their experience, the authors recommend open thoracotomy rather than thoracoscopy for the treatment of midline giant HTDs.

Anterior lumbar interbody fusion for treatment of failed back surgery syndrome: an outcome analysis.

OBJECTIVE: Anterior lumbar interbody fusion (ALIF) has gained popularity for the treatment of degenerative disease of the lumbar spine. In this report, we present our experience with the ALIF procedure for treatment of failed back surgery syndrome (FBSS) in a noncontrolled prospective cohort. METHODS: In a 2-year period, we treated patients diagnosed with FBSS with ALIF. Clinical and radiological outcomes were recorded in a prospective, nonrandomized, longitudinal manner. Neurological, pain, and functional outcomes were measured preoperatively and 12 months after surgery. Operative data, perioperative complications, and radiological and clinical outcomes were recorded. RESULTS: Thirty-three patients with a preoperative diagnosis of FBSS, with degenerative disc disease (n = 17), postsurgical spondylolisthesis (n = 13), or pseudarthrosis (n = 3), underwent ALIF. Back pain, leg pain, and functional status improved significantly, by 76% (P < 0.01), 80% (P < 0.01), and 67% (P < 0.01), respectively. CONCLUSION: On the basis of our results, we found ALIF to be a safe and effective procedure for the treatment of FBSS for selected patients.

Thoracoscopic approaches to the thoracic spine: experience with 241 surgical procedures.

INTRODUCTION: Microsurgical thoracoscopic approaches to the thoracic spine allow access to the spinal cord, spinal nerves, disc spaces, vertebral bodies, paravertebral soft tissues, and sympathetic chain with minimal invasiveness. METHODS: Between January 1994 and January 2000, 241 thoracoscopic procedures were performed: 164 thoracic sympathectomies, 60 discectomies, 5 neurogenic tumor resections, 8 corpectomies and spinal reconstructions, 2 anterior releases, and 2 biopsies. Cases were reviewed to evaluate the efficacy, surgical results, and complications of the thoracoscopic procedures. RESULTS: An adequate sympathectomy was achieved in all 164 sympathectomies. There was 100% relief of palmar and 95% relief of axillary hyperhidrosis. Reflex sympathetic dystrophy responded poorly to sympathectomy with recurrent pain. Thoracoscopic discectomy achieved complete decompression in 98% of patients. Gross total tumor resection was achieved in all five paraspinal neurogenic tumors. There was no operative mortality. Morbidity compared favorably with open surgical approaches to the thoracic spine. CONCLUSION: Thoracoscopic spinal surgery is an effective technique that provides full, direct access to the ventral thoracic spine. Its morbidity rate appears to be lower than that associated with open thoracotomy. It improves patient comfort and cosmetic results and shortens recovery. This technique has become the authors' surgical approach of choice for removing benign intrathoracic paraspinal neurogenic tumors and central herniated thoracic discs and for performing biopsies and thoracic sympathectomies. The senior author still prefers open surgical approaches for most thoracic corpectomies and spinal reconstruction procedures.

Biportal thoracoscopic sympathectomy: surgical techniques and clinical results for the treatment of hyperhidrosis.

OBJECTIVE: To describe a bilateral thoracoscopic sympathectomy procedure, using a biportal approach, for the treatment of severe hyperhidrosis. METHODS: Between May 1996 and September 2000, 103 consecutive patients underwent thoracoscopic sympathectomy procedures to treat bilateral hyperhidrosis (206 procedures). Operative results, complications, and patient satisfaction were determined by reviews of hospital and office charts and by follow-up assessments in the outpatient clinic. Long-term results were determined with clinical examinations, follow-up office visits, and follow-up questionnaires. RESULTS: Ninety-three patients presented with primary palmar hyperhidrosis, eight with primary axillary hyperhidrosis, and two with primary craniofacial hyperhidrosis. Rates of complete resolution in the primary area affected were 100% in palmar and craniofacial cases and 75% in axillary cases. The average length of hospitalization was 1.06 days, and 96 patients (93.2%) were discharged on or before the end of the first postoperative day. Of 59 patients (57.3%) who developed compensatory hyperhidrosis, only 11 patients (10.7%) reported that it was bothersome and none considered it disabling. All postoperative complications were transient; five patients experienced unilateral Horner's syndrome, three patients experienced intercostal neuralgia, and two patients required a chest tube after surgery because of a pneumothorax. CONCLUSION: Thoracoscopic sympathectomy using a biportal approach effectively treats hyperhidrosis and is associated with short hospital stays, high patient satisfaction rates, and low rates of compensatory hyperhidrosis or other complications.