Sympathectomy eliminates the psychogalvanic reflex

Sympathectomy eliminates the psychogalvanic reflex

Some Observations on the Psychogalvanic Reflex

ABRAHAM VERGHESE M.D., D.P.M.¹

¹ Department of Psychiatry, Christian Medical College & Hospital, Vellore, India

Some P.G.R. studies in a female subject who had bilateral cervical sympathectomy were described. It was found that sympathectomy abolished P.G.R. and that intra-arterial infusion of acetylcholine evoked marked P.G.R. changes in the sympathectomized limb. These findings support the theory that the P.G.R. is mediated through the cholinergic fibres of the sympathetic nervous system. Submitted on May 22, 1967

Mia: Was told by a heart specialist, jokingly that the patient can gain employment as spy after sympathectomy: it eliminates fear responses, abolishes the psychogalvanic response, and there will be no sudden jump in heart rate. No problems with lie-detectors....ever.

http://bjp.rcpsych.org/cgi/content/abstract/114/510/639

Cardiovascular collapse caused by carbon dioxide insufflation during sympathectomy

Carbon dioxide insufflation into the pleural space during one-lung anaesthesia for thoracoscopic surgery is used in some centres to improve surgical access, even though this practice has been associated with well-described cardiovascular compromise. The present report is of a 35-year-old woman undergoing thoracoscopic left dorsal sympathectomy for hyperhidrosis. During one-lung anaesthesia the insufflation of carbon dioxide into the non-ventilated hemithorax for approximately 60 seconds, using a pressure-limited gas inflow, was accompanied by profound bradycardia and hypotension that resolved promptly with the release of the gas.

Harris, R. J.
Benveniste, G.
Pfitzner, John
Citation: Anaesthesia and Intensive Care, 2002; 30 (1):86-89
Publisher: Australian Society of Anaesthetists

Cervical sympathectomy reduces the heterogeneity of oxygen saturation in small cerebrocortical veins

Sympathectomy significantly reduced this heterogeneity in the anterior cortex through a reduction in the number of low O2 saturation veins (coefficient of variation 11.7%).

H. M. Wei, A. K. Sinha and H. R. Weiss
Department of Anesthesia, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Piscataway 08854-5635
J Cereb Blood Flow Metab. 1993 Mar;13(2):269-75

Anterior cingulate cortex: includes both the ventral and dorsal areas of the cingulate cortex, and appears to play a role in a wide variety of autonomic functions like regulation of blood pressure and heart rate, as well as rational cognitive functions, such as reward anticipation, decision-making, empathy and emotion.

Supersensitivity to substance P

The sympathetically denervated parotid gland of the rat develops a supersensitivity to substance P, and VIP injected intravenously. Further, the neuropeptide conttent (VIP and CGRP) of the parasympathetic salivary innervation tends to increase as a a consequence of sympathetic denervation. It has been reported by Harrop and Garrett that little acinar degranulation (or decrease in glandular amylase activity) occurs in the parotid gland in response to food intake in rats if subjected to unilateral sympathetic decentralization before feeding.

Neural Mecahinism of Salivary Gland Secretion By John Raymond Garrett, Jörgen
Published by Karger Publishers, 1999

Parotid Degeneration secretion after sympathectomy

Volume 162, Number 1 / September, 1975

Cell and Tissue Research
Parotid glands of rat have been examined 12, 24 and 48 hours after avulsion of the cervical sympathetic ganglion and compared with the normally innervated left glands. Formaldehyde-induced fluorescence showed a relatively normal complement of adrenergic nerves at 12 hours but most of the nerves had lost their noradrenaline content by 24 hours and no fluorescent nerves were detected at 48 hours.
This loss of granules is considered to be due to sympathetic degeneration secretion caused by the release of noradrenaline from the degenerating adrenergic nerves between 12 and 24 hours after ganglionectomy. This is thought to be the first example of morphological change resulting from degeneration activation to be recorded microscopically.
http://www.springerlink.com/content/n08314p052546477/

Monckeberg Sclerosis following symathectomy

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).

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.

Goebel FD, Fuessl HS.
Diabetologia. 1983 May;24(5):347-50.

Post- sympathectomy gustatory sweating has been reported in 28% of patients

Jack Collin, consultant surgeon.
Paul Whatling, higher specialist trainee.

John Radcliffe Hospital, Oxford OX3 9DU

Postsurgery, severe compensatory sweating was experienced in 90% of patients

Video-assisted Transthoracic Sympathectomy in the Treatment of Primary Hyperhidrosis: Friend or Foe?

Main outcome measures included the incidence of dry hands, compensatory sweating, chest pain, upper-limb muscle weakness, shortness of breath, and gustatory phenomena; in addition, patient perception of the success of the surgical procedure was assessed.

Postsurgery, severe compensatory sweating was experienced in 90% of patients.

Because the occurrence of severe compensatory sweating is unpredictable, a reversible sympathectomy may be desirable.

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 10(4):226-229, August 2000.
Fredman, Brian MB BCh; Zohar, Edna MD; Shachor, Dov MD; Bendahan, Jose MD; Jedeikin, Robert BSc, MB, ChB, FFA(SA)

New Name for CS: Abnormal Sweating

What are the risks of a sympathectomy?

* Risks from anaesthesia
* Bleeding
* Infection
* Worsening of pain
* Creation of a new pain syndrome
* Abnormal sweating

1. Mailis-Gagnon A, Furlan A. Sympathectomy for neuropathic pain. The Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD002918. DOI: 10.1002/14651858.CD002918.

Recurrent palmar hyperhidrosis occurs

Recurrent palmar hyperhidrosis occurs in 5.4% of cases, but can be cured by a second thoracoscopic sympathectomy. Horner's syndrome is an avoidable complication of thoracoscopic sympathectomy.

Volume 17, Issue 4, Pages 343-346 (April 1999)

The Results of Thoracoscopic Sympathetic Trunk Transection for Palmar Hyperhidrosis and Sympathetic Ganglionectomy for Axillary Hyperhidrosis

Eurpean Journal of Vascular and Endosvascular Surgery

pathologic coupling of sympathetic and afferent activity after a mechanically induced peripheral nerve lesion

Under physiological conditions there is no interaction between the sympathetic and the afferent nociceptive system; stimulation of the sympathetic trunk does not induce any activity in afferent neurons.65,79 However, under pathophysiological conditions the situation dramatically changes.80 Neurophysiological and neuroanatomical experiments in animals show that a pathologic coupling of sympathetic and afferent activity may follow a mechanically induced peripheral nerve lesion. This may take place between sympathetic fibers and regenerating or intact nociceptive C-fibers in the periphery, or between sympathetic vasoconstrictor fibers and afferent somata within the dorsal root ganglion.81 The interaction is chemically via noradrenaline from sympathetic endings and adrenoreceptors that are expressed on afferent neurons under pathophysiological conditions (Figure 4A). Accordingly, mRNA for alpha2A-adrenoceptors is up-regulated in DRG neurons after nerve lesion.82

Complex regional pain syndrome – diagnostic, mechanisms,
CNS involvement and therapy
G Wasner1 (#aff1) , J Schattschneider1 (#aff1) , A Binder1 (#aff1) and R Baron1 (#aff1)
Spinal Cord (2003) 41, 61–75. doi:10.1038/sj.sc.3101404

A partial nerve lesion is the important preceding event in CRPS II

Autonomic disturbances

A partial nerve lesion is the important preceding event in CRPS II (Reflex Regional Pain Syndrome). Therefore, it has generally been assumed that abnormalities in skin blood flow within the territory of the lesioned nerve are due to peripheral impairment of sympathetic function and sympathetic denervation. During the first weeks after transection of vasoconstrictor fibers, vasodilatation is present within the denervated area. Later the vasculature may develop increased sensitivity to circulating catecholamines, probably due to upregulation of adrenoceptors.⁶⁶ Similar observations were recently described in the chronic nerve constriction injury model in rats.^67,68 The skin on the lesioned side was abnormally warm for about the first post-operative week and then evolved to a chronically cold status. The late-stage cold skin was present despite a complete absence of fluorescence for norepinephrine. Thus, in this animal model, the skin is cold due to denervation supersensitivity of adrenoceptors rather than excessive sympathetic vasoconstrictor activity.

Further important signs of sympathetic dysfunction in CRPS are unilateral sweating abnormalities.⁷⁸ Quantitative measurements of sudomotor activity show enhanced sweat production in the disturbed limb in the acute and chronic stage of the disease in many CRPS patients.^23,26 This unilateral hyperhidrosis indicates enhanced sympathetic sudomotor activity.

In conclusion, the combination of increased sudomotor and decreased cutaneous sympathetic vasoconstrictor outflow is a well known centrally regulated thermoregulatory function to keep body core temperature constant in different environments. However, under physiological conditions all extremities are involved. Therefore, the unilateral activation of sudomotor and inhibition of cutaneous sympathetic vasoconstrictor neurons indicates a centrally located thermoregulatory dysfunction in CRPS.

Complex regional pain syndrome – diagnostic, mechanisms,
CNS involvement and therapy
G Wasner1 (#aff1) , J Schattschneider1 (#aff1) , A Binder1 (#aff1) and R Baron1 (#aff1)
Spinal Cord (2003) 41, 61–75. doi:10.1038/sj.sc.3101404

A critical analysis and long-term results

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).

F Herbst, E G Plas, R Függer, and A Fritsch

Department of Surgery, University of Vienna, Austria.
Ann Surg. 1994 July; 220(1): 86–90.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1234291

Sympathectomy was never evaulated for effectiveness or safety

No systematic reviews, meta-analyses, or clinical trials that evaluated the
effectiveness of endoscopic thoracic sympathectomy for treating facial
blushing were identified. However, we have identified four case series
related to the request (Drott et al. 1998, Rex et al. 1998, Telaranta 1998,
Yilmaz et al. 1996). These studies were conducted in three countries
(Sweden, Finland and the Netherlands).

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.

Centre for Clinical Effectiveness

Omar Ahmed PhD,
Monash University, 2001

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

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

(1)	Physiologisches Institut der Ludwig-Maximilian-Universität München, Germany

Received: 18 April 1973

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. After a recovery period of 60–90 sec, moderate treadmill exercise could be continued; steady state attainment of hemodynamic parameters was considerably delayed.

Mean arterial pressure and total peripheral resistance were significantly reduced at rest and during steady state of exercise as compared to controls prior to sympathectomy identical .

The significant fall in left circumflex coronary flow was proportional to the decline in external heart work due to sympathectomy both at rest and under exercise.

Effect of chemical sympathectomy on coronary flow and cardiovascular adjustment to exercise in dogs

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

	Pflügers Archiv European Journal of Physiology
	Springer Berlin / Heidelberg