Heart rate significantly decreased after bilateral but not after unilateral right sympathectomy

http://www.ncbi.nlm.nih.gov/pubmed/12643398

surgical and chemical sympathectomy can both modulate bone cell function

It is known that surgical and chemical sympathectomy can both modulate bone cell function.  However, the sympathetic
nervous system (SNS) can give rise to both anabolic and catabolic effects [28-31] and its role in regulating bone remodeling is, therefore, controversial. For example, some researches reported that if bone is deprived of its sympathetic innervation, bone
deposition and mineralization is reduced and bone resorption increases [31], while in some other reports a sympathectomy impairs bone resorption [28].
Wei Fan BSc, MSc
Institute of Health and Biomedical Innovation
Faculty of Built Environment & Engineering
Queensland University of Technology

eprints.qut.edu.au/35722/7/35722b.pdf

Sustained Benefit (sic!) Lasting One Year from T4 Instead of T3-T4 Sympathectomy

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664277/

No statistically significant association between the CS with age, family history, type of HH and extent of (Sympathectomy) TS

http://ejcts.oxfordjournals.org/content/34/3/514.full

Sympathectomy exacerbated the inflammation and osteopathic destruction of arthritic joints

http://www.ncbi.nlm.nih.gov/pubmed/8632052

results of sympathectomy deteriorate with time

results of sympathectomy deteriorate with time (T.S. Lin & Fang, 1999; Walles et al., 2008). This recurrent postoperative sweating may be due to local nerve regeneration but has not yet been proven (Lee et al., 1999).
http://www.intechopen.com/books/topics-in-thoracic-surgery/surgical-management-of-primary-upper-limb-hyperhidrosis-a-review

Pain in the form of intercostal neuralgia with dysesthesia at the site of trocar insertion is rarely documented but more frequent than generally recognized

Pain in the form of intercostal neuralgia with dysesthesia at the site of trocar insertion is rarely documented but more frequent than generally recognized. Many centres perform short-stay surgery that may lead to underestimation of pain results. In most series pain resolves within months, but Walles and colleagues could detect a persistence for years (Walles et al., 2008).
http://www.intechopen.com/books/topics-in-thoracic-surgery/surgical-management-of-primary-upper-limb-hyperhidrosis-a-review

Loss of impulse control as a side-effect of surgery for blushing and sweaty hands

http://www.sympatix.fi/blog/?lang=en_

left thoracic sympathectomy to prevent electrical storms in CPVT patients

Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT), a life threatening arrhythmia induced by sympathetic stimulation in susceptible individuals is often refractory to antiarrhythmic agents. First line of treatment, beta-blockers can be ineffective in up to 50% with implantable cardioverter-defibrillator (ICD) placement for refractory cases. Paradoxically ICD can be arryhthmogenic from shock-associated sympathetic stimulation, initiating more shocks and "electrical storms". This has led to the use of more effective beta blockade offered by left sympathectomy, now performed by minimally invasive video assisted thoracoscopic surgery (VATS).
To our knowledge this is first such reported case.
Heart Lung Circ. 2011 Nov;20(11):731-3. Epub 2011 Apr 7.
 http://www.ncbi.nlm.nih.gov/pubmed/21478052

Sympathectomy for the treatment of polymorphic ventricular tachycardia

Bilateral thoracoscopic cervical sympathectomy for the treatment of recurrent polymorphic ventricular tachycardia.

Turley AJ, Thambyrajah J, Harcombe AA.
Despite potassium and magnesium supplements, beta blockade, implantation of a single then dual chamber implantable cardioverter defibrillator (ICD), amiodarone, nicorandil, and mexiletine, the patient continued to experience arrhythmia storms, receiving more than 700 ICD discharges over seven months. She was ultimately treated successfully with bilateral thoracoscopic cervicothoracic sympathectomies. This is the first reported bilateral thoracoscopic treatment of a patient with LQTS and symptomatic life threatening ventricular tachyarrhythmias refractory to current pharmacological and pacing techniques.

Cardiothoracic Division, The James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, UK. andrew.turley@stees.nhs.uk

Heart. 2005 Jan;91(1):15-7.
http://www.ncbi.nlm.nih.gov/pubmed/15604323

compensatory sweating is extremely common and often worse than the original problem

Endoscopic thoracic sympathectomy is useful only when all other treatments fail and then should be considered only with caution as compensatory sweating is extremely common and often worse than the original problem.

BMJ 2009;338:b1166    doi:10.1136/bmj.b1166

This is how "compensatory" sweating looks like

http://www.sympatix.fi/blog/?p=706

cutaneous area innervated by the sympathetic T2 and T3 ganglia extends to zones influenced by T1 in up to 20.75% of patients

The territory influenced by the T2 and T3 sympathetic ganglia is more extensive than has been described by classical anatomical studies. The cutaneous area innervated by the sympathetic T2 and T3 ganglia extends to zones influenced by T1 in up to 20.75% of patients with primary hyperhidrosis.
http://www.ncbi.nlm.nih.gov/pubmed/12550015

dynamic cerebral autoregulation is altered by ganglion blockade

We measured arterial pressure and cerebral blood flow (CBF) velocity in 12 healthy subjects (aged 29+/-6 years) before and after ganglion blockade with trimethaphan. CBF velocity was measured in the middle cerebral artery using transcranial Doppler. The magnitude of spontaneous changes in mean blood pressure and CBF velocity were quantified by spectral analysis. The transfer function gain, phase, and coherence between these variables were estimated to quantify dynamic cerebral autoregulation. After ganglion blockade, systolic and pulse pressure decreased significantly by 13% and 26%, respectively. CBF velocity decreased by 6% (P <0.05). In the very low frequency range (0.02 to 0.07 Hz), mean blood pressure variability decreased significantly (by 82%), while CBF velocity variability persisted. Thus, transfer function gain increased by 81%. In addition, the phase lead of CBF velocity to arterial pressure diminished. These changes in transfer function gain and phase persisted despite restoration of arterial pressure by infusion of phenylephrine and normalization of mean blood pressure variability by oscillatory lower body negative pressure.
Conclusions-: These data suggest that dynamic cerebral autoregulation is altered by ganglion blockade. We speculate that autonomic neural control of the cerebral circulation is tonically active and likely plays a significant role in the regulation of beat-to-beat CBF in humans.
Circulation. 106(14):1814-1820, October 1, 2002.
http://www.problemsinanes.com/pt/re/dyslipidaemia/abstract.00003017-200210010-00017.htm;jsessionid=PX6phQHYFG5PD1p2DMS1cJLvG1TbtLLLH0bfJT6vKJgLLx1zn0Xf!1816077220!181195629!8091!-1?nav=reference

Effects of cervical sympathectomy, stage of the estrous cycle and estradiol treatment.

C A CA Nagle, D P DP Cardinali and J M JM Rosner Life Sci 13(8):1089-103 (1973) PMID 4357690

Horner syndrome, pneumothorax, hemothorax, asymmetry of results, intercostal neuralgia, causalgia, hypoesthesia, incomplete results, paresthesia in the anterolateral abdominal wall, dyspareunia

The complications and side effects are very significant, such as irreversible compensatory sweating (20% to 50%), low satisfaction with results, Claude-Bernard-Horner syndrome, pneumothorax, hemothorax, asymmetry of results, intercostal neuralgia, causalgia, incomplete results, and anesthetic complications^11-13.

Retroperitoneoscopic lumbar sympathectomy (video-assisted): this technique is effective in the treatment of isolated or persistent plantar hyperhidrosis (compensatory after thoracic sympathectomy). The treatment consists of removing the nerves of the sympathetic chain located in the abdomen, in the anterolateral portion of the lumbar vertebrae. It requires hospitalization and is carried out under general anesthesia. It may lead to complications such as lesions of structures adjacent to the sympathetic chain, light abdominal distension, neuralgia, and causalgia as well as hypoesthesia in the thighs and groin, limitation of leg movement,
paresthesia in the anterolateral abdominal wall, change in libido, dyspareunia, pulmonary thromboembolism, hemorrhages, arrhythmias, and cardiac decompensation, amongst others. It definitively eliminates plantar hyperhidrosis14,15.  
http://www.scielo.br/scielo.php?pid=S1983-51752011000400008&script=sci_arttext&tlng=en#end

SADS - sympathectomy and CPVT

SADS - sympathectomy and CPVT

limited understanding of the role of the sympathetic nervous system in mediating pain

The role of sympathetic blocks in herpes zoster (HZ) and postherpetic neuralgia (PHN) remains controversial due to methodologic shortcomings in published studies and limited understanding of the role of the sympathetic nervous system in
mediating pain.


Information for Health Professionals          Hunter Integrated Pain Service         Updated January 2010

Procedural Intervention Guideline 

Vasodilation; Vasomotor Disturbances

Complex regional pain syndromes (CRPS) are characterized by vascular disturbances primary affecting the microcirculation in the distal part of the involved extremity. In the acute stage inhibited sympathetic vasoconstriction and exaggerated neurogenic inflammation driven by central and peripheral mechanisms, respectively, seem to be the major pathophysiological mechanisms inducing vasodilation. During the chronic course of the disease as well as early in some patients vasoconstriction dominates the clinical picture induced by changes in the microcirculation itself such as endothelial dysfunction or vascular hyperreactivity, whereas sympathetic vasoconstrictor activity returns and neurogenic inflammation is less severe. It can be suggested that the interaction between different mechanisms underlying vasomotor disturbances as well as the severity of each single mechanism in the individual patient have a great impact on the variety of the overall clinical picture in CRPS. Irrespective of the underlying pathophysiology, measurements of skin temperature differences between the affected and the contralateral extremity can serve as a diagnostic tool in CRPS, in particular when sensitivity and specificity is increased by considering dynamic alterations in skin temperature asymmetries.
http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2010.00914.x/abstract

Epidemiology /Etiology

CRPS is found to result:^[1]
- After traumatic injury (65%)

• 1-2% of all fractures result in CRPS
• Largest risk of CRPS for fractures of the wrist

- After surgical intervention (19%)
- Infection (4%)
- Prior inflammation (2%)
- No clear cause (10%)
A review stated that women are predominantly affected, by a factor of 3,5 and a genetic predisposition has also been theorized.
The disease affects all ages, though most cases are between 50 and 70 years old, and it is generally believed to occur mainly in caucasian and Japanese people.^[4]

Characteristics/Clinical Presentation

The following symptoms have been found in literature:^[5]
- Autonomic and trophic disorders:

• Distal Edema in 80% of the patients
• Skin temperature changes at the affected body part in 80% of the patients, initially warmer and in 40% of patients gradually cools down until colder in comparison to the rest of the body as the disease progresses. Another review mentioned that 30% of the patients start off from the primarily cold stage.3
• In 40% of the patients skin at the affected body part starts showing redness, but becomes pale or livid in later stages
• In 55% altered sweating takes place, with hyperhydrosis being more common than hypohydrosis.
• Hair and nail growth possibly increase in early stages
• Atrophy of skin and muscles in later stages, as well as contractures may severely restrict movement

- Sensory disturbances (90%) typically in a glove or stocking-like distribution

• Spontaneous pain occurs in 75%, usually burning dragging or stinging

• 68% felt in deep structures
• 32% felt in skin
• In 77% pain shows fluctuating intensity, lesser proportion shows shooting pain
• Pain can be increased by orthostasis, anxiety, exercise or temperature changes.
• In many cases, pain is more pronounced at night

• Sensory gain (Mechanical hyperalgesia, allodynia, ...) or sensory loss (hypaesthesia, hypalgesia, …) may be present.

- Motor dysfunction

• Motor weakness
• Severe impairment of complex movements
• Impairment of range of motion, initially by concomitant edema, later by contractures and fibroses
• Neglect like symptoms have been found in some patiënts, described as the body part in question feeling foreign.
• Enhanced physiological tremor in around 50%
• Myoclonus or dystonia, especially in type II CRPS

http://www.physio-pedia.com/Complex_Regional_Pain_Syndrome

Sympathectomy involves division of adrenergic, cholinergic and sensory fibers which elaborate adrenergic substances during the process of regulating viscera

http://pharmrev.aspetjournals.org/content/18/1/611.full.pdf+html

effect of bilateral cervical sympathetic ganglionectomy on the architecture of pial arteries

The influence of the cranial sympathetic nerves on the architecture of pial arteries in normo- and hypertension was examined. For this purpose the effect of bilateral superior cervical ganglionectomy was evaluated in normotensive rats (WKY) and stroke-prone spontaneously hypertensive rats (SHRSP). The operations were performed at the age of 1 wk, which is just prior to the onset of ganglionic transmission. The length of the inner media contour was measured and the media cross-sectional area was determined planimetrically, with computerized digitalization of projected photographic images of transversely sectioned pial arteries. Four wk after sympathectomy there was a 20% reduction in media cross-sectional area and a consequent reduction in the ratio between media area and calculated luminal radius in the major pial arteries at the base of the brain in WKY but not in SHRSP. Conversely, in small pial arteries linear regression analysis showed that in WKY subjected to ganglionectomy the relationship between media cross-sectional area and luminal radius was significantly larger in arteries with a radius less than 21 microns compared to untreated WKY. No such effect was seen in the corresponding SHRSP vessels. In addition, the cross-sectional area of the internal elastic membrane (IEM) in the basilar arteries of WKY was measured by means of a computerized image-analysing system. Mean cross-sectional area of the IEM was approximately 45% larger following SE than in control animals. The present findings propose a 'trophic' role for the sympathetic perivascular nerves in large pial arteries of the rat. The increased media-radius ratio in the small pial arteries of the WKY following sympathectomy might reflect a compensatory hypertrophy due to reduced protection from the larger arteries against the pressure load. The inability to detect any morphometrically measurable effect of the sympathectomy in the cerebral arteries of SHRSP is probably explained by a marked growth-stimulating effect of the high pressure load in these animals.
http://www.ncbi.nlm.nih.gov/pubmed/7701941

Postural Hypotension and Postural Dizziness

The subjects were 204 consecutive non–insulin-dependent patients with diabetes and 408 age- and sex-matched nondiabetic control subjects who underwent physical examinations for preventive reasons at the National Cheng Kung University Hospital between October 1992 and September 1994. Subjects were excluded from the study for sympathectomy, anemia, thyroid disorder, pregnancy, chronic alcohol use, and/or use of anti-Parkinson drugs, narcotics, sedatives, antipsychotic agents, or antidepressants within 2 weeks of the study. The subjects with diabetes included 114 men and 90 women with a mean age ± SD of 57.9 ± 10.5 years. The nondiabetic control subjects were 228 men and 180 women with a mean age ± SD of 57.1 ± 9.5 years.
Postural Hypotension and Postural Dizziness in Patients With Non–Insulin-Dependent Diabetes
Jin-Shang Wu, MD; Feng-Hwa Lu, MD; Yi-Ching Yang, MD; Chih-Jen Chang, MD
[+] Author Affiliations
Arch Intern Med. 1999;159(12):1350-1356. doi:10-1001/pubs.Arch Intern Med.-ISSN-0003-9926-159-12-ioi80679

Causes of orthostatic hypotension - surgical sympathectomy

Causes of orthostatic hypotension (modified from Simon et al9).
Hypovolemia or hemorrhage Addison’s disease Drug-induced hypotension • Antidepressants • Antihypertensives • Bromocriptine • Diuretics • Levodopa • Monoamine oxidase (MOA) inhibitors • Nitroglycerin • Phenothiazines Polyneuropathies • Myeloid neuropathy • Diabetic neuropathy • Guillain-Barre syndrome • Porphyric neuropathy • Vincristine neuropathy 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 (syphilis) • Wernicke’s encephalopathy Cardiovascular disorders Prolonged bed rest or immobilization
http://www.scribd.com/doc/15030687/Dizziness-Classification-and-Pathophysiology

significant fall in left circumflex coronary flow was proportional to the decline in external heart work due to sympathectomy

http://www.springerlink.com/content/k2n6j4555g16x773/

sympathectomy affects the heart, sweating, and circulation

heart rate was significantly reduced at rest (14%), at sub-maximal exercise (12.3%), and at peak exercise (5.7%), together with a significant increase in oxygen pulse (11.8, 12.7, and 7.8%, respectively). The rate pressure product (RPP) was also significantly reduced following the surgical procedure at all three study stages, while all other physiological variables measured remained unchanged. It is suggested that thoracic-sympathetic denervation affects the heart, sweating, and circulation of the respective denervated region

Eur J Appl Physiol. 2008 Sep;104(1):79-86. Epub 2008 Jun 10.

"ETS has proved moderately successful in treating hyperhidrosis, although the operation does carry a high risk of complications. "

Other complications of ETS include:

• sweating on the face and neck after eating food (gustatory sweating),
• inflammation of the nose (rhinitis), and
• air becoming trapped between the layers of the lung (pneumothorax) which can cause chest pain and breathing difficulties (although this usually resolves itself without the need for treatment).

Rarer complications of ETS include:

• Horner's syndrome, a condition that causes drooping of the eyelids, and
• damage to the phrenic nerve (a nerve that is used to help in breathing).

Phrenic nerve damage can lead to shortness of breath, though it may be possible to repair the nerve during surgery.

http://www.knowsley.nhs.uk/health-a-to-z/h/hyperhidrosis-excessive-sweating/

Ovarian sympathectomy as treatment for pain

Lateral pelvic structures receive their innervation mostly via nerve fibres traversing the infundibulopelvic ligaments. Thus, for lateral pelvic pain, ovarian sympathectomy could theoretically alleviate the pain. However it is rarely performed because of the high risk of vascular complication and its squeal on ovarian functions.

The Internet Journal of Gynecology and Obstetrics ISSN: 1528-8439

Chronic Pelvic Pain: A Frustrating Scenario
http://www.ispub.com/journal/the-internet-journal-of-gynecology-and-obstetrics/volume-10-number-1/chronic-pelvic-pain-a-frustrating-scenario.html

75% pneumothorax expected after sympathectomy

A small insignificant pneumothorax can be expected after ETS in about 75% of cases [15], which gets spontaneously absorbed, usually within 24 h.

Comparing T2 and T2–T3 ablation in thoracoscopic sympathectomy for palmar hyperhidrosis: a randomized control trial
A. N. Katara, J. P. Domino, W.-K. Cheah, J. B. So, C. Ning, D. Lomanto
Received: 13 October 2006/Accepted: 2 November 2006
Surg Endosc (2007) DOI: 10.1007/s00464-007-9241-9



[15] Ojimba TA, Cameron AEP (2004) Drawbacks of endoscopic thoracic sympathectomy. Br J Surg 91: 264–269



Permanent side effects included compensatory sweating in 67.4%, gustatory sweating in 50.7% and Horner's trias in 2.5%. However, patient satisfaction declined over time, although only 1.5% recurred. This left only 66.7% satisfied, and a 26.7% partially satisfied. Compensatory and gustatory sweating were the most frequently stated reasons for dissatisfaction. Individuals operated for axillary hyperhidrosis without palmar involvement were significantly less satisfied (33.3% and 46.2%, respectively).
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1234291/

sympathectomy improves skin blood flow at the thermoregulatory but not the nutritive level of skin microcirculation

sympathectomy improves skin blood flow at the thermoregulatory but not the nutritive level of skin microcirculation. This may be related to the fact that the thermoregulatory vessels are mainly sympathetically controlled, whereas the nutritive capillaries are mainly controlled by local (nonneural) factors.
http://www.springerlink.com/content/ukwtrn2y72age93t/

Depending on the series and the duration of follow-up, the success rate of sympathectomy varies from 12% to 97%

http://www.ispub.com/journal/the-internet-journal-of-pain-symptom-control-and-palliative-care/volume-2-number-1/complex-regional-pain-syndrome-a-clinical-review.html

typical CRPS changes also occur following sympathectomy, which has traditionally been considered curative of CRPS

(p.557) 

Handbook of Neurosurgery

Mark S. Greenberg

Thieme, 22/02/2010 - 1352 pages

For two decades, Handbook of Neurosurgery -- now in a fully updated seventh edition -- has been an invaluable companion for every neurosurgery resident and nurse, as well as neurologists and others involved in the care of patients with brain and spine disorders.

Sympathectomy has been discredited in this condition

Vasospastic conditions

Raynaud’s syndrome

http://surgeryonline.wordpress.com/category/arterial-disorders/

Drug warning - Karvezide, AVAPRO HCT - 'you must tell your doctor if you have had sympathectomy'

Tell your doctor if:

* you have had a sympathectomy

* you have been taking diuretics

*you have a history of allergy or asthma


www.racgp.org.au/cmi/swckarvz.pdf

2. Before you start to take AVAPRO HCT

Tell your doctor if:

• you suffer from any medical conditions especially-
  - kidney problems, or have had a kidney transplant or dialysis
  - heart problems
  - liver problems, or have had liver problems in the past
  - diabetes
  - gout or have had gout in the past
  - lupus erythematosus
  - high or low levels of potassium or sodium or other electrolytes in your blood
  - primary aldosteronism
• you are strictly restricting your salt intake
• you are lactose intolerant or have had any allergies to any other medicine or any other substances, such as foods, preservatives or dyes.
• have had a sympathectomy
• you have been taking diuretics
• you have a history of allergy or asthma

http://www.mydr.com.au/medicines/cmis/avapro-hct-300-25-tablets

Published by MIMS/myDr March 2011

UBM Medica Australia uses its best endeavours to ensure that at the time of publishing, as indicated on the publishing date for each resource (e.g. Published by MIMS/myDr January 2007), the CMI provided was complete to the best of UBM Medica Australia's knowledge.  

Cannon's law of denervation (supersensitivity)

Cannon's law of denervation states that when a tissue is deprived of its nerve supply, it will develop hypersensitivity to its own neurotransmitter(s). 

Adult and Pediatric Urology, Volume 2

Jay Young Gillenwater

1 Review

Lippincott Williams & Wilkins, 2002

An enigma in the past, and today a source of great interest to neurobiologists, the importance of denervation supersensitivity with regard to pain has not been appreciated. The implications of Cannon's Law of denervation are probably far more embracing than the few conditions briefly discussed here. It is possible that many other forms of pain, eg, trigeminal or postherpetic (neuralgic) and even chronic low-back pain, are a postdenervation supersensitivity phenomenon rather than the result of noxious stimuli. Thus, pain may be the central perception of 1) an afferent barrage from noxious stimuli or 2) the abnormal input into the central nervous system from ordinarily non-noxious stimuli rendered excessive through overly sensitive receptors (or a variable combination of both). Consider, therefore, the chronic "low back" patient whose discomfort still persists following resolution of the acute phase. Though not crippled or even in distress, he is unable to cope with any but light activities. Such a patient many not be "hyperalgesic" in that ordinarily non-noxious stimuli, eg, prolonged standing, sitting, or walking, can cause symptoms. "Pain" as a scientific term should preferably be discarded and a distinction made between "nociception" and "hyperalgesia," because different approaches are required in their management.
http://www.istop.org/spondylosis.html

Variations in dynamic lung compliance during endoscopic thoracic sympathectomy with CO2 insufflation

The current study examined the effects of capnothorax on dynamic lung compliance (DLC) of the ventilated lung during ETS.
One way analysis of variance (ANOVA) was used for analysis of data before, during and after OLCV. P<0.05 was considered significant. The mean values of the DLC were 52 +/- 6, 30 +/- 3, 39 +/- 5 and 53 +/- 9 ml/cmH(2)O before, during (at 10 and 5 mmHg IPP) and after OLCV respectively with significant differences before and at 10 and 5mmHg IPP. In conclusions, during OLCV and capnothorax for ETS, DLC tends to decrease with increasing of intrapleural CO(2) insufflation pressure. However, in short procedures it has no deleterious postoperative effect. To the best of our knowledge this is the first study performed to investigate DLC changes during OLCV with capnothorax.
Clin Auton Res. 2003 Dec;13 Suppl 1:I94-7.

Number of sympathectomies is on the increase in Australia - the power of medical advertising

years 2000 - 2001:
Total: 1034

years 2001-2002:
Total: 1575

years 2002 - 2003
Total: 1228

years 2003 - 2004
Total: 1193

years 2004 - 2005
Total: 1483

years 2005 - 2006
Total:1358

years 2006 - 2007
Total: 972

years  2007 - 2008
Total: 850

years 2008 - 2009
Total: 891

years  2009 - 2010
Total: 1083

source: aihw.gov.au

Iatrogenic harlequin syndrome resulting from sympathectomy

Postgrad Med J 2003;79:278 doi:10.1136/pmj.79.931.278

A 29 year old man with severe facial hyperhidrosis underwent an uncomplicated right thoracoscopic sympathectomy. Before operating on his left side, a starch-iodine preparation was applied to his face in order to demarcate residual sudomotor function. The preparation becomes blue on exposure to moisture, thereby representing residual sweat gland activity.

Figure 1 demonstrates that sympathetic innervation to the face is strictly unilateral, and nerve fibres do not appear to cross the midline. This is essentially an iatrogenic variation of the harlequin syndrome,² which usually results from interruption of post-ganglionic sympathetic fibres secondary to malignant invasion.

His facial hyperhidrosis was completely treated once the contralateral sympathectomy was performed.

T3 sympathectomy leads to subclinical pupillary dysfunction with a tendency for miosis

We found statistically significant differences (P < 0.001) between the preoperative P/I ratio [0.40 mm (standard deviation, SD 0.07 mm)] and the postoperative basal ratio [0.33 (SD 0.05)] at 24 h. The P/I ratio at 24 h increased from 0.33 to 0.36 (SD 0.09), a nonsignificant increase (P = 0.45), after instillation of medicated eye drops. No differences were observed between the preoperative [0.40 (SD 0.07)] and 1-month basal values [0.38 (SD 0.07)], and instillation of apraclonidine no longer induced a hypersensitivity response.

CONCLUSIONS:

T3 sympathectomy leads to subclinical pupillary dysfunction with a tendency for miosis, even though this impairment is not generally evident on standard physical examination or reported by patients. This subclinical dysfunction may be caused by injury to an undefined group of presympathetic nerve cell axons in caudocranial direction that communicate with the cervical sympathetic ganglia and whose function is mydriatic pupillary innervation.
http://www.ncbi.nlm.nih.gov/pubmed/22044979

nerves that sent blood-pressure-raising flight-or-fight signals to the brain were cut

page 187:
It was a grueling operation called sympathectomy, in which the nerves that sent blood-pressure-raising flight-or-fight signals to the brain were cut...The nerve cutting scrambled signals to her circulatory system. She was cold on one side of her body and warm on the other.

The Happy Bottom Riding Club: The Life and Times of Pancho Barnes (Paperback)

by Lauren Kessler (Author)

The second thoracic sympathetic ganglion was most commonly located (50%) in the second intercostal space

Presence of the stellate ganglion was noted in 56 (84.8%) sides, and 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.

J Thorac Cardiovasc Surg  2002 Mar;123(3):498-501

Chung IH, Oh CS, Koh KS, Kim HJ, Paik HC, Lee DY.

Sympathectomy increased the pain threshold and made the sympathectomized rats hypesthetic.

Normal adult rats were sympathectomized at L2-L3. The threshold for thermal noxious pain by hot-plate analgesia test and changes in neuropeptides in the lumbar dura mater and dorsal root ganglia using light microscopic immunohistochemistry were assessed and compared with control rats.

Results: In the hot-plate analgesia test, sympathectomized rats increased their hot-plate latency time compared with that of sham-operated rats. Density of calcitonin gene-related peptide immunoreactive fibers in sympathectomy side of the lumbar dura mater decreased to 45.5% compared with the contralateral side. The number and size of calcitonin gene-related peptide immunoreactive cells in dorsal root ganglia showed no difference between sympathectomized and contralateral side.

Conclusion: Sympathectomy increased the pain threshold and made the sympathectomized rats hypesthetic. A large numbers of sensory fibers innervated the lumbar dura mater via L2-L3 sympathetic nerve in rats. Sympathectomy reduced the number of these nerve fibers in the lumbar dura mater. Sympathetic nerves may play an important role for low back pain involving the lumbar dura mater.

http://journals.lww.com/spinejournal/Abstract/1996/04150/An_Anatomic_Study_of_Neuropeptide.4.aspx

Long-term sympathectomy induces sensory and parasympathetic fibres sprouting, and mast cell activation in the rat dura mater

http://discovery.ucl.ac.uk/1330488/

There are similarities between the delayed onset of the human pain state and the delayed rise in sensory peptides after sympathectomy

The effect of sympathectomy on the calcitonin gene-related peptide (CGRP) level in the rat primary trigeminal sensory neurone was investigated. Six weeks after bilateral removal of the superior cervical ganglion there was a 70% rise in the CGRP content of the iris and the pial arteries, a 34% rise in the concentration in the trigeminal ganglion but no change in the brainstem. The CGRP rise in both end organs suggests that this phenomenon may be common to all peripheral organs receiving combined sensory and sympathetic innervations. The lack of any rise in the brainstem CGRP content raises the possibility that this process spares central terminations. In contrast, the level of neuropeptide Y, a peptide mainly contained in sympathetic terminals, fell to 35% of control values in the iris and pial arteries whilst the trigeminal ganglion and brainstem concentrations remained unchanged. The possible relevance of these observations to the clinical syndrome of postsympathectomy pain (sympathalgia) is discussed. There are similarities between the delayed onset of the human pain state and the delayed rise in sensory peptides after sympathectomy.
http://www.ncbi.nlm.nih.gov/pubmed/3877546

sympathectomy resulted in complete disappearance of histochemically detected adrenergic and a considerable decrease of cholinergic nerve fibers in the pial arterial walls

http://www.ncbi.nlm.nih.gov/pubmed/7173422

Digital infrared thermal image after T2 sympathicotomy or T3 ramicotomy

(A) Clear cut change of skin temperature after a T2 sympathicotomy. (B) An even distribution of skin temperature after ramicotomy.

Gossot and colleagues [8] analyzed a group of T2, T3, T4 sympathectomy patients in comparison with a group of patients undergoing a T2, T3, T4 ramicotomy and they reported no statistical difference regarding the incidence of CS between the two groups studied (72.2% and 70.9%). However in terms of the severity of CS (embarrassing, disabling) causing inconveniences to daily life, they reported 27% and 13% incidences in these two groups, respectively. These findings suggest that by preserving the sympathetic trunk, it was possible to reduce the severity of CS.

The preganglionic fibers of the sympathetic nerve to the arm originate mostly from the spinal segments T3–T6 and the postganglionic fibers of the sympathetic nerve to the arm originate from T2 and, to a lesser extent, the T3 ganglia [9]. This implies that the division of preganglionic fibers (rami communicantes) reduces the extent of denervation of the sympathetic nerve as compared with the division of postganglionic fibers (sympathetic trunk) in the treatment of palmar hyperhidrosis.
Sympathectomy or sympathicotomy is one of the procedures used to divide the sympathetic trunk. Sympathicotomy distinctively changes sympathetic nerve distribution in comparison with a ramicotomy. Figure 4A illustrates the clear-cut changes of skin temperature after a T2 sympathicotomy. However the overall sympathetic nerve distribution to the body is not markedly changed after a T3 ramicotomy because a T3 ramicotomy is a procedure that is used to divide one of the preganglionic fibers and to preserve the sympathetic trunk. Figure 4B illustrates an even distribution of skin temperature after T3 ramicotomy.

 http://ats.ctsnetjournals.org/cgi/content/full/78/3/1052#FIG4

Drionic effectively "...reduced sweating for up to 6 weeks..."

Clinical Studies

The following comments are from clinical studies which demonstrated the safety and effectiveness of Drionic:

1. Efficacy of the Drionic unit in the treatment of hyperhidrosis. J Am Acad Dermatol 1987;16:828-832. "...the Drionic unit appears to have a definite place in the treatment of hyperhidrosis." Daniel L. Akins, M.D. John L. Meisenheimer, M.D. Richard L. Dobson, M.D., Professor & Chairman, Dept. of Dermatology From the Department of Dermatology, Medical University of South Carolina, Charleston, South Carolina
   
2. A new device in the treatment of hyperhidrosis by iontophoresis. Cutis 1982;29:82-89. Drionic effectively "...reduced sweating for up to 6 weeks..." Further, the study concluded that "Because of its design, it has great potential for home use." CPT John L. Peterson, M.D. MAJ Sandra I. Read, M.D. COL Orlando G. Rodman, M.D. Chief, Dermatology Service From the Dermatology Service, Dept. of Medicine, Walter Reed Army Medical Center, Washington, DC
3. Tap water iontophoresis in the treatment of hyperhidrosis. Int J Dermatol 26;1987:194-197. "Tap water iontophoresis is a recognized method of reducing sweat in various parts of the body. The Drionic device is a battery-operated method of inducing tap water iontophoresis. This simple device may be used at home and is effective in reducing hyperhidrosis for as long as 6 weeks." Mervyn L. Elgart, M.D., Professor & Chairman, Dept. of Dermatology Glenn Fuchs, M.D. From the Department of Dermatology, George Washington Univ. Medical Center, Washington, DC.
4. Efficacy of the Drionic unit in the treatment of hyperhidrosis. JAm Acad Dermatol 16:828-832, Apr. 1987. Elgart ML, Fuchs G: Tap water iontophoresis in the treatment of hyperhidrosis. Int J Dermatol 26: 194-197, Apr. 1987. (old model)

Informing the patient of the seriousness of the consequences before this operation is absolutely necessary

http://ats.ctsnetjournals.org/cgi/content/full/80/3/1160-a

pathological pain, such as occurs in response to peripheral nerve injury

It is recently become clear that activated immune cells and immune-like glial cells can dramatically alter neuronal function. By increasing neuronal excitability, these non-neuronal cells are now implicated in the creation and maintenance of pathological pain, such as occurs in response to peripheral nerve injury.
http://www.ncbi.nlm.nih.gov/pubmed/17706291

CS is referred to as perilesional hyperhidrosis - the shifting narrative

Central and/or peripheral denervation of large numbers of sweat glands produces increased sweat output in innervated glands, maximal in contiguous dermatomal regions, occurs in PAF, Ross syndrome, SCI and post-surgical sympathectomy. (p.555)

Primer on the Autonomic Nervous System

David Robertson, Italo Biaggioni, Geoffrey Burnstock, Phillip A. Low, Julian F.R. Paton

Academic Press, 01/11/2011 - 730 pages

Sympathectomy, ganglionopathies and myelopathies produce such pattern

Segmental Anhidrosis

This pattern occurs when a large, contiguous body area of sweat loss with sharply demarcated borders conforming to sympathetic or somatic dermatomes are present.
Sympathectomy, ganglionopathies and myelopathies produces such pattern. When borders are not well defined and anhidrosis not contiguous, a regional pattern is said to exist. Both postganglionic and preganglionic lesions may produce these distributions. (p.557)

Primer on the Autonomic Nervous System

 edited by David Robertson, Italo Biaggioni, Geoffrey Burnstock, Phillip A. Low, Julian F.R. Paton

Disorders of sweating - Iatrogenic causes: Surgical sympathectomy/sympathotomy

(p. 558)

Primer on the Autonomic Nervous System

 edited by David Robertson, Italo Biaggioni, Geoffrey Burnstock, Phillip A. Low, Julian F.R. Paton

sympathectomy cannot by direct effect on the muscle vessels either abolish or lessen claudication

http://pmj.bmj.com/content/29/335/459

reductions in heart rate variability are a predictor of sudden cardiac death, even in individuals without a prior history of cardiovascular disease

Research indicates that a highly variable heart rate increases your capacity to respond and adapt to life’s challenges.
In a sense, it makes your cardiovascular system more flexible. If you’re less able to switch to the rest system, you’re more likely to feel stressed because your body is indicating that there’s danger in the environment – even if there isn’t.
Research has shown that reductions in heart rate variability are a predictor of sudden cardiac death, even in individuals without a prior history of cardiovascular disease.

1. Daniel Quintana

   PhD candidate and researcher at University of Sydney
   

2. Andrew Kemp

   NHMRC Career Development Fellow at University of Sydney
   

http://theconversation.edu.au/depression-can-break-your-heart-literally-1102

sympathectomy is not universally accepted as a treatment modality for CRPS in Australia

Sympathetic ganglion blockades may provide temporary relief to facilitate rehabilitation, but cervical sympathectomy is not universally accepted as a treatment modality for CRPS.
RACS Annual Scientific Congress, Thursday, 11 May 2007
ANZ J. Surg. 2007; 77: 603

"This is a field in which the unknown is still substantial and some of the known - controversial."

M. Hashmonai, ISSS President
6th International Symposium on Sympathetic Surgery (ISSS) 4th -6th May 2005, Vienna Medical Academy,  Austria

compensatory sweating was perceived in 56% of the adults and all of the children, or CS was lower in children - illustrations of typical contradictions about effects of ETS

compensatory sweating was perceived in 56% of the adults and all of the children. With the compensatory sweating, the effect on the life was severe in children and the patient's satisfaction was 50-60%, showing a large difference from the satisfaction of the adult patients at nearly 100%. As for other complications, neuralgia was recognized in 9% of the adults, but not in the children, and the crisis of perceptual disorder, hemorrhage and Horner's syndrome did not occur in both the adults and children. The compensatory sweating in the child patients was more remarkable than in the adult patients and the postoperative satisfaction was low, and it seems better to perform thoracoscopic sympathic blockade after the adolescence.
http://sciencelinks.jp/j-east/article/200513/000020051305A0251361.php

Do children tolerate thoracoscopic sympathectomy better than adults? CS appeared within 6 months postoperatively in 81.8% of all the patients but significantly less in children
(69.8%) compared to the others (88.5%; P < 0.001). CS increased with time in 12% of the participants, but decreased in 20.8% of the children versus 10.5% of the others (P = 0.034), usually within the first two postoperative years. The severity of the CS was also lower in children: it was absent or mild in 54.3% of the children versus 38.0% of the others, and moderate or severe in 45.7 versus 62%, respectively (P = 0.004). Fifty-one percent of the participants claimed that their quality of life decreased moderately or severely as a result of CS, but only one-third of them (7.9% children vs. 22.4% others, P = 0.001) would not have undergone the operation in retrospect.
http://www.ncbi.nlm.nih.gov/pubmed/17999068

Atrioventricular Block and Transient Prolongation of PQ Intervals after Endoscopic Thoracic Sympathectomy for Palmer Hyperhidrosis

http://sciencelinks.jp/j-east/article/199913/000019991399A0219673.php

hypoaesthesia in the bilateral axillar region after endoscopic thoracic sympathectomy for palmar hyperhidrosis

http://sciencelinks.jp/j-east/article/199920/000019992099A0655152.php

Heart Rate Variability before and after the Endoscopic Transthoracic Sympathectomy in Hyperhidrosis

The etiology of primary hyperhidrosis has been speculated as "unknown" hyperactivity of the sympathetic nervous system. In our clinic, we performed endoscopic transthoracic sympathectomy(ETS) for the treatment of hyperhidrosis. In this study, we studied the cardiac autonomic nervous function using heart rate variability(HRV) before and after ETS in 70 patients with hyperhidrosis, and compared with normal control. Before ETS, high frequency(HF) power was lower in hyperhidrosis than control group, however, there was no significant difference in LF/HF. After ETS, LF/HF decreased by 31%, and lower than control. No Severe cpomplications were occurred by ETS. In conclusion, on the cardiac autonomic nervous tone, hyperhidrosis patients had the relative dominance of the sympathetic nervous tone by suppression of the parasympathetic nervous tone. After ETS, the sympathetic nervous tone was suppressed. Clinical symptoms in hyperhidrosis patients were impoved by ETS. Although ETS affected the cardiac autonomic nervous tone, it was useful and safety method for hyperhidrosis.
http://sciencelinks.jp/j-east/article/200002/000020000299A0930354.php

sympathetic denervation-hypersensitivity and migraine

Regional cerebral blood flow (rCBF) and cerebral vasomotor responses to 5% CO₂ inhalation were measured before and after pharmacologic μ- or β-adrenoceptor manipulation in Migraine (M) and Cluster headaches (C).
There appears to be an asymmetrical adrenoceptor disorder in M and C possibly due to sympathetic denervation-hypersensitivity.

Headache: The Journal of Head and Face Pain

Volume 20 Issue 6, Pages 321 - 335

Published Online: 22 Jun 2005

http://www3.interscience.wiley.com/journal/119584269/abstract

Functional and organic vascular wall changes after sympathectomy and partial nerve damage

http://www.ncbi.nlm.nih.gov/pubmed/14443457

Persistent blushing as a side-effect of the surgery for blushing...

http://www.hyperhidrosis-usa.com/facial_blushing.html

It’s not unusual to hear people who have undergone sympathectomies describe themselves as feeling emotionally “colder” than before

It’s not unusual to hear people who have undergone sympathectomies describe themselves as feeling emotionally “colder” than before. Among psychologists and neurologists alike there is concern, but no evidence, that the procedure limits alertness and arousal as well as fear, and might affect memory, empathy and mental performance. Professor Ronald Rapee, the director of the Centre of Emotional Health at Sydney’s Macquarie University, says he’s counselled several people who complain of feeling “robot-like” in the long-term wake of the operation. “They’re happy they no longer blush, but they miss the highs and lows they used to feel.”
(John van Tiggelen, Good Weekend Magazine, The Age and the Sydney Morning Herald, 10th March 2012)
Full text of the article available here:
John van Tiggelen: RED ALERT 

our advice to patients must reflect the true potential outcomes

Dear Editor,

I refer to the article on palmar hyperhidrosis by Dr Sanjay Sharma (Managing palmar hyperhidrosis, March). I feel that the adverse effects [of thoracoscopic sympathectomy] are understated by my colleague. For example, compensatory hyperhidrosis is common, and can be disabling, leading to regret about the procedure in some patients (up to 51% in one review). Reversal of the procedure is difficult and requires sural nerve transplant if the sympathetic chain is removed.

The procedure can be effective and worthwhile, but our advice to patients must reflect the true potential outcomes.

Dr Ian Gilfillan, Cardiothoracic Surgeon


http://www.medicalhub.com.au/wa-news/letters/3217-palmar-hyperhidrosis-revisited

post-sympathectomy neuralgia is frequent

Surgical sympathectomy has a long heritage for the treatment of peripheral vascular disease and various chronic pain problems.

Despite concerns expressed as long ago as 1942 about the efficacy of surgical sympathectomy for the management of non-cancer pain, the procedure was enthusiastically pursued for the management of reflex sympathetic dystrophy or complex regional pain syndrome (CRPS), migraine, dysmenorrhea, epilepsy, chronic pancreatitis, postherpetic neuralgia of the trigeminal nerve, postdiscectomy syndrome, and phantom limb pain. However, systematic reviews have found no tangible evidence supportive of sympathectomy for the management of neuropathic pain. Furthermore, postsympathectomy neuralgia is a common complaint with a reported incidence between 15% to 50%.

As surgery is often mentioned as a cause of CRPS, it is somewhat illogical to consider surgery as an effective treatment. Nonetheless, surgical sympathectomy has a long anecdotal history in the treatment of RSD, and more recently endoscopic and radiofrequency sympathectomy has been tried.

Bonica's Management of Pain,

Lippincott Williams & Wilkins, 2009 - 2064 pages

Permanent pain following sympathectomy

The mean inpatient pain scores were significantly higher in the biportal group (1.2±0.6) than that in the uniportal group (0.8±0.5, P=0.025). For the first three weeks after operation, four out of 20 (20%) patients in the uniportal group constantly suffered from mild or moderate residual pain while eight out of 25 (32%) cases in the biportal group (P=0.366). Among them, two cases in the uniportal group and five cases in the biportal group need to take analgesics.
Chinese Medical Journal, 2009, Vol. 122 No. 13 : 1525-1528

impairment of the CBF autoregulation after unilateral cervical sympathectomy

Although these findings argued against a neurogenic mechanism, James at al. (1969) reported 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 autoregulation 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

Effect of Sympathectomy on Bone Repair

In each, there was a more rapid healing on the non-sympathectomized side, averaging 3 weeks sooner.

http://ebm.rsmjournals.com/content/30/2/123.extract

HAZARDS ASSOCIATED WITH CERVICO-THORACIC SYMPATHECTOMY

The following is a case report of a healthy 18-year-old woman who had bilateral Cervico- Thoracic sympathectomy done in two stages for severe hyperhidrosis in the palms of her hands.
Two episodes of asystolic arrest occurred during the 2nd stage left Cervico-Thoracic sympathec- tomy.

Thirty-five minutes after starting the operation, as the surgeon was retracting and dissecting the upper thoracic chain,
the cardiac monitor showed sudden onset of sinus bradycardia. The pulse rate was 50 beats per minute. Atropine 1·2 mg was given intravenously but cardiac asystole occurred.
External cardiac compression was started and another dose of atropine 1· 2 mg was given, followed by adrenaline 1·0 mg but there was no response. Following a second dose of adrenaline 1·0 mg and sodium bicarbonate 100 mEq, the
heart restarted with a marked sinus tachycardia.

The cause of hyperhidrosis apparently originates from some poorly understood stimulation of the sympathetic nervous system (Cloward 1969), and in sensitive patients this may possibly lead to excessive vagal stimulation to counteract it, as illustrated by the bradycardia and asystolic reaction to the sudden removal of the sympathetic control, and by the high doses of sympathomimetic drugs necessary to recommence cardiac activity. Anatomically the heart is innervated by the cardiac plexus which consists of the cardiac nerves derived from the cervical and upper thoracic ganglia of the sympathetic trunk and branches of the vagus.The pacemaker of the heart, the sino-atrial node, is innervated by both the parasympathetic and sympathetic nerves (King and Coakley 1958). The ventricular muscle of the heart is supplied solely by the sympathetic nerves, and the larger branches of the coronary arteries are also predominantly innervated by sympathetics (Woollard 1926). These factors may also have a bearing on the hazard of a bilateral cervico- thoracic sympathectomy, which leaves the heart solely under vagal control. Usually, following
denervation, the heart will initiate its own impulse, without recourse to external agencies, but there may be a place for transvenous electrode cardiac pacing, if spontaneous initiationof impulse is delayed, or bradycardia is severe.

R. F. Y. ZEE*
Royal Perth Hospital, Perth
Anaesthesia and Intensive Care, Vol. V, No. 1, February, 1977, Australia

a reduction of the muscular tone and to a secondary neurovascular disorder at the edge of the sympathetic denervation zone

Surgical sympathectomies and chemical sympatholyses bring about a true sympathetic deafferentation. This leads to central retrograde degenerescence reactions of the pre-ganglionic neurons, to a reduction of the muscular tone and to a secondary neurovascular disorder at the edge of the sympathetic denervation zone.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Retrieve&list_uids=2256535&dopt=abstractplus

A POTENTIAL DANGER DURING ENDOSCOPIC THORACIC SYMPATHECTOMY

1.  *Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
2. †Department of Surgery, University of Sydney, Sydney, New South Wales, Australia

Australian and New Zealand Journal of Surgery

Volume 67, Issue 8, pages 578–579, August 1997

A report of a patient with an azygos lobe and an associated anomalous azygos vein covering the upper thoracic sympathetic chain. This anomaly poses a significant risk during the procedure of endoscopic thoracic sympathectomy. A chest X-ray is useful in detecting this anomaly and alerting the surgeon to potential problems.

CAUSES AND MANAGEMENT OF ORTHODEOXIA - The Australian Short Course on Intensive Care Medicine, 2005

DEFINE AND LIST THE CAUSES AND MANAGEMENT OF PLATYPNOEA AND
ORTHODEOXIA

p. 79:
Autonomic
o Parkinson disease (Hussain 2004)
o Bilateral thoracic sympathectomy (van Heerdon 2004)

Published in 2005 by
The Australasian Academy of Critical Care Medicine
“Ulimaroa”
630 St Kilda Rd, Melbourne,
Victoria 3004

ISSN 1327-4759

Occurrence and multiple recurrence of severe vasospasm of the upper extremity following thorascopic sympathectomy for hyperhidrosis

http://www.ncbi.nlm.nih.gov/pubmed/21130009

St Vincent’s Hospital in Melbourne does not perform sympathectomies or gastric banding

http://www.svhm.org.au/gp/clinics/Pages/Hepatobiliary.aspx
https://archive.today/B22NT

Although bilateral sympathectomy almost totally depleted the NA from the right atrium (by 98%), the NPY-ir levels were only reduced by 50%

Unilateral and bilateral sympathectomy produced similar reductions in the concentrations of NPY-ir and NA in the ventricular tissue.
Maccarrone C, Jarrott B.

Source

University of Melbourne, Department of Medicine, Austin Hospital, Heidelberg, Vic., Australia.
http://www.ncbi.nlm.nih.gov/pubmed/3450689

reduced oxygen saturation and shallow respiration after a thoracoscopic sympathectomy

1. D. J. Canty1,2,3,* and  C. F. Royse4,5

¹Department of Anaesthesia, Royal Hobart Hospital, 48 Liverpool Street, Hobart, Tasmania 7000, Australia

1. ²Medical School of The University of Tasmania, Tasmania, Australia
2. ³Department of Pharmacology, The University of Melbourne, Melbourne, Australia
3. ⁴Anaesthesia and Pain Management Unit, Department of Pharmacology, University of Melbourne, Melbourne, Australia
4. ⁵Royal Melbourne Hospital, Victoria, Australia

1. *Corresponding author. E-mail: david.canty@dhhs.tas.gov.au 
2.     http://bja.oxfordjournals.org/content/103/3/352.full

Cervical sympathetic chain injury is a rare complication of surgery for thyroid and parathyroid conditions

ANZ Journal of Surgery. 74(6):442-445, June 2004.
HARDING, JANE L. MB BS; SYWAK, MARK S. MB BS, FRACS; SIDHU, STAN MB BS, PhD, FRACS; DELBRIDGE, LEIGH W. MD, FRACS

Many patients come initially to the surgeon and they want a permanent effective cure

http://www.southernvascular.com.au/html/procedures_sympathectomy.html

A statistically significant drop in the level of norepinephrine occurred in all assessed patients after sympathectomy - the 'lobotomy' effect

http://icvts.oxfordjournals.org/content/5/4/464.full

 As a stress hormone, norepinephrine affects parts of the brain where attention and responding actions are controlled.
Along with epinephrine, norepinephrine also underlies the fight-or-flight response, directly increasing heart rate,
triggering the release of glucose from energy stores, and increasing blood flow to skeletal muscle.

Norepinephrine is also released from postganglionic neurons of the sympathetic nervous system, to transmit the
fight-or-flight response in each tissue respectively. The adrenal medulla can also be counted to such postganglionic
nerve cells, although they release norepinephrine into the blood.
Norepinephrine system
The noradrenergic neurons in the brain form a neurotransmitter system, that, when activated, exerts effects on large
areas of the brain. The effects are alertness and arousal, and influences on the reward system.

www.caam.rice.edu/~cox/wrap/norepinephrine.pdf

"I think the surgeons may not be aware of the long term consequences of denervation"

Email response from Dr. Ahmet Hoke of  John Hopkins School of Medicine,  School of Neurology - Specifically I asked him his opinion on three things:

1. What was his opinion of ETS in terms of risks vs benefits
2. His opinion on why Thoracic surgeons would advertise a surgical reversal approach when, as he sees it, it would  have a very low probability of success
3. His opinion on the Davinci Robot Reversal article regarding surgical reattachment of the sympathetic nerves

1. It all depends on the risk benefit analysis, for some patients yes it may make sense as not everyone develops as severe side effects.
2. I think the surgeons may not be aware of the long term consequences of denervation.

The paper you refer to is not a good model of what happens to the patients because they cut the nerve and immediately repaired it. In such immediate repairs, the ganglia does not loose it's neurons and can regenerate. A better model would be to cut the nerves, wait 6 months and then do the repair; I suspect the recovery would be a lot less.
Ahmet Hoke M.D., Ph.D. FRCPC
Professor of Neurology and Neuroscience
Director, Neuromuscular Division
Johns Hopkins School of Medicine
Department of Neurology
855 N. Wolfe St., Neurology 248
Baltimore, MD, 21205
USA

diabetic autonomic neuropathy has already sympathectomized the patient

This diabetic syndrome has been attributed to a lesion of the sympathetic nerve fibres which control sweat secretion [11] and follow the course of the peripheral nerves [12]. This affects the efferent branch of the reflex arch and is identical to that occurring distal to a surgical sympathectomy [13].

There was no difference found between the histological changes in the nerves of the spontaneous anhidrotic patients
(Fig. 1) and those of the two previously sympathectomized patients.

A number of papers have been published which stressed [22-24] the high failure rate of sympathectomy operations in diabetics. We believe that the failure of the operation is due to the fact that diabetic autonomic neuropathy has already sympathectomized the patient. The results of the present study are compatible with this idea.
http://www.springerlink.com/content/v21h52461037653k/

A dysesthetic syndrome can occur after sympathectomy

A dysesthetic syndrome can occur after sympathectomy; it usually is transient but sometimes can be persistent.

Eugenia-Daniela Hord, MD, Instructor, Departments of Anesthesia and Neurology, Massachusetts General Hospital Pain Center, Harvard Medical School

Surgical procedure advertised as 'reversible' is not reversible

a recent consensus statement by the Society of Thoracic Surgeons recommended that the clipping method should be considered irreversible as the clipped nerve might not be able to recover after the removal of clips [6].
Ann Thorac Surg 2011;91:1642-8.

extreme case of compensatory truncal hyperhidrosis and anhidrosis over the head and neck region which led to a heatstroke

Thoracic sympathectomy is a commonly performed surgical procedure for the treatment of palmar hyperhidrosis. However, one major complication of such a procedure is compensatory truncal hyperhidrosis. We describe an extreme case of compensatory truncal hyperhidrosis and anhidrosis over the head and neck region which led to a heatstroke.

http://icvts.oxfordjournals.org/content/early/2011/12/20/icvts.ivr121.abstract?sid=89a2ce71-1ea3-4573-9e63-17329e7c09cd

Presence of intense dyschromia in the region corresponding to anhidrosis after sympathectomy

http://ats.ctsnetjournals.org/cgi/content/full/88/4/e42

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

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.

distinct patterns of peripheral physiological activity are associated with different emotion

The existence of specific somatic states associated with different emotions remains controversial. In this study, we investigated the profile of cardiorespiratory activity during the experience of fear, anger, sadness and happiness. ECG and respiratory activity was recorded in 43 healthy volunteers during the recall and experiential reliving of one or two potent emotional autobiographical episodes and a neutral episode. Univariate statistics indicated that the four emotions differed from each other and from the neutral control condition on several linear and spectral indices of cardiorespiratory activity. Dependent variables were further reduced to five physiologically meaningful factors using an exploratory principal component analysis (PCA). Multivariate analyses of variance and effect size estimates calculated on those factors confirmed the differences between the four emotion conditions. A stepwise discriminant analyses predicting emotions using the PCA factors led to a classification rate of 65.3% for the four emotions (chance=25%; p=0.001) and of 72.0-83.3% for pair-wise discrimination (chance=50%; p's<0.05). These findings may be considered preliminary in view of the small sample on which the multivariate approach has been applied. However, this study emphasizes the need to better characterize the multidimensional factors involved in cardio-respiratory regulation during emotion. These results are consistent with the notion that distinct patterns of peripheral physiological activity are associated with different emotions.

http://www.ncbi.nlm.nih.gov/pubmed/16439033

Changes in TH mRNA levels after cold stress or sympathectomy were eliminated by denervation of the adrenal gland

http://www.ncbi.nlm.nih.gov/pubmed/2427735

sympathicotomy may cause a temporary impairment of the caudal-to-rostral hierarchy of thermoregulatory control and changes in microcirculation

Patients with palmar hyperhidrosis have been reported to have a much
more complex dysfunction of autonomic nervous system, involving compensatory high parasympathetic
activity as well as sympathetic overactivity (13, 14), suggesting that sympathicotomy initially induces a
sympathovagal imbalance with a parasympathetic predominance, and that this is restored on a
long-term basis (14). Therefore, thoracic sympathicotomy may cause a temporary impairment of the
caudal-to-rostral hierarchy of thermoregulatory control and changes in microcirculation. The reduction
of finger skin temperature on the non-denervated side may be due to either a decrease in the cross-
inhibitory effect or the abnormal control of the inhibitory fibers by the sudomotor center (6).
Vasoconstrictor neurons have been found to be largely under the inhibitory control of various afferent
input systems from the body surface, whereas sudomotor neurons are predominantly under excitatory
control (15). The basic neuronal network for this reciprocal organization is probably located in the spinal
level (15). Therefore, the reduction in the contralateral skin temperature may be explained by cross-
inhibitory control of various afferent in the spinal cord.
In particular, our study showed that, following bilateral T3 sympathicotomy, the skin temperatures on
the hands increased whereas the skin temperatures on the feet decreased. These findings suggest a
cross-inhibitory control between the upper and lower extremities. However, the pattern of skin
temperature reduction on the feet differed from that on the contralateral hand. The skin temperature on
the feet did not decrease after right T3 sympathicotomy but decreased significantly after bilateral T3
sympathicotomy.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2722005/

significant impairment of the heart rate to workload relationship was consistently observed following sympathectomy

The aim of the present prospective study was to confirm that a significant impairment of the heart rate to workload relationship was consistently observed following unilateral and/or bilateral (sympathectomy) surgery. Eur J Cardiothorac Surg 2001;20:1095-1100 http://ejcts.ctsnetjourna...i/content/full/20/6/1095

a correlation of the findings of cytoarchitectonics and sympathectomy with fibre degeneration following dorsal rhizotomy

Autonomic neurons in the spinal cord of the rhesus monkey: a correlation of the findings of cytoarchitectonics and
sympathectomy with fibre degeneration following dorsal rhizotomy.
J Comp Neurol 146:189 –218.
http://onlinelibrary.wiley.com/doi/10.1002/cne.901460205/abstract


Cytoarchitecture or Cytoarchitectonics is the study of the cellular composition of the body's tissues under the microscope.

Objective Assessment Of Sudomotor Response Following Thoracoscopic Sympathectomy

http://www.aats.org/annualmeeting/Abstracts/2006/AM06_44.html

Bradicardia, hypotension and hypoxia are frequently observed during thoracic sympathicotomy

Clinical Autonomic Research

Volume 13, Number 2, 147-161, DOI: 10.1007/s102860300008

ISSS-ABSTRACTS

5^th International Symposium on Sympathetic Surgery 29^th–31^th May 2003

Psychiatrist treating patients with cardiac problems ?

"The guidelines for the block in individual cases:
Sweating of the underarms and hands - T4 or T5
Sweating of the face and blushing - T3 or T4
Blushing of the face alone - T2
Social anxiety with blushing - T2
Social anxiety without FB - T3 and T4 on the left side only
Heart racing and rhythm disorders - T3, T4, and T5 on the left side only "

Telaranta also claims that  after clamping/crushing the nerve  and subsequent removal of the titanium clips, the sympathetic chain will regain full function. Sadly, this is an unproven and unsubstantiated claim.

He also claims that his procedure is "more gentle". Nerve injury - no matter how acquired - remains a nerve injury with it's complications.  
http://www.privatix.fi/index.shtml?&a=0&s=navig_03&l=en&d=01_details

sympathectomy results in a pronounced increase of cerebrospinal fluid production

Electrical stimulation of the sympathetic nerves, which originate in the superior cervical ganglia, induces as much as 30% reduction in the net rate of cerebrospinal fluid (CSF) production, while sympathectomy results in a pronounced increase, about 30% above control, in the CSF formation. There is strong reason to believe that the choroid plexus is under the influence of a considerable sympathetic inhibitory tone under steady-state conditions.

http://ukpmc.ac.uk/abstract/MED/6276421