THE PLACE OF UPPER DORSAL SYMPATHECTOMY IN THE TREATMENT OF PRIMARY RAYNAUD'S DISEASE

Extended Periarterial Sympathectomy: Evaluation of Long-term Outcomes

BACKGROUND

Periarterial sympathectomy is a proposed surgical treatment for patients with refractory Raynaud syndrome; however, there is debate regarding the indications and extent of dissection. Due to the segmental arterial sympathetic innervation, we favor an extended sympathectomy in concert with vein graft reconstruction of occluded vessels when necessary. The purpose of this study is to examine outcomes of extended periarterial sympathectomy in our patients.

METHODS

A retrospective chart review was performed on 46 patients who underwent 58 periarterial sympathectomies (12 bilateral) since 1981. The data collected include demographics, comorbidities, previous therapy, operative details, and surgical outcomes. In addition, we contacted available patients for a phone survey.

RESULTS

Of 58 cases, 68.9% were female, 29.3% were current smokers, and 58.6% had known connective tissue disease. Thirty-three vein graft reconstructions were performed with a long-term patency of 77.4%. Sustained improvement of ischemic pain was reported in 94.8% of cases, and 78% of patients with ulcers completely healed. For the most symptomatic fingertip, mean Semmes-Weinstein monofilament measurements improved from 4.15 preoperatively to 3.29 postoperatively ( P ≤ .05). Mean follow-up was 3.97 years. Of 10 patients contacted by telephone, all reported a decrease in frequency and severity of Raynaud attacks, while 9 reported a long-term decrease in pain an average of 11.6 years after surgery.

CONCLUSIONS

Extended periarterial sympathectomy is an effective and safe procedure for patients with refractory Raynaud syndrome. Our data demonstrate long-term improvement in ischemic pain and sensibility, along with a high rate of ulcer healing and patient satisfaction.

Percutaneous Phenol Block of the Upper Thoracic Sympathetic Chain with Computed Tomography Guidance

Twenty-one percutaneous neurolyses of the upper thoracic sympathetic chain were performed in 12 patients with CT guidance by a single injection of 1 to 3 ml of phenol at the level of Th3. Results were assessed after a follow-up period varying from 4 to 33 months. Three patients with hyperhidrosis had immediate and complete disappearance of symptoms, but only one patient remained dry. In 7/14 procedures done for Raynaud's disease symptoms disappeared or diminished. These long term results are competitive with surgery. Three transitory Horner syndromes and one pneumothorax occurred.

Thoracic origin of a sympathetic supply to the upper limb: the 'nerve of Kuntz' revisited

An understanding of the origin of the sympathetic innervation of the upper limb is important in surgical sympathectomy procedures. An inconstant intrathoracic ramus which joined the 2nd intercostal nerve to the ventral ramus of the 1st thoracic nerve, proximal to the point where the latter gave a large branch to the brachial plexus, has become known as the 'nerve of Kuntz' (Kuntz, 1927). Subsequently a variety of sympathetic interneuronal connections down to the 5th intercostal space were reported and also described as the nerve of Kuntz. The aim of this study was to determine: (1) the incidence, location and course of the nerve of Kuntz; (2) the relationship of the nerve of Kuntz to the 2nd thoracic ganglion; (3) the variations of the nerve of Kuntz in the absence of a stellate ganglion; (4) to compare the original intrathoracic ramus with sympathetic variations at other intercostal levels; and (5) to devise an appropriate anatomical classification of the nerves of Kuntz. Bilateral microdissection of the sympathetic chain and somatic nerves of the upper 5 intercostal spaces was undertaken in 32 fetuses (gestational age, 18 wk to full term) and 18 adult cadavers. The total sample size comprised 99 sides. Sympathetic contributions to the first thoracic nerve were found in 60 of 99 sides (left 32, right 28). Of these, 46 were confined to the 1st intercostal space only. The nerve of Kuntz (the original intrathoracic ramus) of the 1st intercostal space had a demonstrable sympathetic connection in 34 cases, and an absence of macroscopic sympathetic connections in 12. In the remaining intercostal spaces, intrathoracic rami uniting intercostal nerves were not observed. Additional sympathetic contributions (exclusive of rami communicantes) were noted between ganglia, interganglionic segments and intercostal nerves as additional rami communicantes. The eponym nerve of Kuntz should be restricted to descriptions of the intrathoracic ramus of the 1st intercostal space. Any of these variant sympathetic pathways may be responsible for the recurrence of symptoms after sympathectomy surgery.

Limited microsurgical arteriolysis for complications of digital vasospasm

Twenty-two digits in seven patients with chronic digital vasospasm were surgically treated after failed medical management. All patients complained of severe ischaemic pain. Chronic digital tip ulceration was present in seven digits and dry gangrene in one. Following surgical microarteriolysis all digital ulcers healed completely. Severe digital ischaemic pain was significantly improved in all digits and completely resolved in 19 of 22 digits.

The role of sympathectomy in current surgical practice

Historically sympathectomy has been employed in the treatment of a variety of disparate disorders but in most there is little if any objective clinical evidence of its efficacy. Review of the literature confirms that sympathectomy provides an effective and permanent cure for hyperhidrosis of the hands and feet, and at present palmar hyperhidrosis is the major indication for its regular use. Sympathetic denervation of the hands is currently most easily achieved with minimal morbidity by thoracoscopic ablation of the second thoracic ganglion. Some evidence testifies to the efficacy of sympathectomy in the rare patients with true major causalgia. Clinical experience suggests that Raynaud's phenomenon in the feet can be usefully ameliorated by sympathectomy but in the hands any benefit is short lived and there is no effect on the prognosis of the disease. A weak case can be made for sympathectomy for ischaemic rest pain when arterial surgery is impractical but there is no reliable evidence to support its use in Buerger's disease, intermittent claudication, diabetic vascular disease or ischaemic ulceration or gangrene.

Radical microarteriolysis in the treatment of vasospastic disorders of the hand, especially scleroderma

Arterial spasm due to exaggerated sympathetic response is an important mechanism for Raynaud's phenomenon in scleroderma associated often with periadventitial scarring. The results of cervical sympathectomy have been unsatisfactory in the upper limb because of additional sympathetic pathways. Flatt therefore devised a distal sympathectomy by stripping the vessels of their adventitia over a short length of artery. The results of this operation were found by Wilgis in a large series to be poor in patients with scleroderma. A radical distal microarteriolysis including adventitia and surrounding scar is described and the results in 13 patients, 11 with scleroderma, are reported. Minimum follow-up is one year. All patients had relief from pain at rest and healing of painful ulceration. Mild recurrence of small ulcers was seen in only four patients.

Resympathectomy of the upper extremity

Resympathectomy was performed in 27 patients (eight bilaterally) with ischaemic hand phenomena. An extended operative technique, resecting parts of the second and third intercostal nerves and their surrounding tissue, was used. In all 35 procedures the posterior extrapleural approach was used. Follow-up was from 3 to 12 years. Only the sympathetic ganglia had been removed during the previous surgery by the axillary approach (67 per cent of these patients had had a transient response for between 6 months and 2 years; 33 per cent had had no response at all). A direct subjective improvement was seen after 27 of the 35 reoperations (77 per cent). In 14 patients continuous wave Doppler ultrasound studies were available and showed a significant increase in peak forward frequency after operation (P less than 0.001). From these data it may be concluded that it is possible to obtain a resympathectomy effect, but reoperation should be reserved for special cases for whom survival of digits is essential.

Surgery for scleroderma of the hand

The role of hand surgery in systemic sclerosis (scleroderma) has been documented infrequently. Out of a series of 813 consecutive patients with scleroderma, 31 have had one or more surgical procedures on their involved hands--a total of 52 operations. Raynaud's phenomenon and digital tip ulcerations have been controlled medically by vasodilators and meticulous local wound care. Most digital ulcerations progressing to frank gangrene have been allowed to autoamputate to maximize the length of the salvaged finger, but 23 digital amputations have been performed when conservative measures failed. Digital sympathectomy and microsurgical revascularization have produced relief of symptoms in several patients. Severe flexion contractures of the proximal interphalangeal (PIP) joints, with secondary hyperextension of the metacarpophalangeal (MP) joints, have been effectively treated by arthrodesis of the PIP joints in 44 to 55 degrees of flexion. This has allowed both improved hand function and primary healing of dorsal ulcers in 53 PIP joints in 12 patients.

Microsurgical revascularisation of the hand in scleroderma

Raynaud's phenomenon is a prominent manifestation of systemic sclerosis (scleroderma) affecting the hand. The resulting digital ischaemia may progress to digital tip ulceration or gangrene. Four patients with scleroderma, presenting with severe unremitting unilateral pain in the hand, were evaluated by arteriography and plethysmography. In addition to the usual changes of narrowing and occlusion of the digital arteries themselves, arteriography revealed more proximal occlusion of the radial and ulnar arteries at the wrist and the superficial palmar arch. Plethysmography confirmed virtual absence of pulsatile digital blood flow. Two patients underwent microsurgical reconstruction of the radial and ulnar arterial inflow into the hand and the superficial palmar arch using reversed interposition vein grafts, with immediate subjective resolution of their severe pain and rapid healing of the digital ulcers. Both remain pain free 1 year post-operatively, and pulse-volume recordings have confirmed objectively the restoration of pulsatile blood flow to the fingers.

Management of sclerodermal finger ulcers

Ninety-three percent of 59 patients with scleroderma reviewed in this study presented with Raynaud's phenomenon at a mean age of 43 years; 65% of these developed fingertip ulcers within 4 years. Other common findings were sclerodactyly, distal phalangeal resorption, calcinosis cutis, and digital contractures. Medical management of the digital ulcers with systemic and regional vasodilating drugs was unsatisfactory. Sympathectomy, when performed early, temporarily relieved vasospastic pain but did not affect the course of the ulcers. Severe digital pain was the most incapacitating symptom resulting from vasospasm early in the course of the disease and irreversible arterial luminal narrowing later in the course. Conservative fingertip amputations for nonhealing ulcers constituted the management of choice to eradicate the ulcer, to reduce or eliminate the pain, and to return the hand to early useful function. A decision tree for the management of these ulcers is proposed.

Transaxillary sympathectomy--is a one-stage bilateral procedure safe?

During an 11-year period, 80 transaxillary sympathectomies were performed on 51 patients (hyperhidrosis 24, Raynaud's syndrome 18, Buerger's disease 4, others 5).

Bilateral procedures under one anaesthetic were performed in contrast with previous reports which advocated unilateral operations only. The advantages of the transaxillary route over other operative approaches are discussed.

Cutaneous microcirculation in systemic sclerosis and response to intra-arterial reserpine

The cutaneous microcirculation in the hand was measured in 23 patients with systemic sclerosis, 19 with Raynaud's phenomenon and four without Raynaud's phenomenon, and 20 controls. The patients with Raynaud's phenomenon had a reduced basal blood flow and an exaggerated further reduction on local cold stimulation, though both were normal in patients without Raynaud's phenomenon. Reflex-induced vascular changes by cold stimulation of the contralateral hand showed no differences between the three groups. The blood flows were similar in the affected skin of the anterior chest wall in four patients with systemic sclerosis and peripheral Raynaud's phenomenon and matched controls. In the seven most severely affected patients 1 mg of intra-arterial reserpine produced a prompt improvement in the cutaneous microcirculation which usually lasted one to three weeks but occasionally much longer. By judicious use of repeated injection guided by measurements of the microcirculation it was possible to heal indolent ulcers of the fingers. The results indicate that vascular changes are common in systemic sclerosis but are not fundamental in the pathogenesis of the disease. More probably there is a general soft tissue abnormality that usually but not necessarily affects the vessels.

Palmar hyperhidrosis and its surgical treatment: a report of 100 cases

One hundred patients with primary palmar hyperhidrosis (HH) underwent bilateral upper dorsal sympathectomy (UDS) by the supraclavicular approach. Pre-operative epidemiological and clinical data are described. The immediate and late results, as well as the complications and side-effects are detailed. Follow-up was completed on 93 patients between four and 50 months after the operation (average 18 months). Of 93 patients, 91 had drying of the hands. In 58% some moisture returned to the hands but in no case did the hyperhidrotic state recur. Subjective patient evaluation was excellent or good in 83 patients (89%) and only one patient (a technical failure) was completely dissatisfied. Reasons for some degree of dissatisfaction with operation were mainly compensatory HH in non denervated areas, and Horner's syndrome. Compensatory HH usually decreased with passage of time and, permanent Horner's syndrome occurred in 8% of patients (4% of procedures). Technical failure can be avoided by use of frozen section examination intraoperatively. For severe cases of palmar HH that cause social, professional and emotional embarassment, bilateral simultaneous UDS by the supraclavicular approach is the procedure of choice: Morbidity is small, and almost all patients enjoy improved quality of life after the operation.

The Raynaud syndrome

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Evaluation of a new alpha-blocking vasodilator agent (thymoxamine) in peripheral vascular disease

The effects on peripheral cutaneous blood-flow of the alpha-receptor blocking drug thymoxamine were measured by strain-gauge plethysmography in 58 subjects. The intravenous drug produced a substantial, though often transient, vasodilatation in the feet of normal subjects, and in most instances increased pedal blood-flow in non-sympathectomized patients with lower-limb arterial occlusions and healthy feet. In patients previously sympathectomized for either non-occlusive or occlusive disease of the lower limbs the effect of the drug was variable, even bringing about a reduction in pedal blood-flow in a number of cases. Intravenous thymoxamine regularly though briefly produced vasodilatation in the hands of patients sympathectomized for primary Raynaud'S disease, but the oral drug had no such action in most instances. It is concluded that systemic thymoxamine is unlikely to be of therapeutic benefit to the sympathecromized patient.

Upper-limb resympathectomy

Details are given of a case in which reoperation for upper-limb sympathectomy was carried out 7 years after the first operation. On each side the returned sympathetic activity was abolished by a removal of tissue from the area of the previous operation and without the production of Horner's syndrome. Gustatory sweating, which had developed after the first operation, was abolished by the second. These observations are discussed, particularly in relation to the writer's earlier tests with paravertebral blocks. It is concluded that the fibres responsible for sympathetic activity returning to the hand after sympathectomy arise from a regrowth of fibres sectioned at the operation. The writer's operation, designed to make functioning reconnexion more difficult, is more effective than the usual procedures.

Effect of sympathectomy on development of chronic osteoarthritis: case report

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