Cell body reorganization in the spinal cord after elective surgery to treat palmar sweating

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.
www.ubcmj.com/pdf/ubcmj_2_1_2010_24-29.pdf

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

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

Thursday, November 26, 2009

Patients may develop bradycardia after surgical procedure

Upper-Thoracic Sympathectomy; Patients may develop bradycardia after surgical procedure
Heart Disease Weekly. Atlanta: Feb 23, 2003. pg. 71

sympathectomy-induced increases in choroidal thickness, vascular luminal area and large venules and large arterioles

Sympathetic denervation for 6 weeks resulted in increased choroidal thickness, vascular luminal area, numbers of large venules and large arterioles, and capillaries in the outer nuclear layer. Capsaicin pretreatment prevented sympathectomy-induced increases in choroidal thickness, vascular luminal area and large venules and large arterioles, whereas pterygopalatine ganglionectomy was without effect."
Biotech Week. Atlanta: Jan 21, 2004. pg. 396

83% of patients reported severe 'compensatory sweating'

Fully 83% of patients who underwent T2 sympathectomy reported severe compensatory sweating one year after surgery and the majority of those reported they regretted the decision to have the surgery.
Heather Ennis. Medical Post. Toronto: Feb 15, 2005. Vol. 41, Iss. 7; pg. 17, 2 pgs

sympathectomy increased the bacterial tissue burden

sympathectomy increased the bacterial tissue burden, which was caused by a reduction in corticosterone tonus, and decreased both interleukin-4 secretion from peritoneal cells and the influx of lymphocytes into the peritoneal cavity. In both models, the peritoneal wall was the critical border for systemic infection. These results show the dual role of the sympathetic nervous system in sepsis. It can be favorable or unfavorable, depending on the innate immune effector mechanisms necessary to overcome infection.
The Journal of Infectious Diseases. Chicago: Aug 15, 2005. Vol. 192, Iss. 4; pg. 560, 13 pgs

pineal gland and extracerebral blood vessels folowing sympathectomy

Following removal of the superior cervical ganglion (SCG), large molecular weight (MW) NGF species, including proNGF-A, were increased in distal intracranial SCG targets, such as pineal gland and extracerebral blood vessels (bv).

Brain Research; Research from Miami University provides new data about brain research

Science Letter. Atlanta: May 15, 2007. pg. 1746

Neuronal Source of Plasma Dopamine

Determinants of plasma norepinephrine (NE) and epinephrine concentrations are well known; those of the third endogenous catecholamine, dopamine (DA), remain poorly understood. We tested in humans whether DA enters the plasma after corelease with NE during exocytosis from sympathetic noradrenergic nerves. We reviewed plasma catecholamine data from patients referred for autonomic testing and control subjects under the following experimental conditions: during supine rest and in response to orthostasis; intravenous yohimbine (YOH), isoproterenol (ISO), or glucagon (GLU), which augment exocytotic release of NE from sympathetic nerves; intravenous trimethaphan (TRI) or pentolinium (PEN), which decrease exocytotic NE release; or intravenous tyramine (TYR), which releases NE by nonexocytotic means. We included groups of patients with pure autonomic failure (PAF), bilateral thoracic sympathectomies (SNS-x), or multiple system atrophy (MSA), since PAF and SNS-x are associated with noradrenergic denervation and MSA is not. Orthostasis, YOH, ISO, and TYR increased and TRI/PEN decreased plasma DA concentrations. Individual values for changes in plasma DA concentrations correlated positively with changes in NE in response to orthostasis (r = 0.72, P < 0.0001), YOH (r = 0.75, P < 0.0001), ISO (r = 0.71, P < 0.0001), GLU (r = 0.47, P = 0.01), and TYR (r = 0.67, P < 0.0001). PAF and SNS-x patients had low plasma DA concentrations. We estimated that DA constitutes 2%-4% of the catecholamine released by exocytosis from sympathetic nerves and that 50%-90% of plasma DA has a sympathoneural source. Plasma DA is derived substantially from sympathetic noradrenergic nerves.
David S Goldstein, Courtney Holmes. Clinical Chemistry. Washington: Nov 2008. Vol. 54, Iss. 11; pg. 1864, 8 pgs

sympathectomy decreased cardiac sympathetic nerve density and norepinephrine level

Cardiac sympathetic innervation was visualized by means of a glyoxylic catecholaminergic histofluorescence method. Transient outward current (I-to) of ventricular myocytes was recorded with the whole-cell configuration of the patch clamp technique. We observed that sympathectomy (i) decreased cardiac sympathetic nerve density and norepinephrine level, (ii) reduced the protein expression of Kv4.2, Kv1.4, and Kv channel-interacting protein 2 (KChIP2), (iii) decreased current densities and delayed activation of I-to channels, (iv) reduced the phosphorylation of extracellular signal-regulated kinase 1 and 2 (ERK1/2) and cAMP response element-binding protein (CREB), and (v) increased the severity of ventricular fibrillation induced by rapid pacing.
Heart Disease Weekly. Atlanta: Dec 28, 2008. pg. 54

Pain following endoscopic sympathectomy

The mean postoperative follow-up period was 11.5 months (range, 3-25 months). The hands of all patients were warm and dry after operation. No conversion to open surgery was necessary, and no operative mortality was recorded in either group. The mean inpatient pain scores were significantly higher in the biportal group (1.2 +/- 0.6) than that in the uniportal group (0.89 +/- 0.5, P=0.025). For the first three weeks after operation, four out of 20 (20%) patients in the uniportal group constantly suffered from mild or moderate residual pain while eight out of 25 (32%) cases in the biportal group (P=0.366). Among them, two cases in the uniportal group and five cases in the biportal group need to take analgesics.
Medical Devices & Surgical Technology Week. Atlanta: Sep 6, 2009. pg. 203

Laparoscopic surgery is associated with an increased incidence of postoperative atelectasis

Atelectasis occurs regularly after induction ofgeneral anesthesia, persists postoperatively, and may contributeto significant postoperative morbidity and additional healthcare costs. Laparoscopic surgery has been reported to be associatedwith an increased incidence of postoperative atelectasis.
Anesth Analg 2009; 109:1511-1516
© 2009 International Anesthesia Research Society

significant adverse effects on cardiopulmonary physiology

Because of technologic advances and improved postoperative recovery, endoscopic surgery has become the technique of choice for many thoracic surgical procedures ⁶^and ²⁵; however, endoscopic visualization of intrathoracic structures requires retraction or collapse of the ipsilateral lung, which can have significant adverse effects on cardiopulmonary physiology. These cardiopulmonary changes can be further affected by the pathophysiologic changes associated with the disease process requiring the surgical procedure.

Because acute changes in cardiopulmonary function can compromise patient safety severely, a clear understanding of the dynamic interaction between the anesthetic–surgical technique and patient physiology is essential. This article discusses the effect of thoracoscopic surgery and the impact of various anesthetic interventions on cardiovascular and pulmonary physiology. In addition, some recommendations for “damage control” are made.

Anesthesiology Clinics of North America
Volume 19, Issue 1, 1 March 2001, Pages 141-152

Surgical Upper Thoracic Sympathectomy Reduces Arterial Oxygenation During One-Lung Ventilation

Journal of Cardiothoracic and Vascular Anesthesia
Volume 19, Issue 5, October 2005, Pages 703-704

PATHOPHYSIOLOGY OF ONE-LUNG VENTILATION

In estimating the degree of shunt that is created by one-lung ventilation when it is performed in the lateral decubitus position, on average, 40% of cardiac output perfuses the nondependent lung and the remaining 60% perfuses the dependent lung (Fig. 1).¹⁵ Mechanisms that tend to decrease the percent of cardiac output perfusing the nondependent, nonventilated lung are passive (e.g., mechanical-like gravity, surgical manipulation, amount of pre-existing lung disease) or active (e.g., hypoxic pulmonary vasoconstriction).¹⁵ The normal response of the pulmonary vasculature to atelectasis is an increase in pulmonary vascular resistance (in the atelectatic lung), and the increase in atelectatic lung resistance is almost entirely caused by hypoxic pulmonary vasoconstriction. Hypoxic pulmonary vasoconstriction is a protective reflex mechanism that diverts blood flow away from the atelectatic lung. With an intact hypoxic pulmonary vasoconstriction response, the transpulmonary shunt through the nondependent lung decreases to approximately 23% of the cardiac output (see Fig. 1).
Anesthesiology Clinics of North America
Volume 19, Issue 3, 1 September 2001, Pages 435-453

sympathectomy will blunt the normal tachycardic response to hypovolemia.

Spinal or epidural analgesia may cause a sympathectomy that will blunt the normal tachycardic response to hypovolemia.
OBSTETRIC ANAESTHESIA OUR WAY
Royal Women's Hospital Melbourne
Author: Dr Philip Popham

Influence of thoracic sympathectomy on cardiac induced oscillations in tissue blood volume

The parameter AM/BL is proportional to the cardiac-induced blood volume increase, which depends on the arterial wall compliance. AM/BL increased after the thoracic sympathectomy treatment (for male patients, from 2.60 ± 1.49% to 4.81 ± 1.21%), as sympathetic denervation decreases arterial tonus in skin. The very low-frequency (VLF) fluctuations of BL or AM showed high correlation (0.90 ± 0.11 and 0.92 ± 0.07, respectively) between the right and left hands before the thoracic sympathectomy, and a significant decrease in the right-left correlation coefficient (to 0.54 ± 0.22 and 0.76 ± 0.20, respectively) after the operation. The standard deviation of the BL or AM VLF fluctuations also reduced after the treatment, indicating sympathetic mediation of the VLF PPG fluctuations. The study also shows that the analysis of the PPG signal and the VLF fluctuations of the PPG parameters enable the assessment of the change in sympathetic nervous system activity after thoracic sympathectomy.
http://cat.inist.fr/?aModele=afficheN&cpsidt=14106877

low heart rate variability is associated with an increased risk for sudden cardiac death

The amount of short- and long-term variability in heart rate reflects the vagal and sympathetic function of the autonomic nervous system, respectively. Therefore heart rate variability can be used as a monitoring tool in clinical conditions with altered autonomic nervous system function. In postinfarction and diabetic patients, low heart rate variability is associated with an increased risk for sudden cardiac death. A sympathovagal imbalance is also detectable with heart rate variability analysis in coronary artery disease and essential hypertension.
http://www.annals.org/content/118/6/436.abstract

Thursday, November 12, 2009

Isointegral mapping revealed that ETS altered electroactivity on the heart

In the head-up tilt study, R–Rintervals significantly increased after the surgery in the head-uptilt positions (P<0.05),> difference in the supine position. There is no significant differencein QTc and Twa before and after the surgery, both in the supineand the head-up tilt positions. There was no significant differencein the LF or HF before and after surgery, either in the supineposition or the head-up tilt positions. In the LF/HF, therewas no significant difference before and after surgery in thesupine position. However, the LF/HF in the head-up tilt positionswas significantly decreased after surgery (P<0.05).> suppression of ETS was recognized more obviously under the steeperhead-up tilt positions. Conclusions: The influences on the cardiacautonomic nerve system of the ETS of upper thoracic sympatheticnerve were seen to be of a lesser degree at rest. However, theresponse to sympathetic stimulation was suppressed after thesurgery.
Eur J Cardiothorac Surg 1999;15:194-198

Obviously, it is not simply a compensatory hyperhidrosis transposition

Obviously, it is not simplya compensatory hyperhidrosis transposition from postoperativereduction of palmar sweating. Based on our observations, wepostulated two possible mechanisms. The first of these mechanismsis denervation hypersensitivity of the surgically injured distalsympathetic stump. This could explain why CH may appear soonafter sympathectomy, but is not found in patients who undergolocal excision of axillary sweat glands or undergo local treatment.Another mechanism is regeneration of preganglionic fibers orcollateral sprouting of sympathetic fibers from the proximalstump of the sympathetic trunk. This could explain the long-termexistence of PCH.

Ann Thorac Surg 2001;72:667-668

collateral effects of thoracic sympathectomy not disclosed to patients

Several reports also demonstrate significantly lower heart rateincreases during exercise in subjects who have undergone bilateralISS [9–12] compared to pre-surgical levels. In spite ofthis high occurrence, recent reviews on the usual collateraleffects of thoracic sympathectomy still do not include thesepossible cardiac consequences [6].
Eur J Cardiothorac Surg 2001;20:1095-1100

similar to beta-blocker therapy

Findings on ¹²³I-MIBG imaging studies indicate that EUTS (endoscopic upper thoracic sympathectomy) suppresses the activation of the sympathetic nervous system slightly, similar to beta-blocker therapy.
JNS - March 2004 Volume 100, Number 3

Introduction Essential hyperhidrosis (EH) is often considered to be related to an increased activity of sympathetic nervous system (SNS). However, there is a lack of studies comparing autonomic nervous system (ANS) activity in controls and in EH patients. The aim of the present study was to simultaneously investigate in patients with severe EH, blood pressure, heart rate variability and plasma catecholamine levels in comparison with controls.

Methods 19 EH patients and 20 controls with normal ANS function assessed by clinical testing were included. Blood pressure (BP) and heart rate (HR) were measured using a Finapres beat-to-beat monitor. BP and HR variabilities (Fast Fourier transformation) and plasma catecholamine levels (HPLC) were obtained at rest and during a 15 min 70° head-up tilt test.

Results At rest, a significantly higher relative energy of low frequency band (LF) of systolic BP was observed in EH in comparison with controls contrasting with the lack of difference in BP, HR, plasma catecholamine levels and in other spectral parameters. During tilt, all changes were comparable in EH and in control subjects excepting relative energy of LF of SBP which remained unchanged when compared to the resting condition in EH group.

Conclusions In EH, SNS is not overreactive even if resting overactivity cannot be excluded.
http://www.springerlink.com/content/xe7g2w72617phl0e/
Volume 13, Number 4 / August, 2003

Clinical conditions that cervico-thoracic sympathetic blockade may benefit

...Miscellaneous conditions in head region: stroke, Meniere disease, tinnitus
Amblyopia due to quinine poisining (also causes retinal artery spasm and thrombosis)

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

Wolters Kluwer Health
Edition: 4 - 2008

Acquired cardiovascular disease following Sympathectomy

Effects of endoscopic thoracic sympathectomy for primary hyperhidrosis on cardiac autonomic nervous activity

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

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

sympathectomy leads to peripheral vasodilation, reduced preload, and subsequently decreased cardiac output

Despite a duration of only 2 week, repeated IVRS (intravenous regional sympathetic block) efferent blocks are an attractive alternative to the higher-risk techniques of thoracic sympathetic block and thoracic surgical or thoracoscopic sympathectomy. (p. 848)

Table 42-1
Classification of percutaneous neural destructive procedures:
Anatomy
1. Peripheral neurotomy (such as destruction of intercostal, ilioinguinal nerves)
2. Rhizotomy (spinal dorsal root rhizotomy, trigeminal rhizotomy)
3. Destruction of sensory pathways in the spinal cord (midline punctuate myelotomy, cordotomy)
4. destruction of brain sensory centers (hypophysectomy)
5. Sympathectomy
(p.992)

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

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

Cardiovascular effects of epidural blockade
"Central" Sympathetic block (T1-T4) - Blockade of
Cardiac sympathetic outflow from vasomotor center
Cardiac sympathetic reflexes at segmental level
Vasoconstrictor fibers to head, neck, and arms

Effect:
HR ↓ CO ↓
Vasodilation in upper limbs
"Inappropriate bradycardia"; "sudden bradycardia"; vagal arrest (p. 247)

↓↓Venous return may result in sudden parasympathetic tone ("faint response")
↓ ↓ HR → cardiac arrest

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

↓HR with visceral traction in presence of blockade to T1.
Total sympathetic block
Unopposed vagus
Changes in vagal tone → profound changes in HR; may → transient asystole (p. 248)

Thermoregulation and Shivering
Hypothermia (a decrease in core temperature) is common in patients undergoing surgery with epidural anesthesia and is thought to result from heat loss to the cold environment due to sympathectomy-induced vasodilation. The normal process by which thermoregulation usually minimizes intraoperative core temperature is prevented, since epidural anesthesia directly inhibits vasoconstriction in the analgesic dermatomes. (p.253)

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

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

Wolters Kluwer Health
Edition: 4 - 2008

Perioperative risks are low, but complications can be devastating

Endoscopic thoracic sympathectomy (ETS) involves divisionof the thoracic sympathetic chain between T2 and T4.

The mainindication for ETS is the treatment of palmar hyperhidrosis.

Themost common method of anaesthesia for ETS uses intermittentpositive pressure ventilation via a standard tracheal tube.

Perioperativerisks are low, but complications can be devastating.

Postoperativecompensatory sweating occurs in almost 50% of patients.

hypoxic pulmonary vasoconstriction may be impaired after Sympathectomy

It is well known that hypoxic pulmonary vasoconstriction(HPV) plays an important role to protect hypoxemia during the atelectasis induced by one-lung ventilation. Thoracic sympathectomy may have effects on pulmonary vasculature(HPV) and hemodynamics during one-lung anesthesia.

Mean arterial blood pressure was decreased from 81.9+/-2.89 to 73.2+/-2.49 mmHg after thoracic sympathectomy and heart rate was decreased from 104.4+/-3.12 to 88.2+/-2.31beats/min. Arterial oxygen tension was decressed from 570.5+/-17.9 to 521.4+/-23.2mmHg after position change, and decreased to 271.1+/-28.1 mmHg under one-lung ventilation, and finally decreased to 217.0+/-18.3 mmHg after thoracic sympathectomy. With the above results, we can conclude that patients for TES should be carefully observed during and after the procedure, and hypoxic pulmonary vasoconstriction may be impaired after TES.
Korean J Anesthesiol. 1993 Aug;26(4):695-699.

profound decrease of arterial oxygen partial pressure during sympathectomy

Left-lung ventilation and right-chest operation caused profound decrease of arterial oxygen partial pressure (PaO2), compared with two-lung ventilation before surgery (70.7%, P > 0.0003) and compared with PaO2 at two-lung ventilation during and after surgery (decrease of 80.1% and 75.3%, respectively; P > 0.001 and < 0.005, respectively). Right-lung ventilation and left-chest operation did not cause hypoxemia.

Pulse oximetry and repeated blood gas measurements are needed during endoscopic transthoracic sympathectomy in order to detect and treat hypoxemic events, which may jeopardize the patient's life.
Journal of Cardiothoracic and Vascular Anesthesia
Volume 10, Issue 2, February 1996, Pages 207-209

Spinal cord infarction occurring during thoraco-lumbar sympathectomy

Spinal cord infarction, because of interference with an important radicular tributary, is a rare complication of thoraco-lumbar sympathectomy.
In a brief survey of the literature we found only 12 previously recorded cases in which this complication
was presumed to have occurred.
J. Neurol. Neurosurg. Psychiat., 1963, 26, 418

Acute Postoperative Shingles After Thoracic Sympathectomy for Hyperhidrosis

Shingles secondary to reactivation of a previous varicella-zostervirus infection has been reported to develop within surgicalwounds and after trauma. We report the case of a 17-year-oldgirl with history of chicken pox in childhood who had acutepostoperative shingles develop along the T3-T4 dermatomes afterthoracic sympathectomy for hyperhidrosis.
Other possible explanationsfor the development of shingles in this patient include (1)the reactivation of the old varicella-zoster virus in the dorsalroot ganglia by manipulation of the sympathetic chain throughpreoperative and postoperative ganglionic axonal connectionsbetween the denervated sympathetic ganglia and the T3 and T4dorsal root ganglia, or (2) reactivation of the virus by directpressure of the thoracoscopic instruments on the third and fourthintercostal nerve bundles.
http://ats.ctsnetjournals.org/cgi/content/full/78/6/2159

Severe 'Compensatory Sweating' in 28%

Compensatory sweating is a common symptom following thoracic sympathectomy; however, the reported incidence of this complication varies greatly, and its severity has not been quantified. METHODS: In this study changes in the distribution of sweating following bilateral T2-3 thoracoscopic sympathectomy for hyperhidrosis were assessed in 42 patients. Sweat production in the palms, axillae, face, trunk and feet was assessed using a linear analogue scale. RESULTS: The operation was most successful in reducing sweat production in the palms, axillae and face (in descending order). The operation also reduced pedal sweat production in 12 of the 29 patients who suffered concomitant pedal hyperhidrosis. Compensatory truncal sweating occurred in 36 of the 42 patients; it was severe in ten, (28%) moderate in 16 and minimal in ten. CONCLUSION: Patients should be warned about compensatory sweating before thoracic sympathectomy.
http://www.ncbi.nlm.nih.gov/pubmed/9448619?dopt=Abstract
Br J Surg. 1997 Dec;84(12):1702-4.

Effect of adrenalectomy or sympathectomy on spinal cord blood flow

After sympathectomy, RSCBF (regional spinal cord blood flow) was unchanged during hypothermia. In the cauda equina, flow fell in all hypothermic rats. The hypothermia-associated increases in RSCBF were not related to changes in mean arterial blood pressure. We conclude that adrenalectomy near-totally ablates the hypothermia-associated increase in RSCBF measured in intact rats and that abdominal sympathectomy totally ablates it. This evidence complements morphological evidence for adrenergic innervation of the spinal cord vasculature.
Am J Physiol. 1991 Mar;260(3 Pt 2):H827-31.

burning causes nerve scaring, which may behave like epilepsy

ETS is a very effective way to treat hyperhidrosis and FB in the vast majority of the cases, but a small group of patients have devastating effects. Unfortunately, we do not know who these patients are before we operate.
Extensive surgery or burning causes nerve scaring, which may behave like epilepsy of the autonomous nervous system and cause the well known devastating side effects.

http://www.sympathectomy.info/

sympathectomy may retard aversive conditioning

"Researchers have examined the role of autonomic feedback in emotional experience using the heartbeat paradigm. Katkin at al. (1982) found that some normal subjects can accurately detect their heartbeats, and it was those individuals who had a stronger emotional response to negative slides as determined by self-report (Hantas et al., 1982). Further support for the importance of autonomic feedback comes from observations. Experiments in animals demonstrate that sympathectomy may retard aversive conditioning (DiGusto and King, 1972), most likely because sympathectomy reduces fear.

In order for a feedback to occur, there must be a means for the viscera and autonomic nervous system to become activated.

Clinical neuropsychology

By Kenneth M. Heilman, Edward Valenstein
Oxford University Press

pain states associated with the loss of sympathetic fibres

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.

Abnormal autonomic functions, however, markedly affect the individual's ability to respond to changing conditions

Normal function of all components of the ANS is not required to maintain life, as long as
environmental conditions are a constant and optimum. Abnormal autonomic functions, however,
markedly affect the individual's ability to respond to changing conditions. This can be demonstrated
by sympathectomy, the removal of sympathetic ganglia. An animal becomes highly sensitive to heat,
cold, or other forms of stress following sympathectomy. In a hot environment the animal's ability to
lose heat by increasing blood flow to the skin and by sweating is decreased. When exposed to the
cold, the animal is less able to reduce blood flow to the skin and conserve heat. Sympathectomy also
results in low blood pressure caused by dilation of peripheral blood vessels and results in the
inability to increase blood pressure during periods of physical activity.
http://www.mhhe.com/biosci/ap/seeleyap/nervous/reading3.mhtml

Degeneration patterns of postganglionic fibers following sympathectomy

In the reg signs of degeneration can already be recognized in the myelinated as well as in the unmyelinated axons 48h after sympathectomy.

In the muscle nerves the first signs of an axonal degeneration of the sympathetic fibers can be recognized 4 days after surgery. The signs of axonal degeneration are most striking about 8 days p.o. They have more or less disappeared another week later. The reactions of the Schwann cells also start on the fourth day but outlast the degenerative processes by some 8 days. Thus the degenerative and reactive processes in the reg precede those in the muscle nerves by 2 days early after surgery and by 6 days 3 weeks later. Seven weeks after surgery, fragments of folded basement lamella and Remak bundles with condensed cytoplasm and numerous flat processes are persisting signs of the degeneration.
http://www.springerlink.com/content/m21m2612n2147011/

Effect of sympathetic blockade on cerebral perfusion

J Neurol. 2002 Jan;249(1):108-9.Links: Effect of sympathetic blockade on cerebral perfusion demonstrated on Tc-99m HMPAO SPECT.

Lang O, Svoboda L, Balon HR.
http://www.ncbi.nlm.nih.gov/pubmed/11954858

Sympathetic nerves protect against blood-brain barrier disruption

Sympathetic nerves protect against blood-brain barrier disruption in the spontaneously hypertensive rat.

http://www.ncbi.nlm.nih.gov/pubmed/7064183?holding=ukpmc

Ultrastructural changes in the nerves innervating the cerebral artery after sympathectomy

Iwayama T. Ultrastructural changes in the nerves innervating the cerebral artery after sympathectomy. Z Zellforsch Mikrosk Anat. 1970;109(4):465–480.
http://www.ncbi.nlm.nih.gov/pubmed/5498231?holding=ukpmc

Alteration in 'fight-or-flight response following sympathectomy

Mental arithmetic produces a psychophysiological arousal similar to the so-called defence-alarm reaction elicited by stimulation ofthe hypothalamic defence area in experimental animals (Folkow, 1982). This reaction pattern is characterized by increased heart rate, cardiac output and blood pressure, whereas total peripheral resistance is unchanged or decreased (Brod, 1970).

The increase of platelet concentration during psychological arousal is also in accordance with what has been observed in response to other stressors, i.e. physical exercise and adrenaline infusion (Sarajas et al, 1961; Gjerloff Schmidt & Waever Rasmussen, 1984; Dawson & Ogston, 1969; Vilen et al, 1980).

The emotional leucocytosis observed in dogs has been claimed to be neurogenic in origin, since sympathectomy abolished the rise in leucocyte count (Garrey & Bryan, 193 5).
Both alpha- and beta-receptors seem to be of importance in the mobilization of lymphocytes (Gader & Cash, 1975).

British Journal of Haematology. 1989. 71, 153-1 56

normal forearm vasodilator response to mental stress was absent months or years after surgical sympathectomy

Additional indirect evidence on this topic in humans comes from a study conducted in the 1950s (3). In this study, the normal forearm vasodilator response to mental stress was absent months or years after surgical sympathectomy.
J Appl Physiol
Vol. 92, Issue 5, 2019-2025, May 2002

Sympathectomy as a way to achive tranquility for the patient

In every case of bilateral cervical or upper dorsal sympathectomy that I have performed the most pronounced feature is a mental change in the patient from one of worry and apprehension to that of tranquillity and a sense of well-being.

Sympathectomy in Relation to Meniere's Disease, Nerve Deafness
and Tinnitus. A Report on 110 Cases
By E. R. GARNETT PASSE, F.R.C.S., F.A.C.S.

Acta Oto-laryngologica

1952, Vol. 42, No. 1-2, Pages 133-151

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

Surgical and chemical sympathectomy can alter cellular proliferation

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

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

Neuroscience Letters 248 (1998) 97– 100

sympathectomy affects the heart, sweating, and circulation

heart rate was significantly reduced at rest (14%), at sub-maximal exercise (12.3%), and at peak exercise (5.7%), together with a significant increase in oxygen pulse (11.8, 12.7, and 7.8%, respectively). The rate pressure product (RPP) was also significantly reduced following the surgical procedure at all three study stages, while all other physiological variables measured remained unchanged. It is suggested that thoracic-sympathetic denervation affects the heart, sweating, and circulation of the respective denervated region

Eur J Appl Physiol. 2008 Sep;104(1):79-86. Epub 2008 Jun 10.

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

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

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

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

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

Acquired cardiovascular disease following Sympathectomy

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

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

DYNAMIC CEREBRAL AUTOREGULATION IS ALTERED BY GANGLION BLOCKADE

After ganglion blockade, systolic and pulse pressure decreased significantly by 13% and 26%, respectively. CBF velocity decreased by 6% (P <0.05). In the very low frequency range (0.02 to 0.07 Hz), mean blood pressure variability decreased significantly (by 82%), while CBF velocity variability persisted. Thus, transfer function gain increased by 81%. In addition, the phase lead of CBF velocity to arterial pressure diminished. These changes in transfer function gain and phase persisted despite restoration of arterial pressure by infusion of phenylephrine and normalization of mean blood pressure variability by oscillatory lower body negative pressure.

Conclusions-: These data suggest that dynamic cerebral autoregulation is altered by ganglion blockade. We speculate that autonomic neural control of the cerebral circulation is tonically active and likely plays a significant role in the regulation of beat-to-beat CBF in humans.

Circulation. 106(14):1814-1820, October 1, 2002.

Segmental myoclonus was associated with thoracic sympathectomy

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

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

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

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

Spinal myoclonus following a peripheral nerve injury: a case report

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

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

significant change after sympathectomy: reduced sympathetic and increased vagal tone

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

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

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

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

the severity of post-sympathectomy (post-SE) dysfunction is unpredictable

SE was diagnosed in 0.5% after ALIF at L5/S1, in 15% after ALIF at Th12-L5 and in 4% after XLIF at T12-L5. SE severely reduced the quality of life in two cases. The ability to distinguish differences in leg temperature by palpation after SE was found in 32%. All physical examinations together were insufficient for reliably disclosing SE. Subjective symptoms of SE were often false positive and proven SE by TG was often a clinically false negative.
CONCLUSION:
This is the first study to examine post-SE dysfunction objectivelya using TG after ALIF and XLIF, and the first to evaluate clinically, the severity of the post-SE syndrome. Before surgery we cannot foresee potentially poor SE results. For this reason, injury to the sympathetic chain during surgery must be avoided. The advantage of TG for identifying SE is its non-invasiveness and reliability.
http://www.ncbi.nlm.nih.gov/pubmed/24263213"

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

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

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

The courts have become the sole policing body for the medical profession

Major lawsuits, with the major judgments that go with them, may not completely keep negligent physicians from practicing, but they are the one way that currently exists to deter these individuals from practicing their inept brand of medicine. "

Over the years, we have given a lot of thought to why the medical profession adheres to this code of silence. What is it about this profession that causes it to protect its own at the expense of the public?"

Harvey F. Wachsman: Lethal Medicine

Publisher: Henry Holt & Co

All patients except one suffered from compensatory sweating

Complications in patients with palmar hyperhidrosis treated with transthoracic endoscopicsympathectomy.

Neurosurgery. 1997 Jul ;41 (1):110-3; discussion 113-5 9218302

OBJECTIVE: To assess the complications in a group of patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy. The extraordinarily high incidence of postoperative compensatory hyperhidrosis in our series is stressed and explained. METHODS: The retrospective study included chart reviews and outpatient assessments. Seventy-two patients underwent T2 or T2-T3 endoscopic sympathectomy for primary palmar hyperhidrosis. Patients' hyperhidrosis severity, precipitating factors, postoperative complications, surgical results, and satisfaction were assessed. Severity of palmar hyperhidrosis and compensatory hyperhidrosis was classified by two grading scales. RESULTS: The success rate of sympathectomy was 93%. All patients except one suffered from compensatory sweating,which was the main cause of patients' dissatisfaction postoperatively. Seventeen percent of the patients (12 of 72 patients) experienced new symptoms of gustatory sweating (facial sweating associated with eating). Twenty-one patients experienced other complications, including pneumothorax, Horner's syndrome,nasal obstruction, and intercostal neuralgia.

hyperhidrosis is not related with social phobia or personality disorder

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

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

Muliptle organ failure as a consequence of elective sympathectomy

In the post-sympathectomy patient, the abnormalsympathetic skin response may lead to peripheral vascular failureor the reduced cardiac chronotropic response may impair thebody’s capacity to compensate for shock. These may havecontributed to the rapid development of shock and severe multipleorgan dysfunction syndrome in this patient.
He had multiple organ dysfunction syndrome develop, with severerenal and hepatic failure, grade II hepatic encephalopathy,and disseminated intravascular coagulation. He responded remarkablywell to aggressive supportive measures including forced alkalinediuresis, 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, sportylifestyle. The only significant medical history was that hehad received thoracic sympathectomy for axillary hyperhidrosis4 years ago at another hospital.

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

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

the muscles that are supplied by these nerves shorten and tighten

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

www.northwestims.com/faq-4.html

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

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

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

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

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

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

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

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

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

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

Anesth Analg 2009; 109:1511-1516

After sympathectomy for hyperhidrosis, very severe discomfort with alarming frequency

our ignorance of the mechanisms of primary hyperhidrosis and of the effect of sympathetic ablation

'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

cervical sympathectomy is a psychosurgery

Limited sympathectomy does not reduce severity of side-effects

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

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

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

Receptor hypersensitivity is a common problem

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

Neuroma following nerve injury/surgery

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

www.tarsaltunnelcenter.com/assets/recurrent.shtml

slowing of the heart rate usually occurs on the second to fourth day after sympathectomy

The rate fell to a level between 40 and 6o per minute, the maximal slowing usually occurring on the second to fourth day after operation. Consistent slowing of the rate was not observed after a unilateral thoracic sympathectomy of either side. While there was some recovery from the maximum bradycardia with the passage of time in most patients, relatively slow resting cardiac rates and failure of tachycardia to develop with postural hypotension or exercise persisted in all patients.

Skoog's12 work has shown that there are marked differences in the number and precise location of the accessory ganglion cells in the cervical region in different patients and on the two sides in the same patient.
Annals of Surgery, 1949 October, Volume 130 Number 4

Permanent thermoregulatory dysfunction after ETS

What you see here is not a result of the surgery gone wrong, this is the inevitable consequence of cutting/clamping the sympathetic chain, independently of skill of the surgeon, experience of the surgeon, T2, or T3, T4, or method used. Once the communication is disrupted, (and it happens with the clamping as well), it will disable the body's thermoregulation and will cause malfunctioning of the sympathetic nervous system. This damage is permanent and irreversible. There has been no controlled clinical trial into the effects of this surgery on humans or its safety, but it is still used for many conditions: angina pectoris, to lower blood pressure, to treat migraine, to reduce pain in cancer patients, to reduce immuneresponses after skin transplant, to treat various cancers in the oral cavity, and among many: to treat anxiety disorders, schizophrenia, and phobias.

These gustatory phenomena were quite different from physiologic gustatory sweating

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

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

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

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

Salivary gland disorders

Eugene N. Myers, Robert L. Ferris

Springer, 2007 - Medical - 517 pages

causes of autonomic dysfunction - sympathectomy

Patients with progressive autonomic dysfunction (including diabetes) have little or no increase in plasma noradrenaline and this correlates with their orthostatic intolerance (Bannister, Sever and Gross, 1977). In patients with pure autonomic failure, basal levels of noradrenaline are lower than in normal subjects (Polinsky, 1988). Similar low values are observed in patients with sympathectomy and in patients with tetraplegia. (p.51)

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

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

Disorders of the Autonomic Nervous System

By David Robertson, Italo Biaggioni

Edition: illustrated

Published by Informa Health Care, 1995

ISBN 3718651467, 9783718651467

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

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

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

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

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

Wolters Kluwer Health
Edition: 4 - 2008

Permanent thermoregulatory Dysfunction after Sympathectomy

The autonomic dysfunction you see on this thermal image is not a result of the surgery gone wrong, this is the result of a ...successful operation; it is the inevitable consequence of cutting/clamping the sympathetic chain, independently of skill of the surgeon, experience of the surgeon, T2, or T3, T4, or method used. Once the communication is disrupted, (and it happens with the clamping as well), it will disable the body's thermoregulation and will cause malfunctioning of the sympathetic nervous system. This damage is permanent and irreversible. "Sympathectomy is analogous to the act of killing the messenger. The sympathetic nervous system has the critical job of properly controlling and preserving the circulation in different parts of the body, especially in the extremities. By paralyzing the system, the extremity will be more apt to have disturbance of circulation and is left unprotected from fluctuation in circulation. Sympathectomy is similar to permanently removing the central heat and air-conditioning system and never replacing it because of malfunction." H. Hooshamand, MD Neurological Associates, Pain Management Center, Vero Beach, Florida

There is potentially a number of safety issues associated with this procedure

Australian Review of ETS surgery

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

Australian Review of ETS surgery - 2001

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

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

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

Centre for Clinical Effectiveness - Monash

Swedish Review

Finnish Review

Conclusions: The evidence of the effectiveness of ETS is weak due to a lack of randomized trials. The intervention leads to severe immediate complications in some of the patients, and to persistent side-effects for many of the patients.
University of Ouluand
Finnish Ofﬁce for HealthTechnology Assessment
University of Helsinki
Finnish Ofﬁce for Health Technology Assessment
University of Copenhagen

For a small group of patients sympathectomy can have devastating effects

ETS is a very effective way to treat hyperhidrosis and FB in the vast majority of the cases, but a small group of patients have devastating effects. Unfortunately, we do not know who these patients are before we operate.

Dr. Giudiceandrea Alberto, general and vascular surgeon
http://sympathectomy.info/

Possible side effects, ranging from trivial to devastating, are of even greater importance with these more permanent procedures.

G D Schott Consultant neurologist
Interrupting the sympathetic outflow in causalgia and reflex sympathetic dystrophy - A futile procedure for many patients
The National Hospital for Neurology and Neurosurgery, London
1998;316;789-790 BMJ

Sympathectomy reduces DOPAMINE - Latent inhibition and creative drive

Dopamine in the mesolimbic pathway increases general arousal and goal directed behaviors and decreases latent inhibition; all three effects increase the creative drive of idea generation. This has led to a three-factor model of creativity involving the frontal lobes, the temporal lobes, and mesolimbic dopamine.^[34]

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.
Diabetologia. 1983 May;24(5):347-50, PMID: 6873514 [PubMed - indexed for MEDLINE]
Goebel FD, Fuessl HS.

Some of these side-effects, as listed on the Swedish support group website:

Side effects of the elective surgery:
Severe compensatory sweating = disabling sweating
Decreased physical capacity
Reduced blood circulation
Stomach problems (constipation or diarrhea)
Impotence
Oversensitivity to stress
Oversensitivity to sounds
Oversensitivity to light
Muscle weakness ("lactic acid in the arms")
Cold hands and feet - denervation supersensitivity
Horners syndrome
Reduced pulse reaction - delay in heart rate and BP responses, dizziness
Shortness of breath
Pain in arms and back - due to nerve sprouting
Chronic fatigue, lack of energy - S affects adrenaline levels
Raynauds disease - denervation supersensitivity

and from research:

Autonomic dysfunction
Vascular disturbances
Calcification of arteries
Permanently disabled thermoregulation
blocked nose or watery discharge/dripping from nose
dry, inflamed eyes
Reduced physical capacity, even when going up a flight of stairs - HR and BP responses delayed
depression - ETS reduces NE and catecholamines, increases serotonin
mood-swings
Altered sympathetic tone, feeling sedated/detached - beta-blocker effect
Inability to experience/respond to strong emotions - S disrupts signals from the viscera
Reduces/eliminates fear
difficulty concentrating, foggyness, memory affected
lack of motivation/drive/cognitive function - reduction of small vessels in the anterior cingulate cortex, altered catecholamines
overheating due to disabled thermoregulation, even when extreme sweating present - fever in hot weather or with physical activity/brain overheating
difficulty falling asleep/getting up - S eliminates circadian rhythm
Destabilized heart rate, arrythmia, dropped beats, morphofunctional changes in the myocardium
Reduced heart rate = reduced alertness, reduced emotional responses, ('not feeling alive'), all affecting long term memory (encoding).
Suppressed or eliminated Baroreflex = MAP instability
Mean Arterial Pressure instability, reduced short-term haemodynamic variability ('not feeling alive')
Hair loss, loss of eyebrows, eyelashes - altered blood flow in the skin
Dehydrated skin on upper body, face, scalp, - dandruff, skin infections, reduced immune responses
Reduced antibody responses - altered immune system

Several publications/books interchange 'Sympathectomy' and 'Spinal Cord Injury' due to the similarity in presentation/ symptoms.

Sweating after sympathetic surgery is a reflex cycle between the sympathetic system and the anterior portion of the hypothalamus according to our investigations. Reflex sweating will not happen if hand sweating can be stopped without interrupting sympathetic tone to the human brain. (sic!)
Chien-Chih Lin, M.D., *Timo Telaranta, M. D.

Presentation at the 4th International Symposium on Sympathetic Surgery

ETS is a relatively safe and simple procedure. However the side effects are possibly devastating All physicians providing this service and all peoples preparing to undergo this treatment should know this well.
Min-Huei Hsu (10 January 2005)
http://www.cmaj.ca/cgi/eletters/172/1/69#1908

Cervical sympathectomy inhibits axonal transport of gonadotropin-releasing hormone during continuous exposure to light

Department of Anesthesiology, Fukushima Medical College, 1 Hikarigaoka, 960-12 Fukushima, Japan
http://www.springerlink.com/content/q261272138632p52/

GNRH secretion is pulsatile in all vertebrates, and is necessary for correct reproductive function. Thus, a single hormone, GNRH1, controls a complex process of follicular growth, ovulation, and corpus luteum maintenance in the female, and spermatogenesis in the male.
http://en.wikipedia.org/wiki/Gonadotropin-releasing_hormone

The severity and manifestations of autonomic hyperreflexia are affected by the level of the sympathectomy. With mid-thoracic lesions below the level of cardiac accelerator fibers, hypertension is accompanied by reflex bradycardia transmitted via cardiac accelerator fibers and the vagus. In patients whose sympathectomy is above the level of the thoracic cardiac accelerator fibers, tachycardia may occur because cardiac accelerator fibers become part of the efferent sympathetic activity rather than part of the central inhibitory input from the brain stem and hypothalamus. Arrythmias and occasional heart block may accompany changes in heart rate.
Clinical manifestations of autonomic hyperreflexia include vasodilation, decresed sympathetic activity, and increased vagal activity above the level of the lesion such as nasal congestion, flushing, headache, dyspnea, nausea, and visceral muscle contraction. Vasoconstriction and increased sympathetic activity below the level of the lesion cause vasoconstrictive pallor, sweating, piloerection, and somatic muscle fasciculation. Patients also develop hypertension with headache, blurred vision, myocardial infarction, andretinal, subarachnoid and cerebral hemorrhages that may lead to syncope, convulsion and death.
Handbook of Neuroanesthesia
page 343
By Philippa Newfield, James E. Cottrell

Sympathectomy has a beta-blocker effect on the healthy patient

Cardiovascular changes after bilateral upper dorsal sympathectomy.

Papa MZ, Bass A, Schneiderman J, Drori Y, Tucker E, Adar R.
"The effect of bilateral upper dorsal sympathectomy (UDS) on cardiac function was investigated in two groups of young healthy patients who underwent bilateral excision of T2 and T3 ganglia for palmar hyperhidrosis.
The mean pulse rate decreased significantly in patients after they underwent bilateral UDS.
Pulse rates taken at rest and after effort were significantly lower than those taken after operation, and the blood pressure response to exercise was blunted. ECG tracings showed a significant change in the electrical frontal plane axis and shortening of
the QTc interval. These changes were evident 30 days after operation and persisted for 2 years. In conclusion, bilateral UDS has no overt arrhythmogenic effect in the young, healthy heart and its beta-blocker-like effect persists for at least 2 years." (the time of the tests performed)

Beta blockers block the action of endogenous catecholamines (epinephrine (adrenaline) and norepinephrine (noradrenaline) in particular), on β-adrenergic receptors, part of the sympathetic nervous system which mediates the fight or flight response.

The increase in heart rate in response to HUT (head-up tilt) was significantly reduced after surgery in the ETS group (from 34 ± 18 to 14 ± 11 beats·min⁻¹). Orthostatic hypertension disappeared completely after ETS , whereas the prevalence of orthostatic hypotension increased significantly after ETS (from 3 of 11 to 9 of 11 patients). http://www.springerlink.com/content/dk8tq89wnhq4naqy/

Cardiac arrest - a major complication of bilateral sympathectomy

Thoracic sympathectomy has usually minimal consequences if unilateral, especially on the right side. For
bilateral procedures, a mean reduction of the heart rate of 12% was reported. Around 50% of patients have bradycardia in the following minutes of abilateral surgery and mean and diastolic blood pressures significantly reduced.
Since the sympathectomy will block the chronotropic response, a significant increase of the ejection volume is observed when the patient moves in the erect position from dorsal decubitus.
Interact Cardiovasc Thorac Surg. 2008 Nov 27. [Epub

Chronotropic incompetence, an attenuated heart rate response to exercise, is a predictor of all-cause mortality in healthy populations. This association may be independent of exercise-induced myocardial perfusion defects.
Impaired Chronotropic Response to Exercise Stress Testing as a Predictor of Mortality
Michael S. Lauer, MD; Gary S. Francis, MD; Peter M. Okin, MD; Fredric J. Pashkow, MD; Claire E. Snader, MS; Thomas H. Marwick, MD
JAMA. 1999;281:524-529.

The haemodynamic effect of thoracoscopic cardiac sympathectomy
Lim-Sim Lee, Chien-Chih Lin, Seok-Mun Ng, Chung-Fai Au
The haemodynamic response to cardiac sympathetic denervation corresponded to the efferent effect of beta-receptor blockade.

Volume 164 Issue S1, Pages 37 - 38, Published Online: 2 Dec 2003

http://www3.interscience.wiley.com/journal/106568649/abstract

After sympathectomy, BP is maintained at nearly normal levels mainly through activation of the renin angiotensin system.

Heart and Circulatory Physiology, Vol 259, Issue 5 1337-H1342, Copyright © 1990 by American Physiological Society

A patient with angina pectoris who had been successfully treated by thoracoscopic cardiac sympathectomy was scheduled to have scalp debridement under general anaesthesia for a scald burn. There were haemodynamic changes during and after the operation including anaesthetic induction, endotracheal intubation, maintenance, and early recovery period. The sympathetic denervated heart showed little chronotropic response to anaesthetic and surgical stimulation. On the contrary, the parasympathetic response was predominant. An episode of severe bradycardia occurred during endotracheal suctioning prior to extubation. The haemodynamic response to cardiac sympathetic denervation corresponded to the efferent effect of beta-receptor blockade.
http://www3.interscience.wiley.com/journal/106568649/abstract

Sympathectomy-induced alterations of immunity

Many studies have demonstrated that ablation of the sympathetic nervous system (SNS) alters subsequent immune responses. Researchers have presumed that the altered immune responses are predominantly the result of the peripheral phenomenon of denervation.
Activation of the CNS was determined by immunocytochemical visualization of Fos protein in brains from male C57BL/6 mice at 8, 24, and 48 h following denervation. A dramatic induction of Fos protein was found in the paraventricular nucleus (PVN) of the hypothalamus and other specific brain regions at 8 and 24 h compared to vehicle control mice. Dual-antigen labeling demonstrates that corticotrophin releasing factor (CRF)-containing neurons in the PVN are activated by chemical sympathectomy; however, neurons containing neurotransmitters which may modulate CRF neurons, such as vasopressin, tyrosine hydroxylase, and adrenocorticotropin, do not coexpress Fos. Our findings suggest an involvement of the CNS in sympathectomy-induced alterations of immunity.
Tracy A. Callahan, Jan A. Moynihan and Diane T. Piekut
Brain, Behavior, and Immunity
Volume 12, Issue 3, September 1998, Pages 230-241

Marked MAP instability following sympathectomy

In conclusion, the results of the present study suggest a major role for the sympathetic nervous system in the regulation of regional circulations, the loss of which in sympathectomized rats results in a marked instability of MAP (mean arterial pressure). The vasodilator component of MAP lability after sympathectomy does not appear to depend on an episodic release of NO synthesized by the L-arginine pathway.

Genetic Hypertension: Proceedings of the 7th International Symposium on SHR and Related Studies Held in Lyon (France), Ecole Normale Supérieure, October 28-30, 1991

By Jean Sassard

These results indicate that chronic surgical sympathectomy of the heart can be successfully accomplished in the rat and guinea pig. Such sympathectomy induces a postjunctional supersensitivity in guinea- pig right atria which is qualitatively and quantitatively similar to that described previously for chronic treatment with reserpine. Bilateral surgical sympathectomy provides a valuable tool for future investigations of the cellular basis of supersensitivity in the myocardium.

What is ETS or Sympathectomy?

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

Are we paying a high price for surgical sympathectomy? - A systematic literature review of late complications.

Surgical sympathectomy, irrespective of approach, is accompanied by several potentially disabling complications. Detailed informed consent is recommended when surgical sympathectomy is contemplated.
J Pain. 2000 Winter;1(4):245-57.

Sympathectomy supressed baroreflex control of heart rate

Loss of Baroreflex = aberrant blood pressure

Reduced baroreflex sensitivity is associated with increased vascular calcification and arterial stiffness

The reduction in BRS and the resulting aberrant blood pressure response to the physiological stress and volume changes of HD may be important in the further understanding of the pathophysiology of the increased mortality in HD patients with vascular calcification.

Lindsay J. Chesterton1, Mhairi K. Sigrist1, Terence Bennett2, Maarten W. Taal1 and Christopher W. McIntyre

T2 results in complete sympathectomy

Removal of only the second dorsal sympathetic. ganglion is stated to result in as complete sympathectomy, in so far as central connections are concerned.
Annual Review of Physiology
Vol. 6: 365-390 (Volume publication date March 1944)
(doi:10.1146/annurev.ph.06.030144.002053)

Visceral Functions of the Nervous System

B A McSwiney

Sympathectomy can be considered a psychiatric surgery

ETS can alter many bodily functions, including sweating, heart rate, heart stroke volume, blood pressure, thyroid, baroreflex, lung volume, pupil dilation, skin temperature, goose bumps and other aspects of the autonomic nervous system. It can diminish the body's physical reaction to exercise and/or strong emotion, and thus is considered psychiatric surgery. In rare cases sexual function or digestion may be modified as well.
©2006 LVHyperhidrosis.com
Dr Nagy, Las Vegas

Prof. Justin Oakley in Morality and the Emotions:
"an emotion is a complex which involves dynamically related elements of cognition, desire and affectivity.

Circadian Rhythm eliminated by Sympathectomy

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

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

Morphofunctional changes in the myocardium following sympathectomy

Vestn Akad Med Nauk SSSR. 1984;(2):80-5.

Morphofunctional changes in the myocardium following sympathectomy and their role in the development of sudden death from ventricular fibrillation
Beskrovnova NN, Makarychev VA, Kiseleva ZM, Legon'kaia , Zhuchkova NI.

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

Marked Mean Arterial Pressure instability following sympathectomy

all regional hemodynamic changes after sympathectomy and suggest that the sympathetic nervous system may play an important role in reducing short-term hemodynamic variability.
Proceedings of the 7th International Symposium on SHR and Related Studies Held in Lyon (France), Ecole Normale Supérieure, October 28-30, 1991
Genetic Hypertension, by Jean Sassard

Changes in Electrophysiology following sympathectomy

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

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

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

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

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

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

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

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

Received: 18 April 1973

disturbed peripheral vascular and heart rate responses after sympathectomy

Thoracicsympathectomy can result in reduced sweating and disturbed peripheralvascular and heart rate responses. Patients should be warnedthat these mechanisms may play a role in the development ofexertional heat stroke.

Alan D.L. Sihoe, FRCSEd(CTh)^a^,_*, Raymond W.T. Liu, MRCP^b, Alex K.L. Lee, MRCP^b, Chak-Wah Lam, FHKAM^b, Lik-Cheung Cheng, FRCS

Cell body reorganization in the spinal cord after elective surgery to treat palmar sweating

Thursday, November 26, 2009

Thursday, November 12, 2009

Clinical neuropsychology

Effect of sympathetic blockade on cerebral perfusion demonstrated on Tc-99m HMPAO SPECT.

Sympathetic nerves protect against blood-brain barrier disruption in the spontaneously hypertensive rat.