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

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

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

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

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

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

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.

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

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

cardiovascular response to different levels of sympathetic blockade varies widely, depending on the degree of sympathetic tone before the block

Anaesthesia and Intensive Care. Edgecliff: Dec 2000. Vol. 28, Iss. 6, p. 620-35 (16 pp.) Australian Society of Anaesthetists

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/