Surgical Upper Thoracic Sympathectomy Reduces Arterial Oxygenation During One-Lung Ventilation

References and further reading may be available for this article. To view references and further reading you must purchase this article.

Journal of Cardiothoracic and Vascular Anesthesia
Volume 19, Issue 5, October 2005, Pages 703-704

PATHOPHYSIOLOGY OF ONE-LUNG VENTILATION

In estimating the degree of shunt that is created by one-lung ventilation when it is performed in the lateral decubitus position, on average, 40% of cardiac output perfuses the nondependent lung and the remaining 60% perfuses the dependent lung (Fig. 1).¹⁵ Mechanisms that tend to decrease the percent of cardiac output perfusing the nondependent, nonventilated lung are passive (e.g., mechanical-like gravity, surgical manipulation, amount of pre-existing lung disease) or active (e.g., hypoxic pulmonary vasoconstriction).¹⁵ The normal response of the pulmonary vasculature to atelectasis is an increase in pulmonary vascular resistance (in the atelectatic lung), and the increase in atelectatic lung resistance is almost entirely caused by hypoxic pulmonary vasoconstriction. Hypoxic pulmonary vasoconstriction is a protective reflex mechanism that diverts blood flow away from the atelectatic lung. With an intact hypoxic pulmonary vasoconstriction response, the transpulmonary shunt through the nondependent lung decreases to approximately 23% of the cardiac output (see Fig. 1).
Anesthesiology Clinics of North America
Volume 19, Issue 3, 1 September 2001, Pages 435-453

sympathectomy will blunt the normal tachycardic response to hypovolemia.

Spinal or epidural analgesia may cause a sympathectomy that will blunt the normal tachycardic response to hypovolemia.
OBSTETRIC ANAESTHESIA OUR WAY
Royal Women's Hospital Melbourne
Author: Dr Philip Popham

Influence of thoracic sympathectomy on cardiac induced oscillations in tissue blood volume

The parameter AM/BL is proportional to the cardiac-induced blood volume increase, which depends on the arterial wall compliance. AM/BL increased after the thoracic sympathectomy treatment (for male patients, from 2.60 ± 1.49% to 4.81 ± 1.21%), as sympathetic denervation decreases arterial tonus in skin. The very low-frequency (VLF) fluctuations of BL or AM showed high correlation (0.90 ± 0.11 and 0.92 ± 0.07, respectively) between the right and left hands before the thoracic sympathectomy, and a significant decrease in the right-left correlation coefficient (to 0.54 ± 0.22 and 0.76 ± 0.20, respectively) after the operation. The standard deviation of the BL or AM VLF fluctuations also reduced after the treatment, indicating sympathetic mediation of the VLF PPG fluctuations. The study also shows that the analysis of the PPG signal and the VLF fluctuations of the PPG parameters enable the assessment of the change in sympathetic nervous system activity after thoracic sympathectomy.
http://cat.inist.fr/?aModele=afficheN&cpsidt=14106877

low heart rate variability is associated with an increased risk for sudden cardiac death

low heart rate variability is associated with an increased risk for sudden cardiac death

The amount of short- and long-term variability in heart rate reflects the vagal and sympathetic function of the autonomic nervous system, respectively. Therefore heart rate variability can be used as a monitoring tool in clinical conditions with altered autonomic nervous system function. In postinfarction and diabetic patients, low heart rate variability is associated with an increased risk for sudden cardiac death. A sympathovagal imbalance is also detectable with heart rate variability analysis in coronary artery disease and essential hypertension.
http://www.annals.org/content/118/6/436.abstract

Thursday, November 12, 2009

Isointegral mapping revealed that ETS altered electroactivity on the heart

In the head-up tilt study, R–R intervals significantly increased after the surgery in the head-up tilt positions (P<0.05),> difference in the supine position. There is no significant difference in QTc and Twa before and after the surgery, both in the supine and the head-up tilt positions. There was no significant difference in the LF or HF before and after surgery, either in the supine position or the head-up tilt positions. In the LF/HF, there was no significant difference before and after surgery in the supine position. However, the LF/HF in the head-up tilt positions was significantly decreased after surgery (P<0.05).> suppression of ETS was recognized more obviously under the steeper head-up tilt positions. Conclusions: The influences on the cardiac autonomic nerve system of the ETS of upper thoracic sympathetic nerve were seen to be of a lesser degree at rest. However, the response to sympathetic stimulation was suppressed after the surgery.
Eur J Cardiothorac Surg 1999;15:194-198

Obviously, it is not simply a compensatory hyperhidrosis transposition

Obviously, it is not simply a compensatory hyperhidrosis transposition from postoperative reduction of palmar sweating. Based on our observations, we postulated two possible mechanisms. The first of these mechanisms is denervation hypersensitivity of the surgically injured distal sympathetic stump. This could explain why CH may appear soon after sympathectomy, but is not found in patients who undergo local excision of axillary sweat glands or undergo local treatment. Another mechanism is regeneration of preganglionic fibers or collateral sprouting of sympathetic fibers from the proximal stump of the sympathetic trunk. This could explain the long-term existence of PCH.

Ann Thorac Surg 2001;72:667-668

collateral effects of thoracic sympathectomy not disclosed to patients

Several reports also demonstrate significantly lower heart rate increases during exercise in subjects who have undergone bilateral ISS [9–12] compared to pre-surgical levels. In spite of this high occurrence, recent reviews on the usual collateral effects of thoracic sympathectomy still do not include these possible cardiac consequences [6].
Eur J Cardiothorac Surg 2001;20:1095-1100

similar to beta-blocker therapy

Findings on ¹²³I-MIBG imaging studies indicate that EUTS (endoscopic upper thoracic sympathectomy) suppresses the activation of the sympathetic nervous system slightly, similar to beta-blocker therapy.
JNS - March 2004 Volume 100, Number 3

Introduction Essential hyperhidrosis (EH) is often considered to be related to an increased activity of sympathetic nervous system (SNS). However, there is a lack of studies comparing autonomic nervous system (ANS) activity in controls and in EH patients. The aim of the present study was to simultaneously investigate in patients with severe EH, blood pressure, heart rate variability and plasma catecholamine levels in comparison with controls.

Methods 19 EH patients and 20 controls with normal ANS function assessed by clinical testing were included. Blood pressure (BP) and heart rate (HR) were measured using a Finapres beat-to-beat monitor. BP and HR variabilities (Fast Fourier transformation) and plasma catecholamine levels (HPLC) were obtained at rest and during a 15 min 70° head-up tilt test.

Results At rest, a significantly higher relative energy of low frequency band (LF) of systolic BP was observed in EH in comparison with controls contrasting with the lack of difference in BP, HR, plasma catecholamine levels and in other spectral parameters. During tilt, all changes were comparable in EH and in control subjects excepting relative energy of LF of SBP which remained unchanged when compared to the resting condition in EH group.

Conclusions In EH, SNS is not overreactive even if resting overactivity cannot be excluded.
http://www.springerlink.com/content/xe7g2w72617phl0e/
Volume 13, Number 4 / August, 2003

Posted by Mia at 3:55 PM

Clinical conditions that cervico-thoracic sympathetic blockade may benefit

...Miscellaneous conditions in head region: stroke, Meniere disease, tinnitus
Amblyopia due to quinine poisining (also causes retinal artery spasm and thrombosis)

Cousins and Bridenbaugh's Neural Blockade in Clinical Anesthesia and Pain Medicine by Michael J Cousins, Phillip O Bridenbaugh, Daniel B Carr, and Terese T Horlocker

Wolters Kluwer Health
Edition: 4 - 2008

Acquired cardiovascular disease following Sympathectomy

Effects of endoscopic thoracic sympathectomy for primary hyperhidrosis on cardiac autonomic nervous activity

We found statistically significant differences (P < .05) in both time and frequency domains. Parameters that evaluate global cardiac autonomic activity (total power, SD of normal R-R intervals, SD of average normal R-R intervals) and vagal activity (rhythm corresponding to percentage of normal R-R intervals with cycle greater than 50 ms relative to previous interval, square root of mean squared differences of successive normal R-R intervals, high-frequency power, high-frequency power in normalized units) were statistically significantly increased after sympathectomy. Low-frequency power in normalized units, reflecting sympathetic activity, was statistically significantly decreased after sympathectomy. Low-/high-frequency power ratio also showed a significant decrease, indicating relative decrease in sympathetic activity and increase in vagal activity.

The Journal of Thoracic and Cardiovascular Surgery
Volume 137, Issue 3, March 2009, Pages 664-669

sympathectomy leads to peripheral vasodilation, reduced preload, and subsequently decreased cardiac output

Despite a duration of only 2 week, repeated IVRS (intravenous regional sympathetic block) efferent blocks are an attractive alternative to the higher-risk techniques of thoracic sympathetic block and thoracic surgical or thoracoscopic sympathectomy. (p. 848)

Table 42-1
Classification of percutaneous neural destructive procedures:
Anatomy
1. Peripheral neurotomy (such as destruction of intercostal, ilioinguinal nerves)
2. Rhizotomy (spinal dorsal root rhizotomy, trigeminal rhizotomy)
3. Destruction of sensory pathways in the spinal cord (midline punctuate myelotomy, cordotomy)
4. destruction of brain sensory centers (hypophysectomy)
5. Sympathectomy
(p.992)

The authors found that the incidence of hypotension was a function of the level of sympathetic denervation, occurring in 60% of patients with a T7 sympathectomy, and in 100% of patient with a T4 or higher level of sympathectomy.
(p 226)

After thoracoscopic sympathectomy for hyperhidrosis, very severe discomfort and hyperhidrosis in the neighboring non-sympathectomized regions occurred with alarming frequency and intensity.
(p.879)

Cardiovascular effects of epidural blockade
"Central" Sympathetic block (T1-T4) - Blockade of
Cardiac sympathetic outflow from vasomotor center
Cardiac sympathetic reflexes at segmental level
Vasoconstrictor fibers to head, neck, and arms

Effect:
HR ↓ CO ↓
Vasodilation in upper limbs
"Inappropriate bradycardia"; "sudden bradycardia"; vagal arrest (p. 247)

↓↓Venous return may result in sudden parasympathetic tone ("faint response")
↓ ↓ HR → cardiac arrest

"Inappropriate" bradycardia (i.e. "normal" HR in face of ↓MAP with sensory level T3-T4)
Peripheral vasodilation should evoke an ↑ HR. But ↓ venous return → ↑vagal tone, so HR remains at preblock rate but is "inappropriately" slow.

↓HR with visceral traction in presence of blockade to T1.
Total sympathetic block
Unopposed vagus
Changes in vagal tone → profound changes in HR; may → transient asystole (p. 248)

Thermoregulation and Shivering
Hypothermia (a decrease in core temperature) is common in patients undergoing surgery with epidural anesthesia and is thought to result from heat loss to the cold environment due to sympathectomy-induced vasodilation. The normal process by which thermoregulation usually minimizes intraoperative core temperature is prevented, since epidural anesthesia directly inhibits vasoconstriction in the analgesic dermatomes. (p.253)

Central neuraxial anesthesia-induced sympathectomy leads to peripheral vasodilation, reduced preload, and subsequently decreased cardiac output. The incidence and extent of hypotension depends on the height of the block, the patient's position, and whether appropriate measures were instituted prophylactically to minimize hypotension.

Cousins and Bridenbaugh's Neural Blockade in Clinical Anesthesia and Pain Medicine by Michael J Cousins, Phillip O Bridenbaugh, Daniel B Carr, and Terese T Horlocker

Wolters Kluwer Health
Edition: 4 - 2008

Perioperative risks are low, but complications can be devastating

Endoscopic thoracic sympathectomy (ETS) involves division of the thoracic sympathetic chain between T2 and T4.

The main indication for ETS is the treatment of palmar hyperhidrosis.

The most common method of anaesthesia for ETS uses intermittent positive pressure ventilation via a standard tracheal tube.

Perioperative risks are low, but complications can be devastating.

Postoperative compensatory sweating occurs in almost 50% of patients.

• Oxford Journals
• Medicine
• BJA: CEACCP
• Volume 9, Number 2
• Pp. 52-55

hypoxic pulmonary vasoconstriction may be impaired after Sympathectomy

It is well known that hypoxic pulmonary vasoconstriction(HPV) plays an important role to protect hypoxemia during the atelectasis induced by one-lung ventilation. Thoracic sympathectomy may have effects on pulmonary vasculature(HPV) and hemodynamics during one-lung anesthesia.

Mean arterial blood pressure was decreased from 81.9+/-2.89 to 73.2+/-2.49 mmHg after thoracic sympathectomy and heart rate was decreased from 104.4+/-3.12 to 88.2+/-2.31beats/min. Arterial oxygen tension was decressed from 570.5+/-17.9 to 521.4+/-23.2mmHg after position change, and decreased to 271.1+/-28.1 mmHg under one-lung ventilation, and finally decreased to 217.0+/-18.3 mmHg after thoracic sympathectomy. With the above results, we can conclude that patients for TES should be carefully observed during and after the procedure, and hypoxic pulmonary vasoconstriction may be impaired after TES.
Korean J Anesthesiol. 1993 Aug;26(4):695-699.

profound decrease of arterial oxygen partial pressure during sympathectomy

Left-lung ventilation and right-chest operation caused profound decrease of arterial oxygen partial pressure (PaO2), compared with two-lung ventilation before surgery (70.7%, P > 0.0003) and compared with PaO2 at two-lung ventilation during and after surgery (decrease of 80.1% and 75.3%, respectively; P > 0.001 and < 0.005, respectively). Right-lung ventilation and left-chest operation did not cause hypoxemia.

Pulse oximetry and repeated blood gas measurements are needed during endoscopic transthoracic sympathectomy in order to detect and treat hypoxemic events, which may jeopardize the patient's life.
Journal of Cardiothoracic and Vascular Anesthesia
Volume 10, Issue 2, February 1996, Pages 207-209

Spinal cord infarction occurring during thoraco-lumbar sympathectomy

Spinal cord infarction, because of interference with an important radicular tributary, is a rare complication of thoraco-lumbar sympathectomy.
In a brief survey of the literature we found only 12 previously recorded cases in which this complication
was presumed to have occurred.
J. Neurol. Neurosurg. Psychiat., 1963, 26, 418

Acute Postoperative Shingles After Thoracic Sympathectomy for Hyperhidrosis

Shingles secondary to reactivation of a previous varicella-zoster virus infection has been reported to develop within surgical wounds and after trauma. We report the case of a 17-year-old girl with history of chicken pox in childhood who had acute postoperative shingles develop along the T3-T4 dermatomes after thoracic sympathectomy for hyperhidrosis.
Other possible explanations for the development of shingles in this patient include (1) the reactivation of the old varicella-zoster virus in the dorsal root ganglia by manipulation of the sympathetic chain through preoperative and postoperative ganglionic axonal connections between the denervated sympathetic ganglia and the T3 and T4 dorsal root ganglia, or (2) reactivation of the virus by direct pressure of the thoracoscopic instruments on the third and fourth intercostal nerve bundles.
http://ats.ctsnetjournals.org/cgi/content/full/78/6/2159

Severe 'Compensatory Sweating' in 28%

Compensatory sweating is a common symptom following thoracic sympathectomy; however, the reported incidence of this complication varies greatly, and its severity has not been quantified. METHODS: In this study changes in the distribution of sweating following bilateral T2-3 thoracoscopic sympathectomy for hyperhidrosis were assessed in 42 patients. Sweat production in the palms, axillae, face, trunk and feet was assessed using a linear analogue scale. RESULTS: The operation was most successful in reducing sweat production in the palms, axillae and face (in descending order). The operation also reduced pedal sweat production in 12 of the 29 patients who suffered concomitant pedal hyperhidrosis. Compensatory truncal sweating occurred in 36 of the 42 patients; it was severe in ten, (28%) moderate in 16 and minimal in ten. CONCLUSION: Patients should be warned about compensatory sweating before thoracic sympathectomy.
http://www.ncbi.nlm.nih.gov/pubmed/9448619?dopt=Abstract
Br J Surg. 1997 Dec;84(12):1702-4.

Effect of adrenalectomy or sympathectomy on spinal cord blood flow

After sympathectomy, RSCBF (regional spinal cord blood flow) was unchanged during hypothermia. In the cauda equina, flow fell in all hypothermic rats. The hypothermia-associated increases in RSCBF were not related to changes in mean arterial blood pressure. We conclude that adrenalectomy near-totally ablates the hypothermia-associated increase in RSCBF measured in intact rats and that abdominal sympathectomy totally ablates it. This evidence complements morphological evidence for adrenergic innervation of the spinal cord vasculature.
Am J Physiol. 1991 Mar;260(3 Pt 2):H827-31.

burning causes nerve scaring, which may behave like epilepsy

ETS is a very effective way to treat hyperhidrosis and FB in the vast majority of the cases, but a small group of patients have devastating effects. Unfortunately, we do not know who these patients are before we operate.
Extensive surgery or burning causes nerve scaring, which may behave like epilepsy of the autonomous nervous system and cause the well known devastating side effects.

http://www.sympathectomy.info/

sympathectomy may retard aversive conditioning

"Researchers have examined the role of autonomic feedback in emotional experience using the heartbeat paradigm. Katkin at al. (1982) found that some normal subjects can accurately detect their heartbeats, and it was those individuals who had a stronger emotional response to negative slides as determined by self-report (Hantas et al., 1982). Further support for the importance of autonomic feedback comes from observations. Experiments in animals demonstrate that sympathectomy may retard aversive conditioning (DiGusto and King, 1972), most likely because sympathectomy reduces fear.

In order for a feedback to occur, there must be a means for the viscera and autonomic nervous system to become activated.

Clinical neuropsychology

By Kenneth M. Heilman, Edward Valenstein
Oxford University Press

pain states associated with the loss of sympathetic fibres

Postsympathectomy limb pain, postsympathectomy parotid pain, and Raeder's
paratrigeminal syndrome are pain states associated with the loss of sympathetic fibres
and in particular with postganglionic sympathetic lesions. There is a characteristic interval
of about 10 days between surgical sympathectomy and onset of pain. It is proposed that
this pain in man is correlated with the delayed rise in sensory neuropeptides seen in
rodents after sympathectomy. These chemical changes probably reflect the sprouting of
sensory fibres and may result from the greater availability of nerve growth factor after
sympathectomy. The balance between the sensory and sympathetic innervations of a
peripheral organ may be determined by competition for a limited supply of nerve growth
factor.
Lancet. 1985 Nov 23;2(8465):1158-60.

Abnormal autonomic functions, however, markedly affect the individual's ability to respond to changing conditions

Normal function of all components of the ANS is not required to maintain life, as long as
environmental conditions are a constant and optimum. Abnormal autonomic functions, however,
markedly affect the individual's ability to respond to changing conditions. This can be demonstrated
by sympathectomy, the removal of sympathetic ganglia. An animal becomes highly sensitive to heat,
cold, or other forms of stress following sympathectomy. In a hot environment the animal's ability to
lose heat by increasing blood flow to the skin and by sweating is decreased. When exposed to the
cold, the animal is less able to reduce blood flow to the skin and conserve heat. Sympathectomy also
results in low blood pressure caused by dilation of peripheral blood vessels and results in the
inability to increase blood pressure during periods of physical activity.
http://www.mhhe.com/biosci/ap/seeleyap/nervous/reading3.mhtml

Degeneration patterns of postganglionic fibers following sympathectomy

In the reg signs of degeneration can already be recognized in the myelinated as well as in the unmyelinated axons 48h after sympathectomy.

In the muscle nerves the first signs of an axonal degeneration of the sympathetic fibers can be recognized 4 days after surgery. The signs of axonal degeneration are most striking about 8 days p.o. They have more or less disappeared another week later. The reactions of the Schwann cells also start on the fourth day but outlast the degenerative processes by some 8 days. Thus the degenerative and reactive processes in the reg precede those in the muscle nerves by 2 days early after surgery and by 6 days 3 weeks later. Seven weeks after surgery, fragments of folded basement lamella and Remak bundles with condensed cytoplasm and numerous flat processes are persisting signs of the degeneration.
http://www.springerlink.com/content/m21m2612n2147011/

Effect of sympathetic blockade on cerebral perfusion

J Neurol. 2002 Jan;249(1):108-9.Links

Effect of sympathetic blockade on cerebral perfusion demonstrated on Tc-99m HMPAO SPECT.

Lang O, Svoboda L, Balon HR.

http://www.ncbi.nlm.nih.gov/pubmed/11954858

Sympathetic nerves protect against blood-brain barrier disruption

Sympathetic nerves protect against blood-brain barrier disruption in the spontaneously hypertensive rat.

http://www.ncbi.nlm.nih.gov/pubmed/7064183?holding=ukpmc

Ultrastructural changes in the nerves innervating the cerebral artery after sympathectomy

Iwayama T. Ultrastructural changes in the nerves innervating the cerebral artery after sympathectomy. Z Zellforsch Mikrosk Anat. 1970;109(4):465–480.
http://www.ncbi.nlm.nih.gov/pubmed/5498231?holding=ukpmc

Alteration in 'fight-or-flight response following sympathectomy

Mental arithmetic produces a psychophysiological arousal similar to the so-called defence-alarm reaction elicited by stimulation ofthe hypothalamic defence area in experimental animals (Folkow, 1982). This reaction pattern is characterized by increased heart rate, cardiac output and blood pressure, whereas total peripheral resistance is unchanged or decreased (Brod, 1970).

The increase of platelet concentration during psychological arousal is also in accordance with what has been observed in response to other stressors, i.e. physical exercise and adrenaline infusion (Sarajas et al, 1961; Gjerloff Schmidt & Waever Rasmussen, 1984; Dawson & Ogston, 1969; Vilen et al, 1980).

The emotional leucocytosis observed in dogs has been claimed to be neurogenic in origin, since sympathectomy abolished the rise in leucocyte count (Garrey & Bryan, 193 5).
Both alpha- and beta-receptors seem to be of importance in the mobilization of lymphocytes (Gader & Cash, 1975).

British Journal of Haematology. 1989. 71, 153-1 56

normal forearm vasodilator response to mental stress was absent months or years after surgical sympathectomy

Additional indirect evidence on this topic in humans comes from a study conducted in the 1950s (3). In this study, the normal forearm vasodilator response to mental stress was absent months or years after surgical sympathectomy.
J Appl Physiol
Vol. 92, Issue 5, 2019-2025, May 2002

Sympathectomy as a way to achive tranquility for the patient

In every case of bilateral cervical or upper dorsal sympathectomy that I have performed the most pronounced feature is a mental change in the patient from one of worry and apprehension to that of tranquillity and a sense of well-being.

Sympathectomy in Relation to Meniere's Disease, Nerve Deafness
and Tinnitus. A Report on 110 Cases
By E. R. GARNETT PASSE, F.R.C.S., F.A.C.S.

Acta Oto-laryngologica

1952, Vol. 42, No. 1-2, Pages 133-151

Bilateral Cervical Sympathectomy for the Relief of Epilepsy

Bilateral Cervical Sympathectomy for the Relief of Epilepsy, With Report of Three Cases; Notes on the Physiologic Effects of Cutting the Sympathetic, and on the Histologic Changes Found in the Cases in Question

Spratling, William P. M.D.; Park, Roswell M.D.

The Journal of Nervous and Mental Disease:

April 1905 - Volume 32 - Issue 4 - ppg 217-232

Haematological changes during stress abolished by sympathectomy

To study haematological effects of emotional stress, blood samples were obtained from 29 healthy, normotensive, non-smoking males aged 20–34 years before, during and after 10 min of mental arithmetic. There were significant increases in pheripheral blood cell count, haemoglobin concentration, and haematocrit in response to mental stress. Parallel to these changes significant increases in heart rate, and systolic and diastolic blood pressure were observed. The relative increments of leucocyte (8%) and platelet (3·5%) count were significantly higher than the increase in haemoglobin concentration (2%). There was a significant positive correlation between the blood pressure increase and the mobilization of leucocytes, whereas the increase in erythrocyte count, haemoglobin concentration, and haematocrit showed significant positive correlations with heart rate reactivity. It is concluded that mental stress causes an increase in leucocyte and platelet count that could not solely be accounted for by the concurrent haemoconcentration.

The emotional leucocytosis observed in dogs has been claimed to be neurogenic in origin, since sympathectomy abolished the rise in leucocyte count (Garrey & Bryan, 19 3 5).
http://www3.interscience.wiley.com/journal/120731423/abstract

the pineal capability of producing antigonadal substance is suppressed by cervical ganglionectomy

Pineal glands of male hamsters 8 weeks after removal of both eyes or both superior cervical ganglia and those of untreated animals were studied by electron microscopy. In the blinded hamsters the reproductive organs were remarkably involuted, whereas the pinealocytes enlarged and were characterized by a tremendous hypertrophy of the smoothsurfaced endoplasmic reticulum, in the mesh of which some dense cored vesicles were distributed. In contrast the pinealocytes of ganglionectomized hamsters atrophied and were noted by a large number of lysosomes and sparsity of the agranular reticulum, the testes being significantly larger than the controls. The findings were interpreted to be compatible with the view that the pineal capability of producing antigonadal substance is augmented by blinding and is suppressed by cervical ganglionectomy due to the impairment of normal functioning of the pineal by denervation.

Fine structural changes in the hamster pineal gland after blinding and superior cervical ganglionectomy

Cell and Tissue Research
Volume 158, Number 3 / May, 1975

Cervical sympathectomy, the method to create (experimental) vasomotor rhinitis

Unilateral and bilateral experimental vasomotor rhinitis was produced in 4 dogs with cervical sympathectomy unilaterally and bilaterally. We studied this problem from several points of view in order to explain the mechanism of vasomotor rhinitis and the relationship between upper and lower respiratory tract.

Acta Oto-laryngologica

1972, Vol. 73, No. 2-6, Pages 212-217

One patient with documented transection of the cord above T5 behaved like subjects after surgical sympathectomy

Increase in blood flow is generally followed by a rise in skin temperature but decrease in blood flow in response to the Gibbon-Landis procedure after sympathectomy is not necessarily accompanied by a fall in surface temperature. This poor correlation between skin temperature and blood flow confirms the previous report of Hoobler and co-workers and helps define the limits of usefulness of measurements
of skin temperature as an index of blood flow to the extremity.

The vasomotor responses to the Gibbon-Landis procedure (reflex response to warming) were studied in hemiplegic patients, subjects with "high transection" of the cord, and in sympathectomized patients.

One patient with documented transection of the cord above T5 behaved like subjects after surgical sympathectomy.
Of 11 sympathectomized limbs tested for vasodilatation in response to the Gibbon-Landis procedure, 4
showed no response, while 7 responded with decrease in blood flow (vasoconstriction).

Vasomotor Responses in the Extremities of Subjects with Various Neurologic Lesions
I. Reflex Responses to Warming
By WALTER REDISCH, M.D., FRANCISCO T. TANGCO, M.D., LOTHAR WERTHEIMER, M.D.,
ARTHUR J. LEWIS, M.D., J. MURRAY STEELE, M.D.
1957;15;518-524 Circulation

increased sensitivity to adrenaline is produced by sympathectomy alone

"The increased sensitivity to adrenaline is produced by sympathectomy alone. I think sensory denervation makes no difference."

Vascular Reactivity Following Sympathectomy

Chapter Author: R. T. Grant

Ciba Foundation Symposium - Peripheral Circulation in Man

Book Series: Novartis Foundation Symposia

Published Online: 27 May 2008

Editor(s): G. E. W. Wolstenholme, Jessie S. Freeman

Print ISBN: 9780470714706 Online ISBN: 9780470715185

there are no reports of phantom sweating without a prior sympathectomy

Phantom sweating - a novel autonomic paresthesia

L. L. Lair, C. Gibbons, R. Freeman
Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
Objective: To report a novel autonomic paresthesia in a patient with an idiopathic sensory and autonomic neuropathy.
Phantom sweating is the sensation of sweating in the absence of actual sweating. This symptom is reported in 40% of patients after sympathectomy. To our knowledge there are no reports of phantom sweating without a prior sympathectomy.

Quantitative sudomotor axon reflex testing revealed absent sudomotor activity in the dorsal foot with preserved activity in the distal thigh. Skin biopsy showed a loss of epidermal nerve fibers, nerve fiber swellings, and denervation of sweat glands.
Conclusions: We report a patient with symptoms of phantom sweating in the setting of a sensory and post-ganglionic autonomic neuropathy. The pathophysiologic mechanisms underlying this autonomic paresthesia are not known. Possible mechanisms include aberrant reinnervation, ephaptic communication between nerve fibers, ectopic discharges from injured nerve fibers, and a central
response to autonomic deafferentation.
Clin Auton Res (2007) 17:264–327

hypotension-related poorer mental ability is also reflected in diminished cortical activity

EEG studies have demonstrated that the hypotension-related poorer mental ability is also reflected in
diminished cortical activity. Contrary to convention, more recent research has suggested a deficient regulation of cerebral blood flow in persons with low blood pressure. In addition to reduced tonic brain perfusion, studies demonstrated insufficient adjustment of blood flow to cognitive requirements.

Chronically low blood pressure is accompanied by a variety of complaints including fatigue, reduced drive, faintness, dizziness, headaches, palpitations, and increased pain sensitivity [1–4]. In addition, hypotensive individuals report cognitive impairment, above all deficits in attention and memory.
Clin Auton Res. 2007 April; 17(2): 69–76.

Nitric Oxide synthesis contributes to the regulation of vasomotor tone

These findings indicate that NO is involved in the central regulation of sympathetic outflow in humans and suggest that both neuronal and endothelial NO synthesis may contribute to the regulation of vasomotor tone.
Circulation. 1997 Dec 2;96(11):3897-903.

hypoxaemia, a potentially serious complication of Sympathectomy

Consecutive series of patients (n = 210), suffering from upper limb hyperhidrosis, anaesthetised for TES.

SpO2 decreased below 98% in 58 patients. Sudden hypotension and bradycardia in two patients.
The mean PaO2 was significantly (p = 0.03) decreased during two-lung ventilation (TLV), after reinflation of the right lung, compared with TLV after endobronchial intubation. There was no significant difference in mean PaO2 during one-lung ventilation of both lungs. Lowest PaO2 observed during one-lung ventilation was less than 13.3 kPa in three sympathectomies. Postoperative pain, severe on awakening and mainly retrosternal, was relieved with i.v. opiates. CONCLUSION: Controlled ventilation with 100% inspired O2, SpO2 monitoring and one to two gentle manual ventilations when it decreases is the cornerstone of the management of hypoxaemia, a potentially serious complication of TES.
Eur J Surg Suppl. 1994;(572):23-5.

Haemodynamic changes following denervation of the heart

Bilateral cardiac sympathectomy significantly decreased the heart rate and the systemic arterial blood pressure from 191 + 8 to 124 + 6 beats min-' and from 121 + 10 to 88 + 9 mmHg, respectively. These variables increased to 129 + 7 beats min-' and to 103 + 10 mmHg, respectively, following bilateral vagotomy.
Journal of Physiology (1996), 490.3, pp.793-803

inhibition of sympathetic activity and a possible impairment of endothelial function

Alterations in skin microcirculation induced by brachial plexus block can be evaluated by wavelet transform of the laser Doppler flowmetry signal. Brachial plexus block reduces the oscillatory components within the 0.0095- to 0.021- and 0.021- to 0.052-Hz intervals of the perfusion signal. These alterations are related to inhibition of sympathetic activity and a possible impairment of endothelial function.

Anesthesiology:

September 2006 - Volume 105 - Issue 3 - pp 478-484

Clinical Investigations

Endothelial dysfunction, or the loss of proper endothelial function, is a hallmark for vascular diseases, and often leads to atherosclerosis.
http://en.wikipedia.org/wiki/Endothelium

Surgical sympathectomy listed as neurologic disorder (surgically induced)

Other neurologic disorders
- Idiopathic orthostatic hypotension
- Multiple sclerosis
- Parkinsonism
- Posterior fossa tumor
- Shy-Drager syndrome
- Spinal cord injury with paraplegia
- Surgical sympathectomy
- Syringomyelia
- Syringobulbia
- Tabes dorsales (syphillis)
- Wernicke's encephalopathy
Dizziness: Classification and Pathophysiology
The Journal of Manual and Manipulative Therapy, Vol. 12, No 4 (2004)

Sympathectomy: "suppression of the neuroendocrine stress response"

p.254

Neuraxial blocks typically produce variable decrease in blood pressure that might be accompanied by a decrease in heart rate and cardiac contractility. These effects are generally proportional to the degree (level) of the sympathectomy. Vasomotor tone is primarily determined by sympathetic fibres arising from T5 to L1, innervating arterial and venous smooth muscle. Blocking these nerves causes vasodilation of the venous capacitance vessels, pooling of blood, and decreased vvenous terurn to the heart; in some instances, arterial vasodilation may also decrease systemic vascular resistance. The effects of arterial vasodilation may be minimized by compensatory vasoconstriction above the level of the block. A high sympathetic block not only prevents compensatory vasoconstriction but also blocks the sympathetic cardiac accelerator fibres that arise at T1-T4.
Profound hypotension may result from vasodilation combined with bradycardia and decreased contractility. These effects are further exaggerated if venous return is further compromised by a head-up position or from the weight of a gravid uterus. Unopposed vagal tone in some persons may explain cardiac arrest with spinal anesthesia.
p.261

The sympathetic system normally maintains some tonic vasoconstriction on the vascular tree. Loss off this tone following induction of anesthesia or sympathectomy frequently contributes to perioperative hypotension.
p.375

AV conduction abnormalities are usually manifested by abnormal ventricular depolarization (bundle-branch block) prolongation of the P-R interval (first degree AV block) failure of some atrial impulses to depolarize the ventricles (second degree AV block) or AV dissociation (third degree AV block or complete heart block).
p.428

Clinical anesthesiology

By G. Edward Morgan, Maged S. Mikhail, Michael J. Murray
McGraw-Hill, Edition: 3 - 2002

SUPERSENSITIVITY TO NE AFTER ADRENERGIC DENERVATION

H-NOREPINEPHRINE UPTAKE
Portal veins were incubated for 1 hour with 3H-NE 1,3, and 5 days after chemical sympathectomy with 6-OHDA (Fig. 3). Preparations treated with cocaine (10~5 M) were exposed to this drug 15 minutes before 3H-NE incubation and maintained in a cocaine-containing solution throughout the entire incubation period. One day after 6-OHDA treatment, NE uptake was reduced to approximately 21 %
of control; at 3 days it was 33% of controls and 5 days after 6-OHDA it was approximately 39% of controls. The decrease in NE uptake caused by 6-OHDA treatment was comparable to that caused by cocaine.

SUPERSENSITIVITY TO NE AFTER ADRENERGIC DENERVATION

CATECHOLAMINE DEPLETION AFTER CHEMICAL SYMPATHECTOMY

1977;41;198-206 Circ. Res.
Trophic influence of the sympathetic nervous system on the rat portal vein

more complex autonomic dysfunction than generalised sympathetic overactivity

Cardiac autonomic function in patients (n = 63) with primary focal hyperhidrosis and healthy controls (n = 28) was investigated by short-term frequency domain power spectral analysis of heart rate variability. The power of the very-low-frequency band (0.01-0.05 Hz) was significantly lower in patients with axillary hyperhidrosis than in controls. No differences between groups could be observed at investigation of the low-frequency band (0.05-0.15 Hz), which was a surprising finding because this band represents also sympathetic cardiac innervation. At the high-frequency band (0.15-0.5 Hz), which represents parasympathetic cardiac innervation, an interaction of type and position influencing spectral power was detected. Our highly interesting findings indicate that primary focal hyperhidrosis is based on a much more complex autonomic dysfunction than generalised sympathetic overactivity and seems to involve the parasympathetic nervous system as well.
Eur Neurol 2000;44:112-116 (DOI: 10.1159/000008207)
peter.birner@akh-wien.ac.at

Medical Tourism advertising Sympathectomy

http://mondialtourism.webfire.com.au/_webapp_117318/Endoscopic_Thoracic_Sympathectomy

Side Effects

There is the possibility of increased sweating in other areas of the body for example the back of the legs.

Recovery Period

Patients will normally stay one day in hospital. Pain may be present for around a week, patients are normally given medication to control this. Most patients will be able to carry out their daily activities and return to work within a week.

Associated Risks

As with all types of surgery there are certain risks involved, these include infection, bleeding, reaction to anesthesia or nerve damage. The main risk of the surgery as stated before is increased sweating in other areas of the body.

dissociation between conductance and microvascular perfusion

Complete sympathectomy was accompanied by a persistent increase in ear temperature and a dissociation between conductance and microvascular perfusion. Auricular conductance was transiently increased and then decreased to levels below preoperative control values. Microvascular perfusion is decreased immediately following amputation/replantation and thereafter increases.
Microsurgery ISSN 0738-1085 CODEN MSRGDQ

Source / Source

1998, vol. 18, n^o2, pp. 129-136 (26 ref.)

'Emotional' sweating regulated by neocortex and limbic cortex

Careful observations showed that the forearm sweating responded diversely to various mental stimuli, unlike the palmar sweating whose response was always an increase. Mental arithmetic, mental testing and physical exercise caused an immediate increase in the palmar sweating but often elicited a transient decrease in the forearm sweating, whereas pain, noise, and emotional stimuli consistently provoked an increase of sweating on the forearm as well as on the palm. These observations suggest that the activities of higher centers, presumably involving neocortex and limbic cortex, exert various influences on the central mechanisms of palmar and generalized sweating.
Jpn J Physiol. 1975;25(4):525-36.
http://www.ncbi.nlm.nih.gov/pubmed/1206808

90% may experience Gustatory sweating after surgery for Hyperhidrosis

Some individuals (up to 90%) may experience another type of sweating that is increased while eating or smelling certain foods (gustatory sweating) (Hornberger).

Source: Medical Disability Advisor

http://www.mdguidelines.com/sympathectomy

Chronic betablocker therapy can exactly mimic autonomic neuropathy

What is the ultimate effect of cardiac autonomic neuropathy.

Cardiac denervation. The manifestations are

• Tachycardia, exercise intolerance
• Orthostatic hypotension

http://stanford.wellsphere.com/heart-health-article/why-is-angina-pectoris-silent-in-diabetes-mellitus/549631

How Sympathectomy is described by the surgeons who offer the procedure: (Is this what Sympathectomy does - only?)

"With the nerve stimulation data, Dr. McCormack then cuts only those nerves that innervate sweat glands in the areas affected with hyperhydrosis. For example, a patient with palmar hyperhydrosis, T2 and T3 ganglion may individually, or both be involved. The intraoperative nerve testing precisely defines which ganglion has to be cut and avoids injury to the ganglion not involved. This is important because post-operative compensatory sweating problems increase with the number of ganglion cut."
http://www.nosweatsurgery.com/hyperhyd.htm

Gustatory sweating is a frequent side effect after thoracoscopic sympathectomy (32%)

Overall, gustatory sweating occurred in 32% of patients, and the incidence was significantly associated with extent of sympathectomy (p = 0.04). However, because the extent of sympathectomy was always decided by the location of primary hyperhidrosis, the latter may also explain the risk of gustatory sweating. CONCLUSIONS: Gustatory sweating is a frequent side effect after thoracoscopic sympathectomy. This is the first study to report that its incidence is significantly related to the extent of sympathectomy or the location of primary hyperhidrosis. Although there is no pathophysiologic explanation of gustatory sweating, these findings should be considered before planning thoracoscopic sympathectomy and patients should be thoroughly informed.
The Annals of thoracic surgery (Ann Thorac Surg), 2006-Mar; vol 81 (issue 3) : pp 1043-7

Incidence of chest wall paresthesia 50.0%

Paresthetic discomfort distinguishable from wound pain was described by 17 patients (50.0%). The most common descriptions were of ‘bloating’ (41.2%), ‘pins and needles’ (35.3%), or ‘numbness’ (23.5%) in the chest wall. The paresthesia resolved in less than two months in 12 patients (70.6%), but was still felt for over 12 months in three patients (17.6%).
Eur J Cardiothorac Surg 2005;27:313-319

Abolition of sympathetic skin responses following endoscopic thoracic sympathectomy

http://www.ncbi.nlm.nih.gov/pubmed/8618555?dopt=Abstract

Muscle Nerve. 1996 May;19(5):581-6.

abnormal sympathetic skin response may lead to peripheral vascular failure or the reduced cardiac chronotropic response may impair the body

An already impaired cardiovascular system is recognized to be a significant risk factor for development of heat stroke. In the post-sympathectomy patient, the abnormal sympathetic skin response may lead to peripheral vascular failure or the reduced cardiac chronotropic response may impair the body’s capacity to compensate for shock. These may have contributed to the rapid development of shock and severe multiple organ dysfunction syndrome in this patient.
He had multiple organ dysfunction syndrome develop, with severe renal and hepatic failure, grade II hepatic encephalopathy, and disseminated intravascular coagulation. He responded remarkably well to aggressive supportive measures including forced alkaline diuresis, and he was eventually discharged home after 1 month. The patient was previously a healthy, physically fit, nonsmoker. He worked as a body building trainer and led an active, sporty lifestyle. The only significant medical history was that he had received thoracic sympathectomy for axillary hyperhidrosis 4 years ago at another hospital.

http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

sympathectomy can impair the autonomic nervous system’s increase of the heart rate in response to exercise

it has been shown that thoracic sympathectomy can impair the autonomic nervous system’s increase of the heart rate in response to exercise [6]. Although absolute tachycardia is not eliminated, given the endocrine and paracrine stimuli during exercise, the maximum heart rate reached during exercise has been shown to be significantly reduced after sympathectomy. Thus for a given workload during exercise, there will be a relative bradycardia. This may possibly affect the circulatory system’s ability to convey heat from the body core to the extremities for heat loss.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

abnormal peripheral vascular responses to temperature

thoracic sympathectomy has been demonstrated to abolish or alter sympathetic vasoconstrictive responses in the skin, and this may contribute to abnormal peripheral vascular responses to temperature [4]. Paradoxically it has been suggested that in some cases there may be abnormal vasoconstriction rather than the expected vasodilatation after sympathectomy [5]. It is not impossible that such atypical peripheral vascular responses to rising body temperature may have contributed to impaired heat loss during exercise or to an inappropriate response to shock on the development of the heat stroke.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

impaired overall heat loss

the abolition of sweating from the upper body as well as the axillae and both upper limbs may have significantly reduced the capacity of the patient to lose heat through sweating during exercise. Anhidrosis in the head and neck after sympathectomy affects a proportion of patients, but is often neglected in most reports of post-sympathectomy complications [3]. The loss of head and neck sweating in this patient may have further impaired overall heat loss. However we would also note that the degree of heat loss impairment after sympathectomy has never been quantified, and its effect on body temperature during exercise remains to be established.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

facial anhidrosis and disturbed cardiovascular responses to temperature after sympathectomy for hand sweating

"Although thoracic sympathectomy is commonly used to reduce upper limb sweating, it may also lead to facial anhidrosis and disturbed cardiovascular responses to temperature. The resultant effect on overall body heat loss has not been documented. We present a case of a young patient with previous thoracic sympathectomy who suffered severe heat stroke after heavy exercise. http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

Changes in hemodynamics of the carotid and middle cerebral arteries

Jeng and associates observed an increase in cerebral blood flow after T2 sympathectomy, and they suggested the possibility of using such a surgical approach to improve cerebral blood flow in patients with cerebral vascular insufficiency.
Sympathectomy for Pain
ANTONIO A. F. DE SALLES I JOHN PATRICK JOHNSON


Patients who underwent T-2 sympathectomy demonstrated a significant increase in blood flow volume and flow velocities of the CAs and MCA, especially on the left side. Asymmetry of sympathetic influence on the hemodynamics of the CAs and MCA was noted. The usefulness of sympathectomy for the treatment of ischemic cardiovascular and cerebrovascular disease deserves further investigation.
Jeng JS, Yip PK, Huang SJ, et al: Changes in hemodynamics of the carotid and middle cerebral arteries before and after endoscopic sympathectomy in patients with palmar hyperhidrosis: Preliminary results.
J Neurosurg 90:463–467, 1999

side effects, ranging from trivial to devastating

There seem to be no controlled studies demonstrating efficacy of neurolytic sympathetic blocks. Possible side effects, ranging from trivial to devastating, are of even greater importance with these more permanent procedures—painful sequelae may include phenol or alcohol neuritis and postsympathectomy pain (sympathalgia), which can also occur after surgical sympathectomy.⁶

BMJ. 1998 March 14; 316(7134): 792–793.

Sympathectomy induces adrenergic excitability of cutaneous C-fiber nociceptors

1. The effects of ipsilateral removal of the superior cervical ganglion on the subsequent responsiveness of C-fiber polymodal nociceptors (CPMs) of the ear to close-arterial injections of norepinephrine (NE) were evaluated in adult, anesthetized rabbits. 2. In normal unanesthetized rabbits, the two ears were usually at the same temperature.
Immediately after the ganglionectomy, the ipsilateral ear was warmer; however, at the time of electrophysiological recordings (4-23 days) the majority of animals had the ipsilateral ear cooler by > or = 1 degree C, suggestive of denervation supersensitivity. 3.
NE (50 ng) did not activate any CPMs (n = 28) from intact animals. 4. Seven of 22 CPMs recorded from sympathectomized ears were activated by NE (50 ng). The responses varied considerably but typically consisted of 2-4 impulses in the 60 s after the NE injection. In some instances, repetitive activity continued for many minutes. Such prolonged discharge differs from the adrenergic responses seen after partial nerve damage. 5. The induction of adrenergic excitability in CPMs by sympathectomy is
suggested to be a counterpart to postsympathectomy neuralgia in human beings and a possible part of the mechanism leading to sympathetically related pain states.
http://www.ncbi.nlm.nih.gov/pubmed/8822575

Chemical thoracic sympathectomy (CTS) resulted in profound bradycardia

In the CTS group, however, the SD_RR:SD∂_RR ratio decreased significantly from 1.72 ± 0.20 to 1.23 ± 0.11 just after CTS. The previous patient, who had a high SD_RR:SD∂_RR ratio of 3.45 before CTS, exhibited severe bradycardia (22 beats/min).
The decrease in the SD_RR:SD∂_RR ratio indicates a reduction of cardiac sympathetic activity. However, CTS in patients having high SD_RR:SD∂_RR ratios can result in profound bradycardia.

Anesthesiology ISSN 0003-3022

1998, vol. 89, n^o3, pp. 666-670 (12 ref.)

ETS reduces myocardial oxygen demand and plasma noradrenaline levels

"The sympathetic ganglion is not a simple relay station but a site modulated by short inter-neurons and a variety of neurotransmitters and receptors. Therefore, [T2-T3] ETS might have modified the sympathetic regulation of adrenaline secretion from the adrenal medulla. [T2-T3] ETS increases the plasma level of atrial natriuretic peptide, which has widespread sympatholytic activity. [T2-T3] ETS might have influenced the amount of adrenaline secreted from the adrenal medulla via changes in humoral factors such as atrial natriuretic peptide."(Nakamura 2002)

Stroke index and systemic vascular resistance were similar both at rest and at submaximal exercise before and after ETS. Thus, ETS reduces myocardial oxygen demand and plasma noradrenaline levels both at rest and during exercise without significantly depressing cardiac function in terms of stroke volume.
http://www.ncbi.nlm.nih.gov/pubmed/11954949?dopt=Abstract

a technique that is associated with a number of potential problems

Transthoracic endoscopic sympathectomy is now considered the treatment of choice for patients with upper limb hyperhidrosis requiring sympathetic ablation. This procedure requires the use of an endobronchial double lumen tube and subsequent one-lung anaesthesia, a technique that is associated with a number of potential problems. Full patient monitoring is thus required and includes pulse, ECG, non-invasive blood pressure measurement, pulse oximetry, end-tidal carbon dioxide concentration and peak inspiratory airway pressure.

Anaesthetic implications for transthoracic endoscopic sympathectomy.

PMID: 7524779 [PubMed - indexed for MEDLINE] Eur J Surg Suppl. 1994;(572):33-6.

Hypoxaemia is of a major concern during thorascopic sympathectomy

However the pathophysiology of hypoxaemia and consequent decrease in SpO2 differs between the two anaesthetic techniques.

The normal physiological response to massive atelectasis is an increase in pulmonary vascualr resistance (hypoxic pulmonary vasoconstriction) with re-routing of blood to well ventilated lung zones and consequent improvement of in PaO2. However, during endobronchial anaesthesia for thoracic sympathectomy there is an apparent failure of this compensatory mechanism. When more than 70% of the lung is atelectatic, compensation by hypoxic pulmonary vasonstriction appears to be ineffective. Furthermore, in in vitro and animal studies, inhalation anaesthetic agent have been shown to depress hypoxic pulmonary vasoconstriction.

In a study by Hartrey and colleagues, SpO2<95%>20 mm Hg in 21% of patients. Similarly, we have reported sudden hypotension and bradycardia after injudicious carbon dioxide insufflation.

In an interesting study of the delayed cardiac effects of T2-4 sympathectomy, Drott and colleagues demmonstrated significantly reduced heart rate at rest, and during both exercise and the recovery phase of the exercise.
Changes in the electrical axis and shortening of the QT interval have also been reported.
B. Fredman, D. Olsfanger, R. Jedeikin
British Journal of Anaesthesia 1997; 79: 113-119

Loss of coordinated autonomic responses to demands on heart rate and vascular tone

Autonomic dysreflexia - Spinal cord injuries (SCI) above T6 may be complicated by a phenomenon known as autonomic dysreflexia, a manifestation of the loss of coordinated autonomic responses to demands on heart rate and vascular tone [5,6]. Uninhibited or exaggerated sympathetic responses to noxious stimuli lead to diffuse vasoconstriction and hypertension. A compensatory parasympathetic response produces bradycardia and vasodilation above the level of the lesion, but this is not sufficient to reduce elevated blood pressure. SCI lesions lower than T6 do not produce this complication, because intact splanchnic innervation allows for compensatory dilatation of the splanchnic vascular bed.

The estimated frequency of this complication is quite variable, ranging from 20 to 70 percent of patients with SCI lesions above T6 [5,6]. Autonomic dysreflexia is unusual within the first month of SCI but usually appears within the first year [7,8].

Common clinical manifestations are headache, diaphoresis, and increased blood pressure [7]. Flushing, piloerection, blurred vision, nasal obstruction, anxiety, and nausea may also occur. Bradycardia is common; however, some patients have tachycardia instead. The severity of attacks ranges from asymptomatic hypertension to hypertensive crisis complicated by profound bradycardia and cardiac arrest or intracranial hemorrhage and seizures. The severity of the SCI influences both the frequency and severity of attacks.

CAD mortality also appears to be higher among SCI patients [4]. One contributing factor may be that SCI lesions above the T5 level may lead to atypical presentations for cardiac ischemia; manifestations may include autonomic dysreflexia or changes in spasticity rather than typical chest pain.

The autonomic nervous system dysfunction that results from SCI disrupts normal cardiovascular hemostasis. With SCI above the T6 level, baseline blood pressure is usually reduced, and baseline heart rate may be as low as 50 to 60 beats per minute [12,16]. This is generally not a clinical problem, but may contribute to hemodynamic instability and exercise intolerance.

Acute cervical SCI is associated with a risk of cardiac arrhythmia due to excess vagal tone, as well as complicating hypoxia, hypotension, and fluid and electrolyte imbalances.

http://www.uptodate.com/patients/content/topic.do?topicKey=~VwAwFq7EG6jGfV

bradycardia as likely, compensatory sweating as obligatory after Sympathectomy

Clin Auton Res. 2003 Dec;13 Suppl 1:I36-9.

Sequelae of endoscopic sympathetic block.

Schick CH, Horbach T.

Dept. of Surgery, University of Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany. schick@hyperhidrosis.de

Endoscopic sympathetic block as a treatment for primary hyperhidrosis is associated with certain sequelae. The reported occurrence of side effects still varies in the literature. As the majority of patients describe sequelae after sympathetic surgery, the frequency and importance of these persisting changes are still underestimated. Patient's informed consent should include and define side effects like gustatory sweating, olfactory sweating and bradycardia as likely, and compensatory sweating as obligatory.

PMID: 14673671 [PubMed - indexed for MEDLINE]

Räf L, Claes G. Complications are frequent after surgery for excessive hand sweating. Patients should be informed about the risks

Lakartidningen 1999;96:930-2. (In Swedish.)

ETS for palmar HH results in systemic (non-localized) changes of the ANS function

In contrast to compensatory sweating in other parts of the body after T2-3 sympathetomy, improvement in plantar sweating was shown in 72% and worsened symptoms in 6% of patients. The intraoperative plantar skin temperature change and perioperative SSR demonstrated a correlation between these changes.
Associated change in plantar temperature and sweating after transthoracic endoscopic T2-3 sympathectomy for palmar hyperhidrosis.

Chen HJ, Liang CL, Lu K.

Department of Neurosurgery, Chang Gung University and Medical Center at

Kaohsiung, Taiwan. chenmd@ms8.hinet.net
PMID: 11453433 [PubMed - indexed for MEDLINE]

Forced vital capacity, forced expiratory volume were all slightly but significantly decreased after sympathectomy

J Clin Neurosci 2001 Nov;8(6):539-41

Thoracoscopic sympathectomy for palmar hyperhidrosis: effects on pulmonary function.

Tseng MY, Tseng JH.

tmy59100@ms4.hinet.net

Palmar hyperhidrosis, probably caused by an over-reactivity of sympathetic nerves passing through the second and the third thoracic sympathetic ganglia (T2 & T3 ganglia), can only be cured by sympathectomy. Such sympathetic denervation may also alter pulmonary function. In order to investigate the effect of sympathectomy, pulmonary function was compared before and four weeks after operation in 20 patients. Forced vital capacity (FVC) (-2.3%), forced expiratory volume in one second (FEV1) (-6.1%), and FEV1/FVC (-4.6%) were all slightly but significantly decreased four weeks after thoracoscopic sympathectomy. Also the instantaneous forced expiratory flow at 75%, 50% and 25% of the FVC (Vmax25, Vmax50, Vmax75) in flow-volume curves were decreased (-1.6%, -8.4%, and -20% respectively).

PMID: 11787462 [PubMed - indexed for MEDLINE]