Recurrent hyperhidrosis is another potential side effect from hyperhidrosis surgery

The Society of Thoracic Surgeons Expert Consensus for the Surgical Treatment of Hyperhidrosis -- Cerfolio et al. 91 (5): 1642 -- The Annals of Thoracic Surgery: "Recurrent hyperhidrosis is another potential side effect from hyperhidrosis surgery. Incidence rates vary considerably and have been described as 0% to 65%"

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The Society of Thoracic Surgeons Expert Consensus for the Surgical Treatment of Hyperhidrosis -- Cerfolio et al. 91 (5): 1642 -- The Annals of Thoracic Surgery

The Society of Thoracic Surgeons Expert Consensus for the Surgical Treatment of Hyperhidrosis -- Cerfolio et al. 91 (5): 1642 -- The Annals of Thoracic Surgery: "Because the goal of this procedure is to improve quality of life, complications should be minimal and essentially eliminated. The primary side effects of hyperhidrosis surgery include CH, bradycardia, and Horner's syndrome. It is important for patients to be aware, however, of all of the possible complications that can occur. In general, "the higher the level of blockade on the chain, the higher is the expected regret rate" [26]."

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The vasodilating effect of spinal dorsal column stimulation is mediated by sympathetic nerves - Springer

The vasodilating effect of spinal dorsal column stimulation is mediated by sympathetic nerves - Springer: "Immediately after sympathectomy, the contralateral right arm became increasingly cold and cyanotic and the patient complained of chronic painful coldness and severe cold-intolerance in the right arm. Attempts to pharmacologically vasodilate the arm with felodipine did not affect the local vasoconstriction and pain. Dorsal column stimulation (associated with symmetrical paraesthesia in both arms) induced an immediate and marked (ten-fold) increase in skin blood flow in the right arm (and in the leg), whereas skin blood flow in the left arm remained unaffected. The lack of vasomotor response in the left arm was not due to maximal vasodilatation at rest, since skin blood flow in the left arm showed a normal capacity for axon reflex vasodilatation following antidromic activation of sensory afferents. The results suggest that the marked vasodilatation induced by dorsal column stimulation is mediated by sympathetic vasomotor fibres, via modulation of central neuronal circuits involved in the regulation of skin sympathetic discharge."

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Medical Board Disciplines ETS surgeon Dr Nielson

Nielson,  David  Hugh,  M.D.,  Lic.  #K0962,  San  Antonio  TX
On  February  5,  2010,  the  Board  and  Dr.  Nielson  entered  into  an  agreed  order  requiring  Dr. Nielson  to  complete  15  hours  of  CME  in  medical  record-­keeping,  risk  management  and  ethics within  one  year;;  and  pay  an  administrative  penalty  of  $4,000  within  60  days.  The  action  was based  on  the  Board’s  finding  that  Dr.  Nielson  failed  to  keep  adequate  medical  records,  failed to  use  proper  diligence  in  his  professional  practice,  and  failed  to  adequately  supervise  the activities  of  those  acting  under  his  supervision.  The  Board  found  that  digital  photos  that  were part  of  patient  records  were  inadvertently  deleted  and  that  Dr.  Nielson  authorized  a  person  to represent  his  clinic  and  that  person  misrepresented  risks  and  procedures  for  Dr.  Nielson’s treatment  of  rosacea. 
http://www.tmb.state.tx.us/news/press/2010/021710.php

BioEdge: Leveson Inquiry recommends reform of science reporting

BioEdge: Leveson Inquiry recommends reform of science reporting: "Remember patients: don't call something a "cure" that is not a cure."

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catecholamine released from sympathetic nerves, acquires the capacity to activate pain pathways after tissue or nerve injury

What Is Reflex Sympathetic Dystrophy Syndrome or RSD?: "According to the National Institute of Neurological Disorders and Stroke (NINDS), RSD is "a chronic pain condition that is believed to be the result of dysfunction in the central or peripheral nervous systems." According to MedicineNet, RSD involves "irritation and abnormal excitation of nervous tissue, leading to abnormal impulses along nerves that affect blood vessels and skin."

Animal studies indicate that norepinephrine, a catecholamine released from sympathetic nerves, acquires the capacity to activate pain pathways after tissue or nerve injury, resulting in RSD. Another theory suggests that RSD, which follows an injury, is caused by triggering an immune response and symptoms associated with inflammation"

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Transection below T8-T10 is not accompanied by reflex sweating

Reflex sweating in patients with spina... [Arch Phys Med Rehabil. 1977] - PubMed - NCBI: "Sweat glands derive their innervation from the sympathetic nervous system. The spinal sympathetic structures that are located in the intermediolateral areas extend from T1-L2 segments and are under the control of hypothalamic centers. Cord transection abolishes the supraspinal control of sudorimotor function. Since sympathetic innervation does not follow a clear segmental distribution, normal sweating may be preserved at a higher or lower level than skin sensation. Nonthermoregulatory reflex sweating is an indication of unchecked spinal cord facilitation and is precipitated by afferent stimuli from bladder, rectum, and various other sources. It is usually a manifestation of mass reflex or autonomic crisis and occurs particularly in cervical or high thoracic lesions. Transection below T8-T10 is not accompanied by reflex sweating. The phenomenon of thermal relfex sweating is controversial. Although some aspects of nonthermoregulatory reflex sweating are still unclear, proper immediate and continuing preventive management will reduce the incidence of this and other autonomic manifestations. "

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

T3 sympathicotomy segment was the most frequent transection done (95.83%), as only ablation (25%) or in association with T4 (62.50%) or with T2 (8.33%). It was observed increase in RI and PI of the common carotid artery (p < 0.05). The DPV of internal carotid artery decreased in both sides (p < 0.05). The SPV and the DPV of the right and left vertebral arteries also increased (p < 0.05). Asymmetric findings were observed so that, arteries of the right side were the most frequently affected.
CONCLUSIONS: Hemodynamic changes in vertebral and carotid arteries were observed after sympathicotomy for PH. SPV was the most often altered parameter, mostly in the right side arteries, meaning significant asymmetric changes in carotid and vertebral vessels. Therefore, the research findings deserve further investigations to observe if they have clinical inferences.
http://www.ncbi.nlm.nih.gov/pubmed/16186983 

Sympathectomy vs sympathotomy

Sympathectomy vs sympathotomy. Sympathectomy, with use of ganglionectomy and by definition, must sever the primary axon from the neuron in the intermediolateral cell column of the spinal cord (red) before primary or collateral synapse in the T2 ganglion. This injures all the neurons at this level of the spinal cord, some of which may die, and may predispose the patient to spinal cord reorganization and severe compensatory hyperhidrosis. Sympathotomy interrupts only axons after potential T2 ganglion synapses, a less injurious effect on the neuron, and is the least destructive procedure possible with successful treatment of palmar hyperhidrosis. StG, stellate ganglion. 
Atkinson JLD, Fealey RD. Sympathotomy instead of sympathectomy for palmar hyperhidrosis: minimizing postoperative compensatory hyperhidrosis. Mayo Clin Proc 2003;78:167-172.

Gustatory sweating, flushing and other responses after sympathectomy

Gustatory sweating on the head, neck and arms, often occurs after cervico-thoracic sympathectomy. Haxton (1948) reported an incidence of 36 percent, the same as in the present series. It was thought that some information about regeneration in the cervical sympathetic might be revealed by investigation of this surgical curiosity.

Although sweating is the common gustatory response after cervical sympathectomy, other changes are experienced. Haxton (1948) described associated paresthesia and flushing, gooseflesh may occur (Herxheimer, 1958) and vaso-constriction is reported in this paper. These occur together or separately and occasionally sweating might be absent. The subject has been confused by comparison with post-parotidectomy gustatory sweating which has a different mechanism (Glaister et al.,1958; Bloor, 1958).

Sweating is produced by cholinergic sympathetic fibres. In normal individuals both vasocontriction and gooseflesh are adrenergic. This also holds in gustatory responses.  Figure 2 shows blocking of sweating by atropine, whilst gooseflesh continues unchanged.
   The tingling sensations were described as being unlike normal sensation, and likened to plucking out of hair. In one patient in was so unpleasant that she refused to take a test stimulus. Flushing usually occurs on the upper chest and neck, and is an erythema with sharp demarcation, not associated with a rise in skin temperature.
   Of the patients, 29 were found to have gustatory responses, and 24 were studied in detail. Of 22 patients with sweating who could be studied, 11 had gooseflesh, 10 tingling, 6 flushing, and 4 vasoconstriction. Four patients, however, had no sweating and their gustator responses consisted of gooseflesh and tingling in one, tingling alone, and flushing in two. None of these four showed vasoconstriction.
   The stimulus for testing used was usually Worcester sauce, but specificity of the response was sometimes great, and one patient reacted only to boiled sweets made by one particular firm.

http://brain.oxfordjournals.org/content/92/1/137.extract   &
http://ang.sagepub.com/content/17/3/143.extract

No compensatory sweating after botulinum toxin treatment of palmar hyperhidrosis

No compensatory sweating after botulinum toxin... [Br J Dermatol. 2005] - PubMed - NCBI: "Recordings were made at 16 skin areas and compared with subjective estimates of sweating.
RESULTS:
Following treatment, palmar evaporation decreased markedly and then returned slowly towards pretreatment values, but was still significantly reduced 6 months after treatment. No significant increase of sweating was found after treatment in any nontreated skin area.
CONCLUSIONS:
Successful treatment of palmar hyperhidrosis with botulinum toxin does not evoke compensatory hyperhidrosis in nontreated skin territories."

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not exposing patients to the risk of experiencing the side effects of sympathectomy

The use of oxybutynin for treating ... [An Bras Dermatol. 2011 May-Jun] - PubMed - NCBI: "Treatment of facial hyperhidrosis with oxybutynin is a good alternative to sympathectomy, since it presents good results and improves quality of life, in addition to not exposing patients to the risk of experiencing the side effects of sympathectomy."

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rates and characteristics of the paresthesia following needlescopic VATS are similar to those observed after conventional VATS

Incidence of chest wall paresthesia ... [Eur J Cardiothorac Surg. 2005] - PubMed - NCBI: "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%). Post-operative paresthesia and pain did not impact on patient satisfaction with the surgery, whereas compensatory hyperhidrosis in 24 patients (70.6%) did (P=0.001). The rates and characteristics of the paresthesia following needlescopic VATS are similar to those observed after conventional VATS."

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Botulinum toxin type A should be PBS listed for treatment of palmar hyperhidrosis | Medical Journal of Australia

Botulinum toxin type A should be PBS listed for treatment of palmar hyperhidrosis | Medical Journal of Australia:

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Chronic pain can occur after peripheral nerve injury, infection, or inflammation - sympathectomy is a nerve injury

Blocking sympathetic function, whether by surgical sympathectomy, systemic phentol- amine, or systemic guanethidine, relieves partial nerve injury-induced neuropathic pain in laboratory animal models as well as humans (8, 35, 146, 239, 278). Indeed, sympathectomy does not just relieve pathological pain in the body region ipsilateral to the CRPS-initiating event; rather, it also relieves pain arising from anatomically impossible mirror-image sites, that is, the identical body region contralateral to the initiating event (278). Thus sympathetectomy must somehow quiet the contralateral spread of spinal cord hyperexcitability underlying mirror- image pain.

Alterations in sympathetic fibers rapidly follow pe- ripheral nerve injury. This occurs as sprouting of sympa- thetic fibers, creating aberrant communication pathways from the new sympathetic terminals to sensory neurons (35). Sympathetic sprouting has been documented in the region of peripheral terminal fields of sensory neurons (262), at the site of nerve trauma (57), and within the dorsal root ganglia (DRG) containing cell bodies of sen- sory neurons (248, 343). Each of these sites develops spontaneous activity and sensitivity for catecholamines and sympathetic activation (8, 53).

The clearest evidence that immune activation partic- ipates in sympathetic sprouting comes from studies of the DRG. DRG cells receive signals that peripheral nerve injury has occurred via retrograde axonal transport from the trauma site. These retrogradely transported signals trigger sympathetic nerve sprouting into DRG (205, 308). As a result of nerve damage-induced retrogradely trans- ported signals, glial cells within the DRG (called satellite cells) proliferate (248) and become activated (343); mac- rophages are recruited to the DRG as well (63, 176). In turn, the activated satellite glial cells (and, presumably, the macrophages) release proinflammatory cytokines and a variety of growth factors into the extracellular fluid of the DRG (206, 246–248, 258, 277, 308, 358). These sub- stances stimulate and direct the growth of sympathetic fibers, which form basket-like terminals around the satel- lite cells that, in turn, surround neuronal cell bodies (247, 248, 343). For discussion of satellite cell functions, see section IIIA.

LINDA R. WATKINS AND STEVEN F. MAIER

Department of Psychology and the Center for Neuroscience, University of Colorado at Boulder, Boulder, Colorado

Physiol Rev

82: 981–1011, 2002; 10.1152/physrev.00011.2002.

A randomized placebo-controlled trial of oxybuty... [J Vasc Surg. 2012] - PubMed - NCBI

A randomized placebo-controlled trial of oxybuty... [J Vasc Surg. 2012] - PubMed - NCBI: "Palmar and axillary hyperhidrosis improved in >70% of the patients, and 47.8% of those presented great improvement. Plantar hyperhidrosis improved in >90% of the patients. Most patients (65.2%) showed improvements in their quality of life. The side effects were minor, with dry mouth being the most frequent (47.8%).
CONCLUSIONS:
Treatment of palmar and axillary hyperhidrosis with oxybutynin is a good initial alternative for treatment given that it presents good results and improves quality of life."

bilateral sympathectomy may cause bowel, bladder, or sexual dysfunction

If regional sympathetic blockade provides relief, surgical sympathectomy can be considered. Initial pain relief may be significant, but symptoms tend to recur over the next 2 to 5 years.^[53] This is believed to occur owing to incomplete surgical removal of all sympathetic innervation to the extremity. Collateral reinnervation can occur, but bilateral sympathectomy may cause bowel, bladder, or sexual dysfunction.^[14]

It is possible to disrupt the sympathetic chain ganglion by treatments other than surgery. Ablation with radiofrequency devices and caustic chemicals (such as alcohol) have been described, but the region of necrosis may expand beyond the ganglion and long-term results are unknown.[59,][69] As such, surgical sympathectomy is considered strictly as a last resort.  

Knee Disorders: Surgery, Rehabilitation, Clinical Outcomes By Frank R. Noyes, MD

Research indicates that a highly variable heart rate increases your capacity to respond and adapt to life’s challenges

Research has shown that reductions in heart rate variability are a predictor of sudden cardiac death, even in individuals without a prior history of cardiovascular disease.

http://theconversation.edu.au/depression-can-break-your-heart-literally-1102

Effects of unilateral stellate ganglion block on the spectral characteristics of heart rate variability

Effects of unilateral stellate ganglion block on ... [Jpn Circ J. 1999] - PubMed - NCBI: "Effects of unilateral stellate ganglion block on the spectral characteristics of heart rate variability"

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Stellate ganglion block may relieve hot flashes by interrupting the sympathetic nervous system

Stellate ganglion block may relieve hot flash... [Med Hypotheses. 2007] - PubMed - NCBI: "the wide range of conditions that have been reported to respond favorably to stellate ganglion block suggest that its effectiveness may not be solely the result of increased blood flow nor restricted just to its sphere of innervation. We have found that stellate ganglion block is effective in the treatment of hot flashes in postmenopausal women, as well as those with estrogen depletion resulting from breast cancer treatment. Based on evidence that hot flashes may be centrally mediated and that the stellate ganglion has links with the central nervous system nuclei that modulate body temperature, we hypothesize that the stellate ganglion block provides relief of hot flashes by interrupting the central nervous system connections with the sympathetic nervous system, allowing the body's temperature-regulating mechanisms to reset. If this mechanism can be confirmed, this would provide women with intractable hot flashes with an effective, potentially long-lasting means of relieving their symptoms, and potentially widen the range of indications for stellate ganglion block to include other centrally mediated syndromes."

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patients with palmar hyperhidrosis have no overactivity of the sympathetic nerve

HR and BP at rest and cardiovascular response to exercise were similar in patients with palmar hyperhidrosis before ETS and in the normal control population. Therefore, we consider that patients with palmar hyperhidrosis have no overactivity of the sympathetic nerve. However, because bilateral ETS causes the suppression of cardiovascular response to exercise, patients that has been treated with ETS need to be observed during high-level exercise.

http://iars.org/abstracts/browsefile/browse.asp?command=N&absnum=45&dir=S190

These observations further emphasize our ignorance of the mechanisms responsible for primary hyperhidrosis and of the effect of sympathetic ablation

"These observations further emphasize our ignorance of the mechanisms responsible for primary hyperhidrosis and of the effect of sympathetic ablation on the function of the remaining sympathetic system."  

"Only investigators who deviate from accepted standards innovate and thus advance science. Obviously, such deviations may also result in disasters;"  

Statement made by the former President of the International Society of Sympathetic Surgery,  and ETS surgeon, Moshe Hashmonai (Invited Commentary)   

Endoscopic Lumbar Sympathectomy Following Thoracic Sympathectomy in Patients with Palmoplantar Hyperhidrosis    

World J Surg (2011) 35:54–55 DOI 10.1007/s00268-010-0809-5

A significant admission from an ETS surgeon, President of ISSS

"ESB  (whether as ETS as ETSC or ELS) generally represents a substantial interference in regulatory processes of the body.  Therefore decision for this operation requires that previously conservative treatments were made. An ESB is therefore at the end of a treatment history, and never at the beginning." 

Dr. Christoph H. Schick, ETS surgeon, President of the International Society of Sympathetic Surgery (ISSS)  

text has been  translated by google from German

http://www.dhhz.de/index.php?page=8&subPage=&section=32

Post-sympathectomy pain

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

http://www.ncbi.nlm.nih.gov/pubmed/2414615?dopt=Abstract

Surgical treatment for hyperhidrosis causes hyperhidrosis...

Localised hyperhidrosis may also be due to:

▪ Stroke

▪ Spinal nerve damage

▪ Peripheral nerve damage

▪ Surgical sympathectomy

▪ Neuropathy

▪ Brain tumour

▪ Chronic anxiety disorder

http://www.dermnet.org.nz/hair-nails-sweat/hyperhidrosis.html

Sympathectomy to treat the urge to smoke

Lipov, Eugene (Chicago, IL, US)  treating addiction with disruption of the sympathetic chain.

http://www.freepatentsonline.com/y2007/0135871.html

Complications of surgical (Thoracic and Lumbar) Sympathectomy

Post-sympathectomy neuralgia - pain overlying the scapula

Compensatory sweating - involving the lover back or face

Pneumothorax

Bleeding due to azygos vein or intercostal artery injury

Winged scapula due to long thoracic nerve injury (p. 517)

Mastery of Vascular and Endovascular Surgery

Gerald B. Zelenock, Thomas S. Huber, Louis M. Messina, Alan B. Lumsden, Gregory L. Moneta

Lippincott Williams & Wilkins, 15/12/2005 - 900 pages

The custom of a majority is no guarantee of safety and is seldom a guide to best medical practice.

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/content/320/7244/1221?tab=responses

a post-sympathectomy denervation of the lower regions of the body, associated with incapacitating postural hypotension

The traditional biochemical tests of sympathetic nervous system function used in clinical diagnosis (urine and plasma catecholamine measurements) are indices of "overall" sympathetic nervous activity, and incapable of detecting localised changes in sympathetic tone confined to individual organs. Recently developed radiotracer methods, which enable the pattern of sympathetic nervous dysfunction in disease states to be delineated, were used to detect abnormalities in regional sympathetic nervous system activity in two patients presenting problems in management. In one, the abnormality of sympathetic function was iatrogenic, a post-sympathectomy denervation of the lower regions of the body, associated with incapacitating postural hypotension. In the other, unexplained persistent sinus tachycardia proved to be due to an increase in sympathetic nervous tone restricted to the innervation of the heart. Knowledge of the underlying sympathetic nervous pathophysiology in these patients influenced the choice of drugs subsequently used in their treatment.

Aust N Z J Med. 1984 Dec;14(6):855-9.

Two patients with abnormalities of regional sympathetic nervous tone.

O'Hehir R, Esler M, Jennings G, Leonard P, Little P, Johns J, Panetta F.

http://www.ncbi.nlm.nih.gov/pubmed/6598055

reduction in all proline-richproteins (PRP) in the saliva following sympathectomy

The protein constituents in parasympathetically evoked saliva from normal and short-term sympathectomized parotid gland swere compared. There was a reduction in all proline-richproteins (PRP) in the saliva following sympathectomy. The decrease was quantified for acidic PRP by high- performance ion-exchange chromatography, which showed an increase in the ratio of amylase to other proteins. These results suggest that sympathetic impulses influence the synthesis of PRP and amylase in opposite directions. 

Quarterly Journal ofExperimental Physiology (1988) 73, 139-142

No compensatory sweating after botulinum toxin... [Br J Dermatol. 2005] - PubMed - NCBI

No compensatory sweating after botulinum toxin... [Br J Dermatol. 2005] - PubMed - NCBI: "No compensatory sweating after botulinum toxin treatment of palmar hyperhidrosis"

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patient information must include the long-term substantial risk for sever CS and regret of the procedure.

http://www.ncbi.nlm.nih.gov/pubmed/22191130

Another case of disabled thermoregulation and heatstroke following sympathectomy

We describe an extreme case of compensatory truncal hyper- hidrosis and anhidrosis over the head and neck region which led to a heatstroke. 

Six months after the initial operation, he had an episode of heatstroke while perform- ing outdoor duties which required running for around 5 km. The temperature on the day was between 30–32°C, and the relative humidity was between 75 and 85%. At that time, he complained of light-headedness, ‘feeling’ that heat could not dissipate from his head and neck region and muscle cramp in his legs. He was transferred to a hospital and was found to have a body tem- perature of 40°C and shock. His presentation was similar to a previous report by Sihoe et al. [1] on a patient with post- sympathectomy heatstroke. He was subsequently successfully treated with fluid and electrolyte resuscitation and supportive care.
  

Interactive CardioVascular and Thoracic Surgery 14 (2012) 350–352

Sympathectomy has a negative risk-benefit balance

http://www.ncbi.nlm.nih.gov/pubmed/20027710

no chance for nerve regeneration as early as 10 days after clipping

*Study presented at the 9th Biannual International Society for Sympathetic Surgery Conference in Odense, Denmark in May 2011. 

www.tswj.com/aip/134547.pdf

69% of patients continued to have relief after ETS, patient satisfaction rate was 56%

There were no operative mortalities, minor complications occurred in 22%. Initial success rate was 88%. Median follow up was 93 (24-168) months, response rate to the questionnaire was 85%. Sixty-nine per cent of patients continued to have relief of initial symptoms, whereas patient satisfaction rate was 56%. CS was present in 42 patients (68%). Long-term satisfaction rates per initial indication group were 42% for facial blushing and 65% for hyperhidrosis (n.s.), and CS was present in 79% vs 61%, respectively.

CONCLUSION:

ETS appears a safe treatment for upper limb hyperhydrosis with acceptable long-term results. For excessive blushing, however, long-term satifaction rates of ETS are severely hampered by a high incidence of disturbing compensatory sweating. ETS should only be indicated in patients with unbearable symptoms refractory to non-surgical treatment. The patient information must include the long-term substantial risk for sever CS and regret of the procedure.

http://www.ncbi.nlm.nih.gov/pubmed/22191130

"sympathectomy highlighted the disparity between what is known in practice and what appears in the literature"

The March 2004 edition was quite outstanding, with an excellent editorial reminding the reader that only good results are published. The review on thoracoscopic sympathectomy highlighted the disparity between what is known in practice and what appears in the literature. 

‘Know Your Results’, the topic of the ASGBI Annual Scientific Meeting, is of outstanding importance; what is more, the surgeon has to go on knowing his/her results to ensure standards of practice do not slip.

The Journal appreciates comments and criticism and the correspondence column remains a crucial part of the BJS in its interaction between editors and reader. It is also part of the scientific process.

A more robust and incisive criticism of articles known to be flawed would prevent the retractions that have recently been published in the Lancet.

Christopher Russell, Chairman, BJS Society

Association of Surgeons of Great Britain and Ireland, ANNUAL REPORT 2004

The effect of bilateral sympathectomy was significantly greater than that of unilateral sympathectomy

The effect of bilateral sympathectomy was significantly greater than that of unilateral sympathectomy. Unilateral and bilateral sympathectomy produced similar reductions in the concentrations of NPY-ir and NA in the ventricular tissue. In contrast dissimilar changes were produced in the atrium. Although bilateral sympathectomy almost totally depleted the NA from the right atrium (by 98%), the NPY-ir levels were only reduced by 50%. These results indicate that approximately half the content of NPY in the right atrium is not present in sympathetic noradrenergic neurones. 

Maccarrone C, Jarrott B.

Source

University of Melbourne, Department of Medicine, Austin Hospital, Heidelberg, Vic., Australia.

J Auton Nerv Syst. 1987 Dec;21(2-3):101-7.

http://www.ncbi.nlm.nih.gov/pubmed/3450689

sympathectomy induced morphological alterations in the masseter muscles

Sympathectomized animals showed varying degrees of metabolic and morphological alterations, especially 18 months after sympathectomy. The first five groups showed a higher frequency of type I fibres, whilst the oldest group showed a higher frequency of type IIb fibres. In the oldest group, a significant variation in fibre diameter was observed. Many fibres showed small diameter, atrophy, hypertrophy, splitting, and necrosis. Areas with fibrosis were observed. Thus cervical sympathectomy induced morphological alterations in the masseter muscles. These alterations were, in part, similar to both denervation and myopathy. These findings indicate that sympathetic innervation contributes to the maintenance of the morphological and metabolic features of masseter muscle fibres.

http://www.ncbi.nlm.nih.gov/pubmed/11454103

Bilateral cervical sympathectomies should be avoided because of the destruction of cardioaccelerator tone

http://www.hiesiger.com/physicians/physicianrfl.html

Chylothorax as complication of sympathectomy

Chylothorax has been reported as a complication of wide range of other operations, including esophagoscopy, stellate ganglion blockade, thoracic sympathectomy, high translumbar aortography, lung resection, thyroid surgery, and spinal surgery.
http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-1-4160-4710-0..00074-2--s0250&isbn=978-1-4160-4710-0&type=bookPage&from=content&uniqId=350894912-2

SURGICAL SYMPATHECTOMY ON THE SENSITIVITY TO EPINEPHRINE OF THE BLOOD VESSELS OF MUSCULAR SEGMENTS OF THE LIMBS

Pursuing this study of the effect of epinephrine on muscle blood flow, Duff and Swan (10) reported that during intravenous epinephrine infusions the initial marked dilatation was succeeded by a second phase of moderate dilatation in normal but not in sympathectomized limbs. Because of its absence in chronically sympathectomized limbs this secondary vasodilatation was at that time thought to be an indirect vasomotor effect mediated by the sympathetic nerves. Re-examination of their data in the light of some subsequent critical experiments now reveals that the difference which they found between normal and sympathectomized limbs may be ascribed largely to vascular hypersensitivity in the later.

In the present paper these additional data are reported, and are incorporated with those of Duff and Swan(10); the whole material being interpreted to provide evidence that hypersensitivity of the vessels of skeletal muscle in the upper and lower limbs may result from pre- and postganglionic sympathectomy in man.

EFFECT OF SURGICAL SYMPATHECTOMY ON THE SENSITIVITY TO EPINEPHRINE OF THE BLOOD VESSELS OF MUSCULAR SEGMENTS OF THE LIMBS, ROBERT S. DUFF

J Clin Invest. 1953 September; 32(9): 851–857.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC438413/

Sympathetic nerves protect against blood-brain barrier disruption

http://www.ncbi.nlm.nih.gov/pubmed/7064183

Nerve regeneration commonly occurs following both surgical of chemical sympathectomy

Sympathectomy is a destructive procedure that interrupts the sympathetic nervous system. Chemical sympathectomies use alcohol or phenol injections to destroy sympathetic nervous tissue (the so‐called "sympathetic chain" of nerve ganglia). Surgical ablation can be performed by open removal or electrocoagulation (destruction of tissue with high‐frequency electrical current) of the sympathetic chain, or minimally invasive procedures using thermal or laser interruption. 

Nerve regeneration commonly occurs following both surgical of chemical ablation, but may take longer with surgical ablation.

This systematic review found only one small study (20 participants) of good methodological quality, which reported no significant difference between surgical and chemical sympathectomy for relieving neuropathic pain. Potentially serious complications of sympathectomy are well documented in the literature, and one (neuralgia) occurred in this study. 

The practice of sympathectomy for treating neuropathic pain is based on very weak evidence. Furthermore, complications of the procedure may be significant.

Authors' conclusions: The practice of surgical and chemical sympathectomy for neuropathic pain and CRPS is based on very little high quality evidence. Sympathectomy should be used cautiously in clinical practice, in carefully selected patients, and probably only after failure of other treatment options.

Editorial Group: Cochrane Pain, Palliative and Supportive Care Group.

Publication status: New search for studies and content updated (conclusions changed).

Citation: Straube S, Derry S, Moore RA, McQuay HJ. Cervico‐thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD002918. DOI: 10.1002/14651858.CD002918.pub2. Link to Cochrane Library. [PubMed]

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0011684/

It is well recognized that preganglionic sympathectomy involves division of cholinergic elements and sensory fibers

It is well recognized that preganglionic sympathectomy involves division of cholinergic elements and sensory fibers. 
Theodore Cooper, Department of Surgery, St Louis University School of Medicine 
Pharmacological Reviews, 1966 Vol. 18, No. 1. Part I

When sympathectomized rats were injected with the same carcinogen, 24 out of 38 developed tumors

"Lesions od the sympathetic nervous system have been shown to increase the incidence, induction, and take and growth, of tumors. In neurally intact rats which were infected with a known carcinogen, only 1 out of 30 developed a tumor. When sympathectomized (intentional sympathetic nerve interference) rats were injected with the same carcinogen, 24 out of 38 developed tumors. These results confirm that sympathetic block enhances tumor implantation."

"Clearly the autonomic nervous system in exquisitely sensitive to information from all parts of the nervous system and may affect many aspects of the immune response."

"Since immune response is initiated by the nervous system, this appears to be a likely place to look for the cause of disease."

Edward E. Cremata, Neural control of immunity, January/February, 1982 The Digest of Chiropractic Economics

1. Couhard, R. and P. Hein, Cancers de types divers provoqucs par lesion du sympathique, CR. Acad. Sci,  2434-2437, 1957.

2. Couhard, R. and F. Heitz, Production de tumeurs malìgncs consecutivas a des lesions des fibres sympaxhiqucs du neri sciatique chez le cobaye. CR. Amd. Scl", 244: 4-09-411, 1957. 

3. Nayar, KK., Arthur, E. and Ballís,  M4, Th: transmission of tumours induced in cockroaches by nerve severance, Experienria, 27: 183, 1971. 

4. Champy, C.. Lesions neum-sympathìques precedam la canccrixation dans Patlaque de Porganìsmc par les substances cancerîgenes, C.R. Acad. Sci, 248: 3665-1666; 1959. 

 www.usapr.org/paperpdfs/75.pdf

we observed significant increase in net survival rate in non sympathectomised rates in comparison to sympathectomised

Chemical sympathectomy was performed by double intraperitoneal administration of 6-hydroxydopamine (6OHDA) 100mg/1 kg. 6OHDA is a neurotoxin used for selective ablation of dopaminergic and noradrenergic neurons. YA cells AH-130 which typically grow as free cells in ascites were injected intraperitoneally in amount of 20 - 25 mil/2 ml.

               

                Four groups of Wistar rats (AnLab, Prague) weighing 150 - 175g were used in the experiment. An absolute control group (8 rats), and a control sympathectomised group (8 rats), a group injected with YA cells (16 rats) and the last group was sympathectomised and injected with YA cells (16 rats).

               

                After a week of acclimatization of rats to conditions of animal room, sympathectomy was performed. One week later, YA cells were applied. The incidence and growth of ascites, and mortality were monitored.

Results

                Graph 1 shows the survival rate in both sympathectomised and non sympathectomised rats after the administration of YA cells. The graph shows an overall shorter survival rate of sympathectomised rats. In both groups there is a steep decrease in survival after 15 days, causing the median survival rate (18 days) of both groups to overlap. On the other hand the net survival rate is increased in non sympathectomised rates by 6 days

References:

1.        Ewa Chelmicka – Szorc, Barry G. W. Arnason. Effect of 6-Hydroxydopamine on Tumor Growth. CANCER RESEARCH 1976, 36, 2382-2384.

2.        Boris Mravec, Neurobiológia chorôb periférnych tkanív, Bratislava, SAP 2008, 220 s.,  ISBN 978-80-8095-030-9

3.        Raju B, Haug SR, Ibrahim SO, Heyeraas KJ. Sympathectomy decreases size and invasiveness of tongue cancer in rats. Neuroscience. 2007;149(3):715-25.

4.        Mravec B ,Gidron Y,Hulin I. Neurobiology of cancer: Interactions between nervous, endocrine

and immune systems as a base for monitoring and modulating the tumorigenesis by the brain. Seminars in Cancer Biology 18 (2008) 150–163.

5.        Paul G. Green,Wilfrid Janig, Jon D. Levinel. Negative Feedback Neuroendocrine Control of Inflammatory Response in the Rat is Dependent on the Sympathetic Postganglionic Neuron. The Journal of Neuroscience, 1997, 17(8):3234 –3238

6.      Aparna A. Bhanushali , R. Raghunathan , Rajiv D. Kalraiya , Narendra G. Mehta. Cancer-related anemia in a rat model: α2-macroglobulin from Yoshida sarcoma shortens erythrocyte survival. European Journal of Haematology 2002. 68(1),42 - 48

The effect of sympathectomy on the growth of intraperitoneally administered Yoshida ascitic cells in rats

El-Hassoun Olia, Coauthors: Zuzana Valašková, Ivan Hulín

Supervisor: Boris Mravec

Institute of Pathophysiology, LF UK Bratislava

http://svoc.fmed.uniba.sk/abstrakty/48/36.html

The alpha-adrenergic sensitivity of smooth muscle following sympathectomy

The data obtained suggest alteration of pharmacological characteristics of smooth muscle alpha-adrenoceptors after interruption of the sympathetic nerve.

Fiziol Zh SSSR Im I M Sechenova. 1988 Sep;74(9):1287-93.

Norepinephrine activates pain pathways after nerve injury

According to MedicineNet, RSD involves "irritation and abnormal excitation of nervous tissue, leading to abnormal impulses along nerves that affect blood vessels and skin."

Animal studies indicate that norepinephrine, a catecholamine released from sympathetic nerves, acquires the capacity to activate pain pathways after tissue or nerve injury, resulting in RSD.

http://arthritis.about.com/od/rsd/a/rsd.htm

Correlating Dermatomal Level to Surface Landmarks

Table 3. Correlating Dermatomal Level to Surface Landmarks
Dermatomal Level	Surface Landmark	Comments
C8	Little finger	Cardioaccelerator fibers blocked (T1 to T4)
T1, T2	Inner aspect of the arm	Above fibers blocked but to lesser degree
T4	Nipple line, root of scapula	Cesarean section, Appendectomy, upper abdominal surgery
T7	Inferior border of scapula; Tip of xiphoid	Splanchnic (T5 to L1) blockage; lower abdominal surgery; T5 to T7 for thoracotomy or fractured ribs (at relevant interspace)
T10	Umbilicus	Usual level for LE procedures, hip surgery, TURP, vaginal delivery
L2 to L3	Anterior thigh	Appropriate for knee, foot surgery
S1	Heel of foot	Part of sacral plexus, difficult to block

http://www.nysora.com/test2/regional_anesthesia/neuraxial_techniques/3026-epidural-blockade.html

"sympathectomy of one side of the body leads to an increase in the development of tumors on the denervated side"

Coujard R, Heitz F. Cancerologic: Production de tumeurs malignes consecutives a des lesions des fibres sympathiques du nerf sciatique chez le Cobaye. C R Acad Sci 1957; 244: 409­411.


This suggest that interference with the sympathetic nervous system (SNS) can lead to a compromise of the body's immune system [81–82]. Conversely, an immunological response can alter the response pattern of the sympathetic nervous system. [83]
http://www.chiro.org/LINKS/FULL/VERTEBRAL_SUBLUXATION_2.shtml 

Management of reflex sweating in spinal cord injured patients

Reflex sweating can be a problem for cervical spinal cord injured patients. Patient comfort and skin breakdown have been the major concerns. Five patients were studied prospectively, using a patch containing 1.5mg of scopolamine. Patches were changed every third day. Each patient was carefully monitored before and after application of the patch for signs and symptoms of anticholinergic side effects such as dizziness, blurred vision and dry mouth. Patients were also monitored for changes in patch signs before and after use, including residual urine volumes, blood pressure, heart rate, and mental status. Our study indicates that topical scopolamine successfully controlled reflex sweating in 5 patients without anticholinergic side effects.

PMID:

2742472

[PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/2742472

Heart rate significantly decreased after bilateral but not after unilateral right sympathectomy

http://www.ncbi.nlm.nih.gov/pubmed/12643398

Sympathectomy or doxazosin, but not propranolol, blunt myocardial interstitial fibrosis

http://www.ncbi.nlm.nih.gov/pubmed/16216989

surgical and chemical sympathectomy can both modulate bone cell function

It is known that surgical and chemical sympathectomy can both modulate bone cell function.  However, the sympathetic
nervous system (SNS) can give rise to both anabolic and catabolic effects [28-31] and its role in regulating bone remodeling is, therefore, controversial. For example, some researches reported that if bone is deprived of its sympathetic innervation, bone
deposition and mineralization is reduced and bone resorption increases [31], while in some other reports a sympathectomy impairs bone resorption [28].
Wei Fan BSc, MSc
Institute of Health and Biomedical Innovation
Faculty of Built Environment & Engineering
Queensland University of Technology

eprints.qut.edu.au/35722/7/35722b.pdf

Sustained Benefit (sic!) Lasting One Year from T4 Instead of T3-T4 Sympathectomy

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664277/

No statistically significant association between the CS with age, family history, type of HH and extent of TS

http://ejcts.oxfordjournals.org/content/34/3/514.full

Sympathectomy exacerbated the inflammation and osteopathic destruction of arthritic joints

http://www.ncbi.nlm.nih.gov/pubmed/8632052

results of sympathectomy deteriorate with time

results of sympathectomy deteriorate with time (T.S. Lin & Fang, 1999; Walles et al., 2008). This recurrent postoperative sweating may be due to local nerve regeneration but has not yet been proven (Lee et al., 1999).
http://www.intechopen.com/books/topics-in-thoracic-surgery/surgical-management-of-primary-upper-limb-hyperhidrosis-a-review

Pain in the form of intercostal neuralgia with dysesthesia at the site of trocar insertion is rarely documented but more frequent than generally recognized

Pain in the form of intercostal neuralgia with dysesthesia at the site of trocar insertion is rarely documented but more frequent than generally recognized. Many centres perform short-stay surgery that may lead to underestimation of pain results. In most series pain resolves within months, but Walles and colleagues could detect a persistence for years (Walles et al., 2008).
http://www.intechopen.com/books/topics-in-thoracic-surgery/surgical-management-of-primary-upper-limb-hyperhidrosis-a-review

Loss of impulse control as a side-effect of surgery for blushing and sweaty hands

http://www.sympatix.fi/blog/?lang=en_

compensatory sweating is extremely common and often worse than the original problem

Endoscopic thoracic sympathectomy is useful only when all other treatments fail and then should be considered only with caution as compensatory sweating is extremely common and often worse than the original problem.

BMJ 2009;338:b1166    doi:10.1136/bmj.b1166

left thoracic sympathectomy to prevent electrical storms in CPVT patients

Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT), a life threatening arrhythmia induced by sympathetic stimulation in susceptible individuals is often refractory to antiarrhythmic agents. First line of treatment, beta-blockers can be ineffective in up to 50% with implantable cardioverter-defibrillator (ICD) placement for refractory cases. Paradoxically ICD can be arryhthmogenic from shock-associated sympathetic stimulation, initiating more shocks and "electrical storms". This has led to the use of more effective beta blockade offered by left sympathectomy, now performed by minimally invasive video assisted thoracoscopic surgery (VATS).
To our knowledge this is first such reported case.
Heart Lung Circ. 2011 Nov;20(11):731-3. Epub 2011 Apr 7.

 http://www.ncbi.nlm.nih.gov/pubmed/21478052

Sympathectomy for the treatment of polymorphic ventricular tachycardia

Bilateral thoracoscopic cervical sympathectomy for the treatment of recurrent polymorphic ventricular tachycardia.

Turley AJ, Thambyrajah J, Harcombe AA.
Despite potassium and magnesium supplements, beta blockade, implantation of a single then dual chamber implantable cardioverter defibrillator (ICD), amiodarone, nicorandil, and mexiletine, the patient continued to experience arrhythmia storms, receiving more than 700 ICD discharges over seven months. She was ultimately treated successfully with bilateral thoracoscopic cervicothoracic sympathectomies. This is the first reported bilateral thoracoscopic treatment of a patient with LQTS and symptomatic life threatening ventricular tachyarrhythmias refractory to current pharmacological and pacing techniques.

Cardiothoracic Division, The James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, UK. andrew.turley@stees.nhs.uk

Heart. 2005 Jan;91(1):15-7.
http://www.ncbi.nlm.nih.gov/pubmed/15604323

This is how "compensatory" sweating looks like

http://www.sympatix.fi/blog/?p=706

The Dangers of ETS Surgery for Excessive Sweating

If you have an excessive sweating problem, you may have heard of endoscopic sympathectomy (ETS) surgery. If you are considering this option - Don't!
This surgery can have severe complications and, in spite of the promises, could leave you in a worse situation than you currently face. Some people have experienced more sweating after the operation than before.
That's right - more sweating. Doesn't sound like a good solution to the problem of excessive sweating, does it? Okay, you have problems with excessive sweating, which can be embarrassing and uncomfortable. You want a solution. That's fair enough. However, ETS Surgery is NOT the solution.
http://howardboon.hubpages.com/hub/The-Dangers-of-ETS-Surgery-for-Excessive-Sweating

dynamic cerebral autoregulation is altered by ganglion blockade

We measured arterial pressure and cerebral blood flow (CBF) velocity in 12 healthy subjects (aged 29+/-6 years) before and after ganglion blockade with trimethaphan. CBF velocity was measured in the middle cerebral artery using transcranial Doppler. The magnitude of spontaneous changes in mean blood pressure and CBF velocity were quantified by spectral analysis. The transfer function gain, phase, and coherence between these variables were estimated to quantify dynamic cerebral autoregulation. 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.
http://www.problemsinanes.com/pt/re/dyslipidaemia/abstract.00003017-200210010-00017.htm;jsessionid=PX6phQHYFG5PD1p2DMS1cJLvG1TbtLLLH0bfJT6vKJgLLx1zn0Xf!1816077220!181195629!8091!-1?nav=reference

Effects of cervical sympathectomy, stage of the estrous cycle and estradiol treatment.

C A CA Nagle, D P DP Cardinali and J M JM Rosner Life Sci 13(8):1089-103 (1973) PMID 4357690

Horner syndrome, pneumothorax, hemothorax, asymmetry of results, intercostal neuralgia, causalgia, hypoesthesia, incomplete results, paresthesia in the anterolateral abdominal wall, dyspareunia

The complications and side effects are very significant, such as irreversible compensatory sweating (20% to 50%), low satisfaction with results, Claude-Bernard-Horner syndrome, pneumothorax, hemothorax, asymmetry of results, intercostal neuralgia, causalgia, incomplete results, and anesthetic complications^11-13.

Retroperitoneoscopic lumbar sympathectomy (video-assisted): this technique is effective in the treatment of isolated or persistent plantar hyperhidrosis (compensatory after thoracic sympathectomy). The treatment consists of removing the nerves of the sympathetic chain located in the abdomen, in the anterolateral portion of the lumbar vertebrae. It requires hospitalization and is carried out under general anesthesia. It may lead to complications such as lesions of structures adjacent to the sympathetic chain, light abdominal distension, neuralgia, and causalgia as well as hypoesthesia in the thighs and groin, limitation of leg movement,
paresthesia in the anterolateral abdominal wall, change in libido, dyspareunia, pulmonary thromboembolism, hemorrhages, arrhythmias, and cardiac decompensation, amongst others. It definitively eliminates plantar hyperhidrosis14,15.  
http://www.scielo.br/scielo.php?pid=S1983-51752011000400008&script=sci_arttext&tlng=en#end

Vasodilation; Vasomotor Disturbances

Complex regional pain syndromes (CRPS) are characterized by vascular disturbances primary affecting the microcirculation in the distal part of the involved extremity. In the acute stage inhibited sympathetic vasoconstriction and exaggerated neurogenic inflammation driven by central and peripheral mechanisms, respectively, seem to be the major pathophysiological mechanisms inducing vasodilation. During the chronic course of the disease as well as early in some patients vasoconstriction dominates the clinical picture induced by changes in the microcirculation itself such as endothelial dysfunction or vascular hyperreactivity, whereas sympathetic vasoconstrictor activity returns and neurogenic inflammation is less severe. It can be suggested that the interaction between different mechanisms underlying vasomotor disturbances as well as the severity of each single mechanism in the individual patient have a great impact on the variety of the overall clinical picture in CRPS. Irrespective of the underlying pathophysiology, measurements of skin temperature differences between the affected and the contralateral extremity can serve as a diagnostic tool in CRPS, in particular when sensitivity and specificity is increased by considering dynamic alterations in skin temperature asymmetries.
http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2010.00914.x/abstract

Epidemiology /Etiology

CRPS is found to result:^[1]
- After traumatic injury (65%)

• 1-2% of all fractures result in CRPS
• Largest risk of CRPS for fractures of the wrist

- After surgical intervention (19%)
- Infection (4%)
- Prior inflammation (2%)
- No clear cause (10%)
A review stated that women are predominantly affected, by a factor of 3,5 and a genetic predisposition has also been theorized.
The disease affects all ages, though most cases are between 50 and 70 years old, and it is generally believed to occur mainly in caucasian and Japanese people.^[4]

Characteristics/Clinical Presentation

The following symptoms have been found in literature:^[5]
- Autonomic and trophic disorders:

• Distal Edema in 80% of the patients
• Skin temperature changes at the affected body part in 80% of the patients, initially warmer and in 40% of patients gradually cools down until colder in comparison to the rest of the body as the disease progresses. Another review mentioned that 30% of the patients start off from the primarily cold stage.3
• In 40% of the patients skin at the affected body part starts showing redness, but becomes pale or livid in later stages
• In 55% altered sweating takes place, with hyperhydrosis being more common than hypohydrosis.
• Hair and nail growth possibly increase in early stages
• Atrophy of skin and muscles in later stages, as well as contractures may severely restrict movement

- Sensory disturbances (90%) typically in a glove or stocking-like distribution

• Spontaneous pain occurs in 75%, usually burning dragging or stinging

• 68% felt in deep structures
• 32% felt in skin
• In 77% pain shows fluctuating intensity, lesser proportion shows shooting pain
• Pain can be increased by orthostasis, anxiety, exercise or temperature changes.
• In many cases, pain is more pronounced at night

• Sensory gain (Mechanical hyperalgesia, allodynia, ...) or sensory loss (hypaesthesia, hypalgesia, …) may be present.

- Motor dysfunction

• Motor weakness
• Severe impairment of complex movements
• Impairment of range of motion, initially by concomitant edema, later by contractures and fibroses
• Neglect like symptoms have been found in some patiënts, described as the body part in question feeling foreign.
• Enhanced physiological tremor in around 50%
• Myoclonus or dystonia, especially in type II CRPS

http://www.physio-pedia.com/Complex_Regional_Pain_Syndrome

Sympathectomy involves division of adrenergic, cholinergic and sensory fibers which elaborate adrenergic substances during the process of regulating viscera

http://pharmrev.aspetjournals.org/content/18/1/611.full.pdf+html

Bilateral lumbar sympathectomies carry a risk of impotence

The influence of the cranial sympathetic nerves on the architecture of pial arteries in normo- and hypertension was examined. For this purpose the effect of bilateral superior cervical ganglionectomy was evaluated in normotensive rats (WKY) and stroke-prone spontaneously hypertensive rats (SHRSP). The operations were performed at the age of 1 wk, which is just prior to the onset of ganglionic transmission. The length of the inner media contour was measured and the media cross-sectional area was determined planimetrically, with computerized digitalization of projected photographic images of transversely sectioned pial arteries. Four wk after sympathectomy there was a 20% reduction in media cross-sectional area and a consequent reduction in the ratio between media area and calculated luminal radius in the major pial arteries at the base of the brain in WKY but not in SHRSP. Conversely, in small pial arteries linear regression analysis showed that in WKY subjected to ganglionectomy the relationship between media cross-sectional area and luminal radius was significantly larger in arteries with a radius less than 21 microns compared to untreated WKY. No such effect was seen in the corresponding SHRSP vessels. In addition, the cross-sectional area of the internal elastic membrane (IEM) in the basilar arteries of WKY was measured by means of a computerized image-analysing system. Mean cross-sectional area of the IEM was approximately 45% larger following SE than in control animals. The present findings propose a 'trophic' role for the sympathetic perivascular nerves in large pial arteries of the rat. The increased media-radius ratio in the small pial arteries of the WKY following sympathectomy might reflect a compensatory hypertrophy due to reduced protection from the larger arteries against the pressure load. The inability to detect any morphometrically measurable effect of the sympathectomy in the cerebral arteries of SHRSP is probably explained by a marked growth-stimulating effect of the high pressure load in these animals.
http://www.ncbi.nlm.nih.gov/pubmed/7701941

Postural Hypotension and Postural Dizziness

The subjects were 204 consecutive non–insulin-dependent patients with diabetes and 408 age- and sex-matched nondiabetic control subjects who underwent physical examinations for preventive reasons at the National Cheng Kung University Hospital between October 1992 and September 1994. Subjects were excluded from the study for sympathectomy, anemia, thyroid disorder, pregnancy, chronic alcohol use, and/or use of anti-Parkinson drugs, narcotics, sedatives, antipsychotic agents, or antidepressants within 2 weeks of the study. The subjects with diabetes included 114 men and 90 women with a mean age ± SD of 57.9 ± 10.5 years. The nondiabetic control subjects were 228 men and 180 women with a mean age ± SD of 57.1 ± 9.5 years.
Postural Hypotension and Postural Dizziness in Patients With Non–Insulin-Dependent Diabetes
Jin-Shang Wu, MD; Feng-Hwa Lu, MD; Yi-Ching Yang, MD; Chih-Jen Chang, MD
[+] Author Affiliations
Arch Intern Med. 1999;159(12):1350-1356. doi:10-1001/pubs.Arch Intern Med.-ISSN-0003-9926-159-12-ioi80679

Bilateral lumbar sympathectomies carry a risk of impotence

           Contraindications. Prior contralateral sympathectomy, significant cardiovascular disease, or autonomic nervous system insufficiency.
           Post-operative course. Mild-moderate post-operative pain, usually lasting less than 2 weeks.
           Results. Sympathetic blocks and sympathectomies may provide significant relief in 60% of patients who undergo them (19-23). The mechanism on which this relief is based is open to question. There may be a significant placebo effect influencing the response to sympathetic blocks (18, 19). Mean time to pain recurrence following sympathectomy is six months (23).
           Benefits. Several months of sympatholysis from a safe, repeatable, outpatient procedure, which doesn't cause local fibrosis, rendering subsequent retroperitoneal surgery difficult.
           Risks. There are various risks associated with sympathectomy. These risks are minimized through the use of CT imaging, careful needle placement, and utilizing RF instead of chemical neurolysis.
           The major risks of radiologically guided sympathectomies include pnemothorax, inadvertent damage to the genitofemoral nerve in the lumbar area, and inadvertent root trauma. Transient hypotension may follow sympathetic blocks and sympathectomies. Bilateral cervical sympathectomies should be avoided because of the destruction of cardioaccelerator tone. Bilateral lumbar sympathectomies carry a risk of impotence.
http://www.hiesiger.com/physicians/physicianrfl.html

significant fall in left circumflex coronary flow was proportional to the decline in external heart work due to sympathectomy

http://www.springerlink.com/content/k2n6j4555g16x773/

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.

Post-sympathectomy neuralgia is a severe complication since pain can be permanent, severe, and incapacitating

http://www.springerlink.com/content/q04711t06j164206/

Possible surgical complications of sympathectomy may include

• Horner's syndrome
• Infection
• Hematoma
• Bleeding
• Postsympathectomy neuralgia
• Pleurotomy
• Pleural effusion
• Phrenic nerve injury
• Subclavian artery injury
• Adverse reaction to anesthesia
• Collapsed lung 

http://www.malonie.com/surgeries/upper-extremity-sympathectomy.htm

"ETS has proved moderately successful in treating hyperhidrosis, although the operation does carry a high risk of complications. "

Other complications of ETS include:

• sweating on the face and neck after eating food (gustatory sweating),
• inflammation of the nose (rhinitis), and
• air becoming trapped between the layers of the lung (pneumothorax) which can cause chest pain and breathing difficulties (although this usually resolves itself without the need for treatment).

Rarer complications of ETS include:

• Horner's syndrome, a condition that causes drooping of the eyelids, and
• damage to the phrenic nerve (a nerve that is used to help in breathing).

Phrenic nerve damage can lead to shortness of breath, though it may be possible to repair the nerve during surgery.

http://www.knowsley.nhs.uk/health-a-to-z/h/hyperhidrosis-excessive-sweating/

75% pneumothorax expected after sympathectomy

A small insignificant pneumothorax can be expected after ETS in about 75% of cases [15], which gets spontaneously absorbed, usually within 24 h.

Comparing T2 and T2–T3 ablation in thoracoscopic sympathectomy for palmar hyperhidrosis: a randomized control trial
A. N. Katara, J. P. Domino, W.-K. Cheah, J. B. So, C. Ning, D. Lomanto
Received: 13 October 2006/Accepted: 2 November 2006
Surg Endosc (2007) DOI: 10.1007/s00464-007-9241-9


[15] Ojimba TA, Cameron AEP (2004) Drawbacks of endoscopic thoracic sympathectomy. Br J Surg 91: 264–269



Permanent side effects included compensatory sweating in 67.4%, gustatory sweating in 50.7% and Horner's trias in 2.5%. However, patient satisfaction declined over time, although only 1.5% recurred. This left only 66.7% satisfied, and a 26.7% partially satisfied. Compensatory and gustatory sweating were the most frequently stated reasons for dissatisfaction. Individuals operated for axillary hyperhidrosis without palmar involvement were significantly less satisfied (33.3% and 46.2%, respectively).
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1234291/

sympathectomy improves skin blood flow at the thermoregulatory but not the nutritive level of skin microcirculation

sympathectomy improves skin blood flow at the thermoregulatory but not the nutritive level of skin microcirculation. This may be related to the fact that the thermoregulatory vessels are mainly sympathetically controlled, whereas the nutritive capillaries are mainly controlled by local (nonneural) factors.
http://www.springerlink.com/content/ukwtrn2y72age93t/