http://archderm.ama-assn.org/cgi/content/extract/144/9/1240
Friday, August 26, 2011
Wednesday, August 24, 2011
The cilio-spinal center is not sharply confined to TI spinal level, but may extend downwards as low as T5
The cilio-spinal center is not sharply confined to TI spinal level, but may extend downwards as low as T5.
Brachial plexus contusion resulting from pressure of retractors usually involved the lower trunk (spinal roots C8 TI, Klumpke's Syndrome). It was usually mild and transient, and became less frequent with increasing experience.
Other complaints of post operative pain were of three types: 1) Post sympathetic neuralgia in 6 patients
usually mild and always transient. 2) Muscular type pains in the neck, back and abdomen, probably secondary to the fasciculations induced by succinylcholine, or to the hyperextension of the neck during the operation. 3) Pleuritic type chest pain probably due to irritation of the apical pleura by the inevitable small hematoma in the operative field.
Average post-operative stay after the operation was four days, considerably shorter than in any other approach to UDS.
Ptosis and miosis are the most constant elements of the post-operative Homer's syndrome. In some of the patients only one of the two was prominent. Facial anhydrosis although common did not correlate with the
previous two signs. Of the ocular complaints only conjunctival hyperemia correlated well with ptosis
and miosis. Mild impairment of vision was noted by 18 patients, non specific complaints of pain or itching
were reported by 12, and in two patients a unilateral decreased secretion of tears was documented
On the surgical treatment of HH. Some describe the operation as a minor procedure with excellent results and very few complications. Others completely object to surgery for what they consider to be a benign functional disorder.' In our extensive experience the truth lies somewhere in between these two extreme views.
Severe palmar HH can be quite crippling, but the operation in spite of giving good results, should not be
taken lightly. Apart from sequellae described in this report, some other aspects have not yet been fully
investigated. These include possible denervation effects on bronchi and lungs, on the myocardium
and the coronary circulation, on salivation and dental health, and on ophthalmic functions such as lacrimation
and accomodation.
Palmar Hyperhidrosis and its Surgical Treatment: A Report of 100 Cases
RAPHAEL ADAR, M.D., F.A.C.S., ALEXANDER KURCHIN, M.D. AMIKAM ZWEIG, M.D., MARK MOZES, M.D., F.A.C.S.
Tuesday, August 23, 2011
To date, sufficient importance has not been placed on the long term effects that could cause dorsal sympathectomy
A scientific society has been created for surgery of the sympathetic nervous system, the International Society of Sympathetic Surgery (ISSS); and in the most recent thoracic surgery and related specialities congresses it fills up a considerable percentage of the programme.
On the other hand, this surgery, especially for hyperhidrosis and facial reddening, is the one that on a percentage basis generates more demands and complaints from the patients, even with medico-legal connotations.7 Despite that the majority of the patients show a very high degree of satisfaction, the presence of a patient operated for hyperhidrosis with important compensatory sweating that repeatedly manifest their dissatisfaction to the surgeon is a very annoying situation with an intractable solution. There are even forums on the Internet that constantly manifest their discomfort with this type of surgery in a violent and insulting tone, for example, the World Against Sympathectomy Website.
In summary, we are faced with a new disorder that is being attended massively in our hospitals and needs a moment of contemplation. What are we doing? Are we doing it properly? What are the future implications in these patients of dorsal sympathetic denervation? For the first 2 questions, we could find the answer in the new clinical guidelines and scientific society norms and with the publication of linger series, randomised systematic studies, reviews and meta-analyses. However, it is perhaps the latter of these that implies greater consideration. To date, sufficient importance has not been placed on the long term effects that could cause dorsal sympathectomy, and the effects on lung function, heart function, skin colouring and psychological state are being studies, among others;10 the most important being the first 2. secondary consequences of the operation.
The consequences of sympathetic denervation after a dorsal sympathectomy on lung function have been studied on several occasions11 and reductions in forced vital capacity, forced expiratory flow in the first second and maximum mesoexpiratory flow have been found, but with no clinical significance. It therefore seems that, despite sympathetic innervation being scarce, it directly influences motor tone, especially of the fine respiratory tracts, which cause a light obstructive pattern after the operation and favours bronchial hyperreactivity.12 It is of great interest to know the results of the research being carried out to recognise the long term effects.
Something similar occurs with heart function, the sympathectomy in the short term causes bradycardia due to a lack of sympathetic stimulation to the heart. Several cases of myocardial infarction13 and
chronotropic heart failure requiring the insertion of a pacemaker14 have been reported. In the long term, dorsal sympathetic interruption causes an effect similar to beta blockers on the heart, and produced a decrease in average heart rate, but with no significant changes in the electrocardiogram (normal Q-T).15 It may be good to know through long term prospective studies which effects it truly has on heart function and what it could mean for the daily lives of the operated patients. For the time being, those individuals who practice aerobic sports (for example, long distance runners and cyclists)
should be informed that with sympathectomy their heart rate may be reduced in situations of maximum effort and lower their performance.16
M. Congregado / Arch Bronconeumol. 2010;46(1):1-2
http://www.archbronconeumol.org/bronco_eng/ctl_servlet?_f=40&ident=13147805
On the other hand, this surgery, especially for hyperhidrosis and facial reddening, is the one that on a percentage basis generates more demands and complaints from the patients, even with medico-legal connotations.7 Despite that the majority of the patients show a very high degree of satisfaction, the presence of a patient operated for hyperhidrosis with important compensatory sweating that repeatedly manifest their dissatisfaction to the surgeon is a very annoying situation with an intractable solution. There are even forums on the Internet that constantly manifest their discomfort with this type of surgery in a violent and insulting tone, for example, the World Against Sympathectomy Website.
In summary, we are faced with a new disorder that is being attended massively in our hospitals and needs a moment of contemplation. What are we doing? Are we doing it properly? What are the future implications in these patients of dorsal sympathetic denervation? For the first 2 questions, we could find the answer in the new clinical guidelines and scientific society norms and with the publication of linger series, randomised systematic studies, reviews and meta-analyses. However, it is perhaps the latter of these that implies greater consideration. To date, sufficient importance has not been placed on the long term effects that could cause dorsal sympathectomy, and the effects on lung function, heart function, skin colouring and psychological state are being studies, among others;10 the most important being the first 2. secondary consequences of the operation.
The consequences of sympathetic denervation after a dorsal sympathectomy on lung function have been studied on several occasions11 and reductions in forced vital capacity, forced expiratory flow in the first second and maximum mesoexpiratory flow have been found, but with no clinical significance. It therefore seems that, despite sympathetic innervation being scarce, it directly influences motor tone, especially of the fine respiratory tracts, which cause a light obstructive pattern after the operation and favours bronchial hyperreactivity.12 It is of great interest to know the results of the research being carried out to recognise the long term effects.
Something similar occurs with heart function, the sympathectomy in the short term causes bradycardia due to a lack of sympathetic stimulation to the heart. Several cases of myocardial infarction13 and
chronotropic heart failure requiring the insertion of a pacemaker14 have been reported. In the long term, dorsal sympathetic interruption causes an effect similar to beta blockers on the heart, and produced a decrease in average heart rate, but with no significant changes in the electrocardiogram (normal Q-T).15 It may be good to know through long term prospective studies which effects it truly has on heart function and what it could mean for the daily lives of the operated patients. For the time being, those individuals who practice aerobic sports (for example, long distance runners and cyclists)
should be informed that with sympathectomy their heart rate may be reduced in situations of maximum effort and lower their performance.16
M. Congregado / Arch Bronconeumol. 2010;46(1):1-2
http://www.archbronconeumol.org/bronco_eng/ctl_servlet?_f=40&ident=13147805
Monday, August 22, 2011
permanent sympathetic nerve damage and hyperthermia due to sympathectomy
"Virtual sympathectomy" secondary to repeated stellate ganglion nerve blocks leading to permanent sympathetic nerve damage and hyperthermia (heat leakage)"
www.rsdrx.com/crps_and_sympathectomy.htm
www.rsdrx.com/crps_and_sympathectomy.htm
Sunday, August 21, 2011
acute response to surgical denervation and abrupt release of sympathetic tone
Intraoperative predictability of successful outcome depends on monitoring of the acute response to surgical denervation and abrupt release of sympathetic tone.
Information on the long-term physiological sequelae is emerging rapidly. Preoperatively, in addition to abnormal sudomotor control, sympathetic cardiovascular regulation may be affected mildly in severe cases of hyperhidrosis. A blunted reflex bradycardia response to parasympathomimetic maneuvers such as Valsalva maneuver or cold water face immersion, as well as an increased heart rate response
to orthostatic stress, suggests a hyperfunctioning sympathetic discharge that is reversed after ETS.25,69 Because sympathetic cardiac accelerator fibers exit the spinal cord from segments T1 to T4, ETS is believed to simulate a mild physiological !-adrenergic blockade.70 This is because the heart rate at rest and during maximal exercise is lower 6 weeks postoperatively
DIAGNOSIS AND TREATMENT OF HYPERHIDROSIS, CONCISE REVIEW FOR CLINICIANS
Mayo Clin Proc. • May 2005;80(5):657-666
Information on the long-term physiological sequelae is emerging rapidly. Preoperatively, in addition to abnormal sudomotor control, sympathetic cardiovascular regulation may be affected mildly in severe cases of hyperhidrosis. A blunted reflex bradycardia response to parasympathomimetic maneuvers such as Valsalva maneuver or cold water face immersion, as well as an increased heart rate response
to orthostatic stress, suggests a hyperfunctioning sympathetic discharge that is reversed after ETS.25,69 Because sympathetic cardiac accelerator fibers exit the spinal cord from segments T1 to T4, ETS is believed to simulate a mild physiological !-adrenergic blockade.70 This is because the heart rate at rest and during maximal exercise is lower 6 weeks postoperatively
DIAGNOSIS AND TREATMENT OF HYPERHIDROSIS, CONCISE REVIEW FOR CLINICIANS
Mayo Clin Proc. • May 2005;80(5):657-666
Surgical Sympathectomy should be first line treatment according to 'Center for the Cure of Sweaty Palms™' surgeon
Given the clear superiority of BTS (bilateral thoracoscopic sympathectomy) for severe palmoplantar hyperhidrosis, deliberately using medical treatments that are known with near certainty to be eneffective and at times considerably noxious simply as a requisite to surgery may not be in the best interest of such patients, nor is such an approach ultimately cost-effective. There is no evidence that surgical intervention should be considered a "last resort" for this form of hyperhidrosis. BTS can safely and confidently be recommended as first-line treatment for the typical, severe form of palmoplantar hyperhidrosis.
(no conflict of interest has been declared by the authors)
Fritz J. Baumgartner
, a, 
, Shana Bertina and Jiri Konecnya
Center for the Cure of Sweaty Palms™
Annals of Vascular Surgery
Volume 23, Issue 1, January-February 2009, Pages 1-7
http://www.sciencedirect.com/science/article/pii/S0890509608001854
(no conflict of interest has been declared by the authors)
Fritz J. Baumgartner
, a, , Shana Bertina and Jiri KonecnyaCenter for the Cure of Sweaty Palms™
Annals of Vascular Surgery
Volume 23, Issue 1, January-February 2009, Pages 1-7
http://www.sciencedirect.com/science/article/pii/S0890509608001854
denervation supersensitivity of alpha receptors after sympathectomy
There is, however, considerable risk of developing a post-sympathectomy pain syndrome that may be the result of a denervation supersensitivity of alpha receptors.
www.mc.vanderbilt.edu/.../Complex%20Regional%20Pain%20Syndrome-1...
Paradoxically it has been suggested that in some cases there may be abnormal vasoconstriction rather than the expected vasodilatation after sympathectomy.
ats.ctsnetjournals.org/cgi/content/full/84/3/1025
compensatory disease may not be immediate after sympathectomy
Newer techniques include the use of clips instead of complete transsection of the nerve but reversal is not always possible as nerve destruction can be quick and compensatory disease may not be immediate.
The main complications with sympathectomy include compensatory sweating, phantom sweating, gustatory sweating, Horner syndrome, and neuralgia.
Management of Hyperhidrosis
Aamir Haider, Nowell Solish and Nicholas J. Lowe
www.sweatclinicsofcanada.com/Book.pdf
The main complications with sympathectomy include compensatory sweating, phantom sweating, gustatory sweating, Horner syndrome, and neuralgia.
Management of Hyperhidrosis
Aamir Haider, Nowell Solish and Nicholas J. Lowe
www.sweatclinicsofcanada.com/Book.pdf
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
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.
Mayo Clin Proc 2003;78:167-172. http://www.mayoclinic.org/medicalprofs/enlargeimage5096.html
of palmar hyperhidrosis.
Mayo Clin Proc 2003;78:167-172. http://www.mayoclinic.org/medicalprofs/enlargeimage5096.html
Sensory nerves impair sympathetic reinnervation and recovery of smooth muscle function
We conclude that sensory nerves limit the extent of sympathetic reinnervation and functional recovery that can occur following neonatal sympathetic denervation.
http://www.ncbi.nlm.nih.gov/pubmed/1397180
http://www.ncbi.nlm.nih.gov/pubmed/1397180
Saturday, August 20, 2011
Sympathectomy alters bone architecture
These data indicate that guanethidine-induced sympathectomy caused a negative balance of bone metabolism, leading to decreased mass by regulating deposition rather than resorption during modeling and remodeling of bone.
http://www.ncbi.nlm.nih.gov/pubmed/18449939
http://www.ncbi.nlm.nih.gov/pubmed/18449939
obliteration of the cervical sympathetic peripheral innervation impairs the capability to produce an induced febrile response.
http://www.sciencedirect.com/science/article/pii/S0165572809000575
reduction in hypothalamic dopamine after sympathectomy, which leads to an increase in serum prolactin level
At this point, it is particularly interesting to recall the earlier reports of middle ear bone remodeling in the gerbil after chemical sympathectomy by guanethidine sulfate (86) or hydroxydopamine (85). Although these neurotoxins do eliminate sympathetic activity, there are, in parallel, major central consequences. In particular, both treatments reduce hypothalamic dopamine, which leads to an increase in serum prolactin levels.
http://ajpendo.physiology.org/content/293/5/E1224.full
"Again, patients admitted with any malignancy, cholecystectomy, thyroidectomy, renal disease, cardiac disease, sympathectomy, or vascular graft were eliminated as controls."
This article reviews the evidence that neuroleptics may increase the risk of breast cancer via their effects on prolactin secretion.
Paul M. Schyve; Francine Smithline; Herbert Y. Meltzer
Neuroleptic-induced Prolactin Level Elevation and Breast Cancer: An Emerging Clinical Issue
Arch Gen Psychiatry, Nov 1978; 35: 1291 - 1301.
http://ajpendo.physiology.org/content/293/5/E1224.full
"Again, patients admitted with any malignancy, cholecystectomy, thyroidectomy, renal disease, cardiac disease, sympathectomy, or vascular graft were eliminated as controls."
This article reviews the evidence that neuroleptics may increase the risk of breast cancer via their effects on prolactin secretion.
Paul M. Schyve; Francine Smithline; Herbert Y. Meltzer
Neuroleptic-induced Prolactin Level Elevation and Breast Cancer: An Emerging Clinical Issue
Arch Gen Psychiatry, Nov 1978; 35: 1291 - 1301.
Body temperature is highly correlated with plasma prolactin in thermally stressed men
(78), suggesting that normal heat defense is associated with decreased central dopamine, and
intraventricular haloperidol produces a coordinated heat-defense response (79). These reports refute a
unique or essential role for central dopamine antagonism in neuroleptic malignant syndrome hyperthermia
and provide additional evidence that state-dependent factors are important mediators of dopamine
antagonist effects.
There is substantial evidence to support the hypothesis that dysregulated sympathetic nervous system hyperactivity is responsible for most, if not all, features of neuroleptic malignant syndrome. A predisposition to more extreme sympathetic nervous system activation and/or dysfunction in response to emotional or psychological stress may constitute a trait vulnerability for neuroleptic malignant syndrome, which, when coupled with state variables such as acute psychic distress or dopamine receptor antagonism, produces the clinical syndrome of neuroleptic malignant syndrome. This hypothesis provides a more comprehensive explanation for existing clinical data than do the current alternatives.
http://ajp.psychiatryonline.org/cgi/content/full/156/2/169
(78), suggesting that normal heat defense is associated with decreased central dopamine, and
intraventricular haloperidol produces a coordinated heat-defense response (79). These reports refute a
unique or essential role for central dopamine antagonism in neuroleptic malignant syndrome hyperthermia
and provide additional evidence that state-dependent factors are important mediators of dopamine
antagonist effects.
There is substantial evidence to support the hypothesis that dysregulated sympathetic nervous system hyperactivity is responsible for most, if not all, features of neuroleptic malignant syndrome. A predisposition to more extreme sympathetic nervous system activation and/or dysfunction in response to emotional or psychological stress may constitute a trait vulnerability for neuroleptic malignant syndrome, which, when coupled with state variables such as acute psychic distress or dopamine receptor antagonism, produces the clinical syndrome of neuroleptic malignant syndrome. This hypothesis provides a more comprehensive explanation for existing clinical data than do the current alternatives.
http://ajp.psychiatryonline.org/cgi/content/full/156/2/169
dural blood flow decreased significantly in the cervical sympathectomy group
Migraine may affect the autonomic nervous system, but the mechanisms remain unclear. The sympathetic and parasympathetic nervous systems may play different roles in the attack. To explore the effect of blocking the cervical sympathetic nerve on vasodilation of the meningeal vessels, jugular vein calcitonin gene-related peptide (CGRP) and meningeal blood flow changes were measured before and after transection of the cervical sympathetic nerve by electrically stimulating the trigeminal ganglion in Sprague–Dawley (SD) rats. We found that CGRP level and meningeal blood flow increased in both the sham-operated and sympathectomized groups (p
<0.05). Compared with the sham-operated group, dural blood flow decreased significantly in the cervical sympathectomy group, but CGRP level was not significantly different between these two groups. The cervical sympathetic nerve may play an important role in the process of neurogenic dural vasodilation in rats; this effect is not entirely dependent on CGRP level.
http://www.autonomicneuroscience.com/article/S1566-0702%2811%2900026-9/abstract
<0.05). Compared with the sham-operated group, dural blood flow decreased significantly in the cervical sympathectomy group, but CGRP level was not significantly different between these two groups. The cervical sympathetic nerve may play an important role in the process of neurogenic dural vasodilation in rats; this effect is not entirely dependent on CGRP level.http://www.autonomicneuroscience.com/article/S1566-0702%2811%2900026-9/abstract
Wednesday, August 17, 2011
Effects of upper abdominal sympathectomy on gastric acid, serum gastrin, and catecholamines
Selective upper abdominal sympathectomy increased basal acid output in rats but was without effect on stimulated acid output, serum gastrin concentration, and gastric mucosal histidine decarboxylase activity. The sympathectomy was verified by fluorescence histochemistry and determination of tissue catecholamines. A drastic reduction in tissue noradrenaline, adrenaline, and dopamine levels occurred after sympathectomy, and fluorescence microscopy showed a complete loss of adrenergic nerve fibers. Vagotomy reduced catecholamine levels in the stomach wall by 50% but did not affect the catecholamine content in the pancreas and small bowel. Surprisingly, combined vagotomy and upper abdominal sympathectomy resulted in lower catecholamine levels than sympathectomy alone in extragastric but not in gastric tissues.
http://www.ncbi.nlm.nih.gov/pubmed/6515311
http://www.ncbi.nlm.nih.gov/pubmed/6515311
Extreme caution is called for when considering surgical sympathectomy
Surgical sympathectomy is carried out on the basis of poor quality evidence, studies without
control groups, and personal experience. Though it would appear logical (and has been
suggested) that surgical sympathectomy is indicated primarily for patients with confirmed
'sympathetic-dependent pain, other authors take the view that the treatment results are
not correlated to this. Eighteen percent of patients undergoing sympathectomy for
neuropathic pain experience compensatory hyperhidrosis and 25% experience neuropathic
complications.
Extreme caution is called for when considering surgical sympathectomy for pain control in
CRPS-I. The procedure should be conducted in the context of a trial in order to ascertain
the efficacy and potential risks.
Guideline
INITIATIVE:
Netherlands Society of Rehabilitation Specialists
Netherlands Society of Anaesthesiologists
WITH THE SUPPORT OF:
Institute for Healthcare Improvement CBO
www.cbo.nl/Downloads/341/rl_crps_eng_07.pdf
control groups, and personal experience. Though it would appear logical (and has been
suggested) that surgical sympathectomy is indicated primarily for patients with confirmed
'sympathetic-dependent pain, other authors take the view that the treatment results are
not correlated to this. Eighteen percent of patients undergoing sympathectomy for
neuropathic pain experience compensatory hyperhidrosis and 25% experience neuropathic
complications.
Extreme caution is called for when considering surgical sympathectomy for pain control in
CRPS-I. The procedure should be conducted in the context of a trial in order to ascertain
the efficacy and potential risks.
Guideline
INITIATIVE:
Netherlands Society of Rehabilitation Specialists
Netherlands Society of Anaesthesiologists
WITH THE SUPPORT OF:
Institute for Healthcare Improvement CBO
www.cbo.nl/Downloads/341/rl_crps_eng_07.pdf
Monday, August 15, 2011
Decreased tanning response after video-assisted thoracoscopic sympathectomy
http://www.ncbi.nlm.nih.gov/pubmed/18794484
Skin depigmentation: could it be a complication caused by thoracic sympathectomy?
Thursday, August 11, 2011
lumbar sympathectomy results in loss of ejaculation
Sympathectomy for the long term management of such patients has been carried out (Abel et al., 1974) and success reported. Loss of ejaculation does follow sympathectomy but this is a minor problem in patients who have an already destroyed sacral cord. (p. 410)
During fever pyrogen is released from leucocytes and his agent causes the disturbed thermoregulation (Atkinson, 1960). For this response to occur, an intact efferent sympathetic system is requred because fever can be markedly reduced by bilateral sympathectomy in the cat (Pinkston, 1935). (p.193)
The autonomic nervous system: an introduction to basic and clinical concepts By Otto Appenzeller, Emilio Oribe, Elsevier Health Sciences, 1997 - Medical
During fever pyrogen is released from leucocytes and his agent causes the disturbed thermoregulation (Atkinson, 1960). For this response to occur, an intact efferent sympathetic system is requred because fever can be markedly reduced by bilateral sympathectomy in the cat (Pinkston, 1935). (p.193)
The autonomic nervous system: an introduction to basic and clinical concepts By Otto Appenzeller, Emilio Oribe, Elsevier Health Sciences, 1997 - Medical
Monday, August 8, 2011
significant change after sympathectomy: reduced sympathetic and increased vagal tone
The HRV analysis showed a significant change of indices reflecting sympatho-vagal balance indicating significantly reduced sympathetic (LF) and increased vagal (HF, rMSSD) tone. These changes still persisted after 2 years. Global HRV increased over time with significant elevation of SDANN after 2 years. QT dispersion was significantly reduced 1 month after surgery and the dispersion was further diminished 2 years later.
http://www.sciencedirect.com/science/article/pii/S0167527399001011
http://www.sciencedirect.com/science/article/pii/S0167527399001011
sympathetic innervation of the salivary glands takes place via preganglionic nerves in the thoracic segments T1-T3
Direct sympathetic innervation of the salivary glands takes place via preganglionic nerves in the thoracic segments T1-T3 which synapse in the superior cervical ganglion with postganglionic neurons that release norepinephrine, which is then received by β-adrenergic receptors on the acinar and ductal cells of the salivary glands, leading to an increase in cyclic adenosine monophosphate (cAMP) levels and the corresponding increase of saliva secretion. Note that in this regard both parasympathetic and sympathetic stimuli result in an increase in salivary gland secretions.[3] The sympathetic nervous system also affects salivary gland secretions indirectly by innervating the blood vessels that supply the glands.
http://en.wikipedia.org/wiki/Salivary_gland
http://en.wikipedia.org/wiki/Salivary_gland
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