Cervical sympathetic chain injury is a rare complication of surgery for thyroid and parathyroid conditions

ANZ Journal of Surgery. 74(6):442-445, June 2004.
HARDING, JANE L. MB BS; SYWAK, MARK S. MB BS, FRACS; SIDHU, STAN MB BS, PhD, FRACS; DELBRIDGE, LEIGH W. MD, FRACS

Many patients come initially to the surgeon and they want a permanent effective cure

http://www.southernvascular.com.au/html/procedures_sympathectomy.html

A statistically significant drop in the level of norepinephrine occurred in all assessed patients after sympathectomy

http://icvts.oxfordjournals.org/content/5/4/464.full

 As a stress hormone, norepinephrine affects parts of the brain where attention and responding actions are controlled.
Along with epinephrine, norepinephrine also underlies the fight-or-flight response, directly increasing heart rate,
triggering the release of glucose from energy stores, and increasing blood flow to skeletal muscle.

Norepinephrine is also released from postganglionic neurons of the sympathetic nervous system, to transmit the
fight-or-flight response in each tissue respectively. The adrenal medulla can also be counted to such postganglionic
nerve cells, although they release norepinephrine into the blood.
Norepinephrine system
The noradrenergic neurons in the brain form a neurotransmitter system, that, when activated, exerts effects on large
areas of the brain. The effects are alertness and arousal, and influences on the reward system.

www.caam.rice.edu/~cox/wrap/norepinephrine.pdf

"I think the surgeons may not be aware of the long term consequences of denervation"

Email response from Dr. Ahmet Hoke of  John Hopkins School of Medicine,  School of Neurology - Specifically I asked him his opinion on three things:

1. What was his opinion of ETS in terms of risks vs benefits
2. His opinion on why Thoracic surgeons would advertise a surgical reversal approach when, as he sees it, it would  have a very low probability of success
3. His opinion on the Davinci Robot Reversal article regarding surgical reattachment of the sympathetic nerves

1. It all depends on the risk benefit analysis, for some patients yes it may make sense as not everyone develops as severe side effects.
2. I think the surgeons may not be aware of the long term consequences of denervation.

The paper you refer to is not a good model of what happens to the patients because they cut the nerve and immediately repaired it. In such immediate repairs, the ganglia does not loose it's neurons and can regenerate. A better model would be to cut the nerves, wait 6 months and then do the repair; I suspect the recovery would be a lot less.
Ahmet Hoke M.D., Ph.D. FRCPC
Professor of Neurology and Neuroscience
Director, Neuromuscular Division
Johns Hopkins School of Medicine
Department of Neurology
855 N. Wolfe St., Neurology 248
Baltimore, MD, 21205
USA

diabetic autonomic neuropathy has already sympathectomized the patient

This diabetic syndrome has been attributed to a lesion of the sympathetic nerve fibres which control sweat secretion [11] and follow the course of the peripheral nerves [12]. This affects the efferent branch of the reflex arch and is identical to that occurring distal to a surgical sympathectomy [13].

There was no difference found between the histological changes in the nerves of the spontaneous anhidrotic patients (Fig. 1) and those of the two previously sympathectomized patients.

A number of papers have been published which stressed [22-24] the high failure rate of sympathectomy operations in diabetics. We believe that the failure of the operation is due to the fact that diabetic autonomic neuropathy has already sympathectomized the patient. The results of the present study are compatible with this idea.
http://www.springerlink.com/content/v21h52461037653k/

A dysesthetic syndrome can occur after sympathectomy

A dysesthetic syndrome canoccur after sympathectomy; it usually is transient but sometimes can be persistent.

Eugenia-Daniela Hord, MD, Instructor, Departments of Anesthesia and Neurology, Massachusetts General Hospital Pain Center, Harvard Medical School


Dysesthethic pain is a common complaint of patients with syringomyelia, traumatic paraplegia, and various myelopathic conditions. Because cavitary lesions of the spinal cord can be defined with good resolution by magnetic resonance imaging, syringomyelia provides a potential model for examining anatomic correlates of central pain. In this study, a syndrome of segmental dysesthesias, characterized by burning pain, hyperesthesia, and a variable incidence of trophic changes, was described by 51 of 137 patients (37%) with syringomyelia at the time of clinical presentation. Complete magnetic resonance scans, including axial images, demonstrated extension of the syrinx into the dorsolateral quadrant of the spinal cord on the same side and at the level of pain in 43 of 51 patients (84%). Surgical treatment of syringomyelia resulted in the relief or improvement of dysesthetic pain in 22 of 37 patients (59%), but 15 patients (41%) reported no improvement or an intensification of pain despite collapse of the syrinx. Postoperative dysesthetic pain was often a disabling complaint that responded poorly to medical therapy, including analgesics, sedatives, antiepileptics, antispasmodics, and anti-inflammatory agents. In most cases, there was a gradual improvement of symptoms, although six patients continued to complain of pain 24 to 74 months postoperatively.

We conclude that painful dysesthesias can be caused by a disturbance of pain-modulating centers in the dorsolateral quadrant of the spinal cord and have certain causalgia-like features that respond in an unpredictable way to surgical collapse of the syrinx.
http://www.ncbi.nlm.nih.gov/pubmed/8727819

Surgical procedure advertised as 'reversible' is not reversible

a recent consensus statement by the Society of Thoracic Surgeons recommended that the clipping method should be considered irreversible as the clipped nerve might not be able to recover after the removal of clips [6].
Ann Thorac Surg 2011;91:1642-8.

extreme case of compensatory truncal hyperhidrosis and anhidrosis over the head and neck region which led to a heatstroke

Thoracic sympathectomy is a commonly performed surgical procedure for the treatment of palmar hyperhidrosis. However, one major complication of such a procedure is compensatory truncal hyperhidrosis. We describe an extreme case of compensatory truncal hyperhidrosis and anhidrosis over the head and neck region which led to a heatstroke.

http://icvts.oxfordjournals.org/content/early/2011/12/20/icvts.ivr121.abstract?sid=89a2ce71-1ea3-4573-9e63-17329e7c09cd

cell death or re-organization in the spinal cord due to sympathectomy

The soles are the most common area with decreased sweating post-ETS, and, along with the axillae and palms, sweating from these areas could be under cortical control, separate from the hypothalamic centers involved in thermoregulation.[72] It has also been proposed that ganglion destruction affects axons of neurons in the interomediolateral spinal cord, which could lead to cell death or re-organization, changing the control of the sympathetic system by the spinal cord and higher, leading to increased sympathetic tone in the other body areas not treated by ETS.[10] http://www.sweathelp.org/en/treatments-hcp/ets-surgery/complications.html

Presence of intense dyschromia in the region corresponding to anhidrosis after sympathectomy

http://ats.ctsnetjournals.org/cgi/content/full/88/4/e42

PATHOPHYSIOLOGY OF ONE-LUNG VENTILATION

In estimating the degree of shunt that is created by one-lung ventilation when it is performed in the lateral decubitus position, on average, 40% of cardiac output perfuses the nondependent lung and the remaining 60% perfuses the dependent lung (Fig. 1).¹⁵ Mechanisms that tend to decrease the percent of cardiac output perfusing the nondependent, nonventilated lung are passive (e.g., mechanical-like gravity, surgical manipulation, amount of pre-existing lung disease) or active (e.g., hypoxic pulmonary vasoconstriction).¹⁵ The normal response of the pulmonary vasculature to atelectasis is an increase in pulmonary vascular resistance (in the atelectatic lung), and the increase in atelectatic lung resistance is almost entirely caused by hypoxic pulmonary vasoconstriction. Hypoxic pulmonary vasoconstriction is a protective reflex mechanism that diverts blood flow away from the atelectatic lung. With an intact hypoxic pulmonary vasoconstriction response, the transpulmonary shunt through the nondependent lung decreases to approximately 23% of the cardiac output (see Fig. 1).
Anesthesiology Clinics of North America
Volume 19, Issue 3, 1 September 2001, Pages 435-453

hypoxic pulmonary vasoconstriction may be impaired after Sympathectomy

It is well known that hypoxic pulmonary vasoconstriction(HPV) plays an important role to protect hypoxemia during the atelectasis induced by one-lung ventilation. Thoracic sympathectomy may have effects on pulmonary vasculature(HPV) and hemodynamics during one-lung anesthesia.

Mean arterial blood pressure was decreased from 81.9+/-2.89 to 73.2+/-2.49 mmHg after thoracic sympathectomy and heart rate was decreased from 104.4+/-3.12 to 88.2+/-2.31beats/min. Arterial oxygen tension was decressed from 570.5+/-17.9 to 521.4+/-23.2mmHg after position change, and decreased to 271.1+/-28.1 mmHg under one-lung ventilation, and finally decreased to 217.0+/-18.3 mmHg after thoracic sympathectomy. With the above results, we can conclude that patients for TES should be carefully observed during and after the procedure, and hypoxic pulmonary vasoconstriction may be impaired after TES.
Korean J Anesthesiol. 1993 Aug;26(4):695-699.

Sympathectomy depresses the function of the adrenal glands, and deprives the experimental animal of its ability to react completely to the stimuli of an emergency situation

Annals of Surgery, June 1951

distinct patterns of peripheral physiological activity are associated with different emotion

The existence of specific somatic states associated with different emotions remains controversial. In this study, we investigated the profile of cardiorespiratory activity during the experience of fear, anger, sadness and happiness. ECG and respiratory activity was recorded in 43 healthy volunteers during the recall and experiential reliving of one or two potent emotional autobiographical episodes and a neutral episode. Univariate statistics indicated that the four emotions differed from each other and from the neutral control condition on several linear and spectral indices of cardiorespiratory activity. Dependent variables were further reduced to five physiologically meaningful factors using an exploratory principal component analysis (PCA). Multivariate analyses of variance and effect size estimates calculated on those factors confirmed the differences between the four emotion conditions. A stepwise discriminant analyses predicting emotions using the PCA factors led to a classification rate of 65.3% for the four emotions (chance=25%; p=0.001) and of 72.0-83.3% for pair-wise discrimination (chance=50%; p's<0.05). These findings may be considered preliminary in view of the small sample on which the multivariate approach has been applied. However, this study emphasizes the need to better characterize the multidimensional factors involved in cardio-respiratory regulation during emotion. These results are consistent with the notion that distinct patterns of peripheral physiological activity are associated with different emotions.
http://www.ncbi.nlm.nih.gov/pubmed/16439033

Changes in TH mRNA levels after cold stress or sympathectomy were eliminated by denervation of the adrenal gland

http://www.ncbi.nlm.nih.gov/pubmed/2427735

sympathicotomy may cause a temporary impairment of the caudal-to-rostral hierarchy of thermoregulatory control and changes in microcirculation

Patients with palmar hyperhidrosis have been reported to have a much
more complex dysfunction of autonomic nervous system, involving compensatory high parasympathetic
activity as well as sympathetic overactivity (13, 14), suggesting that sympathicotomy initially induces a
sympathovagal imbalance with a parasympathetic predominance, and that this is restored on a
long-term basis (14). Therefore, thoracic sympathicotomy may cause a temporary impairment of the
caudal-to-rostral hierarchy of thermoregulatory control and changes in microcirculation. The reduction
of finger skin temperature on the non-denervated side may be due to either a decrease in the cross-
inhibitory effect or the abnormal control of the inhibitory fibers by the sudomotor center (6).
Vasoconstrictor neurons have been found to be largely under the inhibitory control of various afferent
input systems from the body surface, whereas sudomotor neurons are predominantly under excitatory
control (15). The basic neuronal network for this reciprocal organization is probably located in the spinal
level (15). Therefore, the reduction in the contralateral skin temperature may be explained by cross-
inhibitory control of various afferent in the spinal cord.
In particular, our study showed that, following bilateral T3 sympathicotomy, the skin temperatures on
the hands increased whereas the skin temperatures on the feet decreased. These findings suggest a
cross-inhibitory control between the upper and lower extremities. However, the pattern of skin
temperature reduction on the feet differed from that on the contralateral hand. The skin temperature on
the feet did not decrease after right T3 sympathicotomy but decreased significantly after bilateral T3
sympathicotomy.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2722005/

significant impairment of the heart rate to workload relationship was consistently observed following sympathectomy

The aim of the present prospective study was to confirm that a significant impairment of the heart rate to workload relationship was consistently observed following unilateral and/or bilateral (sympathectomy) surgery. Eur J Cardiothorac Surg 2001;20:1095-1100 http://ejcts.ctsnetjourna...i/content/full/20/6/1095

a correlation of the findings of cytoarchitectonics and sympathectomy with fibre degeneration following dorsal rhizotomy

Autonomic neurons in the spinal cord of the rhesus monkey: a correlation of the findings of cytoarchitectonics and
sympathectomy with fibre degeneration following dorsal rhizotomy.
J Comp Neurol 146:189 –218.
http://onlinelibrary.wiley.com/doi/10.1002/cne.901460205/abstract


Cytoarchitecture or Cytoarchitectonics is the study of the cellular composition of the body's tissues under the microscope.

Objective Assessment Of Sudomotor Response Following Thoracoscopic Sympathectomy

http://www.aats.org/annualmeeting/Abstracts/2006/AM06_44.html

Bradicardia, hypotension and hypoxia are frequently observed during thoracic sympathicotomy

Clinical Autonomic Research

Volume 13, Number 2, 147-161, DOI: 10.1007/s102860300008

ISSS-ABSTRACTS

5^th International Symposium on Sympathetic Surgery 29^th–31^th May 2003

sympathectomy results in a pronounced increase of cerebrospinal fluid production

Electrical stimulation of the sympathetic nerves, which originate in the superior cervical ganglia, induces as much as 30% reduction in the net rate of cerebrospinal fluid (CSF) production, while sympathectomy results in a pronounced increase, about 30% above control, in the CSF formation. There is strong reason to believe that the choroid plexus is under the influence of a considerable sympathetic inhibitory tone under steady-state conditions.

http://ukpmc.ac.uk/abstract/MED/6276421

"Lumbar sympathectomy/Sympathectomy and Hydrocephalus sharing one common finding"

http://en.diagnosispro.com/disease_comparison-for/lumbar-sympathectomy-versus-hydrocephalus/16143-22570.html

DiagnosisPro is a medical expert system.^[1] It provides exhaustive diagnostic possibilities for 11,000 diseases and 30,000 findings.^[2] It is supposed to give the most appropriate differential however this is not always the case.^[3] Between Oct 2008 and Oct 2009 the site averaged 61,000 visits per month. ^[4]
http://en.diagnosispro.com/disease_comparison-for/lumbar-sympathectomy-versus-hydrocephalus/16143-22570.html

Hydrocephalus also known as "water in the brain," is a medical condition in which there is an abnormal accumulation of cerebrospinal fluid (CSF) 
http://en.wikipedia.org/wiki/Hydrocephalus

Effect of ganglion blockade on cerebrospinal fluid norepinephrine

Prevention of ganglion blockade-induced hypotension using phenylephrine did not prevent the decrease in CSF NE caused by trimethaphan, and when phenylephrine was discontinued, the resulting hypotension was not associated with increases in CSF NE. The similar decreases in plasma NE and CSF NE during ganglionic blockade, and the abolition of reflexive increases in CSF NE during hypotension in ganglion-blocked subjects, cast doubt on the hypothesis that CSF NE indicates central noradrenergic tone and are consistent instead with at least partial derivation of CSF NE from postganglionic sympathetic nerve endings.

 http://www.mendeley.com/research/effect-of-ganglion-blockade-on-cerebrospinal-fluid-norepinephrine/

Ischemic spinal cord injury has been reported after sympathectomy

Toole's Cerebrovascular Disorders

E. Steve Roach, James F. Toole, Kerstin Bettermann, José Biller

Cambridge University Press, 31/01/2010 - Medical - 408 pages

Severe Bronchospasm Following Bilateral T2-T5 Sympathectomy

http://www.ispub.com/journal/the-internet-journal-of-anesthesiology/volume-12-number-2/severe-bronchospasm-following-bilateral-t2-t5-sympathectomy.html

isolated failure of sympathetic sudomotor activity

The main clinical features include symptoms of heat intolerance: feeling hot, flushed, dyspneic, light-headed, and weak when the ambient temperature is high or when exercising. Recent accounts of acquired idiopathic anhidrosis, however, have emphasized the heterogeneous features and sub-types of this condition.
Fitzpatrick's Dermatology In General Medicine, Seventh Edition: Two Volumes
Pub Date: NOV-07

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

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

http://summaries.cochrane.org/CD002918/cervico-thoracic-or-lumbar-sympathectomy-for-neuropathic-pain

Post sympathectomy syndrome is a poorly understood condition

Post sympathectomy syndrome is a poorly understood condition, which occurs in up to 50% of patients undergoing sympathectomy. This is proposed to be a complex neuropathic and central deafferentation and reafferentation sydnrome. This can occur anywhere from few days to weeks following chemical or surgical sympathectomy. This is characterized by deep, aching pain with superficial burning and hyperesthesia, which may or may not respond to narcotic analgesics. Tricyclic antidepressants may help to reduce the incidence of postsympathoctomy neuralgia. Phenytoin, Carbamazepine or Gabapentin may be useful to reduce spontaneous pain and allodynia. Mexiletine and I.V. lignocaine may help some patients. Occasionally invasive therapies like sympatheic block or more complete sympathectomy can also help.

Stellate ganglion block is one of the most frequently performed procedures in he practice of chronic pain. It can provide good diagnostic, therapeutic and prognostic value.
It can produce complete sympathectomy to the head and neck structures but only a partial sympathetic block of the upper extremity in some patients with variation in anatomy.

Interventional Pain Management

DK. Baheti, Bombay Hospital

Jaypee Brothers Publishers, 2009

Spinal Ischemic Stroke from complications of abdominal surgery, esp. sympathectomy

B. Arterial feeders (e.g. thoracic, intercostal, or cervical branch from subclavian or vertebral artery)
1) thromboembolic disease!
2) complications of abdominal surgery (esp. sympathectomy)
3) dural AV fistulas (between radicular arteries and veins outside dura mater) – cause venous
hypertension → characteristic dilated veins that course on spinal cord surface.

Viktor’s Notes℠ for the Neurosurgery Resident
Please visit website at www.NeurosurgeryResident.net
Updated: April 17, 2010

"Sympathectomy frequently interferes with ejaculation"

Kaplan & Sadock's synopsis of psychiatry:

behavioral sciences/clinical psychiatry

Benjamin J. Sadock, Harold I. Kaplan, Virginia A. Sadock

Lippincott Williams & Wilkins, 2007 - 1470 pages

After peripheral nerve section the amount of GAL produced and present in sensory fibers proximal to the section is dramatically upregulated

Front Neuroendocrinol. 1992 Oct;13(4):319-43.

Galanin in sensory neurons in the spinal cord.

Department of Clinical Physiology, Karolinska Institute, Huddinge University Hospital, Sweden.

The distribution and physiological effects of the neuropeptide galanin (GAL) have been examined in the somatosensory system. GAL is normally present in a few sensory neurons that terminate in the dorsal horn of the spinal cord and it is colocalized with substance P and calcitonin gene-related peptide. After peripheral nerve section, but not dorsal root section, the amount of GAL produced and present in sensory fibers proximal to the section is dramatically upregulated. In parallel functional studies, we could demonstrate that exogenous GAL has a complex effect on the spinal cord reflex excitability, facilitatory at low doses and inhibitory at high doses. Furthermore, GAL inhibits the effect of excitatory neuropeptides physiologically released at the peripheral and central terminals of small diameter afferents that subserve a nociceptive function. After axotomy, the inhibitory effect of GAL is increased. We conclude that GAL may have an important role in the control of nervous impulses that underlie pain states that can occur after peripheral nerve injury.

http://www.ncbi.nlm.nih.gov/pubmed/1281124

Increased expression of galanin in the rat superior cervical ganglion after pre- and postganglionic nerve lesions

http://www.ncbi.nlm.nih.gov/pubmed/7515354

Galanin is a neuropeptide encoded by the GAL gene,^[1] that is widely expressed in the brain, spinal cord, and gut of humans as well as other mammals. Galanin signaling occurs through three G protein-coupled receptors.^[2]
The functional role of galanin remains largely unknown; however, galanin is predominately involved in the modulation and inhibition of action potentials in neurons. Galanin has been implicated in many biologically diverse functions, including: nociception, waking and sleep regulation, cognition, feeding, regulation of mood, regulation of blood pressure, it also has roles in development as well as acting as a trophic factor.^[3] Galanin is linked to a number of diseases including Alzheimer’s disease, epilepsy as well as depression, eating disorders and cancer.^[4][5] Galanin appears to have neuroprotective activity as its biosynthesis is increased 2-10 fold upon axotomy in the peripheral nervous system as well as when seizure activity occurs in the brain. It may also promote neurogenesis.^[2]
http://en.wikipedia.org/wiki/Galanin

Compensatory changes in contralateral sympathetic neurons of the superior cervical ganglion and in their terminals in the pineal gland following unilateral ganglionectomy

The sympathetic noradrenergic neurons of the rat superior cervical ganglia (SCGs) provide the major source of innervation to the pineal gland. The present study sought to determine if this sympathetic innervation can undergo collateral sprouting following partial denervation of the pineal by unilateral removal of the SCG (ganglionectomy), and whether such growth of axon terminals is associated with biochemical changes in the contralateral SCG. In the pineal gland following partial denervation, residual noradrenergic terminals underwent compensatory changes indicative of collateral sprouting, as evidenced by: a rapid reduction in tyrosine hydroxylase (TH) activity and in [3H]norepinephrine (NE) uptake, to about 50% of control by 2 days, which was followed by a gradual but sustained increase to levels of approximately 80% of control by 10 days and a reduction in the intensity and density but not in the distribution of fibers containing NE-induced fluorescence by 2 days, which was followed by a sustained increase. In the contralateral SCG, choline acetyltransferase (CAT) activity, a marker of cholinergic preganglionic terminals, was transiently increased to about 115% of control by 4 days and returned to control levels by 14 days after unilateral ganglionectomy; later, TH activity in noradrenergic cell bodies was gradually increased to about 140% of control by 10 days where it remained for up to 52 days. Unilteral ganglionectomy combined with decentralization of the contralateral SCG by preganglionic nerve cut prevented the compensatory changes in noradrenergic nerve terminals within the pineal.
http://www.ncbi.nlm.nih.gov/pubmed/2861259

Hypertrophy and neuron loss: structural changes in sheep SCG induced by unilateral sympathectomy

Interaction effects between time and ganglionectomy-induced changes were significant for SCG volume and mean perikaryal volume. These findings show that unilateral superior cervical ganglionectomy has profound effects on the contralateral ganglion. For future investigations, it would be interesting to examine the interaction between SCGs and their innervation targets after ganglionectomy. Is the ganglionectomy-induced imbalance between the sizes of innervation territories the milieu in which morphoquantitative changes, particularly changes in perikaryal volume and neuron number, occur? Mechanistically, how would those changes arise? Are there any grounds for believing in a ganglionectomy-triggered SCG cross-innervation and neuroplasticity?
http://www.ncbi.nlm.nih.gov/pubmed/21334426

SYMPATHECTOMY ON THE FATTY DEPOSIT IN CONNECTIVE TISSUE

The effect of unilateral extirpation of the stellate and the superior cervical ganglia on the amount of the pericardial fat and the effect of unilateral extirpation of the lumbar and sacral ganglia on the abdominal and subcutaneous fat on the denervated side make it likely that the effects of the splanchnic nerves on the perirenal fat may be extended to describe the relation between fat storage in and sympathetic innervation of connective tissue in general.
http://ep.physoc.org/content/27/1/1

Retrograde Changes in the Nervous System Following Unilateral Sympathectomy

In consequence of right-sided smpathectomy at the level of C5 it was found that in the sheep the cervical sympathetic trunk contains nerve fibres which proceed from cells situated in the first four segments of the thoracic part of the spinal cord and in the stellate ganglion. These fibres are about 85 per cent of all fibres of the sympathetic trunk. The remaining 15 per cent proceed from nerve cells situated nasally of the anterior cervical ganglion.
http://onlinelibrary.wiley.com/doi/10.1111/j.1439-0442.1967.tb00255.x/abstract

Patients with sympathectomy are not suitable controls for sleep study. Why?

Exclusions:
Patients with permanent pacemaker, non-sinus cardiac arrhythmias, peripheral vasculopathy or neuropathy, severe lung disease, status postbilateral cervical or thoracic sympathectomy, finger deformity that precludes adequate sensor application, using a-adrenergic receptor blockers, or alcohol or drug abuse during the last 3 years.

Evaluation of a Portable Device Based on Peripheral Arterial Tone for Unattended Home Sleep Studies

 The clinic sleep laboratory of the Technion Sleep Medicine Centre, Israel
http://chestjournal.chestpubs.org/content/123/3/695.long
CHEST March 2003 vol. 123 no. 3 695-703

MSAC Application no 1130, Assessment Report

II. Patients who have undergone sympathectomy are not suitable controls. Why?

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.

The amount of compensatory sweating depends the amount of cell body reorganization in the spinal cord after surgery

The amount of compensatory sweating depends on the patient, the damage that the white rami communicans incurs, and the amount of cell body reorganization in the spinal cord after surgery.

Other potential complications include inadequate resection of the ganglia, gustatory sweating, pneumothorax, cardiac dysfunction, post-operative pain, and finally Horner’s syndrome secondary to resection of the stellate ganglion.
www.ubcmj.com/pdf/ubcmj_2_1_2010_24-29.pdf

ETS considered psychiatric surgery - says Dr Nagy

"ETS (sympathectomy) 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. "

http://www.lvhyperhidrosis.com/treatment.html

MD admits stellate ganglion block impacts on the insular cortex of the brain and alters emotions

Dr. Lipov says, "What really intrigued me about Dr, DeWall's study was he showed Tylenol exerted this emotional effect by acting on the insular cortex of the brain. That's exactly the same area that's affected by a Stellate Ganglion Block.[4]" The specialist is also Director of Chronic Pain Research at Northwest Community Hospital in Arlington Heights.
http://www.medicalnewstoday.com/releases/227298.php

Individual cardiovascular response to different levels of sympathetic blockade varies widely, depending on the degree of sympathetic tone before the block

The cardiovascular responses to epidural anaesthesia are almost entirely due to the fact that the local anaesthetic injected into the epidural space not only blocks somatic, sensory and motor fibres, but also produces preganglionic sympathetic denervation.

Postganglionic sympathetic nerves play an important role in controlling cardiac function and vascular tone. The most important of the cardiovascular effects are related to blockade of vasoconstrictor fibres (below T4) with resulting dilatation of resistance and capacitance vessels and/or cardiac sympathetic fibres with loss of chronotropic and inotropic drive to the myocardium (T1-5) (Figure 1).



The cardiac sympathetic outflow emerges from C5 to T5 levels, with the main supply to the ventricles from T1 to T4. A significant part of the chronotropic and inotropic control of the heart is mediated through the upper four thoracic spinal segments.
Denervation of preganglionic cardiac accelerator fibres leaving the cord at T1-T5 results in minimal vasodilatory consequences. Changes however in heart rate, left ventricular function and myocardial oxygen demand may occur due to high thoracic epidural blockade and are discussed below.

The major determinant of heart rate is the balance between sympathetic and parasympathetic systems with the latter predominating. A high thoracic epidural anaesthesia (TEA) covering the cardiac segments (T1-T4) produces small but significant reductions in heart rate4-8. During cardiac sympathetic denervation, parasympathetic cardiovascular responses, including those involved in baroreflexes, may dominate.

It was suggested that the sympathetic control of heart rate modified the dominating parasympathetic tone, rather than functioning as an active cardiac accelerator. In this study there was no compensation for changes in preload;
therefore cardiopulmonary baroreceptors affected by changes in central volume secondary to peripheral vasodilatation or vasoconstriction might have altered arterial baroreceptor heart rate reflex as well.


High TEA added to general anaesthesia significantly decreased the cardiac acceleration in response to decreasing blood pressure, suggesting that baroreflex-mediated heart rate response to a decrease in arterial blood pressure depends on the integrity of the sympathetic nervous system. However general anaesthesia, in addition to high levels of epidural anaesthesia, may have modified the balance between sympathetic and parasympathetic tone as well.
By applying power spectral analysis, i.e., frequency analysis of electrocardiographic R-R interval, the individual components of the autonomic nervous system can be discerned and can be used as a sensitive indicator of sympathovagal interaction.

Individual cardiovascular response to different levels of sympathetic blockade varies widely, depending on the degree of sympathetic tone before the block.
Anaesth Intensive Care 2000; 28: 620-635
B. T. VEERING*, M. J. COUSINS†
Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands and Department of Anaesthesia and
Pain Management, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales

diabetic autonomic neuropathy has already sympathectomized the patient

Although not specific, the symptoms suffered by diabetics from sweating disturbances are fairly typical [5]. Initially there is heat intolerance accompanied by hyperhidrosis of the upper half of the body, particularly affecting the face, neck, axillae and hands. It is of interest that these patients rarely perspire excessively below the umbilicus. This diabetic syndrome has been attributed to a lesion of the sympathetic nerve fibres which control sweat secretion [11] and follow the course of the peripheral nerves [12]. This affects the efferent branch of the reflex arch and is identical to that occurring distal to a surgical sympathectomy [13].




There was no difference found between the histological changes in the nerves of the spontaneous anhidrotic patients
(Fig. 1) and those of the two previously sympathectomized patients.


A number of papers have been published which stressed [22-24] the high failure rate of sympathectomy operations in diabetics. We believe that the failure of the operation is due to the fact that diabetic autonomic neuropathy has already sympathectomized the patient. The results of the present study are compatible with this idea.
http://www.springerlink.com/content/v21h52461037653k/

Production of neurogenic electrocardiographic changes by unilateral alteration of sympathetic tone

Circ Res 1966;18:416-428. 51.

Sympathectomy decreased CD4+ T-cells in lymph nodes

Alterations in lymphocyte activity does not always correlate with changes in the proportions of T- or B-lymphocyte subsets. Sympathetic denervation leads to loss of an important regulatory mechanism in immune system physiology. This is apparently site specific in that both lymph node and spleen T-cell proliferative responses are reduced.
Article by Dr. Brian A. Smith
http://home.earthlink.net/~doctorsmith/hivandchiro.htm

catecholamine-induced activation of vagal afferent pathways in regulation of sympathoadrenal system activity

Stress-induced activation of the hypothalamic-pituitary-adrenal axis and sympathoadrenal system is precisely regulated by well-documented negative feedback mechanisms. These include direct negative feedback effect of glucocorticoids on brain structures regulating the hypothalamic-pituitary-adrenal axis activity. However, since the blood-brain-barrier is impermeable to circulating catecholamines, the role of circulating epinephrine and norepinephrine in feedback regulation of the sympathoadrenal system activity is unclear. Here we show that vagal innervation of the adrenal medulla combined with the presence of β-adrenergic receptors on vagal sensory neurons, the epinephrine-induced activation of vagal afferents, and increased plasma epinephrine levels following subdiaphragmatic vagotomy indicate that sensory fibers of the vagus nerve participate in the monitoring of plasma and tissue catecholamine concentrations. Furthermore, it shows that signaling transmitted by vagal afferents regulates sympathoadrenal system activity at the level of the brain. Therefore, we propose that vagal sensory fibers, directly activated by epinephrine and norepinephrine, represent the afferent limb of a negative feedback loop that adjusts the activity of the sympathoadrenal system according to actual plasma and tissue catecholamine levels.
http://www.unboundmedicine.com/medline/ebm/record/21314209

sympathectomy will block the chronotropic response

Around 50% of patients have bradycardia in the following minutes of a bilateral surgery with mean and diastolic blood pressure significant reduction. Since the sympathectomy will block the chronotropic response, a significant increase of the ejection volume is observed when the patient moves in the erect position from dorsal decubitus [6]. Two cardiovascular complications were reported in the literature. First, an asystolic cardiac arrest in an 18-year-old woman during the second side (left) of bilateral sympathectomy for severe hyperhidrosis, requiring resuscitation maneuvers, with no chronic sequelae [7]. The second case was reported in a 23-year-old woman in whom a bilateral T₂ sympathectomy was performed for facial hyperhidrosis. Two years later, following electrophysiologic studies confirming unopposed vagotonic stimulation, she underwent permanent pacemaker insertion for symptomatic bradycardia [8].
http://icvts.ctsnetjournals.org/cgi/content/full/8/2/238

HAZARDS ASSOCIATED WITH CERVICO-THORACIC SYMPATHECTOMY

The need for a realistic appraisal of the potentialities for harm in Cervico-Thoracic sympathectomy is apparent on anatomic grounds alone (Orkin et al. ] 950). Fatalities occur from time to time, but only a few reports of such fatalities find their way into the literature (Adriani et al. 1952). Reported complications associated with Ccrvico-Thoracic sympathectomy, which is, in effect a permanent Stellate Ganglion block (Moore 1954), include pneumothorax, Horner's syndrome, phrenic and recurrent laryngeal nerve damage, infection from oesophageal puncture, cardiac arrhythmias (Tochinai 1974), and very infrequently cardiac arrest (Moore 1954).
The following is a case report of a healthy 18-year-old woman who had bilateral Cervico-Thoracic sympathectomy done in two stages for severe hyperhidrosis in the palms of her hands.
Two episodes of asystolic arrest occurred during the 2nd stage left Cervico-Thoracic sympathectomy.
The cause of hyperhidrosis apparently originates from some poorly understood stimulation of the sympathetic nervous system (Cloward 1969), and in sensitive patients this may possibly lead to excessive vagal stimulation to counteract it, as illustrated by the bradycardia and asystolic reaction to the sudden removal of the sympathetic control, and by the high doses of sympathomimetic drugs necessary to recommence cardiac activity. Anatomically the heart is innervated by the cardiac plexus which consists of the cardiac nerves derived from the cervical and upper thoracic ganglia of the sympathetic trunk and branches of the vagus.
The pacemaker of the heart, the sino-atrial node, is innervated by both the parasympathetic and sympathetic nerves (King and Coakley 1958). The ventricular muscle of the heart is supplied solely by the sympathetic nerves, and the larger branches of the coronary arteries are also predominantly innervated by sympathetics (Woollard 1926). These factors may also have a bearing on the hazard of a bilateral cervico-thoracic sympathectomy, which leaves the heart solely under vagal control. Usually, following denervation, the heart will initiate its own impulse, without recourse to external agencies, but there may be a place for transvenous electrode cardiac pacing, if spontaneous initiation of impulse is delayed, or bradycardia is severe.

Anaesthesia and Intensive Care, Vol. V, No. 1, February, 1977
R. F. Y. ZEE
Royal Perth Hospital, Perth

abnormalities of the autonomic nervous system are correlated with death risk

Michael Lauer: It's been known for a long time that abnormalities of the autonomic nervous system are correlated with death risk, but the problem is that the way in which these abnormalities are measured are very difficult. They require sophisticated equipment and they require the kind of tests which simply have not entered the realm of normal clinical practice. What we find is that these very, very simple measures that are obtained as part of regular routine exercise testing deflect what happens to the autonomic nervous system and provides us with just as powerful predictors of risk of death.
(Dr Michael Lauer, cardiologist, Cleveland Clinic in Cleveland, Ohio)
http://www.abc.net.au/rn/talks/8.30/helthrpt/stories/s63595.htm

The response to injury in the perihperal nervous system

Persisting neurones switch to a ‘survivor’ phenotype and the expression of hundreds of genes^8,9 is changed to compensate for the loss or diminution of target-derived neurotrophic factors,¹⁰ and in order to regrow their axons across the site of the injury and back into the periphery. Proximal changes, such as synaptic reorganisation in the cortex^11–13 and spinal cord, occur upstream of axotomised first-order motor and sensory neurones, and may influence the functional outcome months or even years later.^14–16 Distal to the injury, a series of molecular and cellular events, some simultaneous, others consecutive, and collectively called Wallerian degeneration, is triggered throughout the distal nerve stump and within a small reactive zone at the tip of the proximal stump (Fig. 2).^17–19

http://web.jbjs.org.uk/cgi/content/full/87-B/10/1309

'Improved sympathectomy' - is it an oxymoron?

"also it seems like the more bad and negative affects were from 10 to 12 years ago when they had just started performing the surgery.. they must have improved it a lot by now?"

This procedure has been performed since the 1920's. Yes, the 1920's. In the 1980's they started to do it using "keyhole" surgery which means they don't have to make a big incision. But, the surgery is no different than what they've been doing for the last 70+ years. It's a nerve injury. You can't "improve" they way you inflict a nerve injury. You can't injure the nerve in some "special" way such that the injury suddenly has a different effect on the body.

The functional name for the this surgery is "sympathetic denervation". It's not some super-advanced, modern cure based on recent discoveries in neurophysiology. It's a primitive, destructive procedure. It's a method used on animals for research. It's brute force method...destroy the pathways to the sweat glands over a large region. Unfortunately, it destroys pathways to and from many other organs including the heart and lungs and causes a large number of neuropathological dysfunction. That hasn't changed in the last ten years. It will not and cannot change in the next 1000 years because it will still be a nerve injury 1000 years from now. I'm not making this up. It's a simple fact. Don't let some doctor take advantage of your ignorance
http://etsandreversals.yuku.com/topic/4919/Should-i-have-ETS-surgery#.Tok-TE8YAyk

Distribution of GABA-immunoreactive nerve fibers and cells in the cervical and thoracic paravertebral sympathetic trunk

These data suggest that the GABAergic innervation of paravertebral sympathetic ganglia is more complex than previously suspected. What appears as preganglionic afferents from several spinal segments (C8-Th7) innervate GABAergic neurons in the sympathetic trunk which have ascending axons and focus their inhibitory effects on the cervical sympathetic ganglia, predominantly the SCG. These data suggest that GABAergic small interganglionic neurons form a feed-forward inhibition system, which may be driven by multisegmental spinal input in the paravertebral sympathetic ganglion chain.
http://onlinelibrary.wiley.com/doi/10.1002/cne.903340209/abstract

So numerous are the possible variations that the outcome of a sympathectomy is unpredictable

The sympathetic pathways to the heart are extremely variable in their topography, and the diversity of arrangements encountered accounts for the morphological contradictions in the literature. So numerous are the possible variations that the outcome of a sympathectomy is unpredictable. Where denervation is incomplete, collateral sprouting and regeneration of nerves could even lead to hyperstimulation via the sympathetic pathways.
http://onlinelibrary.wiley.com/doi/10.1002/aja.1001240203/abstract

After severing the cervical sympathetic trunk, the cells of the cervical sympathetic ganglion undergo transneuronic degeneration

In consequence of right-sided smpathectomy at the level of C₅ it was found that in the sheep the cervical sympathetic trunk contains nerve fibres which proceed from cells situated in the first four segments of the thoracic part of the spinal cord and in the stellate ganglion. These fibres are about 85 per cent of all fibres of the sympathetic trunk. The remaining 15 per cent proceed from nerve cells situated nasally of the anterior cervical ganglion.

The spinal cord. Changes found in the segment Th1 – Th4 in sheep III and IV closely resembled those
seen in the stellate ganglion (Figures 6, 7).

2. After severing the sympathetic trunk, the cells of its origin undergo complete disintegration within
a year.

3. After severing the cervical sympathetic trunk, the cells of the cervical sympathetic ganglion
undergo transneuronic degeneration.
http://onlinelibrary.wiley.com/doi/10.1111/j.1439-0442.1967.tb00255.x/abstract

sympathectomy created imbalance of autonomic activity and functional changes of the intrathoracic organs

Surgical thoracic sympathectomy such as ESD (endoscopic thoracic sympathectic denervation) or heart transplantation can result in an imbalance between the sympathetic and parasympathetic activities and result in functional changes
in the intrathoracic organs.
Therefore, the procedures affecting sympathetic nerve functions, such as epidural anesthesia, ESD, and heart transplantation, may cause an imbalance between sympathetic and parasympathetic activities (1, 6, 16, 17). Recently, it has been reported that ESD results in functional changes of the intrathoracic organs.


In conclusion, our study demonstrated that ESD adversely affected lung function early after surgery and the BHR was affected by an imbalance of autonomic activity created by bilateral ESD in patients with primary focal hyperhidrosis.
Journal of Asthma, 46:276–279, 2009
http://informahealthcare.com/doi/abs/10.1080/02770900802660949

important relationship among cognitive performance, HRV, and prefrontal neural function

These findings in total suggest an important relationship among cognitive performance, HRV, and prefrontal neural function that has important implications for both physical and mental health. Future studies are needed to determine exactly which executive functions are associated with individual differences in HRV in a wider range of situations and populations.
http://www.ncbi.nlm.nih.gov/pubmed/19424767

Low HRV is a risk factor for pathophysiology and psychopathology

The intimate connection between the brain and the heart was enunciated by Claude Bernard over 150 years ago. In our neurovisceral integration model we have tried to build on this pioneering work. In the present paper we further elaborate our model. Specifically we review recent neuroanatomical studies that implicate inhibitory GABAergic pathways from the prefrontal cortex to the amygdala and additional inhibitory pathways between the amygdala and the sympathetic and parasympathetic medullary output neurons that modulate heart rate and thus heart rate variability. We propose that the default response to uncertainty is the threat response and may be related to the well known negativity bias. We next review the evidence on the role of vagally mediated heart rate variability (HRV) in the regulation of physiological, affective, and cognitive processes. Low HRV is a risk factor for pathophysiology and psychopathology. Finally we review recent work on the genetics of HRV and suggest that low HRV may be an endophenotype for a broad range of dysfunctions.
http://www.ncbi.nlm.nih.gov/pubmed/18771686

Fundamentals of psychoneuroimmunology

The long-held concept that the nervous, endocrine and immune systems are separate entities has given way to a new understanding of human biology. Psychoneuroimmunology addresses the realisation that the neural, immune, and endocrine systems are inextricably linked and that the effects of each affect all-the systems work together as a complicated set of triggers and balances, an intertwining of the physiological and emotional states. Beginning with the fundamentals of immune and neuroendocrine function, Fundamentals of Psychoneuroimmunology explores the complexities of behavioural assessment, the basic types of immunity, the importance of immune cell redistribution in the response to challenges such as infection and stress, and the multifaceted roles of nerves, hormones and cytokines.
http://books.google.com/books/about/Fundamentals_of_psychoneuroimmunology.html?id=h0mEge8Oec8C

Sympathectomy should not be considered for such persons because of the risk of permanent worsening of erythromelalgia symptoms

The literature contains reports of remission with sympathectomy, but careful case selection is imperative before this procedure is performed.  Sympathectomy should be considered only for those whose erythromelalgia improves with blocks.  Conversely, if a sympathetic block causes worsening of a person's erythromelalgia, treatment should be discontinued.  Sympathectomy should not be considered for such persons because of the risk of permanent worsening of erythromelalgia symptoms.
Jay S. Cohen MD,
medicationsense.com/articles/2010/erythromelalgia0510.pdf

Limbic-cortical dysregulation: a proposed model of depression

cognition and reward processing

Recent functional magnetic resonance imaging (fMRI) investigations of the interaction between cognition and reward processing have found that the lateral prefrontal cortex (PFC) areas are preferentially activated to both increasing cognitive demand and reward level. Conversely, ventromedial PFC (VMPFC) areas show decreased activation to the same conditions, indicating a possible reciprocal relationship between cognitive and emotional processing regions. We report an fMRI study of a rewarded working memory task, in which we further explore how the relationship between reward and cognitive processing is mediated. We not only assess the integrity of reciprocal neural connections between the lateral PFC and VMPFC brain regions in different experimental contexts but also test whether additional cortical and subcortical regions influence this relationship. Psychophysiological interaction analyses were used as a measure of functional connectivity in order to characterize the influence of both cognitive and motivational variables on connectivity between the lateral PFC and the VMPFC.

These findings provide evidence for a dynamic interplay between lateral PFC and VMPFC regions and are consistent with an emotional gating role for the VMPFC during cognitively demanding tasks. Our findings also support neuropsychological theories of mood disorders, which have long emphasized a dysfunctional relationship between emotion/motivational and cognitive processes in depression.
http://dl.acm.org/citation.cfm?id=1480468

depression that may occur as part of stress system dysfunction

Stress precipitates depression and alters its natural history. Major depression and the stress response share similar phenomena, mediators and circuitries. Thus, many of the features of major depression potentially reflect dysregulations of the stress response. The stress response itself consists of alterations in levels of anxiety, a loss of cognitive and affective flexibility, activation of the hypothalamic-pituitary-adrenal (HPA) axis and autonomic nervous system, and inhibition of vegetative processes that are likely to impede survival during a life-threatening situation (eg sleep, sexual activity, and endocrine programs for growth and reproduction).
http://www.nature.com/mp/journal/v7/n3/full/4001032a.html

Limbic-cortical dysregulation: a proposed model of depression

A working model of depression implicating failure of the coordinated interactions of a distributed network of limbic-cortical pathways is proposed. Resting state patterns of regional glucose metabolism in idiopathic depressed patients, changes in metabolism with antidepressant treatment, and blood flow changes with induced sadness in healthy subjects were used to test and refine this hypothesis. Dorsal neocortical decreases and ventral paralimbic increases characterize both healthy sadness and depressive illness; concurrent inhibition of overactive paralimbic regions and normalization of hypofunctioning dorsal cortical sites characterize disease remission. Normal functioning of the rostral anterior cingulate, with its direct connections to these dorsal and ventral areas, is postulated to be additionally required for the observed reciprocal compensatory changes, since pretreatment metabolism in this region uniquely predicts antidepressant treatment response. This model is offered as an adaptable framework to facilitate continued integration of clinical imaging findings with complementary neuroanatomical, neurochemical, and electrophysiological studies in the investigation of the pathogenesis of affective disorders.
http://neuro.psychiatryonline.org/cgi/content/short/9/3/471

ELECTRICAL STIMULATION OF THE SYMPATHETIC NERVE CHAIN

The present invention provides a method of affecting physiological disorders by stimulating a specific location along the sympathetic nerve chain. Preferably, the present invention provides a method of affecting a variety of physiological disorders or pathological conditions by placing an electrode adjacent to or in communication with at least one ganglion along the sympathetic nerve chain and stimulating the at least one ganglion until the physiological disorder or pathological condition has been affected.

[0009] A number of treatment regiments utilizing electrical stimulation can be employed for a vast array of physiological disorders or pathological conditions associated with the sympathetic and parasympathetic nervous system. Physiological disorders that may be treated include, but are not limited to, hyperhydrosis, complex regional pain syndrome and other pain syndromes such as headaches, cluster headaches, abnormal cardiac sympathetic output, cardiac contractility, excessive blushing condition, hypertension, renal disease, heart failure, angina, hypertension, and intestinal motility disorders, dry eye or mouth disorders, sexual dysfunction, asthma, liver disorders, pancreas disorders, and heart disorders, pulmonary disorders, gastrointestinal disorders, and biliary disorders. The number of disorders to be treated is limited only by the number, variety, and placement of electrodes (or combinations of multiple electrodes) along the sympathetic nervous system.

http://www.faqs.org/patents/app/20110098762

changes in the intracranial vascular bed due to the leakage and disappearance of the noradrenaline transmitter from the degenerating nerve terminals followed by denervation supersensitivity

The intracranial pressure, measured as the ventricular fluid pressure (VFP), was recorded continuously during about 2 days via a cannula inserted into the left lateral ventricle of the brain of conscious rabbits. The effect of bilateral removal of the superior cervical ganglia on the VFP was studied at various time-periods after operation, and the results were compared with those from unoperated control animals. The pressure changes attributed to the sympathectomy are referred to as the net VFP. The operation ultimately caused a disappearance of noradrenaline from intracranial sympathetic nerves. The net VFP was not affected during an 8-hr period of the recording starting 5–8 hrs after sympathectomy. During the following 35 hrs it was reduced by approximately 25 mm physiological saline followed by a return to initial or somewhat higher levels. Four days after sympathectomy the net VFP was significantly increased throughout the recording period. Two weeks after the operation the pressure had returned to the same, or even lower level compared with the non-sympathectomized control animals. The variations in the net VFP at different time-periods after sympathectomy are considered to reflect mainly changes in the intracranial vascular bed due to the leakage and disappearance of the noradrenaline transmitter from the degenerating nerve terminals followed by denervation supersensitivity. The results are discussed in terms of a sympathetic influence on the intracranial pressure mediated through the volume of the intracranial vascular bed, and/or the cerebrospinal fluid production in the choroid plexuses.
http://onlinelibrary.wiley.com/doi/10.1111/j.1748-1716.1971.tb05049.x/abstract

Endoscopic sympathetic block--new treatment of choice for social phobia?

Ann Chir Gynaecol. 2001 ;90 (3):177-84  11695789  Cit:3

Central neural integration for the control of autonomic responses associated with emotion

http://www.ncbi.nlm.nih.gov/pubmed/6370083
http://www.google.com.au/search?q=neural+integration+for+the+control+of+autonomic+responses+associated+with+emotion&ie=utf-8&oe=utf-8&aq=t&rls=org.mozilla:en-US:official&client=firefox-a

ganglion block for unbalanced sympathetic nervous system disorders

Stellate ganglion blocks (SGB) are widely used for pain relief in outpatient clinics due to its many therapeutic indications and easy maneuvering. It is used locally over stellate ganglion territory disorders in the craniocervical (head and neck) or upper limbs and systemically for angina pectoris, psychosomatic disorders, hormonal disorders, or unbalanced sympathetic nervous system disorders [1].
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2872892/

Presentations at the 4th International Symposium on Sympathetic Surgery

http://www.angelfire.com/ab/ets/201.htm#_Hlt521158972

Bilateral cervical vagotomy

Bilateral cervical vagotomy was followed by prolonged changes in heart rate, blood pressure, and respiration, and a progressive deterioration of cardiac function. This study was based on recordings from 18 unanesthetized, unrestrained, reclining dogs prior to and after gastroenterostomy, arterial catheterization, and bilateral cervical vagotomy. During the first 7 days after denervation, the heart rate was almost doubled and the pulse pressure was decreased. The diastolic pressure was increased only on the first day, whereas on the second day after denervation the systolic pressure became significantly lower. The markedly elevated heart rate was maintained for 3 weeks. There was a complete loss of inspiratory tachycardia for 20 weeks, a prolonged inspiratory period for 2 weeks, and a high incidence of retching and vomiting for over 43 weeks. Although the animals refused to exercise strenuously, they were fully ambulatory and showed normal interest in their surroundings. Death in 13 cases occurred by the second week postvagotomy and was associated with lung congestion or consolidation, and in two cases the liver had a nutmeg appearance.
http://ajplegacy.physiology.org/content/206/2/265.abstract

sympathectomy can result in spinal cord infarction

Uncommon causes include decompression sickness, which has a predilection for spinal ischemic damage; complications of abdominal surgery, particularly sympathectomy;...

http://www.neurology-asia.com/Spinal_Cord_Infarction.php

For blood pressure control in certain acute hypotensive states (e.g., pheochromocytomectomy, sympathectomy...

Norepinephrine (Levophed ®) -
For blood pressure control in certain acute hypotensive states (e.g., pheochromocytomectomy, sympathectomy, poliomyelitis, spinal anesthesia, myocardial infarction, septicemia, blood transfusion, and drug reactions).
http://www.globalrph.com/norepinephrine_dilution.htm

Unilateral sympathectomy leads to decreases in ventral prostate weight

http://www.biolreprod.org/content/51/1/99

Sympathectomy decreased NE and DA concentrations of muscles to approximately 10% of control values

We studied the effect of unilateral sympathectomy on rat quadriceps and gastrocnemius muscle concentrations of endogenous dihydroxyphenylalanine (DOPA), dopamine (DA), and norepinephrine (NE) and assessed the relationships between these catecholamines in several rat tissues. Catecholamines were measured by reverse-phase high-performance liquid chromatography with electrochemical detection. Sympathectomy decreased NE and DA concentrations of muscles to approximately 10% of control values, whereas the DOPA concentration tended to increase. Relatively high concentrations of DOPA were found in the gastrointestinal tract, kidney, and spleen. No correlations were obtained between the tissue concentration of DOPA and NE. A DA-to-NE ratio approximately 1% was observed in liver, muscle, pancreas, spleen, and heart, whereas we found exponentially increasing DA values with increasing NE concentration in tissues obtained from stomach, small and large intestine, kidney, and lung. In conclusion, endogenous DOPA in muscle tissue is not located in sympathetic nerve terminals but probably in muscle cells. DA concentrations in the gastrointestinal tract and in the kidneys were greater than could be ascribed to its role as a precursor in the biosynthesis of NE.
http://ajpendo.physiology.org/content/256/2/E284.abstract

After severing the cervical sympathetic trunk, the cells of the cervical sympathetic ganglion undergo transneuronic degeneration

After severing the sympathetic trunk, the cells of its origin undergo complete disintegration within
a year.
After severing the cervical sympathetic trunk, the cells of the cervical sympathetic ganglion undergo transneuronic degeneration.



The spinal cord. Changes found in the segment Th1 – Th4 in sheep III and IV closely resembled those
seen in the stellate ganglion (Figures 6, 7). Changes in sheep I and II were the same as described in the
previous paper (5).
The nervus caroticus internus. In all the sheep a myelinated fasciculus was found in this nerve
(Figure 8), which proves that the nervus caroticus internus contains a fasciculus of fibres which run
from the front to the rear in the anterior sympathetic trunk (5).
www.date.hu/acta-agraria/2002-08i/welento.pdf

painful vasospastic condition in the right arm following surgical sympathectomy on the left side

Spinal dorsal column stimulation has been used in the treatment of a patient with a painful vasospastic condition in the right arm following surgical sympathectomy on the left side. After sympathectomy the left arm became constantly dry and warm and consistently lacked skin vasomotor (laser Doppler flowmetry) responses to arousing stimuli, indicating a complete loss of sympathetic vasomotor innervation.
http://www.springerlink.com/content/n823388l26q330m3/

Several autonomic reflexes were dramatically affected after sympathectomy for hyperhidrosis

major effects on local blood flow and temperature are elicited by TES. Complex autonomic reflexes are also affected. The patient should be completely informed before surgery of the side effects elicited by transthoracic endoscopic sympathicotomy (TES).
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0404.2008.01046.x/abstract

stellate ganglion block in the treatment of panic/anxiety symptoms

Both patients experienced immediate, significant and durable relief as measured by the PCL (score minimum 17, maximum 85). In both instances, the pre-treatment score suggested a PTSD diagnosis whereas the post-treatment scores did not. One patient requested repeat treatment after 3 months, and the post-treatment score remained below the PTSD cutoff after 7 additional months of follow-up. Both patients discontinued all antidepressant and antipsychotic medications while maintaining their improved PCL score.

CONCLUSION:

Selective blockade of the right stellate ganglion at C6 level is a safe and minimally invasive procedure that may provide durable relief from PTSD symptoms, allowing the safe discontinuation of psychiatric medications.
http://www.ncbi.nlm.nih.gov/pubmed/20412504

Stellate ganglion block effectively "reboots" the insular cortex

The following is a summary from our publications in Lancet Oncology and Medical Hypothesis

The picture demonstrates the connections from the stellate ganglion to other neural structures.  This was demonstrated using retro rabies virus techniques and functional MRI.  Both are objective data demonstrating the effect on the insula by the stellate ganglion.  Stellate ganglion block effectively "reboots" the insular cortex, allowing for a reduction in hot flashes

The stellate ganglion refers to the ganglion formed by the fusion of the inferior cervical and the first thoracic ganglion as they meet anterior to the vertebral body of C7. It is present in 80% of subjects. It usually lies on or above the neck of the first rib. http://dardipainclinic.com/stellate_ganglion_block.php

US pain specialist performing chemical sympathectomy to treat PTSD, smoking addiction

http://stopptsdnow.com/

skin discoloration after ETS surgery

http://archderm.ama-assn.org/cgi/content/extract/144/9/1240