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

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.
http://onlinelibrary.wiley.com/doi/10.1111/j.1439-0442.1967.tb00255.x/abstract

Monday, November 26, 2012

Hemodynamic changes in vertebral and carotid arteries were observed after sympathicotomy

T3 sympathicotomy segment was the most frequent transection done (95.83%), as only ablation (25%) or in association with T4 (62.50%) or with T2 (8.33%). It was observed increase in RI and PI of the common carotid artery (p < 0.05). The DPV of internal carotid artery decreased in both sides (p < 0.05). The SPV and the DPV of the right and left vertebral arteries also increased (p < 0.05). Asymmetric findings were observed so that, arteries of the right side were the most frequently affected.
CONCLUSIONS: Hemodynamic changes in vertebral and carotid arteries were observed after sympathicotomy for PH. SPV was the most often altered parameter, mostly in the right side arteries, meaning significant asymmetric changes in carotid and vertebral vessels. Therefore, the research findings deserve further investigations to observe if they have clinical inferences.
http://www.ncbi.nlm.nih.gov/pubmed/16186983

Monday, November 19, 2012

Gustatory sweating, flushing and other responses after sympathectomy

Gustatory sweating on the head, neck and arms, often occurs after cervico-thoracic sympathectomy. Haxton (1948) reported an incidence of 36 percent, the same as in the present series. It was thought that some information about regeneration in the cervical sympathetic might be revealed by investigation of this surgical curiosity.

Although sweating is the common gustatory response after cervical sympathectomy, other changes are experienced. Haxton (1948) described associated paresthesia and flushing, gooseflesh may occur (Herxheimer, 1958) and vaso-constriction is reported in this paper. These occur together or separately and occasionally sweating might be absent. The subject has been confused by comparison with post-parotidectomy gustatory sweating which has a different mechanism (Glaister et al.,1958; Bloor, 1958).

Sweating is produced by cholinergic sympathetic fibres. In normal individuals both vasocontriction and gooseflesh are adrenergic. This also holds in gustatory responses. Figure 2 shows blocking of sweating by atropine, whilst gooseflesh continues unchanged.
   The tingling sensations were described as being unlike normal sensation, and likened to plucking out of hair. In one patient in was so unpleasant that she refused to take a test stimulus. Flushing usually occurs on the upper chest and neck, and is an erythema with sharp demarcation, not associated with a rise in skin temperature.
   Of the patients, 29 were found to have gustatory responses, and 24 were studied in detail. Of 22 patients with sweating who could be studied, 11 had gooseflesh, 10 tingling, 6 flushing, and 4 vasoconstriction. Four patients, however, had no sweating and their gustator responses consisted of gooseflesh and tingling in one, tingling alone, and flushing in two. None of these four showed vasoconstriction.
   The stimulus for testing used was usually Worcester sauce, but specificity of the response was sometimes great, and one patient reacted only to boiled sweets made by one particular firm.

http://brain.oxfordjournals.org/content/92/1/137.extract &
http://ang.sagepub.com/content/17/3/143.extract

Sunday, November 11, 2012

not exposing patients to the risk of experiencing the side effects of sympathectomy

The use of oxybutynin for treating ... [An Bras Dermatol. 2011 May-Jun] - PubMed - NCBI: "not exposing patients to the risk of experiencing the side effects of sympathectomy"

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Saturday, November 10, 2012

rates and characteristics of the paresthesia following needlescopic VATS are similar to those observed after conventional VATS

Incidence of chest wall paresthesia ... [Eur J Cardiothorac Surg. 2005] - PubMed - NCBI: "Paresthetic discomfort distinguishable from wound pain was described by 17 patients (50.0%). The most common descriptions were of 'bloating' (41.2%), 'pins and needles' (35.3%), or 'numbness' (23.5%) in the chest wall. The paresthesia resolved in less than two months in 12 patients (70.6%), but was still felt for over 12 months in three patients (17.6%). Post-operative paresthesia and pain did not impact on patient satisfaction with the surgery, whereas compensatory hyperhidrosis in 24 patients (70.6%) did (P=0.001). The rates and characteristics of the paresthesia following needlescopic VATS are similar to those observed after conventional VATS."

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Hemodynamic changes in vertebral and carotid arteries were observed after sympathicotomy

T3 sympathicotomy segment was the most frequent transection done (95.83%), as only ablation (25%) or in association with T4 (62.50%) or with T2 (8.33%). It was observed increase in RI and PI of the common carotid artery (p <>CONCLUSIONS: Hemodynamic changes in vertebral and carotid arteries were observed after sympathicotomy for PH. SPV was the most often altered parameter, mostly in the right side arteries, meaning significant asymmetric changes in carotid and vertebral vessels. Therefore, the research findings deserve further investigations to observe if they have clinical inferences.
http://www.ncbi.nlm.nih.gov/pubmed/16186983

sympathectomy interrupts neural messages to many different organs, glands and muscles

Surgical and chemical sympathectomy can alter cellular proliferation

Surgical denervation and chemical sympathectomy can alter cellular proliferation, B- and T-cell responsiveness and lymphocyte migration in lymphoid organs [17].

In vitro studies have shown that neuropeptides can have numerous effects, either inhibiting or stimulating the proliferation, differentiation and functions of immune cells [19]* Development of systemic lupus erythematosus in mice is associated with alteration of neuropeptide concentrations in inﬂamed kidneys and immunoregulatory organs

Neuroscience Letters 248 (1998) 97– 100

Acquired cardiovascular disease following Sympathectomy

We found statistically significant differences (P < .05) in both time and frequency domains. Parameters that evaluate global cardiac autonomic activity (total power, SD of normal R-R intervals, SD of average normal R-R intervals) and vagal activity (rhythm corresponding to percentage of normal R-R intervals with cycle greater than 50 ms relative to previous interval, square root of mean squared differences of successive normal R-R intervals, high-frequency power, high-frequency power in normalized units) were statistically significantly increased after sympathectomy. Low-frequency power in normalized units, reflecting sympathetic activity, was statistically significantly decreased after sympathectomy. Low-/high-frequency power ratio also showed a significant decrease, indicating relative decrease in sympathetic activity and increase in vagal activity.

The Journal of Thoracic and Cardiovascular Surgery
Volume 137, Issue 3, March 2009, Pages 664-669

Hemodynamic changes in vertebral and carotid arteries were observed after sympathicotomy for PH

Segmental myoclonus was associated with thoracic sympathectomy

Spinal myoclonus was associated with laminectomy, remote effect of cancer, spinal cord injury, post-operative pseudomeningocele, laparotomy, thoracic sympathectomy, poliomyelitis, herpes myelitis, lumbosacral radiculopathy, spinal extradural block, and myelopathy due to demyelination, electrical injury, acquired immunodeficiency syndrome, and cervical spondylosis.

http://www.ncbi.nlm.nih.gov/pubmed/3753263

Spinal myoclonus is typically associated with a localized area of damaged tissue (focal lesion). The injured area may include direct damage of the spinal cord or may cause abnormal changes in the function of the spinal cord.

http://www.wemove.org/myo/myo_pc.html

Spinal myoclonus following a peripheral nerve injury: a case report

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526081/

decreased conditioning-related activity in insula and amygdala after autonomic denervation

The degree to which perceptual awareness of threat stimuli and bodily states of arousal modulates neural activity associated with fear conditioning is unknown. We used functional magnetic neuroimaging (fMRI) to study healthy subjects and patients with peripheral autonomic denervation to examine how the expression of conditioning-related activity is modulated by stimulus awareness and autonomic arousal. In controls, enhanced amygdala activity was evident during conditioning to both "seen" (unmasked) and "unseen" (backward masked) stimuli, whereas insula activity was modulated by perceptual awareness of a threat stimulus. Absent peripheral autonomic arousal, in patients with autonomic denervation, was associated with decreased conditioning-related activity in insula and amygdala. The findings indicate that the expression of conditioning-related neural activity is modulated by both awareness and representations of bodily states of autonomic arousal.

http://www.ncbi.nlm.nih.gov/pubmed/11856537

Receptor hypersensitivity is a common problem

Because of their size and location, injuries to the sympathetic ganglia or chain is rarely indicated or performed. Receptor hypersensitivity is a common problem after significant sympathetic injury, including clammy hands, erythema, and allodynia. When sympathetic nerves regenerate, they may establish aberrant connections to sensory receptors, muscles, or other sympathetics receptors; this may lead to an over-response or abnormal response.
http://wiki.cns.org/wiki/index.php/Injury,_Sympathetic_Nerve

decline in external heart work due to sympathectomy both at rest and under exercise

Retrograde Changes in the Nervous System Following Unilateral Sympathectomy

limited sympathectomy does not reduce postoperative compensatory sweating

On univariate and multivariate analysis, the extent of denervation was not associated with the occurrence or the severity of compensatory sweating.

Compensatory sweating and temporary relief/recurrence were equally considered to be the main causes of dissatisfaction. CONCLUSION: Compensatory sweating was the most common long-term complication of thoracodorsal sympathectomy for primary hyperhidrosis. Its incidence and severity were not associated with the extent of sympathectomy.

http://www.ncbi.nlm.nih.gov/pubmed/12514588

Alteration in 'fight-or-flight response following sympathectomy

Mental arithmetic produces a psychophysiological arousal similar to the so-called defence-alarm reaction elicited by stimulation ofthe hypothalamic defence area in experimental animals (Folkow, 1982). This reaction pattern is characterized by increased heart rate, cardiac output and blood pressure, whereas total peripheral resistance is unchanged or decreased (Brod, 1970).

The increase of platelet concentration during psychological arousal is also in accordance with what has been observed in response to other stressors, i.e. physical exercise and adrenaline infusion (Sarajas et al, 1961; Gjerloff Schmidt & Waever Rasmussen, 1984; Dawson & Ogston, 1969; Vilen et al, 1980).

The emotional leucocytosis observed in dogs has been claimed to be neurogenic in origin, since sympathectomy abolished the rise in leucocyte count (Garrey & Bryan, 193 5).
Both alpha- and beta-receptors seem to be of importance in the mobilization of lymphocytes (Gader & Cash, 1975).

British Journal of Haematology. 1989. 71, 153-1 56

sympathectomy may retard aversive conditioning

"Researchers have examined the role of autonomic feedback in emotional experience using the heartbeat paradigm. Katkin at al. (1982) found that some normal subjects can accurately detect their heartbeats, and it was those individuals who had a stronger emotional response to negative slides as determined by self-report (Hantas et al., 1982). Further support for the importance of autonomic feedback comes from observations. Experiments in animals demonstrate that sympathectomy may retard aversive conditioning (DiGusto and King, 1972), most likely because sympathectomy reduces fear.

In order for a feedback to occur, there must be a means for the viscera and autonomic nervous system to become activated.

Clinical neuropsychology

By Kenneth M. Heilman, Edward Valenstein
Oxford University Press

ATELECTASIS IS A COMMON PULMONARY COMPLICATION FOLLOWING THORACIC AND UPPER ABDOMINAL PROCEDURES

General anesthesia and surgical manipulation lead to atelectasis by causing diaphragmatic dysfunction and diminished surfactant activity. The atelectasis is typically basilar and segmental in distribution. After induction of anesthesia, atelectasis increases from 1 to 11% of total lung volume. End-expiratory lung volume is also found to be decreased.

Postoperative atelectasis is extremely common. Lobar atelectasis is also common. The incidence and prevalence of this disorder are not well documented.

http://emedicine.medscape.com/article/296468-overview#a0104

Atelectasis occurs regularly after induction of general anesthesia, persists postoperatively, and may contribute to significant postoperative morbidity and additional health care costs. Laparoscopic surgery has been reported to be associated with an increased incidence of postoperative atelectasis.

Anesth Analg 2009; 109:1511-1516

Patient with transection of the cord above T5 behaved like subjects after surgical sympathectomy

Increase in blood flow is generally followed by a rise in skin temperature but decrease in blood flow in response to the Gibbon-Landis procedure after sympathectomy is not necessarily accompanied by a fall in surface temperature. This poor correlation between skin temperature and blood flow confirms the previous report of Hoobler and co-workers and helps define the limits of usefulness of measurements
of skin temperature as an index of blood flow to the extremity.

The vasomotor responses to the Gibbon-Landis procedure (reflex response to warming) were studied in hemiplegic patients, subjects with "high transection" of the cord, and in sympathectomized patients.

One patient with documented transection of the cord above T5 behaved like subjects after surgical sympathectomy.
Of 11 sympathectomized limbs tested for vasodilatation in response to the Gibbon-Landis procedure, 4
showed no response, while 7 responded with decrease in blood flow (vasoconstriction).

Vasomotor Responses in the Extremities of Subjects with Various Neurologic Lesions
I. Reflex Responses to Warming
By WALTER REDISCH, M.D., FRANCISCO T. TANGCO, M.D., LOTHAR WERTHEIMER, M.D.,
ARTHUR J. LEWIS, M.D., J. MURRAY STEELE, M.D.
1957;15;518-524 Circulation

he could not be thrilled in the sympathectomized half of his body

Sweet* has reported the case of a very intelligent patient, the dean of a graduate school, who after a unilateral sympathectomy to treat his upper limb hyperhidrosis, found that his previous and customary sensation of shivering while listening to a stirring passage of music occurred in only one side and he could not be thrilled in the sympathectomized half of his body. These cases were interesting because emotions are usually experienced in a rather diffuse and bilateral fashion unless innervation has been specifically interrupted. (p.134.)
Jose M.R. Delgado, M.D.
Physical control of the mind,
Harper Torchbooks, Harper & Row Publishers, 1971

*Sweet, W.H. Participant in "Brain Stimulation in Behaving Subjects". Neurosciences Research Program Workshop. Dec. 1966

'Emotional' sweating regulated by neocortex and limbic cortex

Careful observations showed that the forearm sweating responded diversely to various mental stimuli, unlike the palmar sweating whose response was always an increase. Mental arithmetic, mental testing and physical exercise caused an immediate increase in the palmar sweating but often elicited a transient decrease in the forearm sweating, whereas pain, noise, and emotional stimuli consistently provoked an increase of sweating on the forearm as well as on the palm. These observations suggest that the activities of higher centers, presumably involving neocortex and limbic cortex, exert various influences on the central mechanisms of palmar and generalized sweating.
Jpn J Physiol. 1975;25(4):525-36.
http://www.ncbi.nlm.nih.gov/pubmed/1206808

burning causes nerve scaring, which may behave like epilepsy

slowing of the heart rate usually occurs on the second to fourth day after sympathectomy

The rate fell to a level between 40 and 6o per minute, the maximal slowing usually occurring on the second to fourth day after operation. Consistent slowing of the rate was not observed after a unilateral thoracic sympathectomy of either side. While there was some recovery from the maximum bradycardia with the passage of time in most patients, relatively slow resting cardiac rates and failure of tachycardia to develop with postural hypotension or exercise persisted in all patients.

Skoog's12 work has shown that there are marked differences in the number and precise location of the accessory ganglion cells in the cervical region in different patients and on the two sides in the same patient.
Annals of Surgery, 1949 October, Volume 130 Number 4

Cell body reorganization in the spinal cord after elective surgery to treat blushing

cross-inhibitory control of various afferent in the spinal cord

In conclusion, our results suggest that cross-inhibitory control by various afferents in the spinal cord may exist in the feet as well as in the contralateral hand. The release of cross-inhibitory control by T3 sympathicotomy results in vasoconstriction and a decrease of skin temperature on the contralateral hand and the feet.

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.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2722005/

the muscles that are supplied by these nerves shorten and tighten

This now well-established but generally under-appreciated principle of physiology is aptly known as 'Cannon's Law of Denervation Supersensitivity'. It describes the wide ranging effects of the complete loss of nerve inputs to a variety of bodily structures under experimental conditions. One of the many responses to nerves that are sick or dysfunctional (now termed Disuse Supersensitivity) is that the muscles that are supplied by these nerves shorten and tighten (due to the supersensitivity of both the muscle's specialized stretch receptors and motor nerve-muscle junctions), resulting not only in muscle spasm and stiffness which limit flexibility, but a whole sequence of pain compounding reactions. The two earliest are that localized taut bands of muscle fibers begin to compress the small specialized pain sensing (and now extra-sensitive) nerve fibers within the muscle (known as myofascial tender or trigger points) causing type 1 pain, and the compressed muscles do not allow proper blood flow in, or waste products to be removed. This leads to a build up of lactic acid, which further enhances the perception of pain through type 2 pain mechanisms. Continued and prolonged muscle shortening or contracture gradually leads to increased mechanical tension on the muscle's tendonous attachments to bone, causing all of the various tendonitis (types 1 & 2 pain) syndromes throughout the body. The end result is a truly vicious snowballing cycle of pain, with the muscle shortening further increasing pressure on the nerves.

www.northwestims.com/faq-4.html

Cannon's law of denervation tells us that if a post-ganglionic neurone has it's pre-ganglionic input removed, then it will become super-sensitive to the normal neurotransmitters that mediate that pre-ganglionic input. There is a variety of reasons for this, including up-regulation of receptors for the neurotransmitter(s), post-receptor effects, and impaired removal of neurotransmitters from the synapse

www.anaesthetist.com/anaes/patient/ans/

Most authors do not describe clinically significant capsular adhesions as a predominant finding in the chronic phase of this condition. Instead, pathologic data confirm an active process of hyperplastic fibroplasia and excessive type III collagen secretion that lead to soft-tissue contractures of the aforementioned structures (ie, the coracohumeral ligament, soft tissues of rotator interval, the subscapularis muscle, the subacromial bursae). However, these findings were observed in surgical patients who had severe and late-phase disease and cannot be applied to early phases of the disease.

From the chromosomal, cytochemical, and histologic points of view, the soft-tissue contractures are identical to those seen in a Dupuytren contracture of the hand. These contractures result in the classic progressive loss of ROM of the glenohumeral joint, which affects external rotation and abduction, then flexion, adduction, and extension (in descending order of severity). Despite these histopathologic similarities, the favorable and regressive outcome of adhesive capsulitis differs from the unfavorable and progressive outcome of Dupuytren disease.

http://emedicine.medscape.com/article/326828-overview#a0104

The courts have become the sole policing body for the medical profession

Major lawsuits, with the major judgments that go with them, may not completely keep negligent physicians from practicing, but they are the one way that currently exists to deter these individuals from practicing their inept brand of medicine. "

Over the years, we have given a lot of thought to why the medical profession adheres to this code of silence. What is it about this profession that causes it to protect its own at the expense of the public?"

Harvey F. Wachsman: Lethal Medicine

Publisher: Henry Holt & Co