CERVICAL SYMPATHECTOMY AND CEREBROSPINAL FLUID PRESSURE: THEIR RELATIONSHIP TO BRAIN METABOLISM

http://www.ncbi.nlm.nih.gov/pubmed/14247422




Factors Affecting Cerebral BloodFlow- Experimental Review: 

Sympathectomy, Hypothermia, CO2 Inhalation andPavarine 

The cerebral spinal fluid pressure increased significantly (86.86to 117.34) immediately after operation but returned to normalwithin 2 weeks.

Ann Surg. 1966 May;163(5):771-7.

Shackelford RT, Hegedus SA.

PMID: 5930460 [PubMed - indexed for MEDLINE]PMCID: PMC1477179

Effects of increased cerebrospinal fluid pressure on the blood flow and on the energy metabolism of the brain. An experimental study.

Zwetnow NN.

PMID: 4316893 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/4316893
Acta Physiol Scand Suppl. 1970;339:1-31

The effect of carotid ligation and cervical sympathectomy in guinea-pigs on the ascorbic acid content of the aqueous humour at varying plasma levels

http://www.ncbi.nlm.nih.gov/pubmed/12985402

Surgical Denervation of Ocular Sympathetic Afferents Decreases Local Transforming Growth Factor-β and Abolishes Immune Privilege

Mounting evidence points to a role for the sympathetic nervous system in suppressing inflammation. This role might be of specific relevance for immune privilege in the eye, where, sporadically, patients with denervated sympathetic fibers develop chronic inflammation.


Our results show that in the absence of functional sympathetic fibers, the eye loses its ability to prevent either the immune rejection of intraocular allogeneic tumor cells or the suppression of delayed type hypersensitivity responses against soluble antigens injected in the anterior chamber. This loss of immune privilege is accompanied by a decrease in the concentration of transforming growth factor-β in the aqueous humor. These results suggest that immune privilege is lost in the absence of a functional sympathetic innervation of the eye, allowing intraocular immune responses to become exaggerated. We conclude that ocular sympathetic nerves are critical for the generation and maintenance of immune privilege in the eye through the facilitation of local transforming growth factor-β production.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2731140/

increased substance P within the iris, reproducing the effects of sympathectomy

www.springerlink.com/index/XHN321575M3556G3.pdf

chemical sympathectomy leads to lowering of aqueous humor production

GRAEFE'S ARCHIVE FOR CLINICAL AND EXPERIMENTAL OPHTHALMOLOGY

Volume 200, Number 3, 223-226, DOI: 10.1007/BF01028537

Cervical sympathectomy causes photoreceptor-specific cell death in the rat retina

Changes in the regulation of the vasculature of the eye may be related to some age-related ocular diseases. We have previously shown that loss of sympathetic innervation, as can normally occur with age, resulted in substantial vascular growth of the choroid. The current study was designed to determine whether changes induced by sympathetic denervation causes significant loss of photoreceptors and increased glial cell reactivity in the retina. Sympathetic denervation was performed followed by immunohistochemistry, TUNEL staining, and protein expression analysis to investigate photoreceptor loss. There was a significant reduction (30%) in photoreceptor numbers in the sympathectomized eye. This loss was due to apoptosis, as there was over a doubling in apoptotic cell numbers after sympathectomy. This loss of photoreceptors in the sympathectomized eye resulted in a significantly reduced width of the outer nuclear layer of the retina when compared to the contralateral eye. Increased glial fibrillary acidic protein (GFAP) staining was also noted after sympathectomy in the ganglion cell layer with streaking toward the bipolar cell layer. These results suggest that loss of sympathetic innervation may cause significant changes to the physiology of the choroid.

Autonomic Neuroscience
Volume 120, Issues 1-2, 15 June 2005, Pages 46-51

morphological changes in the retina noted after sympathectomy

Results: Mice treated with PDGF inhibitor AG 1296 showed an inhibition of corneal neovascularization and a reduction of pericytes in the new formed vessels compared to untreated animals. 

Retina from sympathectomized eyes receiving saline treatment had significantly  reduced PEDF mRNA and protein expression relative to the contralateral eye receiving saline treatment. These results are similar to previous work and indicate that injection alone did not alter the results. Intravitreal PEDF administration to sympathectomized eyes returned both mRNA and protein levels to those of the contralateral eye. PEDF administration also normalized retinal morphometry to prevent the sympathectomy-induced increases 

in capillary density of the outer plexiform layers, as well as the ganglion cell layer. 

Conclusions: These results suggest that one injection of PEDF can restore protein and mRNA 

levels to those noted in an untreated animal. Furthermore, these results also indicate that 

one injection of PEDF can reverse the morphological changes noted after sympathectomy 

in the retina. 

CR:  J.J. Steinle,  B.L. Lashbrook,

files.abstractsonline.com/SUPT/25/1421/SessionPDF/119.pdf

sympathectomy led to an exacerbation of colitis

Substance P (SP) is a pro-inflammatory neuropeptide in colitis, whereas sympathetic neurotransmitters are anti-inflammatory at high concentrations.


Results: In all layers, Crohn’s disease patients demonstrated a loss of sympathetic nerve fibres. Sprouting of SP⁺ nerve fibres was particularly observed in the mucosa and muscular layer in Crohn’s disease. SEMA3C was detected in epithelial cells, and there was a marked increase of SEMA3C-positive crypts in the mucosa of Crohn’s disease patients compared to controls. In Crohn’s disease, the number of SEMA3C-positive crypts was negatively related to the density of mucosal sympathetic nerve fibres. Sympathectomy reduced acute DSS colitis but increased chronic DSS colitis. Sympathectomy also increased chronic colitis in Il10^−/−mice.
Gut 2008;57:911-921 doi:10.1136/gut.2007.125401

Secondary Effects of Sympathectomy - Disturbance of Sexual Function

If a portion of the autonomic nervous system is removed to modify a specific disease process, unrelated physiologic mechanisms will also be affected. The degree to which these other mechanisms may be affected often governs the selection of operative procedures. The results produced by interfering with mechanisms other than those for which the operation is performed might be designated as side-effects or secondary effects. . . .
N Engl J Med 1951; 245:121-130July 26, 1951
http://www.nejm.org/doi/full/10.1056/NEJM195107262450401

Massive intestinal infarction following retroperitoneoscopic right lumbar sympathectomy

 We describe a fatal case of intestinal infarction following an elective retroperitoneoscopic right sympathectomy. 
J Minim Access Surg. 2006 December; 2(4): 222–223.

sympathectomy controversial

"This is a field in which the unknown is still substantial and the some of the known -  controversial."
M. Hashmonai, 2005
President of the International Society of Sympathetic Surgery

CLINICAL AUTONOMIC RESEARCH

Volume 15, Number 2, 130-145, DOI: 10.1007/s10286-005-0271-x

The role of sympathectomy to treat RSD/CRPS is controversial and in some cases, the procedure worsens symptoms

http://www.neurologychannel.com/rsd/treatment.shtml

symptoms of Autonomic Neuropathy closely resemble the symptoms described by many who have undergone sympathectomy

the symptoms of Autonomic Neuropathy closely resemble the symptoms described by many who have undergone sympathectomy - a surgery where the surgeon destroys part of the ANS, a surgery that can result in a deranged functioning of the ANS. Surgeons are allowed to market ETS/ESB  as an elective (life-style) procedure, often referred to as a 'cure'. Autonomic neuropathy:
"Cardiovascular symptoms: exercise intolerance, fatigue, sustained heart rate, syncope, dizziness, lightheadedness, balance problems
Gastrointestinal symptoms: dysphagia, bloating, nausea and vomiting, diarrhea, constipation, loss of bowel control
Genitourinary symptoms: loss of bladder control, urinary tract infection, urinary frequency or dribbling, erectile dysfunction, loss of libido, dyspareunia, vaginal dryness, anorgasmia
Sudomotor (sweat glands) symptoms: pruritus, dry skin, limb hair loss, calluses, reddened areas
Endocrine symptoms: hypoglycemic unawareness
Other symptoms: difficulty driving at night, depression, anxiety, sleep disorders, cognitive changes" http://www.aafp.org/afp/2005/0601/p2123.html

Iontophoresis should be tried before other treatments

Iontophoresis is easy to perform, effective in about 90% of patients in two studies with 54 and 30 participants, free of hazardous side effects, and well accepted by almost all patients.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118569/

We disagree that surgery and botulinum toxin are treatments of choice in severe cases of hyperhidrosis

The truth is exactly the opposite. Surgery is only rarely necessary, and the editorial quite properly warns of numerous surgical pitfalls, which include recurrence of hyperhidrosis, almost certain impotence, compensatory sweating, permanent neurological damage from anoxia, and death (their words). Botulinum toxin, which they recommend for axillary or plantar hyperhidrosis, requires 12 injections per axilla and 24-36 injections per foot. Even this horrendous procedure gives only 11 months' relief, and antibody formation may reduce long term efficiency.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118569/

the Kuntz nerve played no part in the success or failure of ETS surgery

If you research the topic of ETS, you will come across various claims and counter-claims
about the importance or otherwise of the Kuntz nerve. The Kuntz nerve is a small nerve
fibre sometimes seen on the second rib not far from the main sympathetic chain. Its
function is not known in humans. Some web-sites on ETS claim success rates of up to
100% for facial blushing because they search for and destroy the Kuntz nerve(s). These
same people also claim to be able to correct failed ETS operations by reoperating and
destroying the Kuntz nerve.
At the meeting of the International Society for Sympathetic Surgery in Germany, May
2003, attended by a majority of the world’s experts in ETS surgery (including us), all but
one of the surgeons present were of the opinion that the Kuntz nerve played no part in the
success or failure of ETS surgery for facial blushing. We share this majority opinion.
www.lapsurgeryaustralia.com.au

Sympathectomy is a technique about which we have limited knowledge, applied to disorders about which we have little understanding."

http://www.pfizer.no/templates/Page____886.aspx

Following sympathectomy the basal t-PA activity in plasma was 70% less than controls

Following sympathectomy: (i) the basal t-PA activity in plasma was 70% less than controls (2.92 ± 1.96 versus 9.33 ± 1.72 IU/ml;P ≤ 0.001); (ii) the acute release from isolated vessels induced by bradykinin or phenylephrine was comparably reduced; and (iii) the greatest reductions occurred in densely innervated small vessel explants. The results provide new support for an autonomic regulation of neural t-PA release into the vessel wall matrix and blood of densely innervated thin-walled microvessels.

Blood Coagulation & Fibrinolysis:

September 2002 - Volume 13 - Issue 6 - pp 471-481

reparative dentin formation was reduced after sympathectomy

Textbook of Endodontology, By Gunnar Bergenholtz, Preben Hørsted-Bindslev, Claes Reit

John Wiley and Sons, 2009

POSTSYMPATHECTOMY PAIN AND CHANGES IN SENSORY NEUROPEPTIDES

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.
The Lancet, Volume 326, Issue 8465, Pages 1158 - 1160, 23 November 1985

link between sympathectomy and osteoclast-mediated bone resorption

Recent investigations have demonstrated a link between sympathectomy and osteoclast-mediated bone resorption. The exact nature of this link, however, is unknown, We hypothesize that substance P, a potent vasoconstrictive neuropeptide found in peripheral sensory fibers, including those innervating bone, is the mediator of this phenomenon. To test this theory, the effects of substance P on in vitro calcium release from cultured neonatal mouse calvaria were assessed. In addition, an in vivo study was conducted whereby gerbils were injected with capsaicin to eliminate substance P-containing fibers before sympathectomy with 6-hydroxydopamine. If the effects of 6-hydroxydopamine were eliminated by prior administration of capsaicin, the role of sensory nerves in sympathectomy-induced resorption would be strongly implicated.


The results indicate that substance P is capable of inducing resorption and that substance P-containing sensory nerves are required for the induction of resorption after sympathectomy in the gerbil.

Otolaryngol Head Neck Surg November 1, 1995 vol. 113 no. 5 569-581

diabetic autonomic neuropathy is due to a lesion of the sympathetic nerve supply to the skin

"We conclude that the diabetic anhidrotic syndrome, a form of diabetic autonomic neuropathy, is due to a lesion of the sympathetic nerve supply to the skin."

Diabetologia

Volume 22, Number 2, 96-99, DOI: 10.1007/BF00254836

Sympathectomy IS a (surgically caused) lesion of the sympathetic nerve supply to the skin 

Cardiovascular collapse developing during thoracoscopic thoracic sympathectomy

Cardiovascular collapse developing during thoracoscopic thoracic sympathectomy in a patient with essential palmar hyperhidrosis: A case report.  
Park SJ, Jee DL.

Department of Anesthesiology and Pain Medicine, College of Medicine, Yeungnam University, Daegu, Korea. djee@medical.yeungnam.ac.kr

Thoracoscopic thoracic sympathectomy (TTS) is usually a safe and uncomplicated procedure for treating essential palmar hyperhidrosis. However, we report a case of cardiovascular collapse that developed in a healthy patient undergoing TTS. The surgeon performed the left sympathectomy without incident. However, scarcely had an incision been made in the skin of the right chest when the patient developed sinus bradycardia and sudden, severe hypotension. Pulseless ventricular tachycardia occurred immediately thereafter, which rapidly progressed to ventricular fibrillation and cardiovascular collapse. The patient required resuscitation with 200 J of direct current shock defibrillation along with an intravenous injection of epinephrine 1 mg. She recovered without sequelae. We believe the Bezold-Jarisch reflex was triggered by pooling of venous blood and surgical stimuli, and the patient developed cardiovascular collapse as a result.

In 70 % compensatory sweating severe, recurrence rates were 15% and 19% at 1 and 2 years after surgery

In T2 and T3 resection, all patients experienced Compensatory Sweating and over 70% of the patients felt it was severe. Even in T2 resection, 90% of patients experienced CS and in 50% of these it was severe. High rates of CS are reported in Asian countries with hot and humid climates.

In T2 resection, recurrence rates were 15% and 19% at 1 and 2 years after surgery.It was not rare for a patient to experience recurrence more than 3 years after surgery.
Motoki Yano, MD, PhD and Yoshitaka Fujii, MD, PhD

Volume 138, Issue 1, Pages 40-45 (July 2005)

a strong association of autonomic dysfunction and impaired cerebral autoregulation

Furthermore, we found a strong association of autonomic dysfunction and impaired autoregulation indicated by a correlation between the LF/HF ratio and Sx (p <>Drug and Alcohol Dependence
Volume 110, Issue 3, 1 August 2010, Pages 240-246

Conditions arising after Sympathectomy

After stellate ganglion blockade: HORNER'S SYNDROME

• Drooping eyelid
• Constricted pupil (impaired vision in low light)
• Absent/reduced sweating one side of the face and head
• Redness of eyes
• Facial flushing
  

After regional sympathectomy: DUMPING SYNDROME:

• Rapid emptying of the stomach: lower end of small intestine fills too quickly
• Early dumping: nausea/vomiting/bloating/diarrhoea/shortness of breath
• Late dumping: 1-3 hours after eating: weakness/sweating/dizziness
• Both types may co-exist.

http://www.theaword.org/index.php?option=com_content&view=article&id=223:conditions-arising-after-sympathectomy&catid=84:the-sympathetic-nervous-system&Itemid=41

Sympathectomy is one of the causes or Orthostatic Hypotension

Causes of Orthostatic Hypotension

Peripheral

Amyloidosis

Diabetic, alcoholic, or nutritional neuropathy

Familial dysautonomia (Riley-Day syndrome)

Guillain-Barré syndrome

Paraneoplastic syndromes

Pure autonomic failure (formerly called idiopathic orthostatic hypotension)

Surgical sympathectomy

http://www.merckmanuals.com/professional/sec07/ch069/ch069d.html

Bilateral sympathectomy produced fatal heart block in a few of their experiments

Mendlowitz. Schauer, and Gross⁴ pointed out that the heart rate became slower after removal of the sympathetic chain, but this bradycardia was only temporary. Bilateral sympathectomy produced fatal heart block in a few of their experiments.

American Heart Journal
Volume 22, Issue 4, October 1941, Pages 545-548

bradycardia and other cardiac complications common side effects?

The most common side effects of sympathectomy are compensatory sweating, gustatory sweating and cardiac changes including decreasing heart rate, systolic-diastolic and mean arterial pressure. The mechanism of bradycardia and other cardiac complications that develop after thoracic sympathectomy are still unclear. (2009)

http://tipbilimleri.turkiyeklinikleri.com/abstract_54802.html

"It is a lie that sympatholysis may specifically cure patients

with unqulified "reflex sympathetic dystrophy". This was already stated by the father of sympathectomy, Rene Leriche, more than half a century ago.
...it is not an error, but a lie. While conceptual errors are not only forgivable, but natural to inexact medical science, lies, particularly when entrepreneurially inspired are condemnable and call for a peer intervention.

J. Neurology (1999) 246: 875-879

unavoidable side effects and unforeseeable and unacceptable complications

Most of the difficulties associated with hyperhidrosis surgery are due to unavoidable side effects and unforeseeable and unacceptable complications. Careful patient selection is important before surgery so surgeons can avoid some of these pitfalls. Patients should also be fully informed of all potential side effects and complications before surgical

treatment.http://www.ncbi.nlm.nih.gov/pubmed/18557592

impairment of autoregulation after unilateral cervical sympathectomy

Although these findings argued against a neurogenic mechanism, James at al. (1969) reported impairment impairment of autoregulation after unilateral cervical sympathectomy in the babbon. Gotoh et al. (1971/1972) observed impairment of autoregulation in patients with the Shy-Drager syndrome.
It was concluded that the autonomic nervous system plays an important role in the mechanism of autoregulation of CBF and that his mechanism is independent of the chemical control of the cerebral vessels. This was confirmed by direct observation of the pial vessels in cats, where separate sites of action in the vascular tree for autoregulation and chemical control were demonstrated; the autoregulatory reaction was located in pial arteries with a diameter larger than 50 μ, and the reaction to carbon dioxide in pial arteries of smaller diameter (Gotoh et al. 1975).
They concluded that the arteries operating in autoregualtin were the larger ones with the dense innervation, while the smaller arteries with sparse innervation were involved in chemical control.
Coronna and Plum (1973) demonstrated the absence of CBF autoregulation in a patient with a Shy-Drager syndrome who had a postganglionic denervation....

Gotoh et al (1979) subsequently showed that autoregulation in patients with this syndrome was impaired irrespective of the localization of the damage to the cervical sympathetic nervous system (preganglionic, central, postganglionic) as judged by the eye instillation test.
Handbook of Clinical Neurology,

Vascular Diseases, Part I by P. J. Vinken, G. W. Bruyn, H. L. Klawans, and J. F. Toole

, Volume 53, Part 1

Elsevier Health Sciences, 1988

The practice of surgical and chemical sympathectomy is based on poor quality evidence, uncontrolled studies and personal experience

Cochrane Database Syst. Review
”The practice of surgical and chemical sympathectomy is based on poor quality evidence, uncontrolled studies and personal experience.“
Cochrane Database Syst Rev. 2003;(2):CD002918.

Side effects were common

UK Review of ETS surgery
We did not identify any controlled trials or cohort studies. The evidence about effectiveness, based on three case series, was therefore very limited. The main weakness of these studies was their lack of a comparison group and their resulting inability to exclude a placebo response to surgery. In addition, the methods of assessing outcome were poorly described and not validated, and the range of outcomes assessed was limited. The studies provided very limited evidence that sympathectomy improves blushing. Side effects were common.
London: Bazian Ltd (Editors), Wessex Institute for Health Research and Development, University of Southampton 2003: 11

"Lifestyle" surgical procedure carries unrecognized risk of complications.”

Wiley & Sons, Inc, news release - 2004

"Lifestyle" surgical procedure carries unrecognized risk of complications.”
Hoboken, NJ: John Wiley & Sons, Inc, British Journal of Surgery, Feb 5, 2004
Posted by Mia at 2/08/2011

The intervention leads to severe immediate complications in some of the patients

Finnish Review
Conclusions: The evidence of the effectiveness of ETS is weak due to a lack of randomized trials. The intervention leads to severe immediate complications in some of the patients, and to persistent side-effects for many of the patients.
UniversityofOuluand FinnishOfficeforHealthTechnologyAssessment
FinnishOfficeforHealthTechnologyAssessment
UniversityofHelsinki and FinnishOfficeforHealthTechnologyAssessment
UniversityofCopenhagenand FinnishOfficeforHealthTechnologyAssessment

poor evidence is available about ETS as regards side effects, risks, and short-term effects

Swedish Review
The findings by SBU Alert show that poor* evidence is available about ETS as regards side effects, risks, and short-term effects. There is no* scientific evidence demonstrating the long-term results of the method or its cost effectiveness in relation to other methods.
(Swedish Council on Technology Assessment in Health Care (SBU), the Medical Products Agency, the National Board of Health and Welfare, and the Federation of Swedish County Councils.
Published: 1999-08-30 Revised: 2002-09-30

Reported success stories on ETS are "prone to bias and have significant methodological problems"

Australian Review of ETS surgery - 2001
The four case series were not critically appraised because they are prone to bias and have significant methodological problems. These studies represent level IV evidence according to the NHMRC criteria and one should not draw firm conclusions from their findings.

To date, the benefits or side effects associated with endoscopic thoracic sympathectomy for treating facial blushing have not been properly evaluated and reported.

Further research using a well-designed controlled trial is warranted to assess the efficacy of endoscopic thoracic sympathectomy for treating facial blushing.

Centre for Clinical Effectiveness - Monash

There is potentially a number of safety issues associated with this procedure

Australian Review of ETS surgery
"A lack of high quality randomised trial evidence on ETS means that it is difficult to make a judgment on the safety and effectiveness of this technique. There is potentially a number of safety issues associated with this procedure. ASERNIP-s suggests that a full systematic review including all available comparative and case series information, together with clinical inpuut, should be undertaken to provide up-to-date and comprehensive assessment of the safety and effectiveness of ETS." (ASERNIP-s Report No. 71, August 2009)

After thoracoscopic sympathectomy for hyperhidrosis, very severe discomfort and hyperhidrosis in the neighboring non-sympathectomized regions occurred

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

Lack of disclosure to ETS patients is unethical and would be criminal in a just society

It is the doctor's moral and ethical duty to provide you with full and honest disclosure of the facts prior to surgery. The whole doctrine of informed consent is to prevent patients from having to realize they made a mistake in hindsight. You shouldn't have had to find out from a former patient's wife that the surgery would cause drenching sweating on your back. It was Garza's job to do that. He completely lied to you regarding the supposed reversibility. Anyone who goes through medical school knows that can't crush a nerve with a metal clamp, remove it later and have the nerve return to normal functioning.

Although it is not possible to predict exactly what will occur in each individual case, there is nearly 100 years of published scientific and medical research available on the effects of sympathectomy. That research paints a very different picture of the effects of this surgery than the one presented to patients considering this surgery. That's the issue. Generally, they lie and tell patients that CS is inconsequential in all but a tiny fraction of cases and simply fail to disclose a huge number of verified adverse effects of the surgery. They take advantage of the patient's ignorance on medical matter. It's unethical and would be criminal in a just society.

In short, you do have a way of knowing what will likely occur as a result of the surgery before you have it done. All the information necessary to make an informed decision exists. It's just not getting to patients.

http://etsandreversals.yuku.com/reply/22927/Would-you-do-it-again#reply-22927

Surgical sympathectomy listed as neurologic disorder

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)

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

collateral events that may not be beneficial - reinnervation errors

Axonal regeneration and organ reinnervation are the necessary steps for functional recovery after a nerve lesion. However, these processes are frequently accompanied by collateral events that may not be beneficial, such as: (1) Uncontrolled branching of growing axons at the lesion site. (2) Misdirection of axons and target organ reinnervation errors, (3) Enhancement of excitability of the parent neuron, and (4) Compensatory activity in non-damaged nerves. Each one of those possible problems or a combination of them can be the underlying pathophysiological mechanism for some clinical conditions seen as a consequence of a nerve lesion. Reinnervation-related motor disorders are more likely to occur with lesions affecting nerves which innervate muscles with antagonistic functions, such as the facial, the laryngeal and the ulnar nerves. Motor disorders are better demonstrated than sensory disturbances, which might follow similar patterns. In some instances, the available examination methods give only scarce evidence for the positive diagnosis of reinnervation-related disorders in humans and the diagnosis of such condition can only be based on clinical observation. Whatever the lesion, though, the restitution of complex functions such as fine motor control and sensory discrimination would require not only a successful regeneration process but also a central nervous system reorganization in order to integrate the newly formed peripheral nerve structure into the prepared motor programs and sensory patterns.
Clinical Neurophysiology
Volume 122, Issue 2, February 2011, Pages 219-228

without any increase of nutritional blood flow

Techniques with effect on the sympathetic nerve system, sympathetic block or sympathectomy increase blood flow, mainly due to opening of arteriovenous shunts and without any increase of nutritional blood flow. However, some patients may benefit in terms of reduced pain.
Little evidence exists but a review from 1985 concluded that sympathectomy could be beneficial in patients with rest pain and pregangrene. It is, however, most unlikely that diabetic patients can respond as they usually have a reduced sympathetic tone in the ischemic leg.
Cardiovascular and Interventional Radiological Society of Europe / 2007
Clinical Practice in Interventional Radiology, Volume I,

82.9% Were Disturbed Because CS Was More Than Expected

Endoscopic thoracic sympathectomy (ETS) for palmar hyperhidrosis was performed using a 3-mm small endoscope at our hospital, and we conducted a questionnaire for the purpose of studying the conditions and satisfaction after surgery. The subjects were comprised of 50 patients, of which 35 patients (75%) answered the survey. The average age of the respondents was 27 years old (range: 12?62 years old) including 13 males and 22 females and the average postoperative observation period was 33 months (1?114 months). The results showed the good effects of surgery in all of the patients for palmar sweating while patient satisfaction was 79.4 points, which concluded that ETS was sufficiently accepted as treatment for palmar hyperhidrosis. However, compensatory sweating (CS) developed in 97.1% of the patients, and 82.9% answered that they were disturbed because it was more than they had expected. This result makes us realize further the importance of preoperative informed consent for CS. The problem of palmar hyperhidrosis is very serious for patients, and hence it is important to give treatment with a thorough understanding of the effectiveness and problems of ETS for palmar hyperhidrosis according to the analytical results of this questionnaire.

http://ci.nii.ac.jp/naid/110006980508/en

Sympathectomy limits blood flow to a vital organ like the brain

However, sympathetic blockade at the level of the neck eliminated the beta-1 blockade induced attenuation in delta MCA V(mean) (10.2 2.5 cm s(-1)). These results indicate that a reduced ability to increase CO during exercise limits blood flow to a vital organ like the brain and that this flow limitation is likely to be by way of the sympathetic nervous system.

PMID: 10971220 [PubMed - indexed for MEDLINE]
1. Acta Physiol Scand. 2000 Sep;170(1):33-8.

GAP-43 mRNA and calcitonin gene-related peptide mRNA expression in sensory neurons are increased following sympathectomy

Sympathectomy has been shown to result in an increased density of fibers immunoreactive for sensory peptides in peripheral targets innervated by both sensory and sympathetic neurons, providing evidence for functional interactions between sympathetic and sensory systems. These findings provided the background for examining the hypothesis that axonal outgrowth is induced from sensory neurons following sympathectomy. We examined the expression of GAP-43 mRNA, a specific marker for axonal outgrowth, in cervical (C3, C7, C8) and thoracic (T1, T2) dorsal root ganglia (DRG) of the rat following bilateral removal of the superior cervical ganglion, to assess whether the described increases in peptidergic afferent fibers reflected axonal outgrowth. In situ hybridization was used with ³⁵S labeled riboprobes complementary to GAP-43 mRNA, and to calcitonin gene-related peptide (CGRP) mRNA, a marker for a major subset of thin-fiber sensory neurons. The density of GAP-43 mRNA nearly doubled by 18 h following sympathectomy and reached a threefold increase by 3 days. By 45 days following surgery, the GAP-43 mRNA level was still nearly twice that of normal animals. CGRP immunoreactivity was also examined: the density of fibers in the iris and cornea of sympathectomized animals was considerably greater from two weeks to 45 days following surgery, than in sham-operated controls. Concomitantly, there was a slight but significant increase in CGRP mRNA expression in T1 and C3 DRG 14 days post

http://www.refdoc.fr/Detailnotice?idarticle=15110598

anatomic variations of the T2 nerve root

6 (9.1%) sides showed a single large ganglion formed by the stellate and the second thoracic sympathetic ganglia. The second thoracic sympathetic ganglion was most commonly located (50%) in the second intercostal space. Conclusion: The anatomic variations of the intrathoracic nerve of Kuntz and the second thoracic sympathetic ganglion were characterized in human cadavers.

Journal of thoracic and cardiovascular surgery Y. 2002, vol. 123, No. 3, pages 498-501 [bibl. : 14 ref.

http://www.refdoc.fr/Detailnotice?idarticle=9466218

immune privilege is lost in the absence of a functional sympathetic innervation of the eye

Mounting evidence points to a role for the sympathetic nervous system in suppressing inflammation. This role might be of specific relevance for immune privilege in the eye, where, sporadically, patients with denervated sympathetic fibers develop chronic inflammation. The present study used mice to investigate whether the robust innervation of intraocular structures by the sympathetic system plays a role in maintaining ocular immune privilege. We first performed surgical removal of the superior cervical ganglion, which supplies sympathetic fibers to the eye, and studied the immune response generated against soluble antigens or allogencic tumor cells injected into the ocular anterior chamber under these conditions. Our results show that in the absence of functional sympathetic fibers, the eye loses its ability to prevent either the immune rejection of intraocular allogeneic tumor cells or the suppression of delayed type hypersensitivity responses against soluble antigens injected in the anterior chamber. This loss of immune privilege is accompanied by a decrease in the concentration of transforming growth factor-β in the aqueous humor. These results suggest that immune privilege is lost in the absence of a functional sympathetic innervation of the eye, allowing intraocular immune responses to become exaggerated. We conclude that ocular sympathetic nerves are critical for the generation and maintenance of immune privilege in the eye through the facilitation of local transforming growth factor-β production.
http://cat.inist.fr/?aModele=afficheN&cpsidt=21889071

Results of life-style surgery:

The rate of compensatory sweating in group 2 (72.7%) was significantly lower than in group 1 (95.4%) (P<0.039). The chance of embarrassing and disabling compensatory sweating was lower in group 2 than in group 1; 76.5% (embarrassing in 8 patients, disabling in 9) in group 1, and 36.4% (embarrassing in 7 patients, disabling in 1) in group 2 which was statistically significant (P<0.006).

http://www.ejcts.ch/cgi/content/full/26/2/396

Sympathectomy is used to treat various conditions, including Raynaud's. But is it effective?

"Recurrent and enhanced vasoconstrictor function 3 months following endoscopic sympathetic block has major implications for its use to treat enhanced vasoconstriction."

http://www.ncbi.nlm.nih.gov/pubmed/12796529

bilateral ETS causes the suppression of cardiovascular response to exercise

HR and BP at rest and cardiovascular response to exercise were similar in patients with palmar hyperhidrosis before ETS and in the normal control population. Therefore, we consider that patients with palmar hyperhidrosis have no overactivity of the sympathetic nerve. However, because bilateral ETS causes the suppression of cardiovascular response to exercise, patients that has been treated with ETS need to be observed during high-level exercise.

http://iars.org/abstracts/browsefile/browse.asp?command=N&absnum=45&dir=S190

Undisclosed side-effects of ETS procedure

After a mean of 123 mo 36 patients could be re-evaluated. Eighteen patients (50%) were free from former symptoms, while sequels were still present in 18 patients (50%).

Numbness and paresthesia are rarely reported in the literature but are present in up to 10% of patients 1 year after a thoracoscopic procedure [2,9]. It is known that numbness and dysesthesia may decrease by time, but long-term results are not known.

Early postoperative sequels are frequently found in VATS procedures, but patients with pain even after years have a nearly 50% chance to eliminate their problems. In addition, numbness and dysesthesia seem to disappear almost completely several years after the procedure.

http://www.ejcts.ch/cgi/content/full/32/3/409

Sympathotomy Instead of Sympathectomy for Palmar Hyperhidrosis: Minimizing Postoperative Compensatory Hyperhidrosis

www.sweathelp.org/pdf/Atkinson.pdf
or
www.sciencedirect.com/science/article/pii/S0025619611625494

Mia: An elective surgical procedure enthusiastically declared "almost miraculous" needs modifications to reduce severe side-effects?

CNS activation following peripheral sympathectomy

Many studies have demonstrated that ablation of the sympathetic nervous system (SNS) alters subsequent immune responses. Researchers have presumed that the altered immune responses are predominantly the result of the peripheral phenomenon of denervation. We, however, hypothesized that chemical sympathectomy will signal and activate the central nervous system (CNS).

Dual-antigen labeling demonstrates that

corticotrophin releasing factor (CRF)-containing neurons in the PVN are

activated by chemical sympathectomy; however, neurons containing

neurotransmitters which may modulate CRF neurons, such as vasopressin,

tyrosine hydroxylase, and adrenocorticotropin, do not coexpress Fos. Our

findings suggest an involvement of the CNS insympathectomy-induced

alterations of immunity.

Brain, Behavior, and Immunity

Volume 12, Issue 3, September 1998, Pages 230-241

Cervical sympathectomy affects the lower extremities, providing further evidence that the effects of this procedure is not local or limited

Bilateral cervical sympathectomy reduced mechanical allodynia and cold allodynia in the rat

model of neuropathic pain suggesting that neuropathic pain, although the lesions are localized in low extremities, may be correlated with functional disturbance of sympathetic nerve fibers of supraspinal or brain level and help explain the mechanism of neuropathic pain.

Korean J Anesthesiol. 1999 Feb;36(2):327-334. Korean.

Effect of cervical sympathectomy and circulatory hypoxia on time course of prostaglandin concentration in brain tissues

http://www.springerlink.c...ontent/j705306763158841/

Some workers suggest a possible "transmembrane" role of PG in the nervous system.

If the increase in the PG level during ischemia is regarded as a protective reaction, it must be admitted that no increase took place 1 day after CSE (cervical sympathectomy) and it was considerably weakened 7-40 days after CSE.

The effect of cerebral ischemia was virtually indistinguishable from the action of CSE itself.

It can be tentatively suggested that PGF plays the main role in the regulation of tone of the vascular wall and in the regulation of metabolism under conditions of ischemia when the sympathetic regulation is disturbed.