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.
Other potential complications include inadequate resection of the ganglia, gustatory sweating, pneumothorax, cardiac dysfunction, post-operative pain, and finally Horner’s syndrome secondary to resection of the stellate ganglion.

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.

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

Saturday, March 19, 2011

There is not one single physical health benefit that can be gained from a nerve injury on the sympathetic chain

Nerve injuries have a negative effect on the healthy functioning of the human body. Period. This point cannot be disputed.
That is why the surgeons -- in complete opposition to established medical ethics -- use subjective patient testimonials and surveys exclusively to justify the surgery and do not perform objective diagnosis or follow-ups. The fact that some people who undergo the surgery prefer the unhealthy physical dysfunction brought about by this insult to the nervous system does not in any way change the scientific fact that it does cause the body to operate in a diseased fashion.
Somehow, we must find a way to change the dialog on ETS from one of subjective value judgments of satisfaction/dissatisfaction to a scientific and objective conversation on physical health and the proper functioning of the human body.

the many indications of sympathectomy - a proof that it will impact on more than sweating or blushing

Sympathectomy is, by definition, the intentional destruction of some part of the sympathetic chain. Sympathectomies are broadly divided into 2 categories – lumbar and thoracic. The first such operation took place in 1889. Because the sympathetic system runs to so many different organs, glands and muscles, surgeons have since 1920 regularly performed sympathectomy in experimental attempts to treat a great long list of physical and mental disorders:
  • angina pectoris
  • anxiety
  • epilepsy
  • erythrophobia (fear of blushing)
  • glaucoma
  • goiter
  • hyperhidrosis (excessive sweating)
  • idiocy
  • raynaud’s disease
  • reflex sympathetic dystrophy
  • pain
  • social phobia
  • long QT syndrome
(See Hashmonai et al 2003; also Wikipedia)
Several of these indications, such as idiocy and glaucoma, have been abandoned. Recently (2005) two new experimental indications have emerged - headaches and hyperactive bronchial tubes. There is also current interest in treating schizophrenia with ETS. Teleranta 2003. In any case, clearly the surgery affects a great many body parts, as evidenced by the wide variety of indications.

“denervation super-sensitivity”, otherwise known as “Cannon’s Law”

Since sympathectomy is denervation, a correct model must consider the principle of “denervation super-sensitivity”, otherwise known as “Cannon’s Law”. Receptor cells that are denerved, will, over time, remodel themselves and become super-sensitive to the neurotransmitters and catecholamines which activate them. (see Cannon 1949)

Surgeons have made various claims about achieving high degrees of specificity with their own brands of ETS surgery

Surgeons have made various claims about achieving high degrees of specificity with their own brands of ETS surgery. For example, Timo Telaranta and Chien Lin devised the Lin-Telaranta classification system:
  • Sweating of the hands - T4
  • Sweating and Facial Blushing - T3
  • Blushing of the face alone - T2
  • Social anxiety with Facial Blushing - T2
  • Social anxiety without Facial Blushing - T3 and T4 on the left side only
  • Heart racing and rhythm disorders - T3, T4, and T5 on the left side only (Lin et al. 2001)
Other surgeons have made different, yet no less specific, claims. Many examples have emerged of surgeon advertising websites which state or imply that ETS can target sweat glands exclusively, or can target the hands to the exclusion of other body regions.
However, empirical support for any such degree of specificity is mostly absent, and contradictory data is present. For instance, a study in France showed a lowered cardiac response to exercise after ETS, even if they only operated on one side, and it didn’t matter which side it was. The authors said this was consistent with the “random distribution” of cardiac fibers noted in anatomical studies. (See Abraham et al. 2002). Yet Goldstein and colleagues at NIH produced a graph which appears to indicate that unilateral sympathectomy does not produce the same amount of denervation as does bilateral.
An early study demonstrated a “bottleneck” effect at T2. The authors presented evidence that denervation of the top 1/3 of the body was complete, whether the surgeons took just T2, or T2-T3, or T2-T4. (see Hyndman et al. 1942)

Effect of local autonomic denervation on in vitro responsiveness of lymphocytes

The results further indicate that an appropriate sympathetic and parasympathetic local environment may be needed for immunomodulation, as well as for cyclosporine activity in lymphoid tissue.
Journal of the Autonomic Nervous System
Volume 62, Issue 3, 17 February 1997, Pages 155-162

Post-sympathectomy the peripheral vascular failure or the reduced cardiac chronotropic response can impair the body’s capacity to compensate for shock

First, the abolition of sweating from the upper body as well as the axillae and both upper limbs may have significantly reduced the capacity of the patient to lose heat through sweating during exercise. Anhidrosis in the head and neck after sympathectomy affects a proprotion of patients, but is often neglected in most reports of post-sympathectomy complications [3]. The loss of head and neck sweating in this patient may have further impaired overall heat loss. However we would also note that the degree of heat loss impairment after sympathectomy has never been quantified, and its effect on body temperature during exercise remains to be established.
Second, thoracic sympathectomy has been demonstrated to abolish or alter sympathetic vasoconstrictive responses in the skin, and this may contribute to abnormal peripheral vascular responses to temperature [4]
Paradoxically it has been suggested that in some cases there may be abnormal vasoconstriction rather than the expected vasodilation after sympathectomy. It is not impossible that such atypical peripheral vascular responses to rising body temperature may have contributed to impaired heat loss during exercise or to an inappropriate response to shock on the development of the heat stroke.
In the post-sympathectomy patient, the abnormal sympathetic skin response may lead to peripheral vascular failure or the reduced cardiac chronotropic response may impair the body’s capacity to compensate for shock. These may have contributed to the rapid development of shock and severe multiple organ dysfunction syndrome in this patient.
Third, it has been shown that thoracic sympathectomy can impair the autonomic nervous system’s increase of the heart rate in response to exercise [6]. Although absolute tachycardia is not eliminated, given the endocrine and paracrine stimuli during exercise, the maximum heart rate reached during exercise has been shown to be significantly reduced after sympathectomy. Thus for a given workload during exercise, there will be a relative bradycardia. This may possibly affect the circulatory system’s ability to convey heat from the body core to the extremities for heat loss.

Is Previous Thoracic Sympathectomy a Risk Factor for Exertional Heat Stroke?

Alan D.L. Sihoe, FRCSEd(CTh)a,*, Raymond W.T. Liu, MRCPb, Alex K.L. Lee, MRCPb, Chak-Wah Lam, FHKAMb, Lik-Cheung Cheng, FRCSa

sensory abnormalities, abnormal body sweating, and pathologic gustatory sweating after sympathectomy

The aim of this study is to describe the incidence and characteristics of pain, sensory abnormalities, abnormal body sweating, and pathologic gustatory sweating in pain patients with persistent post-sympathectomy pain.
Results: Seventeen adults (13 females and 4 males) with a mean age of 37 years (range 25-52) at the time of sympathectomy met the inclusion criteria. Five of the 17 patients experienced temporary pain relief for an average of 4 months (range 2-12 months), 3/17 retained the same pain as before the surgery, 1 patient was cured of her original pain but experienced a new debilitating pain, and 8/17 patients continued to have the same or worse pain in addition to a new or expanded pain. Pathologic gustatory sweating was present in 7/11 patients asked, and abnormal sweating (known as compensatory hyperhidrosis) in 11/13 patients asked. Discussion: The present study does not allow for conclusions about the effectiveness of surgical sympathectomy for neuropathic pain.
However, our findings indicate that if the pain persists after the procedure, the complications may be quite serious and at times worse than the problem for which the surgery was originally performed.
The Clinical journal of pain
2003, vol. 19, no3, pp. 192-199

Postsympathectomy pain and changes in sensory neuropeptides

Postsympathectomy limb pain, postsympathectomy parotid pain, and Raeder's paratrigeminal syndrome are pain states associated with the loss of sympathetic fibres and in particular with postganglionic sympathetic lesions.
There is a characteristic interval of about 10 days between surgical sympathectomy and onset of pain. It is proposed that this pain in man is correlated with the delayed rise in sensory neuropeptides seen in rodents after sympathectomy. These chemical changes probably reflect the sprouting of sensory fibres and may result from the greater availability of nerve growth factor after sympathectomy. The balance between the sensory and sympathetic innervations of a peripheral organ may be determined by competition for a limited supply of nerve growth factor.
Lancet. 1985 Nov 23;2(8465):1158-60

Post-sympathectomy neuralgia is a complex neuropathic and central deafferentation/reafferentation syndrome

Post-sympathectomy neuralgia is proposed here to be a complex neuropathic and central deafferentation/reafferentation syndrome dependent on: (a) the transection, during sympathectomy, of paraspinal somatic and visceral afferent axons within the sympathetic trunk; (b) the subsequent cell death of many of the axotomized afferent neurons, resulting in central deafferentation; and (c) the persistent sensitization of spinal nociceptive neurons by painful conditions present prior to sympathectomy. Viscerosomatic convergence, collateral sprouting of afferents, and mechanisms associated with sympathetically maintained pain are all proposed to be important to the development of the syndrome.

1996 Jan;64(1):1-9

postsympathectomy syndrome

In both groups two cases of postsympathectomy syndrome were seen, with one leg being colder and dryer than the other.

Clinical Orthopaedics & Related Research. 360:122-126, March 1999.

Neuroma formation at the ends of the sympathetic chain after Sympathectomy

The authors conclude recomemnding the application of clips and if the syndrome nevertheless appears novocaine infiltration of the upper end of the sympathetic chain. The authors are convinced that the theory of Hermann and Cooley about neuroma formation at the ends of the sympathetic chain after resection of a segment is true.

Traumatic neuroma follows different forms of nerve injury (often as a result of surgery). They occur at the end of injured nerve fibres as a form of ineffective, unregulated nerve regeneration; it occurs most commonly near a scar, either superficially (skin, subcutaneous fat) or deep (e.g., after a cholecystectomy). They are often very painful. It is also known as "pseudoneuroma".

abnormal sympathetic activity may cause pain following sympathectomy

Further evidence suggesting that abnormal sympathetic activity may cause pain comes from reports of pain following sympathectomy. This has occurred after stellate ganglion block and lumbar sympathectomy.
The Nervous System and Adipose Tissue, By Katharine Dalziel, MD, MBBS, MRCP
Clinics in Dermatology
October-December 1989, Volume 7, Number 4, pages 62-77

Autonomic dysequilibrium (local sympathectomy) leading to obesity

A similar reduction of fat mobilization from fat depots occurs after VMH lesions, as after local sympathectomy, suggesting that the sympathetic pathway to the adipose tissue runs through the VMH.
Bray and York hypothesize that the change in energy balance in animals after VMH lesions is a result of autonomic dysequilibrium. The sympathetic outflow is reduced and the parasympathetic outflow increased. This shift in balance results in hyperinsulinemia and altered metabolic pathways leading to obesity. During the digestion and metabolism of a meal, the autonomic nervous system provides important (but not sole) feedback control on satiety.

The Nervous System and Adipose Tissue,
By Katharine Dalziel, MD, MBBS, MRCP
Clinics in Dermatology
October-December 1989, Volume 7, Number 4, pages 62-77

hyperhidrosis is based on a much more complex autonomic dysfunction than generalised sympathetic overactivity

Our highly interesting findings indicate that primary focal hyperhidrosis is based on a much more complex autonomic dysfunction than generalised sympathetic overactivity and seems to involve the parasympathetic nervous system as well.
Cardiac Autonomic Function in Patients Suffering from Primary Focal Hyperhidrosis
Peter Birnera, Harald Heinzlb, Monika Schindlc, Jiri Pumprlad, Peter Schnidera
Eur Neurol 2000;44:112-116

The ANS provides physiological stability

The autonomic nervous system dynamically controls the response of the body to a range of external and internal stimuli, providing physiological stability in the individual. With the progress of information technology, it is now possible to explore the functioning of this system reliably and non-invasively using comprehensive and functional analysis of heart rate variability. This method is already an established tool in cardiology research, and is increasingly being used for a range of clinical applications. This review describes the theoretical basis and practical applications for this emerging technique.
    Functional assessment of heart rate variability: physiological basis and practical applications .
    International Journal of Cardiology , Volume 84 , Issue 1 , Page 1
    J . Pumprla
Copyright © 2003 Elsevier Inc

Hyperhidrosis is not due to sympathetic overactivity - as claimed by the ETS surgeons

Our overall findings suggest that essential hyperhidrosis is a complex autonomic dysfunction rather than sympathetic overactivity, and parasympathetic system seems to be involved in pathogenesis of this disorder.
Dayimi Kaya, M.D.*, Semsettin Karaca, M.D., Irfan Barutcu, M.D., Ali Metin Esen, M.D., Mustafa Kulac, M.D., and Ozlem Esen, M.D.

Annals of Noninvasive Electrocardiology,

Volume 10 Issue 1, Pages 1 - 6
Published Online: 13 Jan 2005

Thursday, March 17, 2011

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

the symptoms of Autonomic Neuropathy closely resemble the symptoms described by many who have undergone sympathectomy - a surgery where the surgeon destroys part of the ANS, a surgery that can result in a deranged functioning of the ANS.
Surgeons are allowed to market ETS/ESB  as an elective (life-style) procedure, often referred to as a 'cure'.
Autonomic neuropathy:

"Cardiovascular symptoms: exercise intolerance, fatigue, sustained heart rate, syncope, dizziness, lightheadedness, balance problems
Gastrointestinal symptoms: dysphagia, bloating, nausea and vomiting, diarrhea, constipation, loss of bowel control
Genitourinary symptoms: loss of bladder control, urinary tract infection, urinary frequency or dribbling, erectile dysfunction, loss of libido, dyspareunia, vaginal dryness, anorgasmia
Sudomotor (sweat glands) symptoms: pruritus, dry skin, limb hair loss, calluses, reddened areas
Endocrine symptoms: hypoglycemic unawareness
Other symptoms: difficulty driving at night, depression, anxiety, sleep disorders, cognitive changes"

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

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

Iontophoresis should be tried before other treatments

Iontophoresis is easy to perform, effective in about 90% of patients in two studies with 54 and 30 participants, free of hazardous side effects, and well accepted by almost all patients.

Wednesday, March 16, 2011

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

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

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

Sunday, March 13, 2011

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

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

Volume 22, Number 2, 96-99, DOI: 10.1007/BF00254836
Sympathectomy IS a (surgically caused) lesion of the sympathetic nerve supply to the skin (and other structures)