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Hashmonai M, Cameron AEP, Licht PB, Hensman C, Schick CH. Thoracic sympathectomy: a review of current indications. Surg Endosc 2015; 30:1255-69. [PMID: 26123342 DOI: 10.1007/s00464-015-4353-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 06/16/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Thoracic sympathetic ablation was introduced over a century ago. While some of the early indications have become obsolete, new ones have emerged. Sympathetic ablation is being still performed for some odd indications thus prompting the present study, which reviews the evidence base for current practice. METHODS The literature was reviewed using the PubMed/Medline Database, and pertinent articles regarding the indications for thoracic sympathectomy were retrieved and evaluated. Old, historical articles were also reviewed as required. RESULTS AND CONCLUSIONS Currently, thoracic sympathetic ablation is indicated mainly for primary hyperhidrosis, especially affecting the palm, and to a lesser degree, axilla and face, and for facial blushing. Despite modern pharmaceutical, endovascular and surgical treatments, sympathetic ablation has still a place in the treatment of very selected cases of angina, arrhythmias and cardiomyopathy. Thoracic sympathetic ablation is indicated in several painful conditions: the early stages of complex regional pain syndrome, erythromelalgia, and some pancreatic and other painful abdominal pathologies. Although ischaemia was historically the major indication for sympathetic ablation, its use has declined to a few selected cases of thromboangiitis obliterans (Buerger's disease), microemboli, primary Raynaud's phenomenon and Raynaud's phenomenon secondary to collagen diseases, paraneoplastic syndrome, frostbite and vibration syndrome. Thoracic sympathetic ablation for hypertension is obsolete, and direct endovascular renal sympathectomy still requires adequate clinical trials. There are rare publications of sympathetic ablation for primary phobias, but there is no scientific basis to support sympathetic surgery for any psychiatric indication.
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Affiliation(s)
- Moshe Hashmonai
- Faculty of Medicine, Technion-Israel Institute of Technology, PO Box 359, 30952119, Zikhron Ya'akov, Haifa, Israel.
| | | | - Peter B Licht
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
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[From wheelchair dependency to the ability to walk: lumbar sympathectomy as a treatment for complex regional pain syndrome]. Schmerz 2009; 23:399-402. [PMID: 19399525 DOI: 10.1007/s00482-009-0794-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A 34-year-old woman developed walking disability with wheelchair dependency for more than 2 years due to chronic regional pain syndrome type II (CRPS II) in the feet. After excluding neurological and vascular disease, lumbar sympathectomy was performed on both sides. Surgical treatment was uneventful, and the patient's symptoms dramatically improved after 2 months. She is now able to walk some 500 m. This case illustrates the fact that surgical lumbar sympathectomy is an effective alternative or adjunct treatment even in fixed CRPS II.
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Schinkel C, Kirschner MH. Status of immune mediators in complex regional pain syndrome type I. Curr Pain Headache Rep 2008; 12:182-5. [DOI: 10.1007/s11916-008-0032-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Schinkel C, Gaertner A, Zaspel J, Zedler S, Faist E, Schuermann M. Inflammatory mediators are altered in the acute phase of posttraumatic complex regional pain syndrome. Clin J Pain 2006; 22:235-9. [PMID: 16514322 DOI: 10.1097/01.ajp.0000169669.70523.f0] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Complex regional pain syndrome type 1 (CRPS 1) is a disorder that can affect an extremity after minor trauma or surgery. The pathogenesis of this syndrome is unclear. It has clinical signs of severe local inflammation as a result of an exaggerated inflammatory response, but neurogenic dysregulation also may contribute to it. METHODS For further insights into the pathogenesis of CRPS 1, the authors investigated inflammatory and neurogenic mediators-C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-8 (IL-8), soluble tumor necrosis factor receptor I/II (sTNFR I/II), sE-selectin, sL-selectin, sP-selectin, substance P, neuropeptide Y, and calcitonin gene-related peptide-in venous blood from both the healthy arm and the arm with acute CRPS I from 25 patients and from 30 healthy volunteers. RESULTS Levels of IL-8 and sTNFR I/II were significantly elevated in patients, whereas all soluble forms of selectins were significantly suppressed. There was no significant difference in white blood cell count (WBC), CRP, and IL-6. Substance P was significantly elevated in patients. The other two neuropeptides were unchanged. None of the parameters studied showed any differences between the CRPS I-affected arm and the normal arm. CONCLUSIONS Elevated IL-8 and sTNFR I/II levels indicate an association between CRPS I and an inflammatory process. Normal WBC, CRP, and IL-6 give evidence for localized inflammation. The hypothesis of neurogenic-induced inflammation mediated by neuropeptides is supported by elevated substance P levels.
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Paraskevas KI, Michaloglou AA, Briana DD, Samara M. Treatment of complex regional pain syndrome type I of the hand with a series of intravenous regional sympathetic blocks with guanethidine and lidocaine. Clin Rheumatol 2005; 25:687-93. [PMID: 16333562 DOI: 10.1007/s10067-005-0122-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2005] [Accepted: 10/12/2005] [Indexed: 11/25/2022]
Abstract
The aim of this study was to evaluate the efficacy of guanethidine and lidocaine in the treatment of complex regional pain syndrome (CRPS) type I of the hand. Seventeen patients, aged between 33 and 72 years, suffering from CRPS type I of the hand received two series of intravenous regional sympathetic block (Bier's block) sessions with guanethidine and lidocaine according to the following therapeutic protocol: (1) 5 sessions (once every second day) composed of intravenous regional administration of 15 mg guanethidine and 1 mg lidocaine/kg body weight each and (2) 20 sessions (twice a week) composed of intravenous regional administration of 10 mg guanethidine and 1 mg lidocaine/kg body weight each. Complete disappearance of pain and return of the normal function and movement of the extremity were achieved. No side effects were observed. The above-described therapeutic protocol method resulted in excellent pain relief and full restoration of both function and range of movement of the affected extremity in 17 patients suffering from CRPS type I of the hand.
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Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular Surgery, Athens University Medical School, Athens, Greece
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Vaneker M, Wilder-Smith OHG, Schrombges P, Oerlemans HM. Impairments as measured by ISS do not greatly change between one and eight years after CRPS 1 diagnosis. Eur J Pain 2005; 10:639-44. [PMID: 16300975 DOI: 10.1016/j.ejpain.2005.10.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2005] [Revised: 09/27/2005] [Accepted: 10/05/2005] [Indexed: 01/19/2023]
Abstract
BACKGROUND Complex Regional Pain Syndrome type 1 (CRPS 1) is a potentially incapacitating complication in which pain seems to be the most disabling factor. We performed a late follow up study of a well-defined CRPS 1 population more than eight years after diagnosis. The relationships between early and late impairments were studied with a view to outcome prediction and to investigate possible differences in long-term impairments according to initial CRPS 1 subdiagnosis (i.e. "warm" or "cold", diagnosed according to skin temperature measured via infrared thermometer). METHODS We again measured patients using the Impairment Level SumScore (ISS) (T8). These data were compared with earlier ISS measurements at CRPS diagnosis (T0) and after one year's treatment (T1). Correlations were determined between these measures. RESULTS Forty-five patients participated in the present study. Total median ISS improved by 55% (statistically/clinically significant) after one year's treatment (T1), and worsened (non-significantly) by 14% from T1 to T8 - without differences according to original subdiagnosis. ISS correlations were stronger for T1 vs. T8 than for T0 vs. T1 or T0 vs. T8, being strongest for the ISS factors related to pain. CONCLUSIONS Considerable impairments, as measured by ISS, are still present over eight years after first CRPS 1 diagnosis. These do not greatly change between one and eight years post-diagnosis. ISS outcomes are similar for "cold" and "warm" CRPS 1 diagnostic subgroups. Component ISS scores associated with pain appear to possess greatest predictive power.
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Affiliation(s)
- Michiel Vaneker
- Pain Centre, Department of Anaesthesiology, Radboud University Medical Centre Nijmegen, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Vaneker M, Wilder-Smith OHG, Schrombges P, de Man-Hermsen I, Oerlemans HM. Patients initially diagnosed as 'warm' or 'cold' CRPS 1 show differences in central sensory processing some eight years after diagnosis: a quantitative sensory testing study. Pain 2005; 115:204-11. [PMID: 15836983 DOI: 10.1016/j.pain.2005.02.031] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2004] [Revised: 02/18/2005] [Accepted: 02/28/2005] [Indexed: 12/12/2022]
Abstract
We used quantitative sensory testing (QST) to gain further insight into mechanisms underlying pain in CRPS 1. Specific goals were: (1) to identify altered patterns of sensory processing some 8 years after diagnosis, (2) to document differences in sensory processing between 'warm' and 'cold' diagnostic subgroups, (3) to determine relationships between changed sensory processing and disease progression regarding pain. The study was performed on a cohort of patients (n=47) clinically diagnosed with CRPS 1 of one upper extremity approximately 8 years previously. Pain was quantified by VAS and MacGill Pain Questionnaire (MPQ), and all subjects underwent electrical and mechanical QST. Cold patients (n=13) had poorer MPQ scores than warm ones (n=34), and more pain on electrical stimulation. Their evoked pain increased with disease progression and correlated with clinical pain measures. For both diagnostic subgroups, thresholds to pressure pain were lower on the affected extremity and with disease progression. Eight years after original diagnosis, cold CRPS 1 patients have poorer clinical pain outcomes and show persistent signs of central sensitisation correlating with disease progression. The latter is not the case for warm CRPS 1 patients. Both diagnostic subgroups show greater pressure hyperalgesia on the affected limb and with disease progression. QST may prove useful in the subdiagnosis of CRPS 1 and in quantifying its progression, with both applications warranting further investigation for clinical and research use.
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Affiliation(s)
- Michiel Vaneker
- Department of Anaesthesiology, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Kumbhat S, Meyer N, Schurr MJ. Complex Regional Pain Syndrome as a Complication of a Chemical Burn to the Foot. ACTA ACUST UNITED AC 2004; 25:189-91. [PMID: 15091146 DOI: 10.1097/01.bcr.0000111768.86660.90] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Complex regional pain syndrome (CRPS) is an unusual complication after burns; however, it is important to recognize so that appropriate treatment can be administered. A 60-year-old man suffered an alkali burn to the right foot. Subsequently, the patient developed CRPS with severe pain and vasomotor changes. Multimodal treatment included the early use of ropivacaine and fentanyl via epidural catheter. Oral extended-release morphine, gabapentin, and amitriptyline also were administered. Once pain was controlled, early aggressive physical therapy was instituted, and attention was turned toward wound coverage. One year after discharge, the patient was ambulating well and has returned to work. His pain was managed with a single morning dose of gabapentin and a nonsteroidal anti-inflammatory agent. Current examination of the foot revealed mild forefoot swelling without residual erythema. Ambiguities exist in the mainstay of treatment for CRPS, but this multimodal method of controlling CRPS after burn injury allowed for control of the patient's pain, early mobilization, and eventual return to work.
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Affiliation(s)
- S Kumbhat
- Department of Surgery, University of Wisconsin Hospital, Madison, USA
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Beglaibter N, Berlatzky Y, Zamir O, Spira RM, Freund HR. Retroperitoneoscopic lumbar sympathectomy. J Vasc Surg 2002; 35:815-7. [PMID: 11932687 DOI: 10.1067/mva.2002.121130] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We present a series of 27 consecutive unselected patients who underwent 29 retroperitoneoscopic lumbar sympathectomies. There were 21 male patients and six female patients, with a mean age of 45 years (RANGE, 21 to 28 years). Twenty-two patients had ischemia of the lower limb, and five patients had severe reflex sympathetic dystrophy. The retroperitoneal space was developed with a balloon trocar inserted through a small incision in the flank. Additional trocars used for endoscopic instruments. The sympathetic chain from the ganglia second lumbar vertebrae to the fourth lumbar vertebrae was resected. The procedure was successfully accomplished in all the patients without any operative or postoperative complications. The mean operative time Was 136 minutes, and the mean hospital stay was 1.4 days. All the patients had significant improvement of pain or dystrophic changes. Retroperitoneoscopic lumbar sympathectomy successfully combines the advantages of minimally invasive surgery with the effectiveness of the open procedure.
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Affiliation(s)
- Nahum Beglaibter
- Department of Surgery, Hadassah University Hospital Mount Scopus and the Hebrew University-Hadassah Medical School, Jerusalem, Israel
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Bandyk DF, Johnson BL, Kirkpatrick AF, Novotney ML, Back MR, Schmacht DC. Surgical sympathectomy for reflex sympathetic dystrophy syndromes. J Vasc Surg 2002; 35:269-77. [PMID: 11854724 DOI: 10.1067/mva.2002.121065] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE The purpose of this study was the assessment of the efficacy of thoracoscopic cervicodorsal and open lumbar sympathectomy for the reduction of pain severity and disability associated with reflex sympathetic dystrophy (RSD). METHODS From 1992 to 2000, 73 patients with RSD underwent 46 video-assisted thoracoscopic (first to fourth thoracic ganglion) or 37 surgical lumbar (first to fourth lumbar ganglion) sympathetic chain resections. The patients were referred from multidisciplinary pain clinics with documented sympathetically maintained pain syndrome on the basis of reproducible more than 50% reduction in pain severity score (0, no pain; 10, most severe pain imaginable) for more than 2 days after sympathetic block therapy. The mean duration of the RSD symptoms before sympathectomy was 26 plus minus 14 months (range, 6 to 100 months). Postoperative pain severity score, limb disability, and overall patient satisfaction were assessed by an independent third-party observer at a mean follow-up period of 30 months. RESULTS No operative mortality or serious morbidity (Horner's syndrome, bleeding that needed transfusion, wound infection) occurred. Transient (<3-month) postprocedural sympathalgia developed in one third of the patients for cervicodorsal sympathectomy and 20% of the patients for lumbar sympathectomy and was treated effectively with trigger point/proximal ganglion block therapy or transcutaneous electrical nerve stimulation. At 3 months after sympathectomy, 10% of the patients had conditions that were judged treatment failures with no reduction in pain severity or limb disability. The remaining patients testified to more than 50% pain reduction, with pain severity scores decreasing from a mean of 8.7 before surgery to 3.4 after sympathectomy. At 1 year, one quarter of the patients had continued significant pain relief (pain severity score, <3) and an additional 50% of the patients indicated continued but reduced pain severity and an increase in daily/work activities. Overall, patient satisfaction (willingness to have procedure again, benefit from sympathectomy) was 77% and was not significantly influenced by patient age, RSD duration/stage, or extremity involvement (lumbar, 84%; cervicodorsal, 72%). CONCLUSION Patients with RSD with a confirmed sympathetically maintained pain syndrome can realize long-term benefit from surgical sympathectomy. Procedural efficacy was similar for both upper limb and lower limb RSD syndromes, although the level of pain reduction did deteriorate with time. After sympathectomy, the patients with RSD had a low incidence rate (7%) of "new" complex regional pain or disabling compensatory sweating syndromes.
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Affiliation(s)
- Dennis F Bandyk
- Department of Vascular Surgery, University of South Florida College of Medicine, Tampa, USA.
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Affiliation(s)
- S S Ahn
- Division of Vascular Surgery, UCLA Center for the Health Sciences, Los Angeles, California, USA
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Maneksha FR, Mirza H, Poppers PJ. Complex regional pain syndrome (CRPS) with resistance to local anesthetic block: a case report. J Clin Anesth 2000; 12:67-71. [PMID: 10773513 DOI: 10.1016/s0952-8180(99)00126-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We present a case of complex regional pain syndrome (CRPS) Type 1 in a 12-year-old girl. The patient did not respond to the usual therapeutic modalities used to treat CRPS, including physical therapy, lumbar sympathetic block, epidural local anesthetic block, intravenous lidocaine infusion, or other oral medications. Of note is the fact that, during epidural block, the patient demonstrated a resistance to local anesthetic neural blockade in the area of the body involved with the pain problem. The mechanism of this resistance could be related to the changes in the dorsal horn cells of the spinal cord, secondary to activation of N-methyl-D-aspartate receptors, which may play a role in the pathophysiology of this pain syndrome.
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Affiliation(s)
- F R Maneksha
- Department of Anesthesiology, Health Sciences Center, State University of New York at Stony Brook, NY 11794-8480, USA
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Furlan AD, Mailis A, Papagapiou M. Are We Paying a High Price for Surgical Sympathectomy? A Systematic Literature Review of Late Complications. THE JOURNAL OF PAIN 2000; 1:245-57. [PMID: 14622605 DOI: 10.1054/jpai.2000.19408] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The purpose of this article was to systematically review the literature in order to assess (1) the current indications for surgical sympathectomy and (2) the incidence of late complications collectively and per indication. All types of upper or lower limb surgical sympathectomies are included. An extensive search strategy looked for controlled trials and observational studies or case series with an english abstract. Out of 1,024 abstracts from MEDLINE and 221 from EMBASE, 135 articles reporting on 22,458 patients and 42,061 procedures (up to april 1998) fulfilled the inclusion criteria. Weighted means were used to control for heterogeneity of data. No controlled trials were found. The main indication was primary hyperhidrosis in 84.3% of the patients. Compensatory hyperhidrosis occurred in 52.3%, gustatory sweating in 32.3%, phantom sweating in 38.6%, and horner's syndrome in 2.4% of patients, respectively, with cervicodorsal sympathectomy, more often after open approach. Neuropathic complications (after cervicodorsal and lumbar sympathectomy) occurred in 11.9% of all patients. Compensatory hyperhidrosis occurred 3 times more often if the indication was palmar hyperhidrosis instead of neuropathic pain (52.3% versus 18.2%), whereas neuropathic complications occurred 3 times more often if the treatment was for neuropathic pain instead of palmar hyperhidrosis (25.2% versus 9.8%). Surgical sympathectomy, irrespective of approach, is accompanied by several potentially disabling complications. Detailed informed consent is recommended when surgical sympathectomy is contemplated.
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Affiliation(s)
- A D Furlan
- Comprehensive Pain Program and Toronto Western Hospital Research Institute, Toronto Western Hospital, Ontario, Canada
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Rex L, Claes G, Drott C, Pegenius G, Elam M. Vasomotor and sudomotor function in the hand after thoracoscopic transection of the sympathetic chain: implications for choice of therapeutic strategy. Muscle Nerve 1998; 21:1486-92. [PMID: 9771674 DOI: 10.1002/(sici)1097-4598(199811)21:11<1486::aid-mus18>3.0.co;2-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The degree of sympatholysis achieved by thoracoscopic transection of the sympathetic chain (sympathicotomy) was evaluated by measuring sudo- and vasomotor function in the hands before and after surgery in 12 patients with palmar hyperhidrosis. Our results show a marked reduction in sweat production and a cutaneous vasodilatation which remained unchanged during the 6 months follow-up, whereas sudo- and vasomotor reflexes normalized within this time. Skin temperature variations did not correlate to skin perfusion changes. Since all subjects reported dry and warm hands throughout the follow-up period, our results indicate that recording reflex responses to sympathoexcitatory stimuli does not adequately reflect clinical outcome of subtotal sympatholytic procedures performed for hyperhidrosis. Monitoring of clinical outcome should therefore include measurement of baseline sweat production and skin perfusion. However, the normalized reflex responses highlight the incomplete sympatholysis achieved by thoracoscopic sympathicotomy, which may be beneficial in some pathological conditions (such as hyperhidrosis) but detrimental in others.
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Affiliation(s)
- L Rex
- Department of Surgery, Borås Hospital, Sweden
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Abstract
The diagnosis and treatment of pain are among the most challenging problems facing orthopaedic surgeons, and reflex sympathetic dystrophy is probably the most frustrating and difficult pain syndrome to manage. Pain, swelling, and autonomic dysfunction are cardinal signs of the condition. Although the pathogenesis is still unclear, many theories have been proposed. Because reflex sympathetic dystrophy is sympathetically mediated, diagnosis can be confirmed on the basis of response of the pain to sympathetic blockade. Treatment may include an appropriate exercise program, a-adrenergic blocking agents, mood-elevating drugs, calcium channel blockers, intravenous regional blocks, and stellate ganglion blocks. Recent additions to therapy include electroacupuncture, transcutaneous electrical nerve stimulation, and biofeedback. Prognosis is, at best, guarded with this perplexing condition, but the best response is obtained when diagnosis is made early (within the first 2 or 3 weeks after injury) and treatment is initiated during the first stage of the disease.
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Schwartzman RJ, Liu JE, Smullens SN, Hyslop T, Tahmoush AJ. Long-term outcome following sympathectomy for complex regional pain syndrome type 1 (RSD). J Neurol Sci 1997; 150:149-52. [PMID: 9268243 DOI: 10.1016/s0022-510x(97)00078-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We performed a retrospective study of 29 patients with CRPS1 (RSD) who were initially examined between 1983 and 1993, and had either transthoracic (lower third of stellate ganglia to T3) or lumbar (L2-L4) sympathectomy. The patients were followed from 24 to 108 months after surgery. Patients with unsuccessful surgical outcomes had significantly longer duration of symptoms before surgery (median, 36 months) than those with successful outcomes (median, 16 months) by Wilcoxon rank sum test (chi2=8.69, df=1, P<0.01). All seven patients (100%) who had sympathectomy within 12 months of injury, nine of 13 patients (69.2%) who had sympathectomy within 24 months of injury, and only four of nine patients (44.4%) who had sympathectomy after 24 months of injury obtained permanent (greater than 24 months) symptom relief. Patient age, sex, occupation, site of injury, type of injury, presence of trophic changes, and duration of follow-up were not significantly related (P>0.05) to surgical outcome.
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Affiliation(s)
- R J Schwartzman
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA 19107, USA
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Abstract
Reflex sympathetic dystrophy presents with pain out of proportion to the cause, loss of function, and significant evidence of an autonomic disorder. These findings are often accompanied by psychological disturbances, which can dominate the condition. There are differences in the symptoms and signs during childhood. It is more frequent among girls than boys, and the legs are more often affected than the arms; and trophic changes may be absent. There may be no history of trauma, and the response to treatment is often satisfactory. There are a number of theories on etiology. A disorder of the sympathetic nervous system with increased activity has been suggested, but on the evidence available super-sensitivity to neurotransmitters is more likely. Also there may be a spinal, as well as a peripheral, component to the sensitivity. Other suggestions include the release of a pain substance, a disturbance of natural opioid metabolism, and an exaggerated inflammatory response. The diagnosis is mainly clinical, supported by X-ray examination, bone scans with Technetium 99m labelled diphosphonates, and a characteristic scintograph pattern. Laser Doppler flowmetry can also, be useful. The most effective preventative measure is control of pain and early mobilisation. Many treatments have been tried, but the response is variable. Drugs include analgesics, non-steroid anti-inflammatory drugs, anti-depressants, and steroids. Betablockers, with gradually increasing doses may help; as may vasodilators. Calcitonin, by intramuscular injection has been given a particularly favourable report. Physiotherapy is of prime importance. Some treatments are only likely to be considered in older children. Blocking of sympathetic pathways can be tried with paravertebral or epidural injections of local anesthetics. Regional intravenous injections of alpha adrenergic blocking agents distal to a tourniquet can relieve pain, but usually only transiently; and ketanserin may act favourably as a serotonin antagonist. Surgical sympathectomy can also be considered.
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Gordon A, Zechmeister K, Collin J. The role of sympathectomy in current surgical practice. EUROPEAN JOURNAL OF VASCULAR SURGERY 1994; 8:129-37. [PMID: 8181604 DOI: 10.1016/s0950-821x(05)80447-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- A Gordon
- University of Oxford, Nuffield Department of Surgery, John Radcliffe Hospital, U.K
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Abstract
Sympathetic denervation of the arm, the hand, and the heart may now be performed using minimal thoracoscopic procedures. During a 5-year period more than 500 patients were operated on with no major and only a few minor complications. An operation time of 25 minutes, a hospital stay of 1 day, and sick leave of less than 1 week have made the operation suitable for autonomous disorders such as hyperhidrosis. Other conditions such as causalgia, vascular insufficiency, and angina pectoris may be improved or disappear after sympathectomy, but the recurrence rate in Raynaud's disease is high.
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Affiliation(s)
- G Claes
- Department of Surgery, Borås Hospital, Sweden
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Fox S. Reflex sympathetic dystrophy--the surgeon's role in management. J Vasc Surg 1992; 16:494. [PMID: 1482481 DOI: 10.1016/0741-5214(92)90390-t] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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