Monckeberg Sclerosis following symathectomy

After unilateral sympathectomy the incidence of calcified
arteries on the side of operation was significantly higher than that on the contralateral
side (88% versus 18%, p less than 0.01).

Of 20 patients who had no evidence of calcinosis
pre-operatively, 11 developed medial calcification after unilateral operation exclusively
on the side of sympathectomy. In seven patients calcinosis was detected in both feet after
bilateral operation. In conclusion, sympathetic denervation is one of the causes of
Monckeberg's sclerosis regardless of diabetes mellitus.

Goebel FD, Fuessl HS.
Diabetologia. 1983 May;24(5):347-50.

Post- sympathectomy gustatory sweating has been reported in 28% of patients

Jack Collin, consultant surgeon.
Paul Whatling, higher specialist trainee.

John Radcliffe Hospital, Oxford OX3 9DU

Postsurgery, severe compensatory sweating was experienced in 90% of patients

Video-assisted Transthoracic Sympathectomy in the Treatment of Primary Hyperhidrosis: Friend or Foe?

Main outcome measures included the incidence of dry hands, compensatory sweating, chest pain, upper-limb muscle weakness, shortness of breath, and gustatory phenomena; in addition, patient perception of the success of the surgical procedure was assessed.

Postsurgery, severe compensatory sweating was experienced in 90% of patients.

Because the occurrence of severe compensatory sweating is unpredictable, a reversible sympathectomy may be desirable.

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 10(4):226-229, August 2000.
Fredman, Brian MB BCh; Zohar, Edna MD; Shachor, Dov MD; Bendahan, Jose MD; Jedeikin, Robert BSc, MB, ChB, FFA(SA)

New Name for CS: Abnormal Sweating

What are the risks of a sympathectomy?

* Risks from anaesthesia
* Bleeding
* Infection
* Worsening of pain
* Creation of a new pain syndrome
* Abnormal sweating

1. Mailis-Gagnon A, Furlan A. Sympathectomy for neuropathic pain. The Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD002918. DOI: 10.1002/14651858.CD002918.

Recurrent palmar hyperhidrosis occurs

Recurrent palmar hyperhidrosis occurs in 5.4% of cases, but can be cured by a second thoracoscopic sympathectomy. Horner's syndrome is an avoidable complication of thoracoscopic sympathectomy.

Volume 17, Issue 4, Pages 343-346 (April 1999)

The Results of Thoracoscopic Sympathetic Trunk Transection for Palmar Hyperhidrosis and Sympathetic Ganglionectomy for Axillary Hyperhidrosis

Eurpean Journal of Vascular and Endosvascular Surgery

pathologic coupling of sympathetic and afferent activity after a mechanically induced peripheral nerve lesion

Under physiological conditions there is no interaction between the sympathetic and the afferent nociceptive system; stimulation of the sympathetic trunk does not induce any activity in afferent neurons.65,79 However, under pathophysiological conditions the situation dramatically changes.80 Neurophysiological and neuroanatomical experiments in animals show that a pathologic coupling of sympathetic and afferent activity may follow a mechanically induced peripheral nerve lesion. This may take place between sympathetic fibers and regenerating or intact nociceptive C-fibers in the periphery, or between sympathetic vasoconstrictor fibers and afferent somata within the dorsal root ganglion.81 The interaction is chemically via noradrenaline from sympathetic endings and adrenoreceptors that are expressed on afferent neurons under pathophysiological conditions (Figure 4A). Accordingly, mRNA for alpha2A-adrenoceptors is up-regulated in DRG neurons after nerve lesion.82

Complex regional pain syndrome – diagnostic, mechanisms,
CNS involvement and therapy
G Wasner1 (#aff1) , J Schattschneider1 (#aff1) , A Binder1 (#aff1) and R Baron1 (#aff1)
Spinal Cord (2003) 41, 61–75. doi:10.1038/sj.sc.3101404

A partial nerve lesion is the important preceding event in CRPS II

Autonomic disturbances

A partial nerve lesion is the important preceding event in CRPS II (Reflex Regional Pain Syndrome). Therefore, it has generally been assumed that abnormalities in skin blood flow within the territory of the lesioned nerve are due to peripheral impairment of sympathetic function and sympathetic denervation. During the first weeks after transection of vasoconstrictor fibers, vasodilatation is present within the denervated area. Later the vasculature may develop increased sensitivity to circulating catecholamines, probably due to upregulation of adrenoceptors.⁶⁶ Similar observations were recently described in the chronic nerve constriction injury model in rats.^67,68 The skin on the lesioned side was abnormally warm for about the first post-operative week and then evolved to a chronically cold status. The late-stage cold skin was present despite a complete absence of fluorescence for norepinephrine. Thus, in this animal model, the skin is cold due to denervation supersensitivity of adrenoceptors rather than excessive sympathetic vasoconstrictor activity.

Further important signs of sympathetic dysfunction in CRPS are unilateral sweating abnormalities.⁷⁸ Quantitative measurements of sudomotor activity show enhanced sweat production in the disturbed limb in the acute and chronic stage of the disease in many CRPS patients.^23,26 This unilateral hyperhidrosis indicates enhanced sympathetic sudomotor activity.

In conclusion, the combination of increased sudomotor and decreased cutaneous sympathetic vasoconstrictor outflow is a well known centrally regulated thermoregulatory function to keep body core temperature constant in different environments. However, under physiological conditions all extremities are involved. Therefore, the unilateral activation of sudomotor and inhibition of cutaneous sympathetic vasoconstrictor neurons indicates a centrally located thermoregulatory dysfunction in CRPS.

Complex regional pain syndrome – diagnostic, mechanisms,
CNS involvement and therapy
G Wasner1 (#aff1) , J Schattschneider1 (#aff1) , A Binder1 (#aff1) and R Baron1 (#aff1)
Spinal Cord (2003) 41, 61–75. doi:10.1038/sj.sc.3101404