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
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.
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)
Elsevier Health Sciences, 2005 - Medical - 872 pages
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. WeberElsevier 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
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 GovoniInforma 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.
Thieme, 2007 - Medical - 424 pages
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. ResnickThieme, 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)
McGraw-Hill Professional, 2005 - Medical - 673 pages
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 PappagalloMcGraw-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)
John Wiley and Sons, 2009 - Medical
Peripheral Receptor Targets for Analgesia: Novel Approaches to Pain Management
By Brian E. CairnsJohn 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)
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)
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)
Hunter House, 2004
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 JurisPost-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
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)
By Bruce D. Browner
Skeletal trauma: basic science, management, and reconstruction, Volume 1
Elsevier Health Sciences, 2003 - 2768 pagesBy 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
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 |
