CNS activation following peripheral sympathectomy

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. We, however, hypothesized that chemical sympathectomy will signal and activate the central nervous

system (CNS).

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.

Brain, Behavior, and Immunity

Volume 12, Issue 3, September 1998, Pages 230-241

Cervical sympathectomy affects the lower extremities, providing further evidence that the effects of this procedure is not local or limited

Bilateral cervical sympathectomy reduced mechanical allodynia and cold allodynia in the rat

model of neuropathic pain suggesting that neuropathic pain, although the lesions are localized in low extremities, may be correlated with functional disturbance of sympathetic nerve fibers of supraspinal or brain level and help explain the mechanism of neuropathic pain.

Korean J Anesthesiol. 1999 Feb;36(2):327-334. Korean.

Effect of cervical sympathectomy and circulatory hypoxia on time course of prostaglandin concentration in brain tissues

http://www.springerlink.c...ontent/j705306763158841/

Some workers suggest a possible "transmembrane" role of PG in the nervous system.

If the increase in the PG level during ischemia is regarded as a protective reaction, it must be admitted that no increase took place 1 day after CSE (cervical sympathectomy) and it was considerably weakened 7-40 days after CSE.

The effect of cerebral ischemia was virtually indistinguishable from the action of CSE itself.

It can be tentatively suggested that PGF plays the main role in the regulation of tone of the vascular wall and in the regulation of metabolism under conditions of ischemia when the sympathetic regulation is disturbed.

Correlation between Changes in Regional Cerebral Blood Flow and Pain Relief in Complex Regional Pain Syndrome

Objective: Analyzing changes in regional cerebral blood flow (rCBF) with SPECT in complex regional pain syndrome type 1 (CRPS 1), formerly known as reflex sympathetic dystrophy, is an optimal method for evaluating effective pain relief. We attempted to investigate the correlation of changes in rCBF with pain relief during treatments of sympathetic blockade and multimodal epidural pain control.

Case Report: We describe a patient with severe CRPS 1 in whom conventional treatment failed to relieve the pain.

Combined repeated lumbar sympathetic blocks and long-term epidural morphine, bupivacaine, and ketamine administration provided satisfactory pain relief and functional activity recovery. Six normal control subjects having one Tc-99m HMPAO scan each and the patient with CRPS having 3 Tc-99m HMPAO scans (once before treatment and twice at 4 months and 6 months after treatment, respectively). The patient with CRPS showed lower rCBF than normal

controls in the left thalamus and higher rCBF than normal controls in the right parietal lobe and left frontal lobe.

After subsequent treatment, the subtraction images showed increased rCBF in the left thalamus and decreased rCBF in the right parietal and left frontal lobes.

Conclusions: Tc-99m HMPAO SPECT showed a relationship of rCBF in the thalamus, parietal lobe, and frontal lobe with pain relief. rCBF alterations may provide an indicator for the quality of pain management for neuropathic pains.

Subtraction analysis between pre- and posttreatment, by using statistical parametric mapping (version 2), can be used as an objective indicator for the effectiveness of therapy.

postsympathectomy neuralgia is frequent

Surgical sympathectomy has a long heritage for the treatment of peripheral vascular disease and various chronic pain problems.

Despite concerns expressed as long ago as 1942 about the efficacy of surgical sympathectomy for the management of non-cancer pain, the procedure was enthusiastically pursued for the management of reflex sympathetic dystrophy or complex regional pain syndrome (CRPS), migraine, dysmenorrhea, epilepsy, chronic pancreatitis, postherpetic neuralgia of the trigeminal nerve, postdiscectomy syndrome, and phantom limb pain. However, systematic reviews have found no tangible evidence supportive of sympathectomy for the management of neuropathic pain. Furthermore, postsympathectomy neuralgia is a common complaint with a reported incidence between 15% to 50%.

As surgery is often mentioned as a cause of CRPS, it is somewhat illogical to consider surgery as an effective treatment. Nonetheless, surgical sympathectomy has a long anecdotal history in the treatment of RSD, and more recently endoscopic and radiofrequency sympathectomy has been tried.

Bonica's Management of Pain,

Lippincott Williams & Wilkins, 2009 - 2064 pages

interrupting sympathetic tone to the human brain - ETS

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.
http://www.hyperhidrosis.com/symposium.htm

Sympathectomy Causes Aggravated Lesions and Dedifferentiation

http://content.karger.com/ProdukteDB/produkte.asp?Doi=93010

Degeneration patterns of postganglionic fibers following sympathectomy

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.

In addition to the differences in time course between the proximal and the distal site of observation, it was also noted that both the axonal degeneration and the reactions of the Schwann cells are more pronounced in the rcg than in the muscle nerve. For example there was abundant mitotic activity in the central endoneural and Schwann cells whereas we could not detect such activity in the periphery.

It is concluded that the time course of degeneration and the intensity of the degenerative and reactive processes is, to a considerable extent, determined by the distance between the site of nerve section and the site from which the specimen is taken. Many of the conflicting data in the literature can be explained by this finding.

http://www.ncbi.nlm.nih.gov/pubmed/4051190

Sympathectomy induces adrenergic excitability of cutaneous C-fiber nociceptors

http://www.ncbi.nlm.nih.gov/pubmed/8822575

J Neurophysiol. 1996 Jan;75(1):514-7.

pH changes in synovial fluid following perivascular sympathectomy

Proc Inst Med Chic. 1947 Nov 15;16(17):465.

http://www.ncbi.nlm.nih.gov/pubmed/18896440

Sympathectomy induces mast cell hyperplasia

Long-term superior cervical sympathectomy induces mastcell hyperplasia and increases histamine and serotonincontent in the rat dura mater.

Neuroscience. 2000;96(1):205-13.

Mast cell hyperplasia is found in different pathologies such as chronic inflammatory

processes, fibrotic disorders, wound healing or neoplastic tissue transformation. The

functional significance of the accumulation of mast cells in these processes is largely

unknown. It is now established that bone marrow-derived mast cell progenitors

circulate in peripheral blood and subsequently migrate into the tissue where they

undergo final maturation under the influence of local microenvironmental factors.

Cytokines are of particular importance for mast cell recruitment, development, and

function. Stem cell factor (SCF) is a unique mast cell growth factor, since mast cells

disappear completely in the absence of SCF. However, several other cytokines such

as IL-3 and IL-4 have been shown to influence mast cell proliferation and function

also. This review focuses on the role of cytokines in the regulation of mast cell

hyperplasia.

Allergy and Immunology, Vol. 127, No. 2, 2002

Ultrastructural Changes in the Cerebral Artery Wall Induced by Long-Term Sympathetic Denervation

UThis study was performed to determine to what extent the morphology of the rabbit middle cerebral artery is affected by the absence of the sympathetic nervous system. Six weeks after unilateral ablation of the superior cervical ganglion, which induced ipsilateral degeneration and disappearance of the perivascular noradrenergic nerve fibers, comparison between the ipsi- and the contralateral middle cerebral arteries revealed that the denervated arterial wall underwent significant thickening. This thickening was principally due to hypertrophy of the smooth muscle cells (SMC), together with an increase in the amount of medial and adventitial collagen. The hypertrophied SMC showed important morphological and ultrastructural modifications – irregular shape, increase in the number of organdies (particularly of Golgi apparatus, free ribosomes, rough endoplasmic reticulum and microtubules), large indented nuclei rich in euchromatin – indicating profound changes in their metabolic and contractile activity which could result in an alteration of their mechanical properties. As these alterations were strictly ipsilateral to the sympathectomy it is likely that they are the direct consequence of the suppression of a regulatory ‘trophic’ factor linked to the presence of sympathetic nerve fibers. This concept is reinforced by the fact that the first SMC affected are those situated at the media/adventitial border, in the vicinity of adventitial nerve bundles. Thus, the sympathetic nervous system appears to play a key role in the long-term regulation of the cerebral vascular tree structure.

Copyright © 1988 S. Karger AG, Basel

http://content.karger.com/ProdukteDB/produkte.asp?Doi=158727

Sympathectomy induces novel purinergic sensitivity in A afferents from sciatic nerve

It is thought that this novel purinergic sensitivity may contribute to neuropathic paraesthesia and pain.

CHEN YONG, ZHANG YI-HONG, BIE BI-HUA, ZHAO ZHI-QI

Shanghai Institute of Physiology, Chinese Academy of Sciences

Acta Pharmacol Sin, 2000 Nov; 21 (11):1002-1004

The nerve endings in Schwann cells under the endothelium degenerated after sympathectomy

ep.physoc.org/content/52/1/31.full.pdf

patients with brain stem lesions and patients after sympathectomy have reduced or absent skin wrinkling on the affected side

Biomedecine & Pharmacotherapy Volume 55, Issue 8, October 2001, Pages 475-478

Effects of Sympathectomy on Muscle

We have previously reported functional and histological studies in five beagle dogs with unilateral lumbar sympathectomy. Three months later, fatiguability in the gracilis muscles was increased on the denervated sides, and this was associated with an increase in the relative distribution of FT fibres. Biochemical studies now show that these changes were associated with an increase in cytosolic protein without change in DNA content; this is consistent with
an increase in cell size. There was a reduction in the proportion of slow myosin light chain isoforms from 50 ± 7 to 34 ± 6%. Noradrenaline levels were increased on the denervated sides but this may reflect greater vascularity. Calcium content did not correlate with fibre type but there was a positive relation with both noradrenaline content (r= 0·73;
P<0·05) and DNA content (r= 0·84; P<0·05). It is concluded that sympathectomy induces several biochemical changes in skeletal muscle which constitute a change and increase in fast myosin light chain synthesis and a corresponding fibre type transformation.

Clinical Physiology (Oxford, England) 1988 Apr; vol 8 (issue 2): pp 181-91

2.
The objective of this paper was to study the effect of sympathetic innervation on morphological and histochemical aspects of skeletal muscle tissue. Rabbit masseter muscle was studied using histochemical and immunohistochemical methods for periods of up to 18 months post-sympathectomy. The morphological and enzymatic characteristics of control masseter muscles were similar on both the left and right sides. The main features were muscle fibres with a mosaic pattern and a predominance of type IIa fibres, followed by type I. Type IIb fibres showed very low frequency. 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.

International Journal of Experimental Pathology
Volume 82, Issue 2, pages 123–128, April 2001

CNS activation following peripheral sympathectomy

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. We, however, hypothesized

that chemical sympathectomy will signal and activate the central nervous

system (CNS). 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.

Central Nervous System Activation following Peripheral Chemical Sympathectomy: Implications for Neural–Immune Interactions

Brain, Behavior, and Immunity

Volume 12, Issue 3, September 1998, Pages 230-241

Changes in hemodynamics of the carotid and middle cerebral arteries before and after endoscopic sympathectomy in patients with palmar hyperhidrosis

There was a significant reduction in diastolic pressure after T-2 sympathectomy (p = 0.003), but not in systolic pressure or heart rate. The vessel diameter was increased after sympathectomy in the left CAs and right CCA. The T-2 sympathectomy led to significant elevation of blood flow volume and Rl in the left CCA. ICA, and ECA (p < 0.05). The authors found significant increases in maximum flow velocity and RI in the left MCA (p < 0.05). Conclusions. Patients who underwent T-2 sympathectomy demonstrated a significant increase in blood flow volume and flow velocities of the CAs and MCA, especially on the left side. Asymmetry of sympathetic influence on the hemodynamics of the CAs and MCA was noted.
Journal of neurosurgery
1999, vol. 90, no3, pp. 463-467 (38 ref.)

Alterations in cytokine and antibody production following chemical sympathectomy

The Journal of Immunology, Vol 155, Issue 10 4613-4620, Copyright © 1995 by American Association of Immunologists

acinar degranulation following sympathectomy

Chronic bilateral postganglionic sympathectomy (4-6 weeks duration) caused a drastic reduction in the capacity of the gland to secrete saliva in response to parasympathetic stimulation, reaching only one-third of that from normal animals. The initial output of amylase was greater than in normal animals but the total output was similar. The control unstimulated sympathectomized glands appeared similar morphologically to normal resting glands. However, on the parasympathetically stimulated side, besides the usual amount of acinar degranulation, there was also a conspicuous development of acinar vacuolation, not seen in the other groups of animals.
September 1, 1988 The Journal of Physiology, 403, 105-116.

Elective treatment for sweaty palms is classified as psychosurgery

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.
LVHyperhidrosis.com
Aury Nagy MD

Differences in the injury/sprouting response

While increased hilar and decreased distal NA innervation in arthritic rats was strikingly similar to that of non-arthritic 6-OHDA-treated rats, there were differences in splenic compartments innervated by sympathetic nerves between these groups. In 6-OHDA-treated rats, NA nerves re-innervated splenic compartments normally innervated by sympathetic nerves. In arthritic rats, sympathetic nerves returned to normally innervated splenic compartments, but also abundantly innervated red pulp. These findings suggest that splenic sympathetic nerves undergo a disease-associated injury/sprouting response with disease development that alters the normal pattern and distribution of NA innervation. The altered sympathetic innervation pattern is likely to change NA signaling to immune cell targets, which could exert long-term regulatory influences on initiation, maintenance, and resolution of immune responses that impact disease pathology.
Brain, Behavior & Immunity; Feb2009, Vol. 23 Issue 2, p276-285, 10p

Phantom sweating occurs frequently after sympathectomy

To describe the biology of phantom sweating, a novel autonomic neuropathy symptom, based on a description of a patient with a small fiber and autonomic neuropathy. Clinical and laboratory assessments. Evidence of a generalized small fiber and autonomic neuropathy. Phantom sweating occurs frequently after sympathectomy but has not been reported previously in patients with a somatosensory or autonomic neuropathy. We suggest that this symptom is an autonomic paresthesia.
Clinical Autonomic Research; Dec2008, Vol. 18 Issue 6, p352-354, 3p,

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

In a previous study, we showed that after sympathectomy, the femoral (FA) but not the basilar (BA) artery from non-pathological rabbits manifests migration of adventitial fibroblasts (FBs) into the media and loss of medial smooth muscle cells (SMCs). The aim of the present study was to verify whether similar behaviour of arteries occurred in the pathological context of atherosclerosis. Thus, similar experiments were conducted on hypercholesterolemic rabbits, which were chemically sympathectomized with 6-hydroxydopamine (n=4) or treated with vehicle for control (n=5). Cross-sections of BA and FA were immunolabelled for five markers of phenotypic modulation of vascular SMCs and FBs: vimentin, desmin, α-smooth muscle actin, β-isoform of actin, and h-caldesmon and examined using a confocal microscope. Also, 3D images were constructed and morphometric analysis performed using image analysis software. Both intact and sympathectomized BA and FA developed atherosclerotic plaques, but the thickening of the intima was more advanced in sympathectomized animals, as judged by increased plaque frequency and by the phenotypic modulation of SMCs in the intima. Our results show that in the media of FAs hypercholesterolemia induces changes similar to those observed in sympathectomized rabbits in non-pathological conditions, i.e., migration of adventitial FBs to the media and loss of medial SMCs. These latter changes, which can be ascribed to pathological events, were accentuated after sympathectomy in the hypercholesterolemic rabbits. The present study reveals that pathological events, including migration and phenotypic modulation of vascular FBs and loss of SMCs, may be under the influence of sympathetic nerves. [Copyright &y& Elsevier]

Orthostatic syncope can occur after a spinal cord injury or sympathectomy

Neurocardiogenic syncope is also referred to as vasovagal, vasodepressor, neurally mediated, and reflex syncope. As the name implies, neurocardiogenic syncope involves the interaction of various autonomic nervous system reflexes, the central nervous system, and the cardiovascular system..sup.1,4,12-14 The Bezold-Harisch reflex is cited as the mechanism responsible for vasovagal syncope and has two components. There is "cardio-inhibitory syncope" due to a vagal (parasympathetic) mediated reflex causing bradycardia or even asystole, plus "vasodepressor syncope" from withdrawal of sympathetic input leading to a drop in PVR with venous pooling in the periphery leading to hypotension.

Vasovagal syncope can occur in heart transplant patients, suggesting that the Bezold-Harisch reflex or vagal stimulation plus sympathetic withdrawal as the only factor may be a somewhat simplistic explanation, and that other variables may also play a role.

Although there are many causes of cardiovascular syncope, the final common mechanism is a decrease in cardiac output causing a decrease in cerebral perfusion.
Orthostatic syncope can occur after a spinal cord injury or sympathectomy, which eliminates
the vasopressor reflexes, and in patients on certain medications, commonly antihypertensive and
vasodilator drugs.
http://www.thefreelibrary.com/Syncope+in+Pediatric+Patients-a0217945432

neuralgia is a severe complication since pain can be permanent

The rate of morbidity reported in the literature for lumbar sympathectomy is low. However, post-operative neuralgia is a severe complication since pain can be permanent, severe, and incapacitating. Relief of pain by traditional means is ofter hazardous and symptoms may persist.

Between March and October 1986, 33 consecutive patients underwent unilateral lumbar sympahtectomy in the Thoracic and Cardiovascular Surgical Unit of the Catholic University in Louvain, Belgium. Ten patients experienced post-sympathectomy neuralgia.

Doppler studies and thermography were used to assess the efficacy of the operation in improving arterial supply to the lower limb on the side of sympathectomy. In all ten cases, neuralgia appeared between the ninth and 30th postoperative days, with mean of 16 days.

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

Effects of sympathectomy on skin and muscle microcirculation during dorsal column stimulation

A cold test with monitoring of cold-induced changes in peripheral blood flow was used to assess the completeness of the sympathectomy. The preoperative cold test induced a reciprocal response, vasoconstriction in the skin and vasodilation in muscle. DCS with clinical parameters did not produce this reciprocity in the control and sham-operated rats, but induced a vasodilation in both skin and muscle. After complete sympathectomy, defined as postoperative disappearance of the vasomotor responses to cold, the vasodilation in skin and muscle in response to DCS was abolished; however, the vasodilatory response to high-intensity stimulation (approximately 10 times the motor threshold) was not affected. Incomplete sympathetic denervation in some animals resulted in partial preservation of a vasodilatory response to DCS.
http://www.ncbi.nlm.nih.gov/pubmed/1758600

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

paraplegia as a postoperative complication

SIX YEARS AGO we encountered paraplegia as a postoperative complication in a patient who had undergone thoraco-lumbar sympathectomy for hypertension. Such a phenomenon was unique in our experience.
After a search of the literature and a number of informal inquiries among our colleagues, we were surprised to find that such an occurrence is not as unusual as we had believed. Bassett, in 1948,1 reporting on his experience with sympathectomy in the treatment of hypertension, stated: 'We
have had four cases of thrombosis of the anterior spinal artery with resultant permanent residual ischemic myelitis.
Poppen, in a personal communication, has stated that, although this complication has not
occurred in his own experienoe, three cases have been brought to his attention in which
paraplegia followed thoraco-lumbar sympathectomy for hypertension. Therefore, we have knowledge of eight cases in which such a catastrophe followed an elective operation which has enjoyed wide usageduring the past decade.
Annals of Surgery, M a r c h, 1 9 5 4

Spinal Cord Infarction caused by sympathectomy

Uncommon causes include decompression sickness, which has a predilection for spinal ischemic damage; complications of abdominal surgery, particularly sympathectomy; circulatory failure as a result of cardiac arrest or prolonged hypotension; and vascular steal in the presence of an arteriovenous malformation.

Author: Thomas F Scott, MD, Professor, Program Director, Department of Neurology, Drexel University College of Medicine; Director, Allegheny MS Treatment Center
Contributor Information and Disclosures

Updated: Aug 21, 2009

cerebral edema is worsened by sympathectomy, which causes increased cerebral blood flow

Although excessive SNS activity may be globally harmful, catecholamines and sympathetic nerves may also have organ-protective effects via reflex arteriolar constriction, which may protect the capillaries of the brain and kidney from surges in SBP. A baroprotective role of cerebral sympathetic nerves was uncovered by Heistad et al., who unilaterally denervated the cerebral vasculature in stroke-prone rats and found that fatal stroke occurred rapidly in the hemisphere ipsilateral to the sympathetic denervation. In the syndrome of malignant hypertension, cerebral edema is worsened by sympathectomy, which causes increased cerebral blood flow.

Role of hte Hypothalamus in Integration of behavior and Cardiovascular Responses (p. 60)

Hypertension: a companion to Brenner and Rector's the kidney

By Suzanne Oparil, Michael A. Weber
Elsevier Health Sciences, 2005 - Medical - 872 pages

depletion of brain noradrenaline levels causes a disturbance in cerebral microvascular tone

A hypertensive condition at a mean arterial pressure of about 160 mm Hg was maintained for 1 hour by intravenous infusion of phenylephrine. In the 6-hydroxydopamine-treated group, CBF increased significantly after the elevation of systemic blood pressure compared with that in the control group, and cerebral autoregulation was impaired. After a 1-hour study, the specific gravity of the cerebral tissue in the treated group significantly decreased; electron microscopic studies at that time revealed brain edema.
It is suggested that depletion of brain noradrenaline levels causes a disturbance in cerebral microvascular tone and renders the cerebral blood vessels more vulnerable to hypertension.

Journal of Neurosurgery, December 1991 Volume 75, Number 6

Unilateral removal of the superior cervical ganglion (SCG) results in the reinnervation of the denervated cerebral vessels by sprouting nerves

Chemical sympathectomy of the mature rat rather than the neonate also leads to sensory hyperinnervation, although there are a few differences. In the lung, sympahtectomy induces a marked increase in CGRP-immunoreactive nerve density around the ariways, blood vessels, and also in the vicinity of the neuroepithelial bodies of the pulmonary epithelium.

Following transection of the preganglionic autonomic nerves or in spinal cord injury, there are marked changes in the nerves that remain. Such changes can be manifested not only as nerve growth and changes in neurotransmitter expression, but remarkably, in reorganization of nerve pathways and their function.

Since sprouting is a common response of the nerves that remain following nerve injury, the close association of the different divisions of the autonomic nervous system in the pelvic region opens up the possibility for new connections to form new pathways. Spinal cord injury can unmask spinal reflexes that are normally inhibited by input from higher centers in the brain.

Handbook of the autonomic nervous system in health and disease

By Liana Bolis, J. Licinio, Stefano Govoni
Informa Health Care, 2003 - Medical - 677 pages

adverse cardiac and cerebral intraoperative events secondary to hypoxia from presumed hypoventilation

The thoracoscopic sympathectomy procedure requires several anesthetic considerations that include an anesthesiologist and operating room staff familiar with thoracic endoscopy. Double-lumen endotracheal tube placement is needed for ventilation of the contralateral lung and active deflation of the ipsilateral lung. Care must be taken to ensure adequate inflation of the lung on the operated side before proceeding to the contralateral side because there have been both published and anecdotal reports of adverse cardiac and cerebral intraoperative events secondary to hypoxia from presumed hypoventilation.
The choice whether to use carbon dioxide insufflation versus ambient pressure coupled with lung deflation and a fan refractor is surgeon specific. There are case reports of intraoperative cardiac arrest requiring resuscitation when carbon dioxide insufflation was used, with speculation that an increased mediastinal or intrathoracic pressure resulted in a decreased stroke volume and subsequent arrhytmia.

Neurosurgical operative atlas: Spine and peripheral nerves

By Christopher E. Wolfla, Daniel K. Resnick
Thieme, 2007 - Medical - 424 pages

alterations in the three-phase bone scan in acute CRPS are similar to those resulting from sympathectomy

There is only limited evidence regarding the efficacy of thoracoscopic or surgical sympathectomy. Four studies reported partial long-lasting benefits in CRPS types 1 and 2.

Postoperatively, no vasoconstriction due to deep inspiration (vasoconstrictor reflex) could be elicited at the affected extremity, indicatin complete sympathetic denervation. Additionally the temperature at the affected hand increased. After 4 weeks, skin temperature decreased, without signs of reinnervation. This denervation supersensitivity was associated with recurrence of pain and is thought to rely on a vascular supersensitivity to could and circulating catecholamines.

Interestingly, alterations in the three-phase bone scan in acute CRPS are similar to those resulting from sympathectomy without being related to the success of the intervention. (p.370)

The neurological basis of pain

By Marco Pappagallo
McGraw-Hill Professional, 2005 - Medical - 673 pages

sympathectomy per se may sensitize peripheral nociceptors and lead to neuralgia

Interestingly, while is used for the treatment of some chronic pain conditions, sympathectomy per se may sensitize peripheral nociceptors to circulating norephinephrine, and this sensitization may lead to post-sympathectomy neuralgia. (p.287)

Peripheral Receptor Targets for Analgesia: Novel Approaches to Pain Management

By Brian E. Cairns
John Wiley and Sons, 2009 - Medical

Compensatory hyperhidrosis reported in 0% to 74.5% of cases

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

Wesley S. Moore, Samuel S. Ahn

Elsevier Health Sciences, 2001

cerebral edema following CO2 insufflation

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

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

Complications in cardiothoracic surgery: avoidance and treatment

By Alex G. Little

Wiley-Blackwell, 2004 - Medical - 454 pages

"Sympathectomy is another animal."

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

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

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

Positive Options for Reflex Sympathetic Dystrophy (RSD):

Elena Juris

6 Reviews

Hunter House, 2004

Post-Sympathectomy pain (neuralgia)

Post-Sympathectomy pain (neuralgia) is a potential complication of all types of sympathectomy. Post-Sympathectomy pain is typically proximal to the original pain (e.g. proximal means that the pain may appear for the first time in the groin or buttock region for sympathectomy of the lower extremity and pain in the chest wall region for sympathectomy of the upper extremity).

Textbook of orthopedics and trauma

GS Kulkarni

Jaypee Brothers Publishers, 2008 - Medical

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

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

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

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

lung and nerve problems

Even with newer endoscopic techniques, the complications can include excessive sweating in other parts of the body and lung and nerve problems. As many of these complications are serious and not reversible, this option is rarely used, and then only as a last resort.
http://awurl.com/4CZkP4bNh
Medical Author: Alan Rockoff, MD
Medical Editor: Frederick Hecht, MD, FAAP, FACMG
Medical Reviewer: Melissa Conrad Stöppler, MD

Horner syndrome continues to occur in about 5% to 10% of cases after upper thoracic sympathectomy for palmar or axillary sympatholysis

http://jtcs.ctsnetjournals.org/cgi/content/full/124/3/636

Cutaneous innervation in man before and after lumbar sympathectomy: Evidence for interruption of both sensory and vasomotor nerve fibres

	Coventry, Brendon John Walsh, J. A.
Citation:	ANZ Journal of Surgery, 2003; 73 (1-2):14-18
Publisher:	Blackwell Science Asia
Issue Date:	2003
ISSN:	1445-1433