Lumbar Sympathectomy: Historical Perspective and Current Role

Abstract

Lumbar sympathectomy continues to be controversial. It is probably a useful procedure for selected patients with advanced peripheral arterial occlusive disease. Although it is most appropriate for patients with causalgia or hyperhidrosis, some patients with nonbypassable atherosclerotic occlusion with rest pain or limited necrosis are said to benefit from lumbar sympathectomy Some surgeons perform sympathectomy for patients with multisegmental arterial occlusive disease undergoing aortoiliac reconstruction or for those with a history of the "blue toe" syndrome. Although much of the increased blood flow associated with this procedure may pass through arteriovenous shunts, some nutrient blood flow may occur. Both clinical judgment and noninvasive diagnostic techniques—particularly digital photoplethysmography-are important for selecting patients who may benefit from lumbar sympathectomy Patients with early foot ischemic rest pain and ischemic ulcers or gangrene limited to the toes or the distal forefoot have been considered candidates. However, sympathectomy may be unnecessary if distal revascularization is possible. Although most procedures are still done conventionally, increasing numbers of studies report good results using laparoscopic techniques. Between 50 and 75% of selected patients may notice subjective and objective improvement after operation.