C H A P T E R195 Sympathectomy for Pain ANTONIO A. F. DE SALLES ■ JOHN PATRICK JOHNSON The popularity of surgical sympathectomy for the treatment of pain has decreased over the years. This reduction reflects the improvement of medical management and the development of less invasive and nondestructive surgical techniques: radiofrequency percutaneous sympathectomy and dorsal column stimulation.1–3 The invasive nature of thoracic or lumbar sympathectomy, requiring thoracotomy, posterior costotransversectomy, large retroperitoneal dissection, or laparotomy, has made this approach less desirable for treating mild cases of sympathetic-mediated pain (SMP). Severe cases of causalgia that failed to respond to all less invasive treatments are the ones that still undergo the large, invasive approaches to the sympathetic chain. There is great interest in the endoscopic approach to the sympathetic nervous system.4–6 In 1994, a symposium dedicated to thoracic endoscopic sympathectomy summarized the main clinical issues and technical advances of this technique.7 The thoracic and lumbar sympathetic ganglia can be readily visualized and severed or electrocoagulated through minimal incisions with the use of several endoscopic ports. This chapter discusses the historical landmarks, rationale, results, and latest techniques for surgery of the sympathetic system to curtail SMP. HISTORY Claude Bernard and Brown Sequard described the physiology of the sympathetic nervous system in 1852. Bernard showed that the removal of the stellate ganglia in rabbits led to an increased temperature in that side of the animal’s face, contrary to his own theory that the temperature should decrease. Gaskell and Langley mapped the sympathetic ganglia distribution, although in a rudimentary fashion, in 1859. The true segmental distribution of the sympathetic nervous system became available only much later. 4 When surgeons became aware of the anatomic distribution and physiologic consequences of this curious system, their creative minds found numerous reasons to surgically intervene in the sympathetic nervous system.8 In 1889, Alexander performed the first cervical sympathectomy for the treatment of epilepsy.9 The result was marginal, as were the results of several other surgical interventions in the sympathetic system. Jaboulay and Jonnesco tried stellectomy for treatment of exophthalmic goiter in 1896.10 Other applications with marginal results were described in the late 1800s and early 1900s, including glaucoma in 1889, trigeminal neuralgia in 1902, optical nerve atrophy in 1905, and angioma of the external carotid artery in 1917.9 Leriche, the famous French vascular surgeon, dedicated his research to the enervation of large arteries such as the femoral and axillary arteries. He was interested in surgical procedures to improve peripheral vascular insufficiency. He was a student of Jaboulay, who in the late 1800s described the stripping of large arteries from their nerve supply to improve distal circulation. Leriche found that sympathectomy was a more effective procedure than artery denervation.11 Vascular surgeons treating peripheral vascular insufficiency largely used this procedure. Two Australian scientists, Royle and Hunter, believed that sympathectomy improved spasticity. They thought that sympathetic fibers maintained skeletal muscle tonus.8 Their work became widely know, but their results could not be reproduced.12 The interest on the physiology of the sympathetic nervous system was greatly enhanced by the theory of Royle and Hunter. The clinical observations of Royle and Hunter were important to support the vascular effects of sympathectomy. Similar to the operation of Royle and Hunter, another application of sympathectomy that fell into disuse was for the treatment of arterial hypertension by resection of the splanchnic plexus.13, 14 Sympathectomy was settled as a treatment of peripheral vascular disease. In 1925, Adson and Brown described the posterior approach for removal of the second thoracic sympathetic ganglion. Davis and Kanavel reported the anterior approach to the upper thoracic sympathetic chain in the same year.8 Atkins developed the transaxillary approach in 1954.15 After 1920, sympathectomy also gained acceptance for treatment of hyperhidrosis through the work of Kotzareff.9 Cloward16 described the dorsal midline approach to both sides of the sympathetic chain in 1969, and the approach gained popularity among neurosurgeons. After Wilkinson 17 described the fluoroscopic approach to the thoracic 3093 describing a chronic pain syndrome of a limb out of proportion in severity to the original injury and implying sympathetic hyperactivity. and show variable progression over time. Sympathectomy can help only patients with SMP and is contraindicated for patients with sympathetic-independent pain.26 It describes a variety of painful situations that follow injury. previously known as causalgia. such as substance P. Bonica37 gave further support to this approach with his detailed accounts of the syndrome variables and with special emphasis on objective assessment of the efficacy of block techniques. In 1928. Rates of 59% to 74% for excellent results and of 9% to 17% for fair control of pain have appeared in the literature. appear regionally. an experiment of electrical stimulation of distal sympathetic stumps after sympathectomy for SMP reproduced presympathectomy pain.19 Since then. and pricking sensations in the fingers. have a distal predominance of abnormal findings. The term sympathetic-mediated pain. A consensus workshop in 1993 suggested the term complex regional pain syndrome (CRPS).25 The term reflex sympathetic dystrophy. meaning heat. Others also embraced this theory. SMP is widely used. the studies of dorsal column stimulation and stimulation of stumps of sympathectomized patients. The only difference between them is that type II has a known nerve injury. meaning pain. abnormal firing of loops in the dorsal horn provoked by an irritative focus in small nerve endings or major nerve trunks activates central projection fibers. subjects could observe a pilomotor response over the entire arm and shoulder. tingling. cluster headaches. if so. An organized nomenclature for the pain phenomenon is necessary to allow comparison of treatment results and to define appropriate treatment for the various forms of pain related to the sympathetic nervous system. properly select patients for clinical or surgical treatment. often result in significant impairment of motor function. exceed in magnitude and duration the expected clinical course of the inciting event. . and bradykinin.26 The same fate has ensued for facial pain syndromes that are difficult to treat and that do not fall in the recognized diagnoses of facial pain such as trigeminal neuralgia. such as reflex sympathetic dystrophy. Before the sensation of discomfort. well-controlled experiment in humans with stimulation of the sympathetic chain between the second and third thoracic sympathetic ganglia reproduced symptoms of SMP such as burning. Resolution of pain with sympathetic blocks gives support to this theory. Patients undergoing sympathectomy for causalgia appear to have more of a painful response to stimulation than patients undergoing sympathectomy for other causes. leading to the release of chemical mediators known to cause pain in inflammatory reactions. leading to pain. and SMP. Taken together.20–22 The term causalgia was derived from two Greek words. support the hypothesis of ephaptic hyperactivity at the level of dorsal NOMENCLATURE Several terms have been used to describe pain related to the sympathetic nervous system. and algos. CRPS is further divided into CRPS type I. He hypothesized that vascular insufficiency of the arm led to the pain and that posterior sympathectomy as described by Adson and Brown improved the circulation and pain. kausos. Certain types of facial pain also may be included in the category of reflex sympathetic dystrophy. and CRPS type II. leaving the terminology of CRPS for situations in which it becomes necessary. became widely popular and often has been used in an inconsistent and misleading fashion.34 Leriche35 developed the vicious cycle hypothesis to explain causalgic pain. or arm. For the purpose of this chapter oriented to the surgical approach. Chuang and colleagues18 described a stereotactic approach to the upper thoracic ganglia for treating hyperhidrosis. The challenge for the clinician is to determine whether a particular patient with CRPS has SMP and. 32. and Livingstone expanded it. the treatment of causalgia and sympathetic dystrophy with sympathectomy has been encouraging. a chronic aching sensation lasted for 24 hours.34 This classic.28–31 Supporting this theory. 27 but facial pain syndromes are not included in the classification of complex regional pain syndrome. although Pare probably described the first case of causalgia in the 16th century. which traditionally was referred to as reflex sympathetic dystrophy.36 Self-sustained. Some theories suggest ephaptic transmission between somatic afferents and sympathetic efferents at the level of the spinal cord. PATHOPHYSIOLOGY OF SYMPATHETIC-MEDIATED PAIN The pathophysiology of SMP is poorly understood. Adler and coworkers18 described the computed tomography (CT)–guided approach. and the popular reflex sympathetic dystrophy denomination came to be. After stimulation. 33 Conversely. The terms SMP and sympathetic-independent pain (SIP) complement the term CRPS. as well as the results of sympathectomy and sympathetic blocks. is a general term indicating that surgery on the sympathetic nervous system may lead to important control of the patient’s chronic pain. it is useful to define whether the CRPS is dependent or independent of the sympathetic activity. Clinically. Spurling19 resected the stellate and first thoracic ganglion for the treatment of causalgia of the upper extremity resulting from a partial lesion of the axillary artery by a gunshot wound. causalgia.2. the results of dorsal column stimulation in suppressing SMP appear to occur because of stimulation-induced suppression of efferent sympathetic hyperactivity. prostaglandin.3094 Section VI ■ Pain sympathetic chain. These substances produce the classic symptoms of vascular instability and temperature changes. hand. introduced by Roberts in 1986. and anesthesia dolorosa.23 The term describing burning pain was coined from the work of Weir Mitchell24 because of his detailed description of the syndrome after major nerve injuries identified during the United States Civil War. shoulder-hand syndrome. In advanced phases of the disease. 44 The clinical diagnosis of SMP must be always confirmed by an objective test. and burning pain that is disproportionate to the injury and that is accompanied by vasomotor instability. Stage II (i.55 Doppler flow studies and plethysmography may also be used as adjunctive studies. including minor causalgia. Regular radiographs of the extremity in question may show patchy demineralization of epiphyses and the short bones of the hands and feet.20 Sudeck’s atrophy and Sudeck’s syndrome focus on the associated osteoporosis observed in late cases. and Prinzmetal’s angina. including major causalgia. but they are not always reliable. the temperature of the affected extremity tends to approach that of the normal extremity. True SMP implies that. neuropathic processes.38 This pattern has also been largely identified in smaller series. fine-detail x-ray films show subperiosteal bone resorption.3. and Sudeck’s atrophy. Classically.17. DIAGNOSTIC ASSESSMENTS AND PATIENT EVALUATION Clinical Diagnosis SMP must be differentiated from chronic pain syndromes with similar features but different maintaining factors. thyrotoxicosis. syndromes with significant dystrophy and variable SMP. despite multiple triggering events in the pain syndrome. psychological problems. 43 Wilkinson 44 mentioned several sympathetic pain syndromes. and osteoporosis. atrophy of skin and subcutaneous tissues.56 Jeng and associates57 observed an increase in cerebral blood flow after T2 sympathectomy. and syndromes with significant vasculopathy and variable SMP. The sensitivity of radiographs was 69% and that of scintilography was 60%. signs of autonomic imbalance. and other conditions associated with rapid bone turnover. in a warm and resting environment. MRI allows a differential diagnosis between SMP and other bone lesions. Numerous manifestations of the disorder by different causes and in different regions of the body have been reported.Chapter 195 ■ Sympathectomy for Pain 3095 horn between sensory afferent and sympathetic efferent elements. OF PATIENTS 20 11 34 NO. Thermography may reveal a temperature difference between extremities or regions in the same extremity. vasospastic vasculopathy such as Raynaud’s syndrome. The specificity of radiographs was 71% and that of scintilography was 86%.45. and tunneling in the cortices. The onset and progression of the SMP syndromes have been divided in three stages.56 Although the blood flow through the affected extremity tends to be lower than the normal extremity in stress conditions.51–53 Kozin and collegues54 compared the sensitivity and specificity of radiographs and scintilography in cases of reflex sympathetic dystrophy. Laboratory Tests Although SMP is a clinical diagnosis confirmed with nerve block. certain laboratory studies may be confirmatory. striation. Although the clinical features of advanced cases of causalgia are easily identifiable. and swelling. 10% of the patients were diagnosed as having sympathetic dystrophy without a previous history of trauma. and TABLE 195–1 ■ Summary of 112 Sympathectomy Procedures in Which Unilateral and Bilateral Approaches Were Used in 65 Patients NO. In a large series. an abnormal response of the sympathetic system mediating the pain can be documented. OF PROCEDURES 22 22 68 APPROACH Unilateral Bilateral (staged) Bilateral (same day) Patient Selection Not all patients with SMP require sympathectomy. Early and frequent use of sympathetic blockade may . 27. peripheral occlusive vasculopathy. Many patients do not have an identifiable trauma triggering sympathetic dystrophy. SMP is associated with burning pain hypersensitivity in the distribution of the injured somatic nerve. intermediate or dystrophy) is characterized by severe pain with skin sensitivity.47. and dystrophic nails.. late or atrophic) shows signs of wasting.e. they may occur in hyperparathyroidism. 46 Soft tissue swelling may be detected.e. edema. and they suggested the possibility of using such a surgical approach to improve cerebral blood flow in patients with cerebral vascular insufficiency. as well as large excavations and tunneling of the endosteal surface. reflex sympathetic dystrophy. including vasospasm of postacute vascular occlusion. an inconsistent finding that may result from a neurovascular reflex or disuse. early or acute) is characterized by constant. and ultimately secondary trophic changes.54 Magnetic resonance imaging (MRI) has been described as a more sensitive study than radiographic examination and radionuclide assessment for detection of changes in the bones of patients with SMP.e. 50 A bone scintilogram usually reveals increased periarticular uptake in the involved limb. It also has the advantage of detecting soft tissue changes such as edema and muscle atrophy. Stage I (i.38. 39–42 diabetic burning foot syndrome. Stage III (i. 48 These changes are not specific for SMP. and peripheral nerve injury. usually relief of pain with sympathetic blockade.. and higher sensitivity may be achieved with triple-phase bone scan. mild cases are difficult to diagnose. stiffness of joints. viral infections. shiny and discolored skin.49. He grouped them as syndromes with principally SMP but little dystrophy or vasculopathy. intense.. such as secondary gain. 50 Paravertebral sympathetic block is the most widely used diagnostic and therapeutic modality for SMP. 78 Subsequently. Reserpine also depletes norepinephrine stores by interfering with its storage. phantom pain).56 Patients must remain naive of the result expected.17. and lumbar sympathetic ganglia. is reached by means of a lower thoracic paramedian incision.65 Cloward66 described a similar approach in 1957. SMP syndromes. Blockade of 1-adrenergic receptors by intravenously administered phentolamine correlates with subjective pain relief. 28. 71–73.59 Use of saline as a placebo control minimizes the chance of a false response. Good pain relief with sympathetic nerve block confirms that the complex regional pain is mediated by the sympathetic nervous system.64 The lower extremity sympathetic outflow can be blocked at L2 and L3 levels. Objective changes in temperature and blood flow to the skin can be detected by careful measurements. or anticonvulsants usually has only limited use and temporary benefit.49. and the splanchnic chain The thoracoscopic paraspinal approach is useful for sympathectomy and for biopsies and thoracic spinal work. The splanchnic procedure is usually indicated for very debilitated patients with cancer pain who are being treated mostly medically or with phenol injection of the splanchnic chain.e. 68 Thoracoscopic resection of the sympathetic ganglia appears to have a lower incidence of morbidity than open thoracotomy or a posterior paraspinal approach.61 Guanethidine displaces norepinephrine in presynaptic vesicles and prevents its reuptake. 75–77 The most common indications for thoracic sympathectomy include hyperhidrosis. Similarly. 74. Results of the blockade must be carefully evaluated clinically by observing for Horner’s syndrome when the upper extremity is blocked and for changes in skin temperature and color when the upper or lower extremity is blocked.16 The retroperitoneal flank approach is predominantly used for the lumbar chain.12 Thoracoscopic Sympathectomy Jacobaeus67 first performed thoracic endoscopic procedures in 1910 for the diagnosis of pulmonary tuberculosis and neoplastic diseases. Withholding surgery too long. and objective findings such as temperature change should be documented.69. and placebo must be used when there is suspicion of secondary gain. which is readily accessible percutaneously. Jacobaeus67 reported a series of more than 1400 endoscopic procedures. the target is the stellate ganglion. This approach has the advantage of bilateral exposure through a single incision. stellate blocks provide temporary relief. Thoracoscopic sympathectomy procedures were originally described by Hughes11 in 1942 and Kux61 in 1951. This surgery involves rib removal and retraction of the pleura. This section discusses endoscopic approaches to the lower cervical. and refractory cardiac tachyarrhythmias.62. however. The visual digital scale must be used as a hard record of the effects of the sympathetic blockade.60 Bier block with guanethidine can be employed to provide regional sympathetic blockade. allowing the patient to pursue rehabilitation in an attempt to resolve the problem. Although the sympathetic innervation to the arm is mainly from T2.3096 Section VI ■ Pain carry the patient through a milder and self-limited episode of causalgic pain. It provides a more direct exposure of the sympathetic ganglia and their rami communicantes. anesthetic agents readily diffuse through paravertebral space to block the sympathetic outflow to the arm. postamputation syndrome (i. Medical therapy with narcotics.12 These procedures are frequently too invasive for the patient’s symptoms. and it can be administered intra-arterially to achieve regional block.6. the most common indications for sympathectomy using the endoscopic approach are discussed. which is why minimally invasive approaches to the sympathetic ganglia are becoming prevalent. There was little interest in this technique until recently. 68–74 Minimally invasive treatment of sympathetic-mediated syndromes affecting the extremities with endoscopic techniques has expanded because of the refinement of techniques and clarification of the indications and applications. The most acceptable open procedure is the modification of MacKay’s paravertebral approach described in 1955.58 Other clinical measures of controlling pain must be exhausted before considering sympathectomy. The transaxillary and posterior paravertebral approaches are advocated by a few authorities for exposure of the upper thoracic and lower cervical ganglia. Sympathetic–Mediated Pain Syndrome Constant burning pain and atrophic skin changes in the extremity are typical signs and symptoms of SMP syndromes. and the long-term successes are not optimal. neuroleptics. Percutaneous sympathectomy procedures have limited efficacy. This result may reflect the magnified endoscopic view of the sympathetic chain and adjacent anatomy. patient demand and improved satisfaction due to shortened hospital stay with reduced costs and morbidity made minimally invasive thoracoscopic sympathectomy an attractive choice for treatment of SMP syndromes of the upper extremities. using a ureteroscope for the treatment of hyperhidrosis. A . sources for most of the sympathetic innervation for the legs..6. Patients with unequivocal pain relief with sympathetic blockade are sympathectomy candidates. 63 For upper extremity pain. Besides the indications of sympathectomy for SMP. my decrease chances of complete pain relief afforded by a sympathectomy. leading to a more precise resection. The patients must have a reliable and objective response to regional sympathetic block encompassing the affected extremity. Raynaud’s syndrome. INDICATIONS SURGICAL TREATMENT There are several approaches for upper thoracic and lower cervical sympathectomy and fewer options for splanchnic and lumbar sympathectomy. upper thoracic. 78. that are exacerbated by cold temperatures or emotional response. but there is a variable rate of recurrence that is difficult to predict. 81 Palmar and axillary hyperhidrosis is the primary indication for thoracoscopic sympathectomy. a left stellate ganglion block with right stellate ganglion stimulation shortens the QT interval. 80. prolonged QT interval syndromes.16 Details of this syndrome and surgical approaches are discussed elsewhere in this volume. that is exacerbated by minor stresses such as handshaking. primarily in the hands. but the incidence may be higher in Asian populations. Despite this cardiac function. 79 Cardiac Arrhythmia Malignant tachyarrhythmias may result from stress and ‘‘sympathetic imbalance’’ due to disproportionate left-right sympathetic outflow. Extreme cases may cause ischemic and gangrenous ulceration of the digits. The initial treatment is avoidance of cold and use of -adrenergic medications that are effective for less severe cases. 49. painful skin blanching. Refractory cases may achieve good initial relief from sympathectomy.57. Hyperhidrosis has an incidence of approximately 1% in Western populations. Resection of the T2-3 sympathetic ganglia that provide sympathetic innervation to the upper extremity through the lower trunk of the brachial plexus provides lasting relief from hyperhidrosis. The cause is unknown. primarily in the hands and fingertips. a left T1-4 sympathectomy produces a ‘‘ -adrenergic effect’’ that shortens the QT interval and may reduce the incidence of medically refractory tachyarrhythmias associated with dangerous. The patient FIGURE 195–1. 80 A right stellate ganglion block coupled with left stellate ganglion stimulation lengthens the QT interval on the electrocardiogram. . Supine positioning of the patient undergoing sequential bilateral thoracoscopic sympathectomies. 80 Stellate ganglion blocks result in temporary drying and decreased sweating in the ipsilateral hand and armpit.68 The sympathetic nervous system innervates eccrine sweat glands through cholinergic nerve fibers arising from the intermediolateral column of the thoracic and upper lumbar spinal cord.Chapter 195 ■ Sympathectomy for Pain 3097 T1-4 sympathectomy provides good initial relief. Hyperhidrosis is characterized by excessive sweating.20. Double-lumen endotracheal tube placement for contralateral lung ventilation and ipsilateral lung deflation is essential. and conversely. the hemodynamics and catecholamine concentrations may not be altered significantly after sympathectomy. 78. but the long-term results may be somewhat less optimal. 62 Vasculitis and Raynaud’s Syndrome Hyperhidrosis Ischemic vascular disorders have episodes of severe. Right and left selective bronchi intubation is performed during the operation on each side.6. Increased sympathetic tone results in vasoconstriction.72. and skin cooling exacerbates the excessive sweating.16. The warming effect is caused by increased blood flow through cutaneous arteriovenous fistulas and cholinergic blockage. Accordingly. SURGICAL AND ANESTHETIC CONSIDERATIONS Endoscopic thoracic sympathectomy procedures require an anesthesiologist and operating room staff familiar with thoracic endoscopy. landmarks for determination of the stellate ganglion. 195–1). including the upper intercostal spaces. is positioned supine for bilateral thoracoscopic procedures (Fig. which are important for the endoscope and instrumentation portals. . Notice the subclavian artery and the first rib. Notice the exposure of the axillary region. 195–2) can be used for unilateral procedures. Lateral positioning of the patient undergoing right thoracoscopic sympathectomy is the same as for a thoracotomy. and the lateral decubitus position (Fig. A standard endoscopic video-monitoring system with a 5. The operating table positioning is important to allow the lung to fall away from the upper thorax and open the intercostal spaces for access into the thorax.to 10-mm- FIGURE 195–3.3098 Section VI ■ Pain FIGURE 195–2. Instruments Thoracoscopic sympathectomy equipment and instruments are similar to those used in general and obstetric-gynecologic procedures. View of the intrathoracic anatomy of the right upper thorax shows the location of the sympathetic ganglia and chain. Ports and Port Placement Two or three ports are used to perform the sympathectomy procedure. with a 2cm skin incision and blunt dissection with a curved hemostat over the rib into the thorax. which should be avoided during this dissection. . The pleura overlying the sympathetic chain should not be pressed excessively with endoscopic instruments. Detailed dissection of the rami communicants for complete release of the sympathetic chain to be removed. The 15-mm-diameter ports (Ethicon Flexi-path. OH) are soft. Notice sectioning of the nerve of Kuntz. The cephalad aspect of the sympathetic chain and limit of the surgical resection is the stellate ganglion. flexible endoscopic cannulas inserted through the chest wall with an introducer. and the highest (supreme) intercostal artery and veins. The anesthesiologist deflates the lung. Endoscopic vascular clips and a retractable fan-type retractor should be available if needed. should be avoided during dissection of the sympathetic chain. If another working port is needed. The endoscope is placed through the port in the fifth intercostal space in the posterior axillary line. The sympathetic chain is a whitish. which is important to avoid Horner’s syndrome. The intercostal nerve must be preserved to avoid postoperative chest wall deafferentation pain. 195–3). and preservation of the upper part of the stellate ganglion. 195–5). a 10mm-diameter curved hemostat. it is placed in the fourth intercostal space in the anterior axillary line. Notice the proximity to the intercostal vessels. Cincinnati. Endoscopic exploration of the thoracic cavity is performed after the ports are placed. subclavian veins. FIGURE 195–5. allowing the lung to be retracted. 195– 4). One port is for the endoscope. longitudinal structure that courses over each rib head (see Fig. raised. It is important to maintain the FIGURE 195–4. Other major vascular structures. rigid laparoscope is needed. and the working ports can be rearranged according to the surgeon’s preference (Fig. which is important to achieve sympathetic denervation of the upper extremity.Chapter 195 ■ Sympathectomy for Pain 3099 diameter. and one or two ports are for the instruments. An instrument port is placed in the same fifth intercostal space. such as the azygous vein. Steps of the Procedure The endoscope provides a panoramic view of the upper thoracic cavity. Basic endoscopic surgical instruments include 5-mm-diameter mini-Metzenbaum scissors with monopolar electrocautery. 195–3). The sympathetic chain is mobilized from T3 with scissors by dividing the rami communicantes at the T23 levels (Fig. because repetitive touch leads to pleural hyperemia that obscures visualization of the chain. Additional lung retraction can be accomplished by rotating or elevating the operating table so that the lung falls away from the vertebral column. and the first port is placed. glistening. Important intrathoracic anatomic landmarks for a sympathectomy are the first and second ribs. Port insertion is similar to chest tube placement. and a 5-mm-diameter suction-irrigator. but the 30-degree endoscope lens occasionally is needed. A 0-degree endoscope usually provides good visualization for most sympathectomy procedures. The stellate ganglion is immediately below the subclavian artery. The sympathectomy begins with a pleural incision over the sympathetic chain at T3 using curved scissors and continuing cephalad above T2 but remaining short of the inferior aspect of the stellate ganglion (Fig. avoiding the intercostal neurovascular bundle. Division of the rami communicants at each level (left) and division of the sympathetic chain at the inferior aspect of the stellate ganglion and T4 (right). and any adhesions to the parietal pleura are coagulated and divided. It provides important sympathetic innervation to the lower trunk of the brachial plexus. which is managed on an outpatient basis. In recent years. TABLE 195–3 DISORDER Hyperhidrosis ■ The follow-up period was 6 months to 6 years. followed by a repeat chest radiograph. The procedures were performed for unilateral or bilateral symptoms. An independent observer collected clinical outcome questionnaires. 11 had mild compensatory sweating in the trunk. OF PATIENTS TABLE 195–4 ■ Patient Satisfaction and Willingness to Undergo a Repeat Procedure WILLINGNESS TO REPEAT (%) 98 65 DISORDER Hyperhidrosis RSD/CRPS Raynaud’s syndrome CRPS. and one chest tube is removed. The dissection bed is irrigated.3100 Section VI ■ Pain ■ TABLE 195–2 Diagnosis of Patients Undergoing Thoracoscopic Sympathectomy NO. and all patients were questioned about their ‘‘overall satisfaction’’ and ‘‘willingness to undergo a repeat procedure. The instrument ports are then removed. where the patient is placed on a water-seal drainage system with suction. OPERATIVE EXPERIENCE Patient Population The experience of the first 100 procedures performed at the University of California–Los Angeles (UCLA) is presented. The port incisions are closed in two layers using absorbable sutures and SteriStrips. and 2 patients suffered gustatory sweating. 34 patients with bilateral symptoms had staged procedures on the same day (see Table 195–1). reflex Hyperhidrosis RSD/vasculitis RSD. reflex sympathetic dystrophy. and the lung is re-inflated with positive pressure by the anesthesiologist.82 The nerve of Kuntz and the stellate ganglion are usually found beneath the fat pad that envelops the subclavian artery (see Fig. Patients with pain disorders were evaluated with the Oswestry Pain Scale to quantify the severity of their preoperative and postoperative symptoms. A large ramus arising laterally from the T2 ganglion is the nerve of Kuntz. Postoperative Care Patients with chronic pain syndromes may require a slow taper of preoperative medications. and 11 patients with bilateral symptoms underwent staged procedures several weeks apart in the early part (1993–1995) of this series. These data represent the use of modern technology and the learning curve resulting when using the thoracic endoscopic approach. Patients with hyperhidrosis were evaluated for the presence or absence of sweaty palms. 195–4). with assessment performed by a clinical examination or telephone interview. The stellate ganglion should remain undisturbed to avoid injury and possible Horner’s syndrome. RSD.’’ Outcomes for 48 Patients with Hyperhidrosis RELIEF OF SYMPTOM 47 PARTIAL RELIEF OF SYMPTOM 1 RECURRENT SYMPTOMS 0* LOST TO FOLLOW-UP 0 * Although no patients experienced recurrent palmar hyperhidrosis. The procedure is repeated for the second chest tube. The operative procedure requires approximately 1 hour. A 16-French (16F) chest tube is inserted and positioned endoscopically through one of the ports. Oral analgesics are adequate for pain control. which is slightly larger than other rami (see Fig. or both. If bleeding is encountered. 195–3). A chest radiograph is obtained to ensure proper lung expansion. Pneumothorax is uncommon and requires chest tube replacement until the leak resolves. pain DISORDER PATIENT SATISFACTION RATE (%) 96 66 48 12 5 syndrome. and hemostasis is ensured. Most intercostal vessels are small. dissection plane immediately beneath the sympathetic chain to avoid the underlying intercostal vessels. and the hospital stay is typically 1 or 2 days. clip ligation or cautery of the vessel achieves the necessary meticulous hemostasis. depending on the anatomic complexity of the individual patient and the experience of the surgeon. Twenty patients underwent unilateral procedures. and delayed-onset complications of compensatory hyperhidrosis or gustatory sweating. surgery-related complications. and a retrospective analysis was performed. they are enlarged or course over the sympathetic chain and require division. The incidence and severity of recurrent pain symptoms were evaluated. The dissected T2-3 sympathetic chain is then divided proximally and distally and sent for histologic evaluation. complex regional sympathetic dystrophy. . Outcome Analysis The chest tube is placed on 15 cm H2O of suction until the patient reaches the recovery room. Sixty-five patients underwent 112 thoracoscopic sympathectomy procedures at UCLA Medial Center for sympatheticmediated disorders between 1993 and 1999. but occasionally. The overall complication rates for thoracoscopic procedures were also comparable with those of previous treatment modalities (Table 195–8). as indicated by their willingness to repeat the procedure.Chapter 195 ■ Sympathectomy for Pain 3101 TABLE 195–5 ■ Outcomes for 17 Patients with Pain and Vasculitis Disorders NUMBER OF PATIENTS TABLE 195–7 ■ Length of Stay after Thoracoscopic Sympathectomy BILAT SYMPATHECTOMY (DAYS) 2 1. complex regional pain syndrome. CRPS. Complications from endoscopic sympathectomy procedures are usually minor and self-limited. most patients were sufficiently satisfied with the result. this re- Outcomes for Pain and Vasculitis Disorders as Measured by the Oswestry Pain Scale* PREOPERATIVE STATUS 42 51 1 MONTH POSTOPERATIVE STATUS (%) 92 96 6 MONTHS POSTOPERATIVE STATUS (%) 65 88 * Oswestry Pain Scale score is derived from a 10-item questionnaire administered to each patient preoperatively and 6 months postoperatively. The hospital length of stay for thoracoscopic sympathectomy patients was usually 1 or 2 days (Table 195–7). but they also had the highest complication rates. probably reflecting the learning curve for TABLE 195–6 DISORDER RSD/CRPS Raynaud’s syndrome/vasculitis ■ endoscopic surgical techniques. RSD. Hashmonai and colleagues76 cited the lower incidence of intercostal neuralgia as the major difference between open supraclavicular and endoscopic sympathectomy procedures. complex regional pain syndrome. † An elderly patient with intractable Raynaud’s died. No patients had worsened pain symptoms after sympathectomy. see also Table 195–4). This problem has been reduced with the use of soft.8 1–3 DISORDER RSD/CRPS Raynaud’s syndrome/ vasculitis (5 patients) Relief of Symptoms 7 4 Recurrence of Symptoms 4 1 Lost to Follow-up 1 0 DURATION Median Mean Range UNILAT SYMPATHECTOMY (DAYS) 1 1. Horner’s syndrome is usually transient and rarely permanent. Patients treated for pain syndromes or vascular disorders had a positive initial response to treatment (see Table 195–2). 83 Intercostal neuralgia can result from intercostal nerve injury during port placement or from pressure during the procedure. The overall satisfaction and willingness to repeat the operative treatment was similarly decreased (see Table 195– 4). however. reflex sympathetic dystrophy. Complications were usually related to compensatory hyperhidrosis manifested as sweating in the trunk or torso. reflex sympathetic dystrophy. with preservation of the rostrally ascending fibers that innervate the ocular and pupillary muscles. They had very high success rates (Tables 195–3 and 195–4). The patients considered historical cohorts at our institution who were treated with posterior paraspinal sympathectomies had a hospital length of stay that typically ranged from 3 to 6 days. flexible ports and a 5-mm endoscope. with a scale of 1 to 100.5 0–4 CRPS. OF PATIENTS 7 1 11 2 1 4 1 3 1 1 Results COMPLICATION Horner’s syndrome Transient Permanent Compensatory hyperhidrosis* Gustatory sweating Pneumothorax (requiring chest tube) Pleural effusion (not requiring thoracocentesis or chest tube) Wound infection Intercostal neuralgia Transient Permanent Death† Patients with hyperhidrosis were the largest group treated by thoracoscopic sympathectomy (Table 195–2). Horner’s syndrome from injury to the stellate ganglion in thoracoscopic procedures occurred more often early in the series. Patient data are presented as a percentage of the mean. . however. outcomes were diminished for some patients after more than 6 months by variable recurrence of symptoms (Tables 195–5 and 195–6. RSD. unilateral sympathectomy. Complications * Only patients with hyperhidrosis experienced compensatory sweating symptoms. The patient suffered a myocardial infarction 1 month after an uncomplicated.49. because only the rami caudal to the stellate that provide sympathetic innervation to the upper extremity are divided. TABLE 195–8 ■ Postoperative Complications after Sympathectomy NO. However. Endoscopic visualization should minimize the incidence of Horner’s syndrome. however. 77. The patient is in the prone position. with anterior dislocation of the kidney and lateral dislocation of the spleen. Peripheral vascular abnormalities should be evaluated with noninvasive methods or angiography to exclude treatable vascular lesions. followed by work with an experienced surgeon who performs these operations on a regular basis. .6. These endoscopic procedures have learning curves that necessitate precise knowledge of the anatomy and an understanding of endoscopic surgical techniques. and ports are placed in the midaxillary line at the level of the intended sympathectomy.1. minimally invasive endoscopic techniques can reduce the surgical morbidity. FIGURE 195–6. Notice the expansion of the retroperitoneal space. Small pleural effusions do not require drainage but should be followed with repeated chest radiographs. the associated morbidity is substantially reduced because of reduced tissue injury. We recommend that surgeons receive formal training for these procedures. but reduced morbidity and hospitalization are the major differences. and the patient was doing well after surgery. 83 Pneumothorax indicates a parenchymal or portsite leak. including didactic and laboratory training.84. agement before consideration of a lumbar sympathectomy procedure. Laparoscopic gas-tight ports are placed for the endoscope and working ports. Notice the direct reach of the sympathetic ganglia with this approach. Pelvic and visceral pain syndromes have also been treated with splanchnic sympathectomy. although less frequently.3102 Section VI ■ Pain port did not reflect the use of flexible ports and smaller instruments. Provocative testing with anesthetic lumbar sympathetic blocks can provide confirmation of diagnosis and useful predictive outcome assessment. 85 The most frequent indications for splanchnic sympathectomy procedures include lower extremity reflex sympathetic dystrophy (or CRPS) and Raynaud’s syndrome. Endoscopic Lumbar Sympathectomy Open lumbar sympathectomy procedures have been used effectively to treat lower extremity vasculitis and pain syndromes but are being supplanted by minimally invasive laparoscopic retroperitoneal techniques. Blunt digital dissection is applied into the retroperitoneum to create an endoscopic working space with a balloon tissue expander or direct carbon dioxide insufflation (Fig. The one death that occurred in the series was several weeks after surgery for severe Raynaud’s with significant preexisting cardiovascular risk factors.86–88 A limited number of published reports with small series suggest results similar to those for open procedures. Similar to thoracoscopic sympathectomy. Exposure and resection of the lumbar sympathetic chain proceed in a manner similar to that for open procedures (Fig. There is a direct approach to the anterolateral aspect of the vertebrae where the sympathetic chain is visualized. 195–7). SURGICAL TECHNIQUE Patients with autonomic lower extremity pain syndromes require similar medical evaluation and man- The patient is placed in the prone position under general anesthesia. 89–91 PATIENT SELECTION FIGURE 195–7. CONCLUSION Minimally invasive endoscopic sympathectomy techniques have surgical goals that are similar to those for open procedures with equivalent outcomes. Most cases can be observed. 195–6). and return to activity due to small surgical incisions and reduced tissue injury. Cross-sectional anatomy through the midlumbar level demonstrates where the retroperitoneal dissection occurs. although a large pneumothorax may require chest tube placement. Lumbar retroperitoneal endoscopic exposure of the lumbar sympathetic chain for a sympathectomy. hospital stay. For most patients with lower extremity pain syndromes. pelvic and lumbar imaging studies are necessary to exclude other treatable disorders. 42. 37. et al: The reflex sympathetic dystrophy syndrome. Arch Neurol Psychiatry 59:559–560. Sadler TR. 1986. Walker AE. p 412. pp 17–89. 1994. pp 85–100. Kozin F. Bay JW: Surgery of the sympathetic nervous system. Drott C: The history of cervicothoracic sympathectomy. Mackinnon SE. 1977. 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