"He knows the procedure is controversial because of the unpredictability of side-effects"

Information about surgery for sweaty hands:  surgeon "knows the procedure is controversial because of the unpredictability of side-effects"



"Ferrar believes much of the controversy lies in surgeons, mainly in America, who perform the surgery on anyone who asks for it, rather than the severe end of the spectrum.
"In America there are so many that have been operated on when it hasn't been necessary, or the surgeon has given the patient false expectations, that there are support groups for people who've had complications or adverse effects. The people that come to me are almost self-selecting; they've tried everything else."
The youngest patient he has performed an endoscopic thoracic sympathectomy on was 8 years old, with most being in puberty (when the condition tends to arise). Or they are in their 20s when they are beginning relationships and jobs."



Publication info: Waikato Times [Hamilton, New Zealand] 07 Apr 2012: 22."

Chest pain, chest hypersensitivity, arm pain, paraesthesias of the upper limb and the thoracic wall, and recurrent pain in the axillary region have all been described

"Chest pain, chest hypersensitivity, arm pain, paraesthesias of the upper limb and the thoracic wall, and recurrent pain in the axillary region have all been described. Intra-operative intrapleural analgesia using bupivacaine can help reduce postoperative pain. Using a 5 mm rather than 1cm post causes less postoperative discomfort, particularly in women with narrow intercostal spaces.

Complications in Vascular and Endovascular Surgery: How to avoid them and how to get out of trouble


Jonothan J Earnshaw, Michael Wyatt,

tfm Publishing Limited, Jan 1, 2012 - Medical - 318 pages"

Sympathectomy is by no means a benign procedure, and sympathectomy for sweating can induce pain and allodynia

"Sympathectomy is by no means a benign procedure, and sympathectomy for sweating can induce pain and allodynia at the border zone which is sometimes associated with pronounced increase in sweating in that area." (p. 534) Surgical Disorders of the Peripheral Nerves by Rolfe Birch Springer, Jan 21, 2011 - Medical - 512 pages original article published in Ann R Coll Surg Engl 2002; 84:181-184"

the autonomic nervous system varies in a unique, autonomous manner, and it is therefore difficult to assess changes in patients in a uniform manner

There are several reasons that stellate ganglion block affects the cardiovascular system. Stellate ganglion block will initially affect both the sympathetic and parasympathetic nervous systems based on the degree of block. The intensity of right stellate ganglion blockage of the sympathetic and parasympathetic nervous system will result in heart rate changes and altered activity of the sympathetic and parasympathetic nervous system. Efferent sympathetic innervation from the right stellate ganglion is primarily distributed over the sinus node of the heart, and the influence of the autonomic nervous system and left stellate ganglion block should be assessed. Further, results will be affected by the health status of participants.

Although efferent sympathetic nerves from the stellate ganglion are primarily distributed over the heart, efferent sympathetic fibers from the 2nd to 5th thoracic ganglia affect the heart as well. Accordingly, the autonomic nervous system of the heart is not completely dependent on the stellate ganglia. The influence of the autonomic nervous system cannot be excluded as well. It is worth noting that the mepivacaine in the present study was a lower dosage than those used in other studies. Finally, the autonomic nervous system varies in a unique, autonomous manner, and it is therefore difficult to assess changes in patients in a uniform manner or just through the application of one or two indicators. Future studies should examine diverse methods for the assessment of autonomic nervous system function.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2872892/

peripheral sympathectomy causes a dramatic increase in NGF levels in the denervated organs

Increased Nerve Growth Factor Messenger RNA and Protein

Peripheral NGF mRNA and protein levels following
sympathectomy
It has been shown previously that peripheral sympathectomy
causes a dramatic increase in NGF levels in the denervated
organs (Yap et al., 1984; Kanakis et al., 1985; Korsching and
Thoenen, 1985).
Increased ,&Nerve Growth Factor Messenger RNA and Protein
Levels in Neonatal Rat Hippocampus Following Specific Cholinergic
Lesions
Scott R. Whittemore,” Lena Liirkfors,’ Ted Ebendal,’ Vicky R. Holets, 2,a Anders Ericsson, and HBkan Persson
Departments of Medical Genetics and’ Zoology, Uppsala University, S-751 23 Uppsala, Sweden, and *Department of
Histology, Karolinska Institute, S-104 01 Stockholm, Sweden

Stratified analysis of clinical outcomes in ... [Ann Thorac Surg. 2008] - PubMed - NCBI

"Significant compensatory sweating in relation to the level(s) of sympathetic chain division occurred in T2 alone, 45%; T2 to T3, 30%; T3 to T4, 14%; T2 to T4, 38%; and more than three levels, 49%"



Ann Thorac Surg. 2008 Feb;85(2):390-3;

http://www.ncbi.nlm.nih.gov/pubmed/18222231

our results indicate that the sympathetic innervation of cutaneous vessels is essential for the precise regulation of tail heat loss

"Neuroscience Letters. Mar2013, Vol. 537, p11-16. 6p."

Surprisingly, many patients experienced mild recurrent symptoms within the first year

Sympathicotomy for isolated facial blushing:... [Ann Thorac Surg. 2012] - PubMed - NCBI: "Mild recurrence of facial blushing occurred in 30% of patients within the first year. One patient experienced Horner's syndrome. Compensatory sweating occurred in 93% of patients, gustatory sweating 36%, and dry hands in 66%; 13% of patients regretted the operation despite thorough preoperative selection and information."

Patients who undergo sympathotomy for hyperhidrosis will commonly report "clinically bothersome" compensatory hyperhidrosis.

J Thorac Cardiovasc Surg. 2014 Apr;147(4):1160-1163.e1. doi: 10.1016/j.jtcvs.2013.12.016. Epub 2014 Jan 2.

Sympathectomy causes wall thinning, elongation, convolution, and aneurysm formation

"Sympathectomy causes basilar artery enlargment, which is beneficial for maintaining cerebral blood flow; however, it also causes wall thinning, elongation, convolution, and aneurysm formation, which may be hazardous in stenoocclusive carotid artery disease. Sympathectomy can prevent new vessel formation and hyperthyrophic changes at the posterior circulation. Neovascularisation is not detected adequately in sympathectomised animals."



Acta Neurochirurgica156.5 (May 2014): 963-9.

"The custom of a majority is no guarantee of safety and is seldom a guide to best medical practice." in Legal Forum

Cameron`s claim that there has been only one death attributable to synchronous bilateral thoracoscopic sympathectomy is implausible. Surgeons and anaesthetists are reticent in publicizing such events and Civil Law Reports of settled cases are an inadequate measure of the current running total. The custom of a majority is no guarantee of safety and is seldom a guide to best medical practice.
Jack Collin,
Consultant Surgeon
Oxford
http://www.bmj.com/content/320/7244/1221?tab=responses

the sympathetic fibers passing through the T2-3 ganglia play an important role in the elaboration or modulation of autonomic function elsewhere

The data indicate that the sympathetic fibers passing through the T2-3 ganglia play an important role in the elaboration or modulation of autonomic function elsewhere.

Journal of the Autonomic Nervous System
Volume 8, Issue 1, May 1983, Pages 33-43

This is the first study to examine post-SE (post-sympathectomy) dysfunction objectively

This is the first study to examine post-SE dysfunction objectively using TG after ALIF and XLIF, and the first to evaluate clinically, the severity of the post-SE syndrome. Before surgery we cannot foresee potentially poor SE results. For this reason, injury to the sympathetic chain during surgery must be avoided. The advantage of TG for identifying SE is its non-invasiveness and reliability.

The aim of this study was to identify retrospectively, lumbar sympathectomy (SE) using thermography (TG) and to evaluate clinically, the severity of post-sympathectomy (post-SE) dysfunction after anterior and lateral lumbar interbody fusion procedures (ALIF, XLIF).
http://www.ncbi.nlm.nih.gov/pubmed/24263213

Inflammation in dorsal root ganglia after peripheral nerve injury: Effects of the sympathetic innervation

Following a peripheral nerve injury, a sterile inflammation develops in sympathetic and dorsal root ganglia (DRGs) with axons that project in the damaged nerve trunk. Macrophages and T-lymphocytes invade these ganglia where they are believed to release cytokines that lead to hyperexcitability and ectopic discharge, possibly contributing to neuropathic pain. Here, we examined the role of the sympathetic innervation in the inflammation of L5 DRGs of Wistar rats following transection of the sciatic nerve, comparing the effects of specific surgical interventions 10-14days prior to the nerve lesion with those of chronic administration of adrenoceptor antagonists. Immunohistochemistry was used to define the invading immune cell populations 7days after sciatic transection. Removal of sympathetic activity in the hind limb by transecting the preganglionic input to the relevant lumbar sympathetic ganglia (ipsi- or bilateral decentralization) or by ipsilateral removal of these ganglia with degeneration of postganglionic axons (denervation), caused less DRG inflammation than occurred after a sham sympathectomy. By contrast, denervation of the lymph node draining the lesion site potentiated T-cell influx. Systemic treatment with antagonists of α1-adrenoceptors (prazosin) or β-adrenoceptors (propranolol) led to opposite but unexpected effects on infiltration of DRGs after sciatic transection. Prazosin potentiated the influx of macrophages and CD4+ T-lymphocytes whereas propranolol tended to reduce immune cell invasion. These data are hard to reconcile with many in vitro studies in which catecholamines acting mainly via β2-adrenoceptors have inhibited the activation and proliferation of immune cells following an inflammatory challenge.
Auton Neurosci. 2013 Dec 23.
http://www.ncbi.nlm.nih.gov/pubmed/24418114

Surgical sympathectomy is rarely performed and its use remains controversial

Although improved in some, persistent or recurrent symptoms were present in all patients after six months postoperatively. Increased sensitivity of digital vessels to circulating catecholamines, nerve fiber regeneration or incomplete sympathectomy have been postulated to lead to recurrence. Five patients developed Horner's syndrome postoperatively. A portion of the stellate ganglion was intentionally resected in 3 of the 5 patients.
http://www.ncbi.nlm.nih.gov/pubmed/8370999

"synaptic reorganization in the sympathetic chain or spinal cord after sympathectomy" - MAYO Clinic

http://www.mayoclinic.org/documents/mc5520-06pdf/DOC-20077566

prolongation of the isometric (tension) period (TP) of the left ventricle occurred in the majority (72 per cent) of all cases after sympathectomy

The prolongation of the isometric (tension) period (TP) of the left ventricle which occurred in the majority (72 per cent) of all cases after unilateral or bilateral transthoracic sympathectomy (without or with unilateral or bilateral transthoracic splanchnicotomy) indicates a diminution of inotropic cardiac action. It can be assumed to correspond to the cholinergic (vagal) preponderance which results from a partial or complete sympathetic denervation of the heart. Reduction of the pulse pressure oc-

curred in 56 per cent of the cases, probably due to the same mechanism.

www.chestjournal.org/content/38/4/423.full.pdfby W RAAB - 1960

change in sympathetic nervous system activity after thoracic sympathectomy

The photoplethysmographic (PPG) signal, which measures cardiac-induced changes in tissue blood volume by light transmission measurements, shows spontaneous fluctuations. In this study, PPG was simultaneously measured in the right and left index fingers of 16 patients undergoing thoracic sympathectomy, and, from each PPG pulse, the amplitude of the pulse (AM) and its maximum (BL) were determined. The parameter AM/BL is proportional to the cardiac-induced blood volume increase, which depends on the arterial wall compliance. AM/BL increased after the thoracic sympathectomy treatment (for male patients, from 2.60±1.49% to 4.81±1.21%), as sympathetic denervation decreases arterial tonus in skin. The very low-frequency (VLF) fluctuations of BL or AM showed high correlation (0.90±0.11 and 0.92±0.07, respectively) between the right and left hands before the thoracic sympathectomy, and a significant decrease in the right-left correlation coefficient (to 0.54±0.22 and 0.76±0.20, respectively) after the operation. The standard deviation of the BL or AM VLF fluctuations also reduced after the treatment, indicating sympathetic mediation of the VLF PPG fluctuations. The study also shows that the analysis of the PPG signal and the VLF fluctuations of the PPG parameters enable the assessment of the change in sympathetic nervous system activity after thoracic sympathectomy.

Medical and Biological Engineering and Computing

2001, Volume 39, Issue 5, pp 579-583
http://link.springer.com/article/10.1007%2FBF02345149

The graph shows an overall shorter survival rate of sympathectomised rats

Results

                Graph 1 shows the survival rate in both sympathectomised and non sympathectomised rats after the administration of YA cells. The graph shows an overall shorter survival rate of sympathectomised rats. In both groups there is a steep decrease in survival after 15 days, causing the median survival rate (18 days) of both groups to overlap. On the other hand the net survival rate is increased in non sympathectomised rates by 6 days

References:

1.        Ewa Chelmicka – Szorc, Barry G. W. Arnason. Effect of 6-Hydroxydopamine on Tumor Growth. CANCER RESEARCH 1976, 36, 2382-2384.

2.        Boris Mravec, Neurobiológia chorôb periférnych tkanív, Bratislava, SAP 2008, 220 s.,  ISBN 978-80-8095-030-9

3.        Raju B, Haug SR, Ibrahim SO, Heyeraas KJ. Sympathectomy decreases size and invasiveness of tongue cancer in rats. Neuroscience. 2007;149(3):715-25.

4.        Mravec B ,Gidron Y,Hulin I. Neurobiology of cancer: Interactions between nervous, endocrine

and immune systems as a base for monitoring and modulating the tumorigenesis by the brain. Seminars in Cancer Biology 18 (2008) 150–163.

5.        Paul G. Green,Wilfrid Janig, Jon D. Levinel. Negative Feedback Neuroendocrine Control of Inflammatory Response in the Rat is Dependent on the Sympathetic Postganglionic Neuron. The Journal of Neuroscience, 1997, 17(8):3234 –3238

6.      Aparna A. Bhanushali , R. Raghunathan , Rajiv D. Kalraiya , Narendra G. Mehta. Cancer-related anemia in a rat model: α2-macroglobulin from Yoshida sarcoma shortens erythrocyte survival. European Journal of Haematology 2002. 68(1),42 - 48

The effect of sympathectomy on the growth of intraperitoneally administered Yoshida ascitic cells in rats

El-Hassoun Olia, Coauthors: Zuzana Valašková, Ivan Hulín

Supervisor: Boris Mravec

Institute of Pathophysiology, LF UK Bratislava

http://svoc.fmed.uniba.sk/abstrakty/48/36.html

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

Bergerot, A; Aubineau, P; (1998) Long-term sympathectomy induces sensory and parasympathetic fibres sprouting, and mast cell activation in the rat dura mater. EUR J NEUROSCI , 10 79 - 79. 

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

Lewis rats are much more likely to develop autoimmune disorders after sympathectomy

Lewis rats are much more likely to develop autoimmune disorders after sympathectomy 
(Dimitrova and Felten, 1995). This finding suggests that if sympathetic regulation were impaired in a 
genetically predisposed individual, an autoimmune disease might develop.  
Betrayal by the Brain: The Neurologic Basis of Chronic Fatigue Syndrome, Fibromyalgia Syndrome and Related Neural Network Disorders  
by Jay A. Goldstein  

published by The Haworth Medical Press, 1996

significant change after sympathectomy: reduced sympathetic and increased vagal tone

The HRV analysis showed a significant change of indices reflecting sympatho-vagal balance indicating significantly reduced sympathetic (LF) and increased vagal (HF, rMSSD) tone. These changes still persisted after 2 years. Global HRV increased over time with significant elevation of SDANN after 2 years. QT dispersion was significantly reduced 1 month after surgery and the dispersion was further diminished 2 years later.

http://www.sciencedirect.com/science/article/pii/S0167527399001011

"sympathectomy is a form of sensory neurectomy" (p.1500)

Bonica's Management of Pain Scott Fishman, Jane Ballantyne, James P. Rathmell Lippincott Williams & Wilkins, 2010 - Medical - 1661 pages

more than 75% of the patients evolved with an improvement in facial hyperhidrosis - nonsurgical treatment works, just don't ask the surgeons

http://www.ncbi.nlm.nih.gov/pubmed/21738960

sympathectomized arteries become more susceptible to lipid accumulation

Combined effect of cholesterol feeding and sympathectomy on the lipid content in rabbit aortas

Atherosclerosis

Volume 37, Issue 4, December 1980, Pages 521–528

Decreased HRV is predictive of adverse cardiovascular outcomes in a variety of disease states

Water immersion-induced skin wrinkling (WISW) is dependent on intact peripheral sympathetic function. WISW was hypothesized to reflect autonomic function in subjects with- out peripheral neuropathy. We prospectively studied 70 healthy subjects (aged 31 88 years, 63% females) without cardiovascular risk factors or neurological disease. All sub- jects underwent short-term heart rate variability (HRV) stud- ies. Time and frequency domain variables were derived in- cluding the HRV index. WISW was graded using a previously validated scale of 1–4 of which 18.6% of subjects exhibited grade 1 (minimal) WISW and 35.7% had grade 2 WISW. On multivariate analysis using the HRV index, WISW was inde- pendently related to height and the HRV index. We conclude that WISW is related to central autonomic function.

Although the mechanism is not fully understood, WISW is felt to be caused by passive diffusion of water across the stratum corneum into the sweat ducts, which in turn alters electrolyte balance, decreases membrane stabilization, increases sympathetic neural firing and stimulates vasoconstriction [1–3, 8].WISW is decreased in diabetic patients and in patients after cervical sympathectomy [4, 9].

Heart rate variability (HRV) is the beat-to-beat variation in cardiac cycle length due to autonomic influence on the sinus node. Decreased HRV is predictive of adverse cardiovascular outcomes in a variety of disease states[5]. The influence of the central nervous system activity on autonomic function suggests that HRV may be a useful prognostic indicator in patients with cerebrovascular events [6].

Cardiology 2010;116:247–250 DOI: 10.1159/000316043

Received: May 10, 2010

Accepted after revision: May 28, 2010 Published online: August 18, 2010

Removal of the clips from the sympathetic trunk does not provide resolution of compensatory sweating

Removal of the clips from the sympathetic trunk does not provide resolution of compensatory sweating in 1 year of observation. T6-9 block does not provide remedy for compensatory hyperhidrosis. Regional abdomino-lumbar iontophoresis seems to be very promising, but further research and followup are mandatory.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3458267/

Natural bodily functioning does not include “purely autonomic” or “purely somatic” responses, just as it does not include ‘purely sympathetic” or “purely parasympathetic” responses

Langley initially expected to find afferent cell bodies in autonomic ganglia, with projections to other ganglia. He believed that activation of these “autonomic afferents” should lead to purely autonomic responses. However Langley’s own careful work demonstrated that there were no such neurons.

The fundamentally important point is that integrative processes responsible for the organization of visceral function occur principally within the central nervous system (brain and/or spinal cord). Both somatic and visceral afferents result in complex, brain mediated, responses that include somatic and visceral function. Autonomic motor activity can be generated by both somatic and visceral inputs to the CNS, and visceral inputs to the CNS initiate responses that are both somatic and autonomic. Natural bodily functioning does not include “purely autonomic” or “purely somatic” responses, just as it does not include ‘purely sympathetic” or “purely parasympathetic” responses.

Bill Blessing and Ian Gibbins (2008), Scholarpedia, 3(7):2787.

revision #46085 [link to/cite this article]

Curator: Dr. Bill Blessing, Centre for Neuroscience, Flinders University, Adelaide, AUSTRALIA

electric stimulation of the sympathetic cord in the upper thoracic level on the middle cerebral artery blood flow velocity

The effect of electric stimulation of the sympathetic cord in the upper thoracic level on the middle cerebral artery blood flow velocity (V(MCA)) in humans was examined using transcranial Doppler sonography monitoring during surgery for palmar hyperhidrosis. Sympathetic stimulation resulted in marked and rapid increases Of V(MCA). The responses were preceded by prompt increases of mean arterial blood pressure (MABP) and heart rate (HR). Division of the sympathetic cord cranially or caudally to the stimulation site partially reduced the V(MCA), MABP and HR responses. Both these operations reduced sympathetic pathways to the heart as reflected by a decrease in HR and MABP. The integrity of the sympathetic pathway from the stimulation site through the superior cervical ganglion and the carotid plexus was not a prerequisite for a V(MCA) response. Our data suggest that the V(MCA) increase mainly results from stimulation of the heart and the cardiovascular system, resulting in marked increases of blood pressure and heart rate.

CEREBROVASCULAR DISEASES Volume: 2 Issue: 6 Pages: 359-364 Published: NOV-DEC 1992

Postsympathectomy pain of such severity that parenteral narcotics afforded no relief

Fifty-six consecutive patients who subsequently underwent ninety-six lumbar sympathectomies were studied prospectively with regard to the development of postoperative pain. Pain after operation was observed in thirty-four extremities by twenty-five of the patients (35 per cent). It began abruptly an average of twelve days after operation and was often accentuated nocturnally. The pain was almost always described as a deep, dull ache and persisted two to three weeks before spontaneously remitting. Postsympathectomy pain of such severity that parenteral narcotics afforded no relief developed in two of these fifty-six patients and in nine additional patients. Treatment with carbamazepine produced dramatic reduction in the intensity of pain in seven of these nine patients within twenty-four hours after the institution of therapy. Two patients were given intravenous diphenylhydantoin and both experienced immediate relief of pain. The mechanisms of the syndrome and of the action of these drugs are uncertain.

http://www.sciencedirect.com/science/article/pii/0002961074902384

Systemic therapy with glycopyrrolate or clonidine can be effective for HH. Nearly two-thirds responded to therapy, and less than a quarter had treatment-limiting adverse effects, all of which were self-limited and nonserious

J Am Acad Dermatol. 2012 Mar;66(3):387-92. doi: 10.1016/j.jaad.2011.01.023. Epub 2011 Aug 4.
http://www.ncbi.nlm.nih.gov/pubmed/21820204

A randomized placebo-controlled trial of oxybutynin for the initial treatment of palmar and axillary hyperhidrosis

Palmar and axillary hyperhidrosis improved in >70% of the patients, and 47.8% of those presented great improvement. Plantar hyperhidrosis improved in >90% of the patients. Most patients (65.2%) showed improvements in their quality of life. The side effects were minor, with dry mouth being the most frequent (47.8%).

Journal of Vascular Surgery, Volume 55, Issue 6, June 2012, Pages 1696-1700

40% affirmed they would ask for the operation if it were to be redone, 53% recurrence

At an average 12 years after surgery, 47% of patients were satisfied with the treatment results, 40% were disappointed. 
53% complaining about a decent to moderate recurrence of hand sweating and compensatory and gustatory sweating were observed in 9 (60%) and 5 (33%) patients, respectively. 
Interact CardioVasc Thorac Surg(2009) 8 (1): 54-57.

Only 56% would recommend thoracoscopic sympathectomy to others with hyperhydrosis

http://www.ncbi.nlm.nih.gov/pubmed/21539945

During sympathectomy procedure we found a significant acute decrease in systolic and pulse pressures

http://www.ingentaconnect.com/content/klu/10286/2004/00000014/00000004/art00012#aff_1

post-sympathectomy hyperalgesia

Behavioral test of tolerance for aversive mechanical stimuli in sympathectomized cats.

C Van Petten

 , 

W J Roberts

  and 

D L Rhodes

Cats were studied behaviorally to determine their suitability as an animal model for the post-sympathectomy hyperalgesia reported to occur in humans. For this study a device and methodology were developed which allow humane testing of tolerance for intense mechanical stimulation of the hindlegs. Behavioral tolerance was measured quantitatively before and after unilateral sympathectomy. The results from this preliminary study of 6 cats are remarkably similar to those reported for humans; 1 of the 6 cats showed a decreased tolerance on the sympathectomized side which was delayed in onset and of limited duration. The new methodology appears to provide relatively stable, quantitative measures of tolerance for aversive stimulation, and the cat shows promise as an animal model for post-sympathectomy hyperalgesia.

Pain. 1983; 15(2)

"return of sweating in the hands is common occurrence in patients followed up for sufficient length of time"

Annals of the Royal College of Surgeons of England (1989) vol. 7.1

significant number of primary hyperhidrosis patients (more than 70%) were so pleased with the results that they decided to forgo the surgery

At the beginning of our study, thoracic sympathectomy was indicated indiscriminately to all primary hyperhidrosis patients. The authors observed a number of patients who were dissatisfied with the results obtained from this technique, particularly due to the undesirable but frequent side effect of compensatory hyperhidrosis. Hyperhidrosis is a condition that deeply affects the individual's emotional component, and many of them, despite being warned previously, are not psychologically prepared to address this new situation. The authors then included a psychologist in the study and directed the patients for routine psychological evaluations to prepare and better select them for surgery. In addition, the authors began to study a pharmacological formula to medicate these patients for the same purpose. Oxybutynin is an anticholinergic drug that has been used safely at high doses (up to 15 mg/day) to treat micturition disorders, and a side effect observed in these patients has been diminished sudoresis. Studies conducted by our group have documented the clinical benefits of a low dose of oxybutynin (10 mg/day). The authors found that a significant number of primary hyperhidrosis patients (more than 70%) were so pleased with the results that they decided to forgo the surgery [50-53].

Expert Review of Dermatology7.6 (Dec 2012): 529-538.

Neuralgia due to sympathectomy

Depending on the skill of the surgeon and difficulty encountered performing various intraoperative maneuvers, the incidence of complications following sympathectomy should be the same as that following any other extraperitoneal or extrapleural operation. However, a frequent complication following sympathectomy, and one which is apparently unrelated to operative technique, is that of postsympathectomy neuralgia.

This neuralgia is characterized by aching thigh pain after lumbar sympathectomy or aching shoulder and arm pain after cervical sympathectomy. The pain is intense in severity, sudden in onset and disappearance, and not related to any major neurologic manifestations.

Recently we have reviewed the files of the Vascular Surgical Service at the West Roxbury Veteran's Hospital and the literature on this condition. This report is a presentation of our findings.

Incidence  Pain following sympathectomy has been described as "an all too common complaint."⁸ Reports have varied in incidence from 2.1% to "practically every case."

http://archsurg.jamanetwork.com/article.aspx?articleid=560162

Autonomic neuropathy in the skin following sympathectomy

In diabetics with the anhidrotic syndrome, autonomic nerve fibres were studied in skin biopsies using argentic techniques and light microscopy. The Minor test was used to differentiate normal from anhidrotic skin areas. In the anhidrotic areas, histology of the nerve fibres showed beading, spindle-shaped thickening and fragmentation adjacent to the sweat glands. These changes were similar to those observed in two patients who had previously undergone lumbar sympathectomy. No abnormalities of the sympathetic nerve endings could be found in biopsies taken from normal areas of the forearm of the same patients. 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.

I. Faerman¹, E. Faccio³, I. Calb², J. Razumny¹, N. Franco², A. Dominguez² and H. A. Podestá¹

Diabetologia

Volume 22, Number 2 / February, 1982

after sympathectomy the hands may become hyperkeratotic, with fissuring and scaling

Sympathectomy for palmar hyperhidrosis is effective, but has risks associated with surgery and a permanent non-sweating hand, which may become hyperkeratotic, with fissuring and scaling.

The autonomic nervous system: an introduction to basic and clinical concepts

By Otto Appenzeller, Emilio Oribe

Cilio-spinal center can extend to T5

The ciliospinal reflex (pupillary-skin reflex) consists of dilation of the ipsilateral pupil in response to pain applied to the neck, face, and upper trunk. If the right side of the neck is subjected to a painful stimulus, the right pupil dilates (increases in size 1-2mm from baseline). This reflex is absent in Horner's syndrome and lesions involving the cervical sympathetic fibers. The enhanced ciliospinal reflex in asymptomatic patients with cluster headache is due to preganglionic sympathetic mechanisms.
http://en.wikipedia.org/wiki/Ciliospinal_reflex

The cilio-spinal center is not sharply confined to TI spinal level, but may extend downwards as low as T5

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1396202/pdf/annsurg00366-0044.pdf

Endoscopic sympathectomy is not minimally invasive - doing an operation through a smaller incision is not necessarily less invasive

The term ‘‘minimally invasive surgery’’ was initially applied to coelioscopic procedures such as laparoscopic cholecystectomy and hernia repair, thoracoscopic sympathectomy, and arthroscopy, but has since been abandoned, because doing the same operation through a smaller incision is not necessarily less invasive. The term ‘‘minimally invasive parathyroidectomy’’ does not fully convey the nature of the techniques, and, as previously debated in the wider field of minimal-access surgery, carries connotations of increased safety that are not necessarily supported by the existing data [12].

Surg Clin N Am 84 (2004) 717–734

F. Fausto Palazzo, MS, FRCS(Gen),
Leigh W. Delbridge, MD, FACS*

Department of Surgery, Royal North Shore Hospital, Sydney 2065, NSW, Australia

progressive hemifacial atrophy following sympathectomy for hyperhidrosis

Some authors consider the disease a variant of mor- phea because the histologic changes are identical to deep scleroderma.2 The possible etiologies include sympathetic denervation, trauma, vascular malformations, immunologic abnormality, heredi- tary disease, or infection by a slow virus.3 To our knowledge, this is the first report of a young patient with a possible association between Parry-Romberg syndrome and thoracoscopic sympathectomy.

Theoretically, thoracoscopic sympathectomy may cause 2 of the aforementioned etiologies of Parry- Romberg syndrome: sympathetic denervation and trauma. Thoracoscopic sympathectomy is a surgical technique for the treatment of palmar hyperhidrosis.

The operation ablates the upper thoracic sympa- thetic nerve ganglions responsible for nerve stimu- lation of the sweat glands of the upper limbs. The most significant complication is Horner’s syn- drome, which results from injury to the stellate sympathetic ganglion.7 In a summary of sympa- thectomies in 67 children and adolescents, compli- cations included Horner’s syndrome in 1 patient (1%) and varying degrees of compensatory sweat- ing in 30 patients (45%).8 Despite the evidence from animal studies that sympathectomy can result in facial atrophy, to our knowledge, there were no previous reports of such an association in humans.

Cutis. 2004;73:343-344, 346.

RSD due to nerve injury

According to the National Institute of Neurological Disorders and Stroke (NINDS), RSD is "a chronic pain condition that is believed to be the result of dysfunction in the central or peripheral nervous systems." According to MedicineNet, RSD involves "irritation and abnormal excitation of nervous tissue, leading to abnormal impulses along nerves that affect blood vessels and skin."

Animal studies indicate that norepinephrine, a catecholamine released from sympathetic nerves, acquires the capacity to activate pain pathways after tissue or nerve injury, resulting in RSD. Another theory suggests that RSD, which follows an injury, is caused by triggering an immune response and symptoms associated with inflammation (redness, warmth, swelling). RSD is not thought to have a single cause, but rather multiple causes producing similar symptoms.

http://arthritis.about.com/od/rsd/a/rsd.htm

Limited sympathectomy does not reduce postoperative compensatory sweating

http://www.jvascsurg.org/article/S0741-5214(02)75164-1/fulltext

Sympathetic chain ganglia are responsible for delivering information to the rest of the body regarding stress situations and the fight or flight response

Sympathetic chain ganglia are responsible for delivering information to the rest of the body regarding stress situations and the fight or flight response. These sympathetic ganglia are the structures that are destroyed during a sympathectomy.
http://www.ast.org/publications/Journal%20Archive/2009/9_September_2009/CE.pdf

After sympathectomy in rats there is an increase in osteoclast-mediated bone resorption as well as an increase in the number of osteoclasts on the sympathectomized side

Paper: Osteoclastic Activation In Periapical Lesions After NPY Knockout (IADR/AADR/CADR 87th General Session and Exhibition (April 1-4, 2009)): "After sympathectomy in rats there is an increase in osteoclast-mediated bone resorption as well as an increase in the number of osteoclasts on the sympathectomized side compared to the control. These findings suggest an inhibitory effect of the SNS on bone resorption via osteoclasts. Our objective was to determine if an SNS mediator, neuropeptide Y (NPY), affects osteoclastic activity after pulpal exposure."

Two-stage unilateral versus one-stage bilateral single-port sympathectomy for palmar and axillary hyperhidrosis

Compensatory sweating occurred in 25 (19%) patients of the one-stage group and in 6 (4%) of the two-stage group (P = 0.0001). No patients developed Horner’s syndrome.
CONCLUSIONS: Both two-stage unilateral and one-stage bilateral single-port video-assisted thoracoscopic sympathectomies are effective, safe and minimally invasive procedures. Two-stage unilateral sympathectomy can be performed with a lower occurrence of compensatory sweating, improving permanently the quality of life in patients with palmar and axillary hyperhidrosis. 
http://icvts.oxfordjournals.org/content/16/6/834.full.pdf+html 

Depletion of peripheral sympathetic noradrenaline led to significant decrements in escape and avoidance responding

PsycNET - Option to Buy: "Chemical sympathectomy and avoidance learning in the rat.
By Di Giusto, E. L.; King, M. G.
Journal of Comparative and Physiological Psychology, Vol 81(3), Dec 1972, 491-500.
Abstract
Reports results of 5 experiments with male Wistar rats (N = 108). Depletion of peripheral sympathetic noradrenaline induced by administration of 6-hydroxydopamine, ip, led to significant decrements in escape and avoidance responding when the required response was difficult, but not when it was relatively easy to acquire. Results are similar to previous findings obtained with adrenal-demedullated Ss. Findings clarify the role of the sympathetic nervous system in the motivation of behavior elicited by aversive stimulation. Implications for 2-process theory and the "Kamin effect," or "learned helplessness," are discussed. (40 ref.) (PsycINFO Database Record (c) 2012 APA, all rights reserved)"

sympathectomy led to significant decrements in escape and avoidance responding

PsycNET - Option to Buy: "Chemical sympathectomy and avoidance learning in the rat.
By Di Giusto, E. L.; King, M. G.
Journal of Comparative and Physiological Psychology, Vol 81(3), Dec 1972, 491-500.
Abstract
Reports results of 5 experiments with male Wistar rats (N = 108). Depletion of peripheral sympathetic noradrenaline induced by administration of 6-hydroxydopamine, ip, led to significant decrements in escape and avoidance responding when the required response was difficult, but not when it was relatively easy to acquire. Results are similar to previous findings obtained with adrenal-demedullated Ss. Findings clarify the role of the sympathetic nervous system in the motivation of behavior elicited by aversive stimulation. Implications for 2-process theory and the "Kamin effect," or "learned helplessness," are discussed. (40 ref.) (PsycINFO Database Record (c) 2012 APA, all rights reserved)"

Hyperhidrosis (excessive sweating). DermNet NZ

Hyperhidrosis (excessive sweating). DermNet NZ: "Localised hyperhidrosis may also be due to:

Stroke
Spinal damage
Peripheral damage
Surgical sympathectomy
Neuropathy
Brain tumour
Chronic anxiety disorder"

Right sympathectomy was associated with a 372% increase in PI (p < 0.0001), and left sympathectomy with a 316% increase in PI

Oximetry-derived perfusion index for intraop... [Ann Thorac Surg. 2005] - PubMed - NCBI: "Baseline oximetric waveforms were adequate in all subjects. Right was associated with a 372% increase in PI (p < 0.0001), and left with a 316% increase in PI (p < 0.029). This occurred as early as 1 minute after transection of the sympathetic chain. The PI in the reference probes as well as the hemodynamics remained constant."

Link between skin innervation and neuropathic pain

Nerve conduction studies for large-diameter motor and sensory nerves were normal. This report documents a pure small-fibre sensory neuropathy after prolonged use of linezolid, and the relationship between skin innervation and corresponding neuropathic pain.

Journal of Neurology, Neurosurgery, and Psychiatry 2008;79:97-99

Impaired skin vasomotor reflexes have been found in patients with sympathetic dystrophies, dysautomias, post-regional sympathectomy and diabetic neuropathies

Not surprisingly, diminished vasoconstrictor responses, similar to the current findings, have been found
in patients with sympathetic dystrophies [26], dysautomias [27], post-regional sympathectomy [28] and
diabetic neuropathies [11].


Additionally, there have been a few reports of EM patients benefitting from sympathectomy or neurolitic
irreversible blocks of the lumbar sympathetic ganglia [22,23], while others have found the symptoms of EM to be aggravated by such treatment [24,25], possibly as a result of denervation supersensitivity.
Clinical Science (1999) 96, 507ñ512 (Printed in Great Britain)
Roberta C. LITTLEFORD, Faisel KHAN and Jill J. F. BELCH
University Department of Medicine, Section of Vascular Medicine and Biology, Ninewells Hospital and Medical School,
Dundee DD1 9SY, Scotland, U.K.

Sympathectomy interrupts neural messages that ordinarily would travel to many different organs, glands and muscles.

Sympathectomy involves dissection of the main sympathetic trunk in the upper thoracic region thus interrupting neural messages that ordinarily would travel to many different organs, glands and muscles. It involves division of adrenergic, cholinergic and sensory fibers which elaborate adrenergic substances during the process of regulating visceral function.
Journal of Applied Sciences Research, 6(6): 659-664, 2010    

Vascular sympathetic denervation can lead to degeneration of the smooth muscle of arteries leading to medial arterial calcification and stiffening of the arteries

Sympathetic denervation of the peripheral arterial system may occur quite early in the evolution of neuropathy and has major effects on blood flow and vascular responses and causes structural changes in the arterial wall (Edmonds 2004). Vascular sympathetic denervation can lead to degeneration of the smooth muscle of arteries leading to medial arterial calcification and stiffening of the arteries. This calcification may assume the histological characteristics of bone.

   Unilateral lumbar sympathectomy in humans, both in diabetics and non-diabetics, has been show to result in medial wall calcification on the ipsilateral side (Goebel and Fuessl 1983). Unilateral sympathectomy in animals leads to excess deposition of cholesterol on the operated side and the occurrence of cholesterol sclerosis in the rabbit's aorta was accelerated by removal of the coeliac ganglion (Harrison 1938). Furthermore, in animal models, denervation of smooth muscle leads to striking pathological changes, including atrophy of muscle fibres with foci of degeneration (Kerper and Collier 1926). Arterial calcification in initiated within senescent atrophic smooth muscle (Morgan 1980).

   Medial arterial calcification in the Pima Indians is significantly associated with an increased prevalence of cardiovascular mortality (Everhart et al 1988). Medial calcification may be important factor in development of peripheral vascular disease, which in diabetes shows a predilection for the distal arteries below the knee and is unexplained. Chantelau reported an association of below knee atherosclerosis to medial arterial calcification (Chantelau et al. 1995).

p. 653

Autonomic Failure: A Textbook of Clinical Disorders of the Autonomic Nervous System[Hardcover]

Christopher J. Mathias (Author), Roger Bannister (Author)

• Publisher: Oxford University Press, USA; 5 edition (July 24, 2013)
• Language: English
• ISBN-10: 0198566344
• ISBN-13: 978-0198566342

sympathectomy leads to fluctuation of vasoconstriction alternated with vasodilation in an unstable fashion

"To quote Nashold, referring to sympathectomy, "Ill- advised surgery may tend to magnify the entire symptom complex"(38). Sympathectomy is aimed at achieving vasodilation. The neurovascular instability (vacillation and instability of vasoconstrictive function), leads to fluctuation of vasoconstriction alternated with vasodilation in an unstable fashion (39). Following sympathectomy the involved extremity shows regional hyper - and hypothermia in contrast, the blood flow and skin temperature on the non- sympathectomized side are significantly lower after exposure to a cold environment (39). This phenomenon may explain the reason for spread of CRPS. In the first four weeks after sympathectomy, the Laser Doppler flow study shows an increased of blood flow and hyperthermia in the extremity (40). Then, after four weeks, the skin temperature and vascular perfusion slowly decrease and a high amplitude vasomotor constriction develops reversing any beneficial effect of surgery (39). According to Bonica , "about a dozen patients with reflex sympathetic dystrophy (RSD) in whom I have carried out preoperative diagnostic sympathetic block with complete pain relief, sympathectomy produced either partial or no relief (40)"

Chronic Pain: 

Reflex Sympathetic Dystrophy : Prevention and Management

Hooshang Hooshmand

CRC PressINC, 1993 - Medical - 202 pages

we stopped performing sympathectomies in 1994, since we were alarmed by the complication and failure rate

Physical  medicine
Russell,  Alan  L.  Patient  Care 13.2  (Feb  2002):  19. 

Several reports have dealt with the alteration of antibody responses of spleen and lymph nodes following sympathectomy

http://www.ncbi.nlm.nih.gov/pubmed/8528891

Impairment of heart action following various methods of surgical denervation

A considerable variation in the distribution of fibres from the left sympathetic trunk to the right heart and from the right sympathetic trunk to the left side of the heart has also been shown (Randall et al., 1968a). However, the normal pattern is that large sympathetic nerves reach the base of the heart anteriorly and descend on either side of the main pulmonary artery. Nerves descending on the right of the pulmonary artery go to the atria and right ventricle. 

Interruption of afferent and efferent innervation of the heart also produces a response from circulatory and renal systems. 


Surgical cardiac denervation was carried out in 25 greyhounds and their responses to exercise, propranolol, and atropine were observed between one and three months afterwards. Our experiments confirm that a denervated heart shows delayed and diminished response to exercise and no response to atropine and propranolol.

Impairment of heart action following various methods of surgical denervation
T. J. OTTO' and P. C. CHEAH
The Nuffield Unit of Clinical Physiology, Department of Surgery, Royal Postgraduate Medical School, Ducane Road, London, W.12
Thorax(1970),25,199.