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, May 28, 2011

dysregulation of the immune system after sympathectomy (Haug and Heyeraas, 2005

The altered pattern of the response suggests that the nitric oxide-dependent portion may be accelerated in sympathectomized limbs

J Appl Physiol. 2002 Feb;92(2):685-90.

Depression of Endothelial Nitric Oxide Synthase but Increased Expression of Endothelin-1 Immunoreactivity in Rat Thoracic Aortic Endothelium Associated With Long-term, but Not Short-term Sympathectomy

Circulation Research. 1996;79:317-323

After unilateral sympathectomy the incidence of calcified arteries on the side of operation was significantly higher than that on the contralateral side

Medial arterial calcification is frequently seen in diabetic patients with severe diabetic neuropathy. Sixty patients (19 diabetic and 41 non-diabetic) were examined radiologically for typical Monckeberg's sclerosis of feet arteries 6-8 years after uni- or bilateral lumbar sympathectomy. Fifty-five out of 60 patients (92%) revealed medial calcification. This calcification was observed in both feet of 93% of patients, who had undergone bilateral operation. After unilateral sympathectomy the incidence of calcified arteries on the side of operation was significantly higher than that on the contralateral side (88% versus 18%, p less than 0.01). Although diabetic patients showed longer
stretches of calcification than non-diabetic subjects, the difference was not significant in terms of incidence and length. Of 20 patients who had no evidence of calcinosis pre-operatively, 11 developed medial calcification after unilateral operation exclusively on the side of sympathectomy. In seven patients calcinosis was detected in both feet after bilateral operation. In conclusion, sympathetic denervation is one of the causes of Monckeberg's sclerosis regardless of diabetes mellitus.
PMID: 6873514 [PubMed - indexed for MEDLINE]
Diabetologia. 1983 May;24(5):347-50.

in the media of FAs hypercholesterolemia induces changes similar to those observed in sympathectomized rabbits in non-pathological conditions

In a previous study, we showed that after sympathectomy, the femoral (FA) but not the basilar (BA) artery from non-pathological rabbits manifests migration of adventitial fibroblasts (FBs) into the media and loss of medial smooth muscle cells (SMCs). The aim of the present study was to verify whether similar behaviour of arteries occurred in the pathological context of atherosclerosis.
Our results show that in the media of FAs hypercholesterolemia induces changes similar to those observed in sympathectomized rabbits in non-pathological conditions, i.e., migration of adventitial FBs to the media and loss of medial SMCs. These latter changes, which can be ascribed to pathological events, were accentuated after sympathectomy in the hypercholesterolemic rabbits. The present study reveals that pathological events, including migration and phenotypic modulation of vascular FBs and loss of SMCs, may be under the influence of sympathetic nerves.
Acta Histochemica; Jul2008, Vol. 110 Issue 4, p302-313, 12p

sympathectomy results in an increased collagen content in the vascular wall, suggesting a stiffening of the vessel wall

From animal experiments, it is known that long-term sympathectomy results in an increased collagen content in the vascular wall, suggesting a stiffening of the vessel wall (9). Giannattasio et al.

Copyright © 2005 by the American College of Sports Medicine
DOI: 10.1249/01.mss.0000174890.13395.e7

Thursday, May 26, 2011

cervical sympathectomy resulted in a moderate and short decrease in milk secretion

Unilateral cervical sympathectomy resulted in a moderate and short decrease in milk secretion, the average amount of milk given by operated animals 10 days after operation being 76-3% of the initial level. Total cervical sympathectomy (the 2nd operation was performed 1 month later) caused a much greater and more prolonged decrease in milk secretion, 59.7% of the initial level being secreted during the 10 days after operation. A gradual increase in milk secretion was observed after the operation and this increase was more gradual after total sympathectomy than after partial sympathectomy. Denervation of the thyroid and parathyroids did not decrease milk secretion. Section of the pituitary stalk in 6 goats, which included complete section (2 goats), complete section with scar tissue at the site of section and considerable damage to the median eminence of the tuber einereum (1 goat) and incomplete section (3 goats) was performed. Milk ejection disappeared completely for 7-11 days in the goats with complete section and remained defective for some weeks after, but was still effective in those where the infundibular stem and part of the glandular portion of the pituitary stalk was still intact. Milk secretion was 28.9% of the initial level in the goats with complete section and 12.9% in the goat with the scar tissue whereas it was 40.5 and 55.7% in the incompletely sectioned and control operated goats. (See also D.S.A. 21 [3081].) D.E.E.;jsessionid=A943A1F56D5D120B419B65425A893BB0

Endoscopic sympathicotomy and endoscopic sympathetic block strongly influence typical symptoms of patients with social phobia

Social phobia is an anxiety disorder which causes fear and anxiety in social interaction or performance situations and can in its worst forms be very debilitating. The patients tend to isolate themselves and suffer from comorbid disorders such as depression, other anxiety disorders and drug and alcohol abuse. Traditional treatment methods such as medication and psychotherapy cause improvement in only 50–70% of patients. METHODS: 164 patients who had been suffering from social phobia for at least 5 years and who were resistant to conservative treatment (medication and/or psychotherapy) were enrolled in this open, uncontrolled, prospective follow-up study. 71 patients underwent endoscopic sympathicotomy (cauterisation); 93 underwent endoscopic sympathetic block (clamping) of the T2–T3 ganglia. Severity of psychic and physical symptoms was assessed by a modified version of Davidson’s brief social phobia scale and patients’ satisfaction was evaluated 1, 6, and 12 months postoperatively. RESULTS: Fear of observation, performance anxiety and embarrassment were alleviated and alertness increased. Likewise, palpitations, trembling of hands and heads, blushing and hyperhidrosis were relieved. All changes were statistically significant. Patients’ satisfaction was high and remained stable over time. Gender, age, and education did not influence satisfaction rates. CONCLUSIONS: Endoscopic sympathicotomy and endoscopic sympathetic block strongly influence typical symptoms of patients with social phobia.
JournalEuropean Surgery
Volume 37, Number 3 / June, 2005

sympathectomy induces several biochemical changes in skeletal muscle

It is concluded that sympathectomy induces several biochemical changes in skeletal muscle which constitute a change and increase in fast myosin light chain synthesis and a corresponding fibre type transformation.
Received 24 August 1987; accepted 26 October 1987

Clinical Physiology and Functional Imaging

"We have previously reported functional and histological studies in five beagle dogs with unilateral lumbar sympathectomy. Three months later, fatiguability in the gracilis muscles was increased on the denervated sides, and this was associated with an increase in the relative distribution of FT fibres. Biochemical studies now show that these changes were associated with an increase in cytosolic protein without change in DNA content; this is consistent with an increase in cell size. There was a reduction in the proportion of slow myosin light chain isoforms from 50 +/- 7 to 34 +/- 6%. Noradrenaline levels were increased on the denervated sides but this may reflect greater vascularity. Calcium content did not correlate with fibre type but there was a positive relation with both noradrenaline content (r = 0.73; P less than 0.05) and DNA content (r = 0.84; P less than 0.05). It is concluded that sympathectomy induces several biochemical changes in skeletal muscle which constitute a change and increase in fast myosin light chain synthesis and a corresponding fibre type transformation."
Journal: Clinical physiology (Oxford, England) (Clin Physiol), published in ENGLAND.
Reference: 1988-Apr; vol 8 (issue 2) : pp 181-91
Dates: Created 1988/06/08; Completed 1988/06/08; Revised 2004/11/17;
PMID: 3359751, status: MEDLINE (last retrieval date: 2/18/2009, IMS Date: )

sympathectomy leading to an extracranial steal phenomenon.

The incidence and extension of brain infarcts was increased in animals with additional ipsilateral cervical preganglionic sympathectomy. Sympathectomy did not affect markedly the respiration and systemic circulation. The effect of sympathectomy was attributed to a cutaneous vasodilation, leading to an extracranial steal phenomenon.
J Neurol Neurosurg Psychiatry. 1983 August; 46(8): 768–773.

increased blood flow after sympathectomy is due to increased nonnutritive AVA flow

In the acute canine model, increased blood flow after sympathectomy is due to increased nonnutritive arteriovenous anastomoses (AVA) flow, with no change in total hindlimb capillary flow, both at rest and during reactive hyperemia.
Surgery. 1977 Jul;82(1):82-9.

90 % of patients experienced severe compensatory sweating

Postsurgery, severe compensatory sweating was experienced in 90% of patients (P < 0.0001). The sites of
compensatory sweating were the back (75%), abdomen (51%), feet (23%), groin and thigh (13%), chest (13%), andaxillae (8%). Transient whole-body sweating for no apparent reason was experienced in 30% of patients.

Thirty-seven patients (11%) regretted having undergone the surgical procedure.

Main outcome measures included the incidence of dry hands, compensatory sweating, chest pain, upper-limb muscle weakness, shortness of breath, and gustatory phenomena;

Surg Laparosc Endosc Percutan Tech. 2000 Aug;10(4):226-9.

Sympathectomy controversial procedure, so why is it advertised as a life-style surgery?

The treatment of facial blushing and or facial sweating is a controversial subject. The uncontrolled and embarrassing situation of facial sweating and blushing was thought to be easily treated with ETS. This came about when ETS was done for patients with sweaty hands. Among those patients who also suffered from facial blushing and/or facial sweating the results were also successful at reducing facial blushing and/or sweating. However over the years two observations were made when this operation was applied only for patients with facial blushing and or facial sweating. Percentage wise these patients developed a higher rate of severe compensatory sweating. Also these patients experienced a higher degree of dissatisfaction due to the side effects. Side effects such as facial flushed feelings, loss of stamina, facial skin sensitivity, increased amount of fatigue and others led Dr. Reisfeld to the decision not to perform ETS when only facial blushing or facial sweating were involved. The clinical experience that was accumulated over the last several years is what has allowed Dr. Reisfeld to reach this assessment. More time is needed to reach a definite conclusion with regard to the most appropriate procedure for patients who suffer from only facial blushing and/or facial sweating.

Wednesday, May 25, 2011

Melatonin production abolished after sympathectomy for palmar hyperhidrosis

The amount of 6-sulphatoxymelatonin, the chief metabolite of melatonin, in the urine was measured in nine patients, who were subjected to
bilateral sympathectomy at the second thoracic ganglionic level for treatment of hyperhidrosis of the palms. All patients showed before surgery had a normal 6-sulphatoxymelatonin excretion with a peak in the excretion during the night time. After the sympathectomy, the high night time excretion
was clearly abolished in five patients but remained high in four patients. This indicates that the segmental locations of the preganglionic sympathetic perikarya in the spinal cord, stimulating the melatonin secretion in the pineal gland in humans, vary between individuals.
© 2006 Elsevier Ireland Ltd. All rights reserved.
Molecular and Cellular Endocrinology 252 (2006) 40–45

Melatonin is an important immunomodulator and is the principal means by which tissues are synchronized to the daily cycle of light exposure and physical activity. Cortisol, on the other hand, is critical for maintaining energy homeostasis and modulating immune function. Melatonin and cortisol tend to run opposite to each other. That is, cortisol approaches its low point at bedtime, whereas melatonin reaches its peak a few hours after  cortisol bottoms out (see Figure 1 below). Deviations from the normal patterns for these hormones can have significant implications for overall health and future risk of cancer. In fact, research shows that low melatonin and high cortisol are independently associated with some of the same health conditions.
Consequently, the balance between these two hormones is important to overall good health. The melatonin-cortisol index (MCI)s an innovative way of examining the balance between these two vital hormones. The MCI may be used to assess cancer risk and immune function, and may also aid in the assessment of depression, heart disease, osteoporosis and weight management issues.
Melatonin | Rocky Mountain Analytical Lab

Vasoconstrictor responses to immersion of the hand in ice water in the sympathetically denervated forearm were abolished

Vasoconstrictor responses to immersion of the hand in ice water in the sympathetically denervated forearm were abolished; during the second minute of the cold pressor test, vascular resistance had increased by 48±20 percent in the innervated limb, whereas it had decreased by 17±5 percent in the denervated limb (P<0.02> limbs). Figs. 1 and 2Go show that L-NMMA infusion evoked a roughly 3-fold larger increase in vascular resistance in the denervated forearm than in the innervated calf. In the forearm, vascular resistance increased by 58±10 percent during L-NMMA infusion whereas in the calf, it increased only by 21±6 percent (P<0.001, forearm vs. calf). The L-NMMA induced vasoconstriction was reversed by L-arginine, but not by D-arginine, infusion (Table 1). In contrast to L-NMMA, infusion of an equipressive dose of phenylephrine increased the vascular resistance comparably in the denervated and the innervated limb (by 24±3 and 26±7 percent, respectively; P>0.5, forearm vs. calf).
Here we used subjects having undergone thoracic sympathectomy for hyperhydrosis, to probe the role of the peripheral sympathetic nervous system in the modulation of the vascular responsiveness to nitric oxide synthase inhibition. We found that sympathectomy markedly potentiated the vasoconstrictor effect of L-NMMA infusion. The L-NMMA induced vasoconstrictor effect was almost three times larger in the denervated than in the innervated limb. These findings provide the first evidence for an important interplay between the peripheral sympathetic nervous system and the L-arginine–nitric-oxide system in the regulation of the vascular tone in humans, and indicate that sympathetic innervation attenuates the vasoconstrictor effect of nitric oxide synthase inhibition.
Cardiovascular Research 1999 43(3):739-743; doi:10.1016/S0008-6363(99)00084-X
© 1999 by European Society of Cardiology

Norepinephrine response to mental challenge

DS Goldstein, G Eisenhofer, FL Sax, HR Keiser and IJ Kopin
Hypertension-Endocrine Branch, National Heart, Lung, and Blood Institute, Bethesda, MD 20892.

We simultaneously infused tracer-labeled norepinephrine (NE) and isoproterenol (ISO) intravenously into 14 subjects to measure forearm and total body NE pharmacokinetics at rest and in response to mental challenge (video game or cognitive task). Mental challenge was associated with significantly increased heart rate (24%), systolic blood pressure (13%), cardiac output (impedance cardiography, 9%), forearm blood flow (38%), and the rate of release of endogenous NE into arterial blood (total body NE spillover, 29%), but not with changes in cardiac output (r = 0.68) and systolic blood pressure (r = 0.60), whereas those of antecubital venous NE were not. Forearm extraction of NE was related inversely to forearm blood flow both at rest (r = -0.80) and during mental challenge (r = -0.81), and total body clearance of NE was positively related to cardiac output at rest (r = 0.78) and during mental challenge (r = 0.54). The results indicate that mental challenge is associated with generally increased sympathetically-mediated NE release that determines the hemodynamic responses. Because of regional changes in sympathetic activity and blood flow during psychological stress, changes in antecubital venous NE and even arterial NE may not reflect accurately sympathetic nerve activity. Measurement of total body and regional NE pharmacokinetics avoids these difficulties.
Psychosomatic Medicine, Vol 49, Issue 6 591-605, Copyright © 1987 by American Psychosomatic Society

it determines the contribution of the extraparenchymal arteries tooverall cerebral blood flow autoregulation

Immediately following experimentation the cerebral vessels were examined for the presence of noradrenergic fibers. The results of the study demonstrate that: (1) superior cervical ganglionectomy produces a significant reduction in the noradrenergic innervation of ipsilateral extraparenchymal arteries; (2) the peripheral sympathetic nervous system contributes to overall cerebral vascular resistance primarily by affecting resistance in extraparenchymal arteries; and (3) as a result, it determines the contribution of the extraparenchymal arteries to overall cerebral blood flow autoregulation.
1975;6;284-292 Stroke

Exaggerated responses to drugs after sympathectomy

Exaggerated responses to drugs following nervous system lesions were described in the medical literature more than a century ago. Although the phenomenon of supersensitivity is still not completely understood, studies in experimental animals have clarified the distinction between denervation and decentralization (for review see Trendelenberg, 1963). These characteristic pharmacologic abnormalities form the basis for distinguishing pre-, and post-ganglionic noradrenergic involvement.
Chronic postgangliionic denervation increases the pressor response to NA, while the effects of indirect symphatomimetics are reduced. Decentralization causes more modest changes in the blood pressure response and is not associated with loss of neuronal NA stores; the increase in pressor sensitivity is non-specific.

Disorders of the Autonomic Nervous System
By David Robertson, Italo Biaggioni
Published by Informa Health Care, 1995
ISBN 3718651467, 9783718651467

Sunday, May 22, 2011

Sympathectomy considered a last resort or end-of-the-road treatment

Surgical sympathectomy has been advocated for patients who do not get permanent pain relief from blocks and is somewhat of a last resort or end-of-the-road treatment. (p.469)

Skeletal trauma: basic science, management, and reconstruction, Volume 1

Elsevier Health Sciences, 2003 - 2768 pages
By Bruce D. Browner

"Sympathectomy is another animal."

Sympathectomy. This is a radical, now-controversial approach to blocking pain, and it includes extremely high risks for additional tissue damage and spread of RSD. (p.40)

Sympathectomy also potentially precludes future new treatments from working. (p.41)

A recent review article by (Johns Hopkins Hospital anesthesiologist and medical school professor) Srinivasa Raja covering all previous articles on sympathectomy showed that 10 percent of sympathectomies done for various reasons have complications. The complication rate for sympathectomy done to treat neuropathic (i.e., RSD) pain is 30 percent. A lot of these people can have a return of pain, and if they do, you can no longer do a sympathetic block to get rid of it. Then you have got these people in terrible pain that you cannot treat. And so, in my book, surgical sympathectomy is out. (p.81)

Positive Options for Reflex Sympathetic Dystrophy (RSD):

Elena Juris
Hunter House, 2004

cerebral edema following CO2 insufflation during sympathectomy

Death after thoracoscopic sympathectomy has been reported, secondary to cerebral edema, when CO2 insufflation has been employed. Another patient in this series sustained severe neurological dysfunction, secondary to cerebral edema. The development of cerebral edema after thoracoscopic sympathectomy is attributable to gas insufflation, which is not required and should be avoided. Major vascular injury during thoracoscopic sympathectomy has also been reported, and this complication should be completely avoidable. Chylothorax after sympathectomy has also been described and is related to division of accessory ducts rather than injury to the thoracic duct.
The most common complications of sympathectomy are related to manipulation of the autonomic nervous system.

Injury to the stellate ganglion is caused by mechanical or thermal damage to T1 during dissection. In order to prevent this injury, precise identification of ribs 1-4 is required prior to dissection of the sympathetic ganglion at T2; no dissection is performed above this level. Furthermore, excessive nerve traction is avoided during dissection. Finally, the use of bipolar cautery or ultrasonic dissection will prevent current diffusion to the stellate ganglion.
Neuralgia along the ulnar aspect of the upper limb may occur after sympathectomy, which usually resolves within 6 weeks. (p.250)

Complications in cardiothoracic surgery: avoidance and treatment

By Alex G. Little

Wiley-Blackwell, 2004 - Medical - 454 pages

Compensatory hyperhidrosis reported in 0% to 74.5% of cases

Compensatory hyperhidrosis is the most common and unpredictable side effect of thoracoscopic sympathectomy and is reported to occur in 0% to 74.5% of cases. (p.555)
Elsevier Health Sciences, 2001