Cell body reorganization in the spinal cord after surgery to treat sweaty palms and blushing

The amount of compensatory sweating depends on the patient, the damage that the white rami communicans incurs, and the amount of cell body reorganization in the spinal cord after surgery.
www.ubcmj.com/pdf/ubcmj_2_1_2010_24-29.pdf

After severing the cervical sympathetic trunk, the cells of the cervical sympathetic ganglion undergo transneuronic degeneration
After severing the sympathetic trunk, the cells of its origin undergo complete disintegration within a year.
http://onlinelibrary.wiley.com/doi/10.1111/j.1439-0442.1967.tb00255.x/abstract

Spinal cord infarction occurring during thoraco-lumbar sympathectomy
J Neurol Neurosurg Psychiatry 1963;26:418-421 doi:10.1136/jnnp.26.5.418

Friday, May 21, 2010

Parallels between effects of spinal cord injury and sympathectomy on cardiac function

Cardiac dysfunctions are common complications following SCI. Cardiovascular disturbances are the leading causes of morbidity and mortality in both acute and chronic stages of SCI. We reviewed epidemiology of cardiac disturbances after SCI, and neuroanatomy and pathophysiology of autonomic nervous system, sympathetic and parasympathetic. SCI causes disruption of descendent pathways from central control centers to spinal sympathetic neurons, originating into intermediolateral nuclei of T1-L2 spinal cord segments. Loss of supraspinal control over sympathetic nervous system results in reduced overall sympathetic activity below the level of injury and unopposed parasympathetic outflow through intact vagal nerve. SCI associates significant cardiac dysfunction. Impairment of autonomic nervous control system, mostly in patients with cervical or high thoracic SCI, causes cardiac dysrrhythmias, especially bradycardia and, rarely, cardiac arrest, or tachyarrhytmias and hypotension. Specific complication dependent on the period of time after trauma like spinal shock and autonomic dysreflexia are also reviewed. Spinal shock occurs during the acute phase following SCI and is a transitory suspension of function and reflexes below the level of the injury. Neurogenic shock, part of spinal shock, consists of severe bradycardia and hypotension. Autonomic dysreflexia appears during the chronic phase, after spinal shock resolution, and it is a life-threatening syndrome of massive imbalanced reflex sympathetic discharge occurring in patients with SCI above the splanchnic sympathetic outflow (T5-T6). Besides all this, additional cardiac complications, such as cardiac deconditioning and coronary heart disease may also occur.
http://www.ncbi.nlm.nih.gov/pubmed/20108532

Neurogenic shock is shock caused by the sudden loss of the autonomic nervous system signals to the smooth muscle in vessel walls. This can result from severe central nervous system (brain and spinal cord) damage. With the sudden loss of background sympathetic stimulation, the vessels suddenly relax resulting in a sudden decrease in peripheral vascular resistance (vasodilation)^[1] and decreased blood pressure.

Signs and symptoms

hypotension
bradycardia
warm, dry extremities
peripheral vasodilation
venous pooling
Poikilothermia
Priapism Due to PNS stimulation
decreased cardiac output (with cervical or high thoracic injury)

Mayo Clinic investigates the same disorder as the one resulting from the elective surgical sympathectomy

Autoimmune autonomic ganglionopathy is characterized by impairment of multiple autonomic domains of which sudomotor function is among the most common. Many patients with this disorder have difficulties with thermoregulation and anhidrosis.

Sudomotor dysfunction in autoimmune autonomic ganglionopathy

http://www.ncbi.nlm.nih.gov/pubmed/19884578

Other alternative more selective methods, rather than cutting the main trunk should be studied

Compensatory sweating remains the most common, and most disabling complication of video-assisted thoracoscopic sympathectomy. Other alternative more selective methods, rather than cutting the main trunk should be studied thoroughly to assess their efficacy in reducing the complication of compensatory sweating.
http://www.ncbi.nlm.nih.gov/pubmed/18521466

Evidence: sympathectomy created imbalance of autonomic activity and functional changes of the intrathoracic organs

Surgical thoracic sympathectomy such as ESD or heart transplantation can result in an imbalance between the sympathetic and parasympathetic activities and result in functional changes
in the intrathoracic organs.
Therefore, the procedures affecting sympathetic nerve functions, such as epidural anesthesia, ESD, and heart transplantation, may cause an imbalance between sympathetic and parasympa-
thetic activities (1, 6, 16, 17). Recently, it has been reported that ESD results in functional changes of the intrathoracic organs.

In conclusion, our study demonstrated that ESD adversely affected lung function early after surgery and the BHR was affected by an imbalance of autonomic activity created by bilateral ESD in patients with primary focal hyperhidrosis.
Journal of Asthma, 46:276–279, 2009

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.

Acquired cardiovascular disease following Sympathectomy

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

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

Surgical and chemical sympathectomy can alter cellular proliferation

Surgical denervation and chemical sympathectomy can alter cellular proliferation, B- and T-cell responsiveness and lymphocyte migration in lymphoid organs [17].

In vitro studies have shown that neuropeptides can have numerous effects, either inhibiting or stimulating the proliferation, differentiation and functions of immune cells [19]* Development of systemic lupus erythematosus in mice is associated with alteration of neuropeptide concentrations in inﬂamed kidneys and immunoregulatory organs

Neuroscience Letters 248 (1998) 97– 100

sympathectomy interrupts neural messages to many different organs, glands and muscles

Hemodynamic changes in vertebral and carotid arteries were observed after sympathicotomy for PH

decreased conditioning-related activity in insula and amygdala after autonomic denervation

The degree to which perceptual awareness of threat stimuli and bodily states of arousal modulates neural activity associated with fear conditioning is unknown. We used functional magnetic neuroimaging (fMRI) to study healthy subjects and patients with peripheral autonomic denervation to examine how the expression of conditioning-related activity is modulated by stimulus awareness and autonomic arousal. In controls, enhanced amygdala activity was evident during conditioning to both "seen" (unmasked) and "unseen" (backward masked) stimuli, whereas insula activity was modulated by perceptual awareness of a threat stimulus. Absent peripheral autonomic arousal, in patients with autonomic denervation, was associated with decreased conditioning-related activity in insula and amygdala. The findings indicate that the expression of conditioning-related neural activity is modulated by both awareness and representations of bodily states of autonomic arousal.

http://www.ncbi.nlm.nih.gov/pubmed/11856537

decline in external heart work due to sympathectomy both at rest and under exercise

DYNAMIC CEREBRAL AUTOREGULATION IS ALTERED BY GANGLION BLOCKADE

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.

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

anatomic variations of the T2 nerve root 6 (9.1%) sides showed a single large ganglion formed by the stellate and the second thoracic sympathetic ganglia. The second thoracic sympathetic ganglion was most commonly located (50%) in the second intercostal space. Conclusion: The anatomic variations of the intrathoracic nerve of Kuntz and the second thoracic sympathetic ganglion were characterized in human cadavers. Journal of thoracic and cardiovascular surgery Y. 2002, vol. 123, No. 3, pages 498-501 [bibl. : 14 ref. http://www.refdoc.fr/Detailnotice?idarticle=9466218

sympathectomy may constitute malpractice

Referring an anxious patient with palmar hyperhidrosis to surgery may constitute malpractice

"A surgical treatment for anxiety-triggered palmar hyperhidrosis is not unlike treating tearfulness in major depression by severing the nerves to the lacrimal glands."

"Referring an anxious patient with palmar hyperhidrosis to surgery without first completing a proper trial of psychotropic medication may constitute malpractice especially if the patient experiences some of the more severe surgical complications which can occur during sympathectomy" (Bracha et al. 2006 .

Br J Dermatol. 2006 Dec;155(6):1299-300.

Limited sympathectomy does not reduce postoperative compensatory sweating

On univariate and multivariate analysis, the extent of denervation was not associated with the occurrence or the severity of compensatory sweating.

Compensatory sweating and temporary relief/recurrence were equally considered to be the main causes of dissatisfaction. CONCLUSION: Compensatory sweating was the most common long-term complication of thoracodorsal sympathectomy for primary hyperhidrosis. Its incidence and severity were not associated with the extent of sympathectomy.

http://www.ncbi.nlm.nih.gov/pubmed/12514588

In conclusion, our results suggest that cross-inhibitory control by various afferents in the spinal cord may exist in the feet as well as in the contralateral hand. The release of cross-inhibitory control by T3 sympathicotomy results in vasoconstriction and a decrease of skin temperature on the contralateral hand and the feet.

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.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2722005/

Contralateral temperature changes of the finger surface during video endoscopic sympathectomy for palmar hyperhidrosis
http://www.ncbi.nlm.nih.gov/pubmed/8832515

Receptor hypersensitivity is a common problem

Because of their size and location, injuries to the sympathetic ganglia or chain is rarely indicated or performed. Receptor hypersensitivity is a common problem after significant sympathetic injury, including clammy hands, erythema, and allodynia. When sympathetic nerves regenerate, they may establish aberrant connections to sensory receptors, muscles, or other sympathetics receptors; this may lead to an over-response or abnormal response.
http://wiki.cns.org/wiki/index.php/Injury,_Sympathetic_Nerve

hyperhidrosis is not related with social phobia or personality disorder

The total reward dependence and persistence scores were significantly higher in hyperhidrosis patients. The fear of uncertainty in the harm avoidance scale was found to be significantly greater in hyperhidrosis patients. Regarding character dimensions, the total score in each of the subscales self-directedness, cooperativeness and self-transcendence was found to be higher in hyperhidrosis patients. Conclusion: The higher scores of all subscales of character dimensions in hyperhidrosis patients suggest that hyperhidrosis is not related with social phobia or personality disorder.

http://www.online.karger.com/ProdukteDB/produkte.asp?Aktion=ShowFulltext&ArtikelNr=99589&Ausgabe=232867&ProduktNr=224164

painful vasospastic condition in the right arm following surgical sympathectomy on the left side

Effects of upper abdominal sympathectomy on gastric acid, serum gastrin, and catecholamines

Selective upper abdominal sympathectomy increased basal acid output in rats but was without effect on stimulated acid output, serum gastrin concentration, and gastric mucosal histidine decarboxylase activity. The sympathectomy was verified by fluorescence histochemistry and determination of tissue catecholamines. A drastic reduction in tissue noradrenaline, adrenaline, and dopamine levels occurred after sympathectomy, and fluorescence microscopy showed a complete loss of adrenergic nerve fibers. Vagotomy reduced catecholamine levels in the stomach wall by 50% but did not affect the catecholamine content in the pancreas and small bowel. Surprisingly, combined vagotomy and upper abdominal sympathectomy resulted in lower catecholamine levels than sympathectomy alone in extragastric but not in gastric tissues.

http://www.ncbi.nlm.nih.gov/pubmed/6515311

Segmental myoclonus was associated with thoracic sympathectomy

Spinal myoclonus was associated with laminectomy, remote effect of cancer, spinal cord injury, post-operative pseudomeningocele, laparotomy, thoracic sympathectomy, poliomyelitis, herpes myelitis, lumbosacral radiculopathy, spinal extradural block, and myelopathy due to demyelination, electrical injury, acquired immunodeficiency syndrome, and cervical spondylosis.

http://www.ncbi.nlm.nih.gov/pubmed/3753263

Spinal myoclonus is typically associated with a localized area of damaged tissue (focal lesion). The injured area may include direct damage of the spinal cord or may cause abnormal changes in the function of the spinal cord.

http://www.wemove.org/myo/myo_pc.html

Spinal myoclonus following a peripheral nerve injury: a case report

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526081/

RESPONSE TO SYMPATHETIC BLOCKADE DEPENDS ON THE DEGREE OF SYMPATHETIC TONE BEFORE THE BLOCK

Denervation of preganglionic cardiac accelerator fibres leaving the cord at T1-T5 results in minimal vasodilatory consequences. Changes however in heart rate, left ventricular function and myocardial oxygen demand may occur due to high thoracic epidural blockade and are discussed below.

The major determinant of heart rate is the balance between sympathetic and parasympathetic systems with the latter predominating. A high thoracic epidural anaesthesia (TEA) covering the cardiac segments (T1-T4) produces small but significant reductions in heart rate4-8. During cardiac sympathetic denervation, parasympathetic cardiovascular responses, including those involved in baroreflexes, may dominate.

Individual cardiovascular response to different levels of sympathetic blockade varies widely, depending on the degree of sympathetic tone before the block.
Anaesth Intensive Care 2000; 28: 620-635
B. T. VEERING*, M. J. COUSINS†
Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands and Department of Anaesthesia and
Pain Management, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales

a reduction of the muscular tone and to a secondary neurovascular disorder

the muscles that are supplied by these nerves shorten and tighten

This now well-established but generally under-appreciated principle of physiology is aptly known as 'Cannon's Law of Denervation Supersensitivity'. It describes the wide ranging effects of the complete loss of nerve inputs to a variety of bodily structures under experimental conditions. One of the many responses to nerves that are sick or dysfunctional (now termed Disuse Supersensitivity) is that the muscles that are supplied by these nerves shorten and tighten (due to the supersensitivity of both the muscle's specialized stretch receptors and motor nerve-muscle junctions), resulting not only in muscle spasm and stiffness which limit flexibility, but a whole sequence of pain compounding reactions. The two earliest are that localized taut bands of muscle fibers begin to compress the small specialized pain sensing (and now extra-sensitive) nerve fibers within the muscle (known as myofascial tender or trigger points) causing type 1 pain, and the compressed muscles do not allow proper blood flow in, or waste products to be removed. This leads to a build up of lactic acid, which further enhances the perception of pain through type 2 pain mechanisms. Continued and prolonged muscle shortening or contracture gradually leads to increased mechanical tension on the muscle's tendonous attachments to bone, causing all of the various tendonitis (types 1 & 2 pain) syndromes throughout the body. The end result is a truly vicious snowballing cycle of pain, with the muscle shortening further increasing pressure on the nerves.

www.northwestims.com/faq-4.html

Cannon's law of denervation tells us that if a post-ganglionic neurone has it's pre-ganglionic input removed, then it will become super-sensitive to the normal neurotransmitters that mediate that pre-ganglionic input. There is a variety of reasons for this, including up-regulation of receptors for the neurotransmitter(s), post-receptor effects, and impaired removal of neurotransmitters from the synapse

www.anaesthetist.com/anaes/patient/ans/

Most authors do not describe clinically significant capsular adhesions as a predominant finding in the chronic phase of this condition. Instead, pathologic data confirm an active process of hyperplastic fibroplasia and excessive type III collagen secretion that lead to soft-tissue contractures of the aforementioned structures (ie, the coracohumeral ligament, soft tissues of rotator interval, the subscapularis muscle, the subacromial bursae). However, these findings were observed in surgical patients who had severe and late-phase disease and cannot be applied to early phases of the disease.

From the chromosomal, cytochemical, and histologic points of view, the soft-tissue contractures are identical to those seen in a Dupuytren contracture of the hand. These contractures result in the classic progressive loss of ROM of the glenohumeral joint, which affects external rotation and abduction, then flexion, adduction, and extension (in descending order of severity). Despite these histopathologic similarities, the favorable and regressive outcome of adhesive capsulitis differs from the unfavorable and progressive outcome of Dupuytren disease.

http://emedicine.medscape.com/article/326828-overview#a0104

ATELECTASIS IS A COMMON PULMONARY COMPLICATION FOLLOWING THORACIC AND UPPER ABDOMINAL PROCEDURES

General anesthesia and surgical manipulation lead to atelectasis by causing diaphragmatic dysfunction and diminished surfactant activity. The atelectasis is typically basilar and segmental in distribution. After induction of anesthesia, atelectasis increases from 1 to 11% of total lung volume. End-expiratory lung volume is also found to be decreased.

Postoperative atelectasis is extremely common. Lobar atelectasis is also common. The incidence and prevalence of this disorder are not well documented.

http://emedicine.medscape.com/article/296468-overview#a0104

Atelectasis occurs regularly after induction of general anesthesia, persists postoperatively, and may contribute to significant postoperative morbidity and additional health care costs. Laparoscopic surgery has been reported to be associated with an increased incidence of postoperative atelectasis.

Anesth Analg 2009; 109:1511-1516

Neuroma following nerve injury/surgery

When a nerve is cut, the piece of nerve that is beyond the cut point eventually dies, however, its Schwann cells, the cells that encircle the nerve fibers remain for a much longer time. These Schwann cells secrete a chemical messenger known as nerve growth factor that tells the cut end of nerve where to grow back. So the cut end of nerve will send out multiple sprouts in the direction of the nerve growth factor, however, these sprouts do not go out in an orderly manner, instead they grow out in all directions and eventually cluster and form a knot of nerve fibers. This eventually leads to the formation of a TRUE neuroma or a END BULB or STUMP neuroma.

www.tarsaltunnelcenter.com/assets/recurrent.shtml

'Emotional' sweating regulated by neocortex and limbic cortex

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

These gustatory phenomena were quite different from physiologic gustatory sweating

In a series of 100 bilateral upper dorsal sympathectomiesperformed for palmar hyperhidrosis, gustatory sweating and othergustatory phenomena were reported by 68 of 93 patients (73%),followed up for an average of 11/2 years. These gustatory phenomenawere quite different from physiologic gustatory sweating: awide range of gustatory stimuli caused a variety of phenomenain varied locations. There was a negative correlation betweenthe incidence of these phenomena and the occurrence of Horner'ssyndrome after sympathectomy. Analysis of our observations,and of clinical and experimental work of others, leads to theconclusion that gustatory phenomena after upper dorsal sympathectomyare the result of preganglionic sympathetic regeneration orcollateral sprouting with aberrant synapses in the superiorcervical ganglion.

http://archneur.ama-assn.org/cgi/content/abstract/34/10/619

cervical sympathectomy is a psychosurgery

denervation supersensitivity of alpha receptors after sympathectomy

Patients who have undergone sympathectomy are not suitable controls

Again, patients admitted with any malignancy, cholecystectomy, thyroidectomy, renal disease, cardiac disease, sympathectomy, or vascular graft were eliminated as controls.

This article reviews the evidence that neuroleptics may increase the risk of breast

cancer via their effects on prolactin secretion.

Paul M. Schyve; Francine Smithline; Herbert Y. Meltzer

Neuroleptic-induced Prolactin Level Elevation and Breast

Cancer: An Emerging Clinical Issue

Arch Gen Psychiatry, Nov 1978; 35: 1291 - 1301.

the primary event of gustatory sweating is a degeneration of the cervical sympathetic neurons

The development of gustatory sweating after cervical sympathectomy can only be explained if one is to admit that the primary event of gustatory sweating is a degeneration of the cervical sympathetic neurons. The initial event is the loss of postganglionic sympathetic neurons and the resulting denervation of the corresponding facial sweat glands. Regeneration of parasympathetic fibers, within the degenerating sympathetic neurilemmal sheets, is a secondary event although it accounts for the observed symptoms.

Salivary gland disorders

Eugene N. Myers, Robert L. Ferris

Springer, 2007 - Medical - 517 pages

causes of autonomic dysfunction - sympathectomy

The finger wrinkling response is abolished by upper thoracic sympathectomy. The test is also abnormal in some patients with diabetic autonomic dysfunction, the Guillan-Barre syndrome and other peripheral sympathetic dysfunction in limbs. (p.46)

Other causes of autonomic dysfunction without neurological signs include medications, acute autonomic failure, endocrine disease, surgical sympathectomy . (p.100)

Disorders of the Autonomic Nervous System

By David Robertson, Italo Biaggioni

Edition: illustrated

Published by Informa Health Care, 1995

ISBN 3718651467, 9783718651467

Australian Review of ETS surgery

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

Australian Review of ETS surgery - 2001

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

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

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

Centre for Clinical Effectiveness - Monash

Swedish Review

Finnish Review

UK Review of ETS surgery - 2003

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

Catastrophic complications

Catastrophic complications such as delayed recognition of tension pneumothorax from left sided CO2 insufﬂation, leading to fatal and disabling consequences was reported.

Ann Thorac Surg 2004; 77: 410 – 414.

baroreflex response for maintaining cardiovascular stability is suppressed in the patients who received the ETS

Our results indicated that T2-3 sympathectomy suppressed baroreflex control of heart rate in both pressor and depressor tests in the patients with palmar hyperhidrosis. We should note that baroreflex response for maintaining cardiovascular stability is suppressed in the patients who received the ETS.

Anesthesiology 2001; 95:A160

Complications of endoscopic sympathectomy

Alan E. P. Cameron

Four cases are presented in which complications occurred during or after thoracic endoscopic sympathectomy (TES). In one patient inappropriate TES resulted in disabling hyperhidrosis. In one patient laceration of the subclavian artery required major surgery. In two cases intraoperative cerebral damage occurred. Training in TES is essential.

British Journal of Surgery

Volume 164 Issue S1, Pages 33 - 35 Published Online: 2 Dec 2003

Side effect of disastrous proportions

Compensatory hyperhidrosis (CHH) remains an unexplained sequel of this treatment, attaining in a small percentage of cases disastrous proportions.
World Journal of Surgery; Nov2008, Vol. 32 Issue 11, p2343-2356, 14p

unable to establish the etiology of redistribution

Regarding the incidence of anhidrosis by anatomical location, statistically significant changes were recorded in the head, hands, axillas, and soles ( p < 0.001).
Bilateral upper thoracic sympathicolysis is followed by redistribution of body perspiration, with a clear decrease in the zones regulated by mental or emotional stimuli, and an increase in the areas regulated by environmental stimuli, though we are unable to establish the etiology of this redistribution.
Surgical Endoscopy; Nov2007, Vol. 21 Issue 11

Given the fact that most of the existing literature is geared towards a) assessing only the effectiveness of the surgical sympathectomy procedures, and b) publishing only studies with positive results, adverse effects and complications are not systematically reported but rather as a secondary outcome. It seems, therefore, highly likely that the complications as reported here, are truly underestimated.

The study indicates that surgical sympathectomy, irrespective of operative approach and indication, may be associated with many and potentially serious complications.

A Systematic Literature Review of Late Complications

Andrea Furlana,c MD, Angela Mailisa,bMD, MSc, FRCPC

(PhysMed) and Marios Papagapioua Msc

response varies depending on the degree of sympathetic tone before the block

Individual cardiovascular response to different levels of sympathetic blockade varies widely, depending on the degree of sympathetic tone before the block.
High TEA added to general anaesthesia significantly decreased the cardiac acceleration in response to decreasing blood pressure, suggesting that baroreflex-mediated heart rate response to a decrease in arterial blood pressure depends on the integrity of the sympathetic nervous system.
Anaesthesia and Intensive Care. Edgecliff: Dec 2000. Vol. 28, Iss. 6, p. 620-35 (16 pp.) Australian Society of Anaesthetists

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

Permanent thermoregulatory dysfunction after ETS

What you see here is not a result of the surgery gone wrong, this is the inevitable consequence of cutting/clamping the sympathetic chain, independently of skill of the surgeon, experience of the surgeon, T2, or T3, T4, or method used. Once the communication is disrupted, (and it happens with the clamping as well), it will disable the body's thermoregulation and will cause malfunctioning of the sympathetic nervous system. This damage is permanent and irreversible. There has been no controlled clinical trial into the effects of this surgery on humans, but it is still used for many different conditions: like angina pectoris, to lower blood pressure, to treat migraine, to reduce pain in cancer patients, to reduce immuneresponses after skin transplant, to treat various cancers in the oral cavity, and among many: to treat anxiety disorders, schizophrenia, and phobias. The operation will change you for ever. In fact, it was used as a predecessor to lobotomy. Every drug introduced into the market has to go through rigorous testing procedures before approval. This does not apply to surgeries. It is left to the surgeon's to decide whether they offer this sugery or not. As soon as there are 2 docotrs who offer a procedure, it is considered acceptable medical practice. The surgery earns the surgeon an avarege of $ 2000 for a one hour procedure. The institutions set up to follow up on medical procedures failed to this day to investigate and follow up on this procedure. It is truly a medical scandal of this century.

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

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

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

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

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

Wolters Kluwer Health
Edition: 4 - 2008

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

“cervical sympathectomy isolates all these sympathetic ganglion cells from the central nervous system and prevents them from responding to reflex or emotional changes in the central nervous system." Cunningham's Manual of Practical Anatomy: Volume III: Head, Neck and Brain, 1986

ETS is a surgical procedure for hand sweating and blushing. This is achieved by cutting the sympathetic chain, resulting in autonomic dysfunction and the inability to sweat on the upper body. But it does more than that.
“cervical sympathectomy isolates all these sympathetic ganglion cells from the central nervous system and prevents them from responding to reflex or emotional changes in the central nervous system."
Cunningham's Manual of Practical Anatomy: Volume lll: Head, Neck and Brain, 1986

disturbed peripheral vascular and heart rate responses after sympathectomy

Denervation supersensitivity leads to Raynaud's Disease

$Denervation supersensitivity leads to Raynaud\$
Cannon and his colleagues showed in the 1930s that section and subsequent degeneration of the sympathetic nerves led to a marked supersensitivity of the sturcture to exogenous catecholamines. The increase in sensitivity ranged from 10-to 100-fold in different tissues, such as the spleen on section of the splenic nerves, or the nictitating membrane on section of the postganglionic cervical sympathetic nerve or the heart on removal of the stellate ganglion. In smooth muscle the increase in sensitivity is mostly explained by the associated loss of neuronal re-uptake of noradrenaline, with only a lesser role for the increase in receptor numbers. Mechanisms of Drug Action on the Nervous System by Ronald W. Ryall, Cambridge University Press, 1989

Changes in Electrophysiology following sympathectomy

Sympathectomised dogs presented significant increases in: basic sinus period, sino-atrial conduction time (SACT), AH and HV intervals of the His bundle electrogram, atrial functional (AFRP) and effective (AERP) refractory periods, atrio-ventricular node functional (AVNFRP) and effective (AVNERP) refractory periods, ventricular functional (VFRP) and effective (EVRP) refractory periods and atrial (AMAP) and ventricular (VMAP) monophasic action potential durations. Corrected sinus recovery time (CSRT) was not affected by chemical sympathectomy. Neither was the atrial ERP/MAP duration ratio. This new form of sympathectomy affects all the levels of the cardiac conduction system. Such results are in accordance with those obtained with surgical sympathectomy or the use of beta-blocking agents.

DIANE GODIN*, CLAUDE GUIMOND{dagger}, RÉGINALD A NADEAU{ddagger} and A ROBERT LEBLANC§

Cardiovascular Research 1982 16(9):524-529;
© 1982 by European Society of Cardiology

Cardiovascular collapse caused by carbon dioxide insufflation during sympathectomy

Carbon dioxide insufflation into the pleural space during one-lung anaesthesia for thoracoscopic surgery is used in some centres to improve surgical access, even though this practice has been associated with well-described cardiovascular compromise. The present report is of a 35-year-old woman undergoing thoracoscopic left dorsal sympathectomy for hyperhidrosis. During one-lung anaesthesia the insufflation of carbon dioxide into the non-ventilated hemithorax for approximately 60 seconds, using a pressure-limited gas inflow, was accompanied by profound bradycardia and hypotension that resolved promptly with the release of the gas.
Australian Society of Anaesthetists 2002

Sympathetic regulation of the cerebral circulation by the carotid chemoreceptor reflex

After bilateral cervical sympathectomy (n = 9), carotid chemoreceptor reflex stimulation induced significantly different (P less than 0.01) effects on cerebral blood flow, which rose by 42 +/- 8%, and cerebral vascular resistance, which did not change.
In "sham" dogs, the repeat response to carotid chemoreceptor stimulation also induced significantly different effects from those in dogs with sympathectomy. Thus, in the conscious dog, stimulation of the carotid chemoreceptor reflex elicits significant sympathetically mediated vasoconstriction in cerebral vessels.
Am J Physiol Heart Circ Physiol 238: H594-H598, 1980;

Effect of sympathectomy on spinal cord blood flow

We conclude that adrenalectomy near-totally ablates the hypothermia-associated increase in RSCBF (regional spinal cord blood flow) measured in intact rats and that abdominal sympathectomy totally ablates it. This evidence complements morphological evidence for adrenergic innervation of the spinal cord vasculature.

Heart and Circulatory Physiology, Vol 260, Issue 3 827-H831, Copyright © 1991 by American Physiological Society

A. Iwai, W. W. Monafo and S. G. Eliasson
Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110.

Sympathectomy induced adrenal hypertropy

Journal of Hypertension. 17(7):933-940, July 1999.
Qiua, Jingxin 1; Nelsona, Sharon H. 1; Spethb, Robert C. 2; Wanga, Donna H. 1,3

Objective: Previous studies indicate that the adrenal gland plays a compensatory role in the maintenance of blood pressure in chemically sympathectomized rats. However, the mechanisms responsible for compensatory adrenal responses are poorly understood. This study examined the regulation of adrenal growth and type 1A, 1B, and type 2 angiotensin II (Ang II) receptor (AT1A, AT1B and AT2) expression in the adrenal gland induced by sympathectomy.

this practice has been associated with well-described cardiovascular compromise

Sympathetic regulation of the cerebral circulation by the carotid chemoreceptor reflex

Effect of adrenalectomy or sympathectomy on spinal cord blood flow

Sympathectomy induced adrenal hypertropy

Journal of Hypertension. 17(7):933-940, July 1999.
Qiua, Jingxin 1; Nelsona, Sharon H. 1; Spethb, Robert C. 2; Wanga, Donna H. 1,3

Sympathectomy supressed baroreflex control of heart rate

Loss of Baroreflex = aberrant blood pressure

Sympathectomy can be considered a psychiatric surgery

Circadian Rhythm eliminated by Sympathectomy

The abrupt increase and decrease in BP observed at the time when the lighting conditions are changed are eliminated by chemical sympathectomy

The disruption of the baroreflex selectively eliminatesthe circadian rhythm of BP, and the circadian rhythms of BP andHR are modulated by the autonomic nervous system in rats. The circadianrhythms of BP and HR are regulated by different mechanisms involvingthe autonomic nervous system.
(Circulation. 1997;96:1667-1674.)
© 1997 American Heart Association, Inc.

retarded adaptation of hemodynamics to a sudden start of exercise following sympathectomy

The exercise capacity and the increase of coronary and systemic hemodynamics under treadmill exercise were studied in 5 dogs, chemically sympathectomized with 6-hydroxy-dopamine.

Completeness of adrenergic denervation was verified by stimulation of the right stellate ganglion, by intravenous administration of tyramine, and by demonstration of supersensitivity to exogenous norepinephrine.

These dogs demonstrated a retarded adaptation of hemodynamics to a sudden start of exercise. A fall in mean arterial pressure below 45 mmHg within 10 to 15 sec lead to collapse.
steady state attainment of hemodynamic parameters was considerably delayed.

E. Bassenge¹, J. Holtz¹, W. v. Restorff¹ and K. Oversohl¹

Received: 18 April 1973

Thermoregulatory Disfunction - Severe CS as the result of the elective surgery.

Note the sharp divisive line on chest: top anhidrosis, the body is unable to sweat and dissipate heat through shoulders, arms and head. 40% of heat is released from top of the head. This function of the thermoregulation is disabled for patients undergoing the selective surgery. Below the level of the T2 cut - Pathological sweating that requires complete change of clothes several times during the day. CS is not just thermoregulatory. It can be triggered by stress, in cold/winter conditions. All this as a result of an elective cosmetic surgery. The result is necessary consequence of disrupting the sympathetic chain and is independent of expertise or experience of the surgeon performing the procedure. Post ETS sweating can not be predicted. Sweating patterns prior to surgery are no relevant. There is no difference in gender or weight when it comes to CS. Some websites promoting the procedure will claim that CS diminished over time. The mechanism of CS is not understood and has not been investigated. In some cases it can take years to develop. Patients who are happy with the initial result of the surgery might deteriorate with the outcome and side-effects becoming worse.

Things you might want to know about ETS:

What is ETS or Sympathectomy?

If you do a quick search on google because you want to find a solution for your sweaty palms, or do not want to blush every time someone looks at you, you will be flooded by all the information from the surgeons offering this procedure. If you only read these and do not have a medical background, you might fall for their statements and think to yourself: well, isn't medical science wonderful?!
You make your booking with one of the surgeons who will charm you and soon you are being wheeled in for the surgery with the promise from the surgeon, that it will change your life. You don't even know how true that is, until you wake up.
Here you will find the other side of the sales pitch and some answers to just how your life will never be the same.

Surgical treatment for sweaty palms and blushing