Bilateral Cervical Sympathectomy for the Relief of Epilepsy

Bilateral Cervical Sympathectomy for the Relief of Epilepsy

Bilateral Cervical Sympathectomy for the Relief of Epilepsy, With Report of Three Cases; Notes on the Physiologic Effects of Cutting the Sympathetic, and on the Histologic Changes Found in the Cases in Question

Spratling, William P. M.D.; Park, Roswell M.D.

The Journal of Nervous and Mental Disease:

April 1905 - Volume 32 - Issue 4 - ppg 217-232

Haematological changes during stress abolished by sympathectomy

To study haematological effects of emotional stress, blood samples were obtained from 29 healthy, normotensive, non-smoking males aged 20–34 years before, during and after 10 min of mental arithmetic. There were significant increases in pheripheral blood cell count, haemoglobin concentration, and haematocrit in response to mental stress. Parallel to these changes significant increases in heart rate, and systolic and diastolic blood pressure were observed. The relative increments of leucocyte (8%) and platelet (3·5%) count were significantly higher than the increase in haemoglobin concentration (2%). There was a significant positive correlation between the blood pressure increase and the mobilization of leucocytes, whereas the increase in erythrocyte count, haemoglobin concentration, and haematocrit showed significant positive correlations with heart rate reactivity. It is concluded that mental stress causes an increase in leucocyte and platelet count that could not solely be accounted for by the concurrent haemoconcentration.

The emotional leucocytosis observed in dogs has been claimed to be neurogenic in origin, since sympathectomy abolished the rise in leucocyte count (Garrey & Bryan, 19 3 5).
http://www3.interscience.wiley.com/journal/120731423/abstract

the pineal capability of producing antigonadal substance is suppressed by cervical ganglionectomy

Pineal glands of male hamsters 8 weeks after removal of both eyes or both superior cervical ganglia and those of untreated animals were studied by electron microscopy. In the blinded hamsters the reproductive organs were remarkably involuted, whereas the pinealocytes enlarged and were characterized by a tremendous hypertrophy of the smoothsurfaced endoplasmic reticulum, in the mesh of which some dense cored vesicles were distributed. In contrast the pinealocytes of ganglionectomized hamsters atrophied and were noted by a large number of lysosomes and sparsity of the agranular reticulum, the testes being significantly larger than the controls. The findings were interpreted to be compatible with the view that the pineal capability of producing antigonadal substance is augmented by blinding and is suppressed by cervical ganglionectomy due to the impairment of normal functioning of the pineal by denervation.

Fine structural changes in the hamster pineal gland after blinding and superior cervical ganglionectomy

Cell and Tissue Research
Volume 158, Number 3 / May, 1975

Cervical sympathectomy, the method to create (experimental) vasomotor rhinitis

Unilateral and bilateral experimental vasomotor rhinitis was produced in 4 dogs with cervical sympathectomy unilaterally and bilaterally. We studied this problem from several points of view in order to explain the mechanism of vasomotor rhinitis and the relationship between upper and lower respiratory tract.

Acta Oto-laryngologica

1972, Vol. 73, No. 2-6, Pages 212-217

One patient with documented transection of the cord above T5 behaved like subjects after surgical sympathectomy

Increase in blood flow is generally followed by a rise in skin temperature but decrease in blood flow in response to the Gibbon-Landis procedure after sympathectomy is not necessarily accompanied by a fall in surface temperature. This poor correlation between skin temperature and blood flow confirms the previous report of Hoobler and co-workers and helps define the limits of usefulness of measurements
of skin temperature as an index of blood flow to the extremity.

The vasomotor responses to the Gibbon-Landis procedure (reflex response to warming) were studied in hemiplegic patients, subjects with "high transection" of the cord, and in sympathectomized patients.

One patient with documented transection of the cord above T5 behaved like subjects after surgical sympathectomy.
Of 11 sympathectomized limbs tested for vasodilatation in response to the Gibbon-Landis procedure, 4
showed no response, while 7 responded with decrease in blood flow (vasoconstriction).

Vasomotor Responses in the Extremities of Subjects with Various Neurologic Lesions
I. Reflex Responses to Warming
By WALTER REDISCH, M.D., FRANCISCO T. TANGCO, M.D., LOTHAR WERTHEIMER, M.D.,
ARTHUR J. LEWIS, M.D., J. MURRAY STEELE, M.D.
1957;15;518-524 Circulation

increased sensitivity to adrenaline is produced by sympathectomy alone

"The increased sensitivity to adrenaline is produced by sympathectomy alone. I think sensory denervation makes no difference."

Vascular Reactivity Following Sympathectomy

Chapter Author: R. T. Grant

Ciba Foundation Symposium - Peripheral Circulation in Man

Book Series: Novartis Foundation Symposia

Published Online: 27 May 2008

Editor(s): G. E. W. Wolstenholme, Jessie S. Freeman

Print ISBN: 9780470714706 Online ISBN: 9780470715185

there are no reports of phantom sweating without a prior sympathectomy

Phantom sweating - a novel autonomic paresthesia

L. L. Lair, C. Gibbons, R. Freeman
Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
Objective: To report a novel autonomic paresthesia in a patient with an idiopathic sensory and autonomic neuropathy.
Phantom sweating is the sensation of sweating in the absence of actual sweating. This symptom is reported in 40% of patients after sympathectomy. To our knowledge there are no reports of phantom sweating without a prior sympathectomy.

Quantitative sudomotor axon reflex testing revealed absent sudomotor activity in the dorsal foot with preserved activity in the distal thigh. Skin biopsy showed a loss of epidermal nerve fibers, nerve fiber swellings, and denervation of sweat glands.
Conclusions: We report a patient with symptoms of phantom sweating in the setting of a sensory and post-ganglionic autonomic neuropathy. The pathophysiologic mechanisms underlying this autonomic paresthesia are not known. Possible mechanisms include aberrant reinnervation, ephaptic communication between nerve fibers, ectopic discharges from injured nerve fibers, and a central
response to autonomic deafferentation.
Clin Auton Res (2007) 17:264–327

hypotension-related poorer mental ability is also reflected in diminished cortical activity

EEG studies have demonstrated that the hypotension-related poorer mental ability is also reflected in
diminished cortical activity. Contrary to convention, more recent research has suggested a deficient regulation of cerebral blood flow in persons with low blood pressure. In addition to reduced tonic brain perfusion, studies demonstrated insufficient adjustment of blood flow to cognitive requirements.

Chronically low blood pressure is accompanied by a variety of complaints including fatigue, reduced drive, faintness, dizziness, headaches, palpitations, and increased pain sensitivity [1–4]. In addition, hypotensive individuals report cognitive impairment, above all deficits in attention and memory.
Clin Auton Res. 2007 April; 17(2): 69–76.

Nitric Oxide synthesis contributes to the regulation of vasomotor tone

These findings indicate that NO is involved in the central regulation of sympathetic outflow in humans and suggest that both neuronal and endothelial NO synthesis may contribute to the regulation of vasomotor tone.
Circulation. 1997 Dec 2;96(11):3897-903.

hypoxaemia, a potentially serious complication of Sympathectomy

Consecutive series of patients (n = 210), suffering from upper limb hyperhidrosis, anaesthetised for TES.

SpO2 decreased below 98% in 58 patients. Sudden hypotension and bradycardia in two patients.
The mean PaO2 was significantly (p = 0.03) decreased during two-lung ventilation (TLV), after reinflation of the right lung, compared with TLV after endobronchial intubation. There was no significant difference in mean PaO2 during one-lung ventilation of both lungs. Lowest PaO2 observed during one-lung ventilation was less than 13.3 kPa in three sympathectomies. Postoperative pain, severe on awakening and mainly retrosternal, was relieved with i.v. opiates. CONCLUSION: Controlled ventilation with 100% inspired O2, SpO2 monitoring and one to two gentle manual ventilations when it decreases is the cornerstone of the management of hypoxaemia, a potentially serious complication of TES.
Eur J Surg Suppl. 1994;(572):23-5.

Haemodynamic changes following denervation of the heart

Bilateral cardiac sympathectomy significantly decreased the heart rate and the systemic arterial blood pressure from 191 + 8 to 124 + 6 beats min-' and from 121 + 10 to 88 + 9 mmHg, respectively. These variables increased to 129 + 7 beats min-' and to 103 + 10 mmHg, respectively, following bilateral vagotomy.
Journal of Physiology (1996), 490.3, pp.793-803

inhibition of sympathetic activity and a possible impairment of endothelial function

Alterations in skin microcirculation induced by brachial plexus block can be evaluated by wavelet transform of the laser Doppler flowmetry signal. Brachial plexus block reduces the oscillatory components within the 0.0095- to 0.021- and 0.021- to 0.052-Hz intervals of the perfusion signal. These alterations are related to inhibition of sympathetic activity and a possible impairment of endothelial function.

Anesthesiology:

September 2006 - Volume 105 - Issue 3 - pp 478-484

Clinical Investigations

Endothelial dysfunction, or the loss of proper endothelial function, is a hallmark for vascular diseases, and often leads to atherosclerosis.
http://en.wikipedia.org/wiki/Endothelium

Surgical sympathectomy listed as neurologic disorder (surgically induced)

Other neurologic disorders
- Idiopathic orthostatic hypotension
- Multiple sclerosis
- Parkinsonism
- Posterior fossa tumor
- Shy-Drager syndrome
- Spinal cord injury with paraplegia
- Surgical sympathectomy
- Syringomyelia
- Syringobulbia
- Tabes dorsales (syphillis)
- Wernicke's encephalopathy
Dizziness: Classification and Pathophysiology
The Journal of Manual and Manipulative Therapy, Vol. 12, No 4 (2004)

Sympathectomy: "suppression of the neuroendocrine stress response"

p.254

Neuraxial blocks typically produce variable decrease in blood pressure that might be accompanied by a decrease in heart rate and cardiac contractility. These effects are generally proportional to the degree (level) of the sympathectomy. Vasomotor tone is primarily determined by sympathetic fibres arising from T5 to L1, innervating arterial and venous smooth muscle. Blocking these nerves causes vasodilation of the venous capacitance vessels, pooling of blood, and decreased vvenous terurn to the heart; in some instances, arterial vasodilation may also decrease systemic vascular resistance. The effects of arterial vasodilation may be minimized by compensatory vasoconstriction above the level of the block. A high sympathetic block not only prevents compensatory vasoconstriction but also blocks the sympathetic cardiac accelerator fibres that arise at T1-T4.
Profound hypotension may result from vasodilation combined with bradycardia and decreased contractility. These effects are further exaggerated if venous return is further compromised by a head-up position or from the weight of a gravid uterus. Unopposed vagal tone in some persons may explain cardiac arrest with spinal anesthesia.
p.261

The sympathetic system normally maintains some tonic vasoconstriction on the vascular tree. Loss off this tone following induction of anesthesia or sympathectomy frequently contributes to perioperative hypotension.
p.375

AV conduction abnormalities are usually manifested by abnormal ventricular depolarization (bundle-branch block) prolongation of the P-R interval (first degree AV block) failure of some atrial impulses to depolarize the ventricles (second degree AV block) or AV dissociation (third degree AV block or complete heart block).
p.428

Clinical anesthesiology

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

SUPERSENSITIVITY TO NE AFTER ADRENERGIC DENERVATION

H-NOREPINEPHRINE UPTAKE
Portal veins were incubated for 1 hour with 3H-NE 1,3, and 5 days after chemical sympathectomy with 6-OHDA (Fig. 3). Preparations treated with cocaine (10~5 M) were exposed to this drug 15 minutes before 3H-NE incubation and maintained in a cocaine-containing solution throughout the entire incubation period. One day after 6-OHDA treatment, NE uptake was reduced to approximately 21 %
of control; at 3 days it was 33% of controls and 5 days after 6-OHDA it was approximately 39% of controls. The decrease in NE uptake caused by 6-OHDA treatment was comparable to that caused by cocaine.

SUPERSENSITIVITY TO NE AFTER ADRENERGIC DENERVATION

CATECHOLAMINE DEPLETION AFTER CHEMICAL SYMPATHECTOMY

1977;41;198-206 Circ. Res.
Trophic influence of the sympathetic nervous system on the rat portal vein

more complex autonomic dysfunction than generalised sympathetic overactivity

Cardiac autonomic function in patients (n = 63) with primary focal hyperhidrosis and healthy controls (n = 28) was investigated by short-term frequency domain power spectral analysis of heart rate variability. The power of the very-low-frequency band (0.01-0.05 Hz) was significantly lower in patients with axillary hyperhidrosis than in controls. No differences between groups could be observed at investigation of the low-frequency band (0.05-0.15 Hz), which was a surprising finding because this band represents also sympathetic cardiac innervation. At the high-frequency band (0.15-0.5 Hz), which represents parasympathetic cardiac innervation, an interaction of type and position influencing spectral power was detected. 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.
Eur Neurol 2000;44:112-116 (DOI: 10.1159/000008207)
peter.birner@akh-wien.ac.at

Medical Tourism advertising Sympathectomy

http://mondialtourism.webfire.com.au/_webapp_117318/Endoscopic_Thoracic_Sympathectomy

Side Effects

There is the possibility of increased sweating in other areas of the body for example the back of the legs.

Recovery Period

Patients will normally stay one day in hospital. Pain may be present for around a week, patients are normally given medication to control this. Most patients will be able to carry out their daily activities and return to work within a week.

Associated Risks

As with all types of surgery there are certain risks involved, these include infection, bleeding, reaction to anesthesia or nerve damage. The main risk of the surgery as stated before is increased sweating in other areas of the body.

dissociation between conductance and microvascular perfusion

Complete sympathectomy was accompanied by a persistent increase in ear temperature and a dissociation between conductance and microvascular perfusion. Auricular conductance was transiently increased and then decreased to levels below preoperative control values. Microvascular perfusion is decreased immediately following amputation/replantation and thereafter increases.
Microsurgery ISSN 0738-1085 CODEN MSRGDQ

Source / Source

1998, vol. 18, n^o2, pp. 129-136 (26 ref.)

'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

90% may experience Gustatory sweating after surgery for Hyperhidrosis

Some individuals (up to 90%) may experience another type of sweating that is increased while eating or smelling certain foods (gustatory sweating) (Hornberger).

Source: Medical Disability Advisor

http://www.mdguidelines.com/sympathectomy

Chronic betablocker therapy can exactly mimic autonomic neuropathy

What is the ultimate effect of cardiac autonomic neuropathy.

Cardiac denervation. The manifestations are

• Tachycardia, exercise intolerance
• Orthostatic hypotension

http://stanford.wellsphere.com/heart-health-article/why-is-angina-pectoris-silent-in-diabetes-mellitus/549631

How Sympathectomy is described by the surgeons who offer the procedure: (Is this what Sympathectomy does - only?)

"With the nerve stimulation data, Dr. McCormack then cuts only those nerves that innervate sweat glands in the areas affected with hyperhydrosis. For example, a patient with palmar hyperhydrosis, T2 and T3 ganglion may individually, or both be involved. The intraoperative nerve testing precisely defines which ganglion has to be cut and avoids injury to the ganglion not involved. This is important because post-operative compensatory sweating problems increase with the number of ganglion cut."
http://www.nosweatsurgery.com/hyperhyd.htm

Gustatory sweating is a frequent side effect after thoracoscopic sympathectomy (32%)

Overall, gustatory sweating occurred in 32% of patients, and the incidence was significantly associated with extent of sympathectomy (p = 0.04). However, because the extent of sympathectomy was always decided by the location of primary hyperhidrosis, the latter may also explain the risk of gustatory sweating. CONCLUSIONS: Gustatory sweating is a frequent side effect after thoracoscopic sympathectomy. This is the first study to report that its incidence is significantly related to the extent of sympathectomy or the location of primary hyperhidrosis. Although there is no pathophysiologic explanation of gustatory sweating, these findings should be considered before planning thoracoscopic sympathectomy and patients should be thoroughly informed.
The Annals of thoracic surgery (Ann Thorac Surg), 2006-Mar; vol 81 (issue 3) : pp 1043-7

Incidence of chest wall paresthesia 50.0%

Paresthetic discomfort distinguishable from wound pain was described by 17 patients (50.0%). The most common descriptions were of ‘bloating’ (41.2%), ‘pins and needles’ (35.3%), or ‘numbness’ (23.5%) in the chest wall. The paresthesia resolved in less than two months in 12 patients (70.6%), but was still felt for over 12 months in three patients (17.6%).
Eur J Cardiothorac Surg 2005;27:313-319

Abolition of sympathetic skin responses following endoscopic thoracic sympathectomy

http://www.ncbi.nlm.nih.gov/pubmed/8618555?dopt=Abstract

Muscle Nerve. 1996 May;19(5):581-6.

abnormal sympathetic skin response may lead to peripheral vascular failure or the reduced cardiac chronotropic response may impair the body

An already impaired cardiovascular system is recognized to be a significant risk factor for development of 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.
He had multiple organ dysfunction syndrome develop, with severe renal and hepatic failure, grade II hepatic encephalopathy, and disseminated intravascular coagulation. He responded remarkably well to aggressive supportive measures including forced alkaline diuresis, and he was eventually discharged home after 1 month. The patient was previously a healthy, physically fit, nonsmoker. He worked as a body building trainer and led an active, sporty lifestyle. The only significant medical history was that he had received thoracic sympathectomy for axillary hyperhidrosis 4 years ago at another hospital.

http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

sympathectomy can impair the autonomic nervous system’s increase of the heart rate in response to exercise

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.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

abnormal peripheral vascular responses to temperature

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 vasodilatation after sympathectomy [5]. 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.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

impaired overall heat loss

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 proportion 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.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

facial anhidrosis and disturbed cardiovascular responses to temperature

"Although thoracic sympathectomy is commonly used to reduce upper limb sweating, it may also lead to facial anhidrosis and disturbed cardiovascular responses to temperature. The resultant effect on overall body heat loss has not been documented. We present a case of a young patient with previous thoracic sympathectomy who suffered severe heat stroke after heavy exercise.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

Changes in hemodynamics of the carotid and middle cerebral arteries

Jeng and associates observed an increase in cerebral blood flow after T2 sympathectomy, and they suggested the possibility of using such a surgical approach to improve cerebral blood flow in patients with cerebral vascular insufficiency.
Sympathectomy for Pain
ANTONIO A. F. DE SALLES I JOHN PATRICK JOHNSON


Patients who underwent T-2 sympathectomy demonstrated a significant increase in blood flow volume and flow velocities of the CAs and MCA, especially on the left side. Asymmetry of sympathetic influence on the hemodynamics of the CAs and MCA was noted. The usefulness of sympathectomy for the treatment of ischemic cardiovascular and cerebrovascular disease deserves further investigation.
Jeng JS, Yip PK, Huang SJ, et al: Changes in hemodynamics of the carotid and middle cerebral arteries before and after endoscopic sympathectomy in patients with palmar hyperhidrosis: Preliminary results.
J Neurosurg 90:463–467, 1999

side effects, ranging from trivial to devastating

There seem to be no controlled studies demonstrating efficacy of neurolytic sympathetic blocks. Possible side effects, ranging from trivial to devastating, are of even greater importance with these more permanent procedures—painful sequelae may include phenol or alcohol neuritis and postsympathectomy pain (sympathalgia), which can also occur after surgical sympathectomy.⁶

BMJ. 1998 March 14; 316(7134): 792–793.

Sympathectomy induces adrenergic excitability of cutaneous C-fiber nociceptors

1. The effects of ipsilateral removal of the superior cervical ganglion on the subsequent responsiveness of C-fiber polymodal nociceptors (CPMs) of the ear to close-arterial injections of norepinephrine (NE) were evaluated in adult, anesthetized rabbits. 2. In normal unanesthetized rabbits, the two ears were usually at the same temperature.
Immediately after the ganglionectomy, the ipsilateral ear was warmer; however, at the time of electrophysiological recordings (4-23 days) the majority of animals had the ipsilateral ear cooler by > or = 1 degree C, suggestive of denervation supersensitivity. 3.
NE (50 ng) did not activate any CPMs (n = 28) from intact animals. 4. Seven of 22 CPMs recorded from sympathectomized ears were activated by NE (50 ng). The responses varied considerably but typically consisted of 2-4 impulses in the 60 s after the NE injection. In some instances, repetitive activity continued for many minutes. Such prolonged discharge differs from the adrenergic responses seen after partial nerve damage. 5. The induction of adrenergic excitability in CPMs by sympathectomy is
suggested to be a counterpart to postsympathectomy neuralgia in human beings and a possible part of the mechanism leading to sympathetically related pain states.
http://www.ncbi.nlm.nih.gov/pubmed/8822575

Chemical thoracic sympathectomy (CTS) resulted in profound bradycardia

In the CTS group, however, the SD_RR:SD∂_RR ratio decreased significantly from 1.72 ± 0.20 to 1.23 ± 0.11 just after CTS. The previous patient, who had a high SD_RR:SD∂_RR ratio of 3.45 before CTS, exhibited severe bradycardia (22 beats/min).
The decrease in the SD_RR:SD∂_RR ratio indicates a reduction of cardiac sympathetic activity. However, CTS in patients having high SD_RR:SD∂_RR ratios can result in profound bradycardia.

Anesthesiology ISSN 0003-3022

1998, vol. 89, n^o3, pp. 666-670 (12 ref.)

ETS reduces myocardial oxygen demand and plasma noradrenaline levels

"The sympathetic ganglion is not a simple relay station but a site modulated by short inter-neurons and a variety of neurotransmitters and receptors. Therefore, [T2-T3] ETS might have modified the sympathetic regulation of adrenaline secretion from the adrenal medulla. [T2-T3] ETS increases the plasma level of atrial natriuretic peptide, which has widespread sympatholytic activity. [T2-T3] ETS might have influenced the amount of adrenaline secreted from the adrenal medulla via changes in humoral factors such as atrial natriuretic peptide."(Nakamura 2002)

Stroke index and systemic vascular resistance were similar both at rest and at submaximal exercise before and after ETS. Thus, ETS reduces myocardial oxygen demand and plasma noradrenaline levels both at rest and during exercise without significantly depressing cardiac function in terms of stroke volume.
http://www.ncbi.nlm.nih.gov/pubmed/11954949?dopt=Abstract

a technique that is associated with a number of potential problems

Transthoracic endoscopic sympathectomy is now considered the treatment of choice for patients with upper limb hyperhidrosis requiring sympathetic ablation. This procedure requires the use of an endobronchial double lumen tube and subsequent one-lung anaesthesia, a technique that is associated with a number of potential problems. Full patient monitoring is thus required and includes pulse, ECG, non-invasive blood pressure measurement, pulse oximetry, end-tidal carbon dioxide concentration and peak inspiratory airway pressure.

Anaesthetic implications for transthoracic endoscopic sympathectomy.

PMID: 7524779 [PubMed - indexed for MEDLINE] Eur J Surg Suppl. 1994;(572):33-6.

Hypoxaemia is of a major concern during thorascopic sympathectomy

However the pathophysiology of hypoxaemia and consequent decrease in SpO2 differs between the two anaesthetic techniques.

The normal physiological response to massive atelectasis is an increase in pulmonary vascualr resistance (hypoxic pulmonary vasoconstriction) with re-routing of blood to well ventilated lung zones and consequent improvement of in PaO2. However, during endobronchial anaesthesia for thoracic sympathectomy there is an apparent failure of this compensatory mechanism. When more than 70% of the lung is atelectatic, compensation by hypoxic pulmonary vasonstriction appears to be ineffective. Furthermore, in in vitro and animal studies, inhalation anaesthetic agent have been shown to depress hypoxic pulmonary vasoconstriction.

In a study by Hartrey and colleagues, SpO2<95%>20 mm Hg in 21% of patients. Similarly, we have reported sudden hypotension and bradycardia after injudicious carbon dioxide insufflation.

In an interesting study of the delayed cardiac effects of T2-4 sympathectomy, Drott and colleagues demmonstrated significantly reduced heart rate at rest, and during both exercise and the recovery phase of the exercise.
Changes in the electrical axis and shortening of the QT interval have also been reported.
B. Fredman, D. Olsfanger, R. Jedeikin
British Journal of Anaesthesia 1997; 79: 113-119

Loss of coordinated autonomic responses to demands on heart rate and vascular tone

Autonomic dysreflexia - Spinal cord injuries (SCI) above T6 may be complicated by a phenomenon known as autonomic dysreflexia, a manifestation of the loss of coordinated autonomic responses to demands on heart rate and vascular tone [5,6]. Uninhibited or exaggerated sympathetic responses to noxious stimuli lead to diffuse vasoconstriction and hypertension. A compensatory parasympathetic response produces bradycardia and vasodilation above the level of the lesion, but this is not sufficient to reduce elevated blood pressure. SCI lesions lower than T6 do not produce this complication, because intact splanchnic innervation allows for compensatory dilatation of the splanchnic vascular bed.

The estimated frequency of this complication is quite variable, ranging from 20 to 70 percent of patients with SCI lesions above T6 [5,6]. Autonomic dysreflexia is unusual within the first month of SCI but usually appears within the first year [7,8].

Common clinical manifestations are headache, diaphoresis, and increased blood pressure [7]. Flushing, piloerection, blurred vision, nasal obstruction, anxiety, and nausea may also occur. Bradycardia is common; however, some patients have tachycardia instead. The severity of attacks ranges from asymptomatic hypertension to hypertensive crisis complicated by profound bradycardia and cardiac arrest or intracranial hemorrhage and seizures. The severity of the SCI influences both the frequency and severity of attacks.

CAD mortality also appears to be higher among SCI patients [4]. One contributing factor may be that SCI lesions above the T5 level may lead to atypical presentations for cardiac ischemia; manifestations may include autonomic dysreflexia or changes in spasticity rather than typical chest pain.

The autonomic nervous system dysfunction that results from SCI disrupts normal cardiovascular hemostasis. With SCI above the T6 level, baseline blood pressure is usually reduced, and baseline heart rate may be as low as 50 to 60 beats per minute [12,16]. This is generally not a clinical problem, but may contribute to hemodynamic instability and exercise intolerance.

Acute cervical SCI is associated with a risk of cardiac arrhythmia due to excess vagal tone, as well as complicating hypoxia, hypotension, and fluid and electrolyte imbalances.

http://www.uptodate.com/patients/content/topic.do?topicKey=~VwAwFq7EG6jGfV

bradycardia as likely, compensatory sweating as obligatory after Sympathectomy

Clin Auton Res. 2003 Dec;13 Suppl 1:I36-9.

Sequelae of endoscopic sympathetic block.

Schick CH, Horbach T.

Dept. of Surgery, University of Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany. schick@hyperhidrosis.de

Endoscopic sympathetic block as a treatment for primary hyperhidrosis is associated with certain sequelae. The reported occurrence of side effects still varies in the literature. As the majority of patients describe sequelae after sympathetic surgery, the frequency and importance of these persisting changes are still underestimated. Patient's informed consent should include and define side effects like gustatory sweating, olfactory sweating and bradycardia as likely, and compensatory sweating as obligatory.

PMID: 14673671 [PubMed - indexed for MEDLINE]

Räf L, Claes G. Complications are frequent after surgery for excessive hand sweating. Patients should be informed about the risks

Lakartidningen 1999;96:930-2. (In Swedish.)

ETS for palmar HH results in systemic (non-localized) changes of the ANS function

In contrast to compensatory sweating in other parts of the body after T2-3 sympathetomy, improvement in plantar sweating was shown in 72% and worsened symptoms in 6% of patients. The intraoperative plantar skin temperature change and perioperative SSR demonstrated a correlation between these changes.
Associated change in plantar temperature and sweating after transthoracic endoscopic T2-3 sympathectomy for palmar hyperhidrosis.

Chen HJ, Liang CL, Lu K.

Department of Neurosurgery, Chang Gung University and Medical Center at

Kaohsiung, Taiwan. chenmd@ms8.hinet.net
PMID: 11453433 [PubMed - indexed for MEDLINE]

Forced vital capacity, forced expiratory volume were all slightly but significantly decreased after sympathectomy

J Clin Neurosci 2001 Nov;8(6):539-41

Thoracoscopic sympathectomy for palmar hyperhidrosis: effects on pulmonary function.

Tseng MY, Tseng JH.

tmy59100@ms4.hinet.net

Palmar hyperhidrosis, probably caused by an over-reactivity of sympathetic nerves passing through the second and the third thoracic sympathetic ganglia (T2 & T3 ganglia), can only be cured by sympathectomy. Such sympathetic denervation may also alter pulmonary function. In order to investigate the effect of sympathectomy, pulmonary function was compared before and four weeks after operation in 20 patients. Forced vital capacity (FVC) (-2.3%), forced expiratory volume in one second (FEV1) (-6.1%), and FEV1/FVC (-4.6%) were all slightly but significantly decreased four weeks after thoracoscopic sympathectomy. Also the instantaneous forced expiratory flow at 75%, 50% and 25% of the FVC (Vmax25, Vmax50, Vmax75) in flow-volume curves were decreased (-1.6%, -8.4%, and -20% respectively).

PMID: 11787462 [PubMed - indexed for MEDLINE]

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

PAROTID DEGENERATION SECRETION FOLLOWING SYMPATHECTOMY

January 1, 1982 Experimental Physiology, 67, 7-15.

Correspondingly the acini were loaded with secretory granules at 12 and 48 hours but were extensively depleted of granules at 24 hours. This loss of granules is considered to be due to sympathetic "degeneration secretion" caused by the release of noradrenaline from the degenerating adrenergic nerves between 12 and 24 hours after ganglionectomy. This is thought to be the first example of morphological change resulting from "degeneration activation" to be recorded microscopically.
Cell Tissue Res. 1975 Sep 16;162(1):1-12.

Degeneration Secretion and Supersensitivity in Salivary Glands following Denervations, and the Effects on Choline Acetyltransferase Activity.
Garrett JR, Ekstr�m J, Anderson LC (eds): Neural Mechanisms of Salivary Gland Secretion.Front Oral Biol. Basel, Karger, 1999, vol 11, pp 166-184
(DOI: 10.1159/000061117)

Circulating catecholamines, however, influence the amount of amylase and peroxidase secreted by the rat parotid gland in response to parasympathetic nerve stimulation and account for most of the increased secretion of these enzymes following chronic sympathectomy.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1193204

There was a reduction in all proline-rich proteins (PRP) in the saliva following sympathectomy.
http://www.find-health-articles.com/rec_pub_2450385-influences-short-term-sympathectomy-composition-proteins-rat-parotid.htm

Sympathectomy decreases the release of tissue plasminogen activator (t-PA) from blood vessels

Sympathectomy decreases and adrenergic stimulation increases the release of tissue plasminogen activator (t-PA) from blood vessels: Functional evidence for a neurologic regulation of plasmin production within vessel walls and other tissue matrices
^{http://www3.interscience.wiley.com/journal/63500193/abstract}

Left cardiac sympathectomy prevents exercise-induced QTc prolongation in congenital long QT syndrome

Exp Clin Cardiol. 2003 Spring; 8(1): 31–32.

PMCID: PMC2716198

Copyright © 2003, Pulsus Group Inc. All rights reserved

Lexin Wang, MD PhD

School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, Australia

Correspondence and reprints: Dr Lexin Wang, School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW 2650, Australia. Telephone +61-2-6933-2909, fax +61-2-6933-2587, e-mail, lwang@csu.edu.au

ability of blood platelets to aggregate is significantly lower

It is shown that the ability of blood platelets to aggregate in partially and completely sympathectomized rats is significantly lower than in intact animals. The blood clotting system of sympathectomized rats is hyperactive. The sympathectomy-provoked changes may be due to the increased content of adrenaline in the blood.

	Cellular and Molecular Life Sciences
Publisher	Birkhäuser Basel
ISSN	1420-682X (Print) 1420-9071 (Online)
Issue	Volume 36, Number 7 / July, 1980

esidual pneumothorax is common,gas exchange may be impaired and the lung is at some risk of recollapse

Editor- Cameron may not advocate that bilateral thoracoscopic sympathectomy should be staged but I certainly do .It may be eccentric but it is safe.Immediate sustained full reexpansion and perfect functioning of a lung that was completely deflated a few minutes before cannot be guaranteed. Residual pneumothorax is common,gas exchange may be impaired and the lung is at some risk of recollapse.To collapse the contralateral normal lung in such circumstances might be the practice of a majority of surgeons but it is still unwise.Collapse of one lung is a misfortune, collapse of both lungs is not compatible with life.

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

After unilateral sympathectomy the incidence of medial calcinosis on the operated side was significantly higher than on the non-operated side

Six to eight years after uni- or bilateral lumbar sympathectomy 60 patients were investigated radiologically for medial calcinosis of foot arteries. Of 60 patients, 55 had Mönckeberg's sclerosis. In 93% of the patients who had undergone bilateral operation medial calcification was seen in both feet. After unilateral sympathectomy the incidence of medial calcinosis on the operated side was significantly higher than on the non-operated side (88% versus 18%, p less than 0.01). There was no significant difference between diabetics and non-diabetics. These findings suggest that medial calcification is related to autonomic neuropathy of peripheral vessels. Fifty-two of 160 patients (32.5%) with severe arterial occlusive disease of the lower limbs showed medial calcification of foot arteries. Mönckeberg's sclerosis was significantly associated with the peripheral type of vascular disease (p less than 0.025).
Klin Wochenschr. 1985 Mar 1;63(5):211-6.
PMID: 3990163 [PubMed - indexed for MEDLINE

Medial arterial calcification (MAC) is a frequent vascular finding in patients with type II diabetes mellitus. Morphologically distinct from focal calcifications of atherosclerosis its radiographically distinct tramline pattern is frequently encountered in the arteries of the lower extremities. MAC is inconsistently related to age, duration and therapy of diabetes. In contrast, a strong association with diabetic polyneuropathy and familial aggregation have been documented. Although initially considered benign MAC is now recognized as a strong predictor of cardiovascular morbidity and mortality in diabetic patients. Investigations into MAC pathogenes and into its role in vascular pathophysiology are underway.

	Zeitschrift für Kardiologie
Publisher	Steinkopff
ISSN	0300-5860 (Print) 1435-1285 (Online)
Issue	Volume 89, Number 14 / February, 2000
DOI	10.1007/s003920070107

Reduced brain perfusion and cognitive performance

Chronically low blood pressure is accompanied by a variety of complaints including fatigue, reduced drive, faintness, dizziness, headaches, palpitations, and increased pain sensitivity [1–4]. In addition, hypotensive individuals report cognitive impairment, above all deficits in attention and memory. Nevertheless, it is generally the case that in research, as well as in clinical practice, relatively little importance is ascribed to hypotension. One reason for this is that, despite mental symptoms, cerebral dysfunction generally is not taken into account [1]. This is a consequence of the current doctrine that low systemic blood pressure is compensated by autoregulatory processes which prevent reduced blood perfusion of the brain [5, 6].

Some recent findings challenge this doctrine: reduced cognitive performance in hypotension has been demonstrated by neuropsychological testing, and EEG studies have revealed diminished cortical activity. Moreover, the assumption of unimpaired brain perfusion in hypotension no longer holds. In the present review the necessity of a reappraisal concerning hypotension is discussed in light of the relationship between blood pressure and cerebral functioning.

Clin Auton Res. 2007 April; 17(2): 69–76. Published online 2006 November 14. doi: 10.1007/s10286-006-0379-7.

PMCID: PMC1858602

Stefan Duschek and Rainer Schandry
Stefan Duschek, Phone: +49-89/2180-5297, Fax: +49-89/2180-5233, Email: duschek@psy.uni-muenchen.de

Only 20.3% suffered from severe CH

Sympathectomy is the treatment of choice for primary hyperhidrosis. One curious occurrence that is difficult to explain from an anatomophysiological point of view in cases of video-assisted thoracoscopic sympathectomy (VATS) for the treatment of palmar hyperhidrosis (PH) is the observed improvement in plantar hyperhidrosis (PLH). Nevertheless, current reports on VATS rarely describe the effect on PLH or just give superficial data. The aim of this study was to prospectively investigate, how surgery affects PLH in patients with PH and PLH over one-year period. From May 2003 to January 2004, 70 consecutive patients with combined PH and PLH underwent VATS at the T2, T3, or T4 ganglion level (47 women and 23 men, with mean age of 23 years). Immediately after the operation, all the patients said they were free from PH episodes, except for two patients (2.8%) who suffered from continued PH. Compensatory hyperhidrosis (CH) of various degrees was observed in 58 (90.6%) patients after one year. Only 13 (20.3%) suffered from severe CH. There was a great initial improvement in PLH in 50% of the cases, followed by progressive regression, such that only 23.4% still presented that improvement after one year. The number of cases without overall improvement increased progressively (from 17.1% to 37.5%) and the numbers with slight improvement remained stable (32.9–39.1%). Of the 24 patients with no improvement after one year, 6 patients graded plantar sweating worse.

Wolosker, Nelson¹ nwolosker@yahoo.com.br
Yazbek, Guilherme¹
Milanez de Campos, José²
Kauffman, Paulo¹
Ishy, Augusto²
Puech-Leão, Pedro¹

Source:

Clinical Autonomic Research; Jun2007, Vol. 17 Issue 3, p172-176, 5p, 1 chart

statistically significant changes were recorded in the head, hands, axillas, and soles

Redistribution of perspiration as reported by the patients comprised significant reduction in the palms, axillas, and soles, and an increase in the abdomen, back, and gluteal and popliteal regions. 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, p2030-2033, 4p, 2 charts

Elimination of the dominant signal (e.g., surgical sympathectomy) may allow a secondary- signal to control phase

Sympathetic input modulates, but does not determine, phase of peripheral circadian oscillators.

American Journal of Physiology: Regulatory, Integrative & Comparative Physiology; Jul2008, Vol. 64 Issue 1, pR355-R360, 6p, 2 charts, 2 graphs

Similar pathological effects of sympathectomy and hypercholesterolemia on arterial smooth muscle cells and fibroblasts

Acta Histochemica; Jul2008, Vol. 110 Issue 4, p302-313, 12p

Six percent of the patients regret the surgery because of severe CS

European Journal of Cardio-Thoracic Surgery; Sep2008, Vol. 34 Issue 3, p514-519, 6p

Pulmonary Function and Bronchial Hyperresponsiveness.

Of 46 patients who had a negative result for methacholine challenge preoperatively, 12 (26%) became positive after surgery. In terms of the level of sympathectomy, T3 sympathectomy significantly increased the ratio of patients exhibiting a positive response to methacholine (from 19% to 34%, respectively) (p <>sympathectomy can adversely affect lung function early after surgery, although the clinical significance is uncertain. It may also exert an influence on the development of bronchial hyperresponsiveness, especially when performed at the T3 level.
Journal of Asthma; Apr2009, Vol. 46 Issue 3, p276-279, 4p, 3 charts

sympathectomy can produce capillary abnormalities in the retina similar to those seen in early diabetes

Diabetes can cause damage to sympathetic nerves, and we have previously shown that experimental sympathectomy can produce capillary abnormalities in the retina similar to those seen in early diabetes.
Experimental Eye Research; Jun2009, Vol. 88 Issue 6, p1014-1019, 6p

Steinle, Jena J.¹ jsteinl1@utmem.edu
Kern, Timothy S.²
Thomas, Steven A.³
McFadyen-Ketchum, Lisa S.⁴
Smith, Christopher P.⁴