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Eroshkin O, Omelchenko A, Romanukha D. Anatomical variability of the relationship between the sympathetic trunk and the intercostal veins during thoracoscopic sympathectomy. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Filion W, Lamb C. Anatomical Variation of the Sympathetic Trunk and Aberrant Rami Communicantes and their Clinical Implications. Ann Anat 2022; 245:151999. [PMID: 36183936 DOI: 10.1016/j.aanat.2022.151999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/04/2022] [Accepted: 09/15/2022] [Indexed: 11/28/2022]
Abstract
Surgical interventions involving the sympathetic trunk are increasingly performed to alleviate symptoms of several disorders such as hyperhidrosis. Anatomical variation has been highlighted as one of the main causes behind surgical failure and symptoms recurrence following surgeries conducted on the chain or its surroundings. This study therefore aimed to record anatomical variants within spinal segments C8-T10 of the sympathetic trunk. Thirty Thiel-embalmed cadavers were investigated bilaterally. The stellate ganglion was recorded on 29 sides. Its size was significantly greater in males and on the right side when the coalescence extended to the subsequent ganglion. The intrathoracic nerve of Kuntz was observed on 21 sides and was significantly more prevalent in males. There was a significant positive association between the presence of this nerve and the descending ramus in the first intercostal space. Aberrant rami found between spinal root C8 and the ventral ramus of the first intercostal nerve were introduced as rami communicantes superi. Aberrant rami communicantes were recorded 50 times in total, of which 70% were found in males. Descending rami showed the highest prevalence in upper intercostal levels, especially in males within the first intercostal space. Aberrant neuronal pathways in upper levels were significantly more prevalent when the stellate ganglion was present. The scientific literature has proven to be stochastic as results were significantly higher in past studies in regard to some sympathetic variants. Anatomical findings of the current study as well as the inconsistency of previous data should be acknowledged and considered for better surgical planning.
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Affiliation(s)
- William Filion
- Centre for Anatomy and Human Identification, Medical Sciences Institute, University of Dundee, Scotland, United Kingdom; Faculty of Medicine and Health Sciences, McGill University, Quebec, Canada; University of Dundee, Nethergate, Dundee DD1 4HN - Scotland, United Kingdom.
| | - Clare Lamb
- Centre for Anatomy and Human Identification, Medical Sciences Institute, University of Dundee, Scotland, United Kingdom; University of Dundee, Nethergate, Dundee DD1 4HN - Scotland, United Kingdom.
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Vanlommel J, Van Look L, Peetermans M, Uyttebroek L, van Nassauw L, Van Schil P. Anatomical variations of the upper thoracic sympathetic chain: a review. Eur J Cardiothorac Surg 2021; 61:515-522. [PMID: 34676399 DOI: 10.1093/ejcts/ezab445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/09/2021] [Accepted: 09/19/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The objective of this study is to provide a thorough overview of the anatomical variations of the upper thoracic sympathetic trunk to improve clinical results of upper thoracic sympathectomy. In addition, this study strives for standardization of future studies regarding the anatomy of the upper thoracic sympathetic chain. METHODS The Web of Science, PubMed and Google Scholar databases were searched using keywords, alone or combined, regarding the anatomy of the thoracic sympathetic chain. The search was limited to studies performed in humans. RESULTS Fifteen studies were finally included. Cervicothoracic ganglion and nerve of Kuntz were present in 77% and 53%, respectively. The upper thoracic ganglia were predominantly located in their corresponding intercostal space with a relatively downwards shift at the lower thoracic levels. The right sympathetic trunk is prone to have more communicating rami then the left. The lower levels of ganglia tend to have more normal rami. No clear pattern was found concerning the presence of the ascending rami and there was a decrease in the number of descending rami as the chain runs caudally. The intercostal rami remain a rare anatomical variation. CONCLUSIONS This study presents an overview of the anatomy of the upper thoracic sympathetic chain. Its results may guide upper thoracic sympathectomy to improve clinical results. This review also provides a baseline for future studies on anatomical variations of the thoracic sympathetic trunk. More uniform reporting is necessary to compare different anatomical studies.
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Affiliation(s)
- Jens Vanlommel
- Department ASTARC, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Lawrence Van Look
- Department ASTARC, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Maxime Peetermans
- Department ASTARC, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Leen Uyttebroek
- Department ASTARC, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Luc van Nassauw
- Department ASTARC, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Paul Van Schil
- Department ASTARC, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
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Vegas DH, Fabiani MA, Gonzalez-Urquijo M, Bignotti A, Seré I, Salvadores P. Novel Combined Approach for Digital Necrosis Secondary to Raynaud's Phenomenon. Vasc Endovascular Surg 2021; 55:766-771. [PMID: 33866879 DOI: 10.1177/15385744211005663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The presence of severe Raynaud's Phenomenon (RP), with permanent pain or digital necrosis is a rare condition. Cervical sympathectomy or distal sympathectomy or A botulinum toxin have demonstrated efficacy after medical treatment failure. We report the case of a 38-year-old female patient with an acute onset of severe RP in both hands secondary to systemic sclerosis. Medical treatment failed, so a novel approach by a combination of a modified distal sympathectomy and injection of A botulinum toxin on digital neuromuscular bundles was performed. Remission of the pain occurred immediately after the procedure and 45 days later she had complete healing of the digital wounds and recovered full mobilization of both hands. The patient remained asymptomatic 6 month after the procedure, and a Doppler ultrasound showed tri-phasic flows distal to the surgical site. This novel technique is described, and a brief review of the literature is performed.
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Affiliation(s)
- Diego Herrera Vegas
- Centro de Estudios Médicos e Investigaciones Clínicas (C.E.M.I.C.), Buenos Aires, Argentina
| | - Mario Alejandro Fabiani
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Monterrey, Nuevo León, México
| | | | - Agustín Bignotti
- Centro de Estudios Médicos e Investigaciones Clínicas (C.E.M.I.C.), Buenos Aires, Argentina
| | - Ignacio Seré
- Centro de Estudios Médicos e Investigaciones Clínicas (C.E.M.I.C.), Buenos Aires, Argentina
| | - Pablo Salvadores
- Centro de Estudios Médicos e Investigaciones Clínicas (C.E.M.I.C.), Buenos Aires, Argentina
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Andresen JR, Scheer F, Schlöricke E, Sallakhi A, Liedke MO, Andresen R. CT-guided thoracic sympathicolysis versus VATS sympathectomy in the therapeutic concept for severe primary palmar Hyperhidrosis. Thorac Cardiovasc Surg 2021; 70:152-158. [PMID: 33860510 DOI: 10.1055/s-0041-1725205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The objective was to compare computed tomography (CT)-guided thoracic sympathicolysis (CTSy) and video-assisted thoracoscopic sympathectomy (VATS) with regard to their feasibility, the occurrence of minor and major complications, and the clinical outcome. MATERIALS AND METHODS In this study, 88 patients treated by CTSy and 86 patients treated by VATS were retrospectively included. CTSy was performed after establishing the entry plane below the level of the intervertebral space T2/3 via a dorsolateral approach using a 22-G coaxial needle. On average of 5 mL of a sympathicolytic mixture was instilled. VATS was performed under intubation anesthesia. After insertion of the instruments via a minithoracotomy, the parietal pleura was dissected and the sympathetic trunk severed below T2. The interventions were performed unilaterally, the contralateral side being treated after approximately 6 weeks. All patients evaluated their sense of discomfort before treatment as well as 2 days, 6, and 12 months after, on the basis of a Dermatology Quality of Life Index and additionally the side effects that occurred. RESULTS Both treatments led to a marked reduction of symptoms, whereby mild recurrent sweating occurred over the further course, significantly higher in the CTSy patient group. Short-term miosis and ptosis were rarely found in both groups. As the most common side effect, transient compensatory sweating was reported by 16/88 patients after CTSy and 10/86 patients after VATS. Pneumothoraces developed postoperatively in 7/86 cases. Temporary pain after thoracotomy was experienced by 12/86 patients. CONCLUSION For patients with palmar hyperhidrosis, CTSy and VATS represented a minimally invasive treatment option that provided a high and largely equivalent level of benefit.
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Affiliation(s)
| | - Fabian Scheer
- Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Heide, Germany
| | - Eric Schlöricke
- Department of Visceral, Thoracic and Vascular Surgery, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Heide, Germany
| | - Aria Sallakhi
- Medical School, Sigmund Freud University, Vienna, Austria
| | - Marc Olaf Liedke
- Department of Visceral, Thoracic and Vascular Surgery, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Heide, Germany
| | - Reimer Andresen
- Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Heide, Germany
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Chin ML. Regional Techniques and Interventions for Intractable Neuropathic Pain. Neurology 2021. [DOI: 10.17925/usn.2021.17.1.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Andresen JR, Scheer F, Schlöricke E, Andresen R. CT-assisted thoracic sympathicolysis for therapy of primary hyperhidrosis palmaris-retrospective analysis of the influence of the amount and position of the sympathetic agent on the therapeutic outcome and side effects. ROFO-FORTSCHR RONTG 2020; 193:574-581. [PMID: 33348382 DOI: 10.1055/a-1299-2098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE The objective of the present study was to evaluate the benefit of a thoracic, computed tomography-guided sympathicolysis (CTSy) in patients with primary, focal hyperhidrosis of the hands. In addition, the influence of the amount and distribution of the administered sympathicolytic agent was to be assessed. PATIENTS AND METHODS Retrospectively, 78 patients [13 (16.7 %) men, mean age 31.2 ± 9 years and 65 (83.3 %) women, mean age 34.2 ± 12 years], who had been treated using CTSy, were included in the study. The indication for treatment was primary focal palmar hyperhidrosis grade II and grade III after exhaustion of all conservative treatment options and a continued high level of suffering. CTSy was performed after establishing the entry plane at the level of the intervertebral space T2 / T3 via a dorsolateral approach using a 22-G coaxial needle. On average 5 (2-10) ml of a sympathicolytic mixture (10 ml consisting of 8 ml 96 % alcohol, 1.6 ml 0.5 % Carbostesin and 0.4 ml 0.9 % NaCl solution, with added amounts of contrast medium) were instilled. The volume of distribution of the sympathicolytic agent was determined in craniocaudal direction using CT images. The patients evaluated their sense of discomfort preinterventionally, 2 days postinterventionally, and 6 and 12 months after the intervention, on the basis of a Dermatology life Quality Index (DLQI) as well as the side effects that occurred. RESULTS The technical success rate of CTSy was 100 %. No major complications occurred. The interventions performed led to a significant reduction (p < 0.001) in the preinterventional sense of discomfort 2 days, 6 and 12 months after CTSy. As the most common side effect, compensatory sweating was reported by 16/78 (20.5 %) of the patients over the further course. In all of these patients, the volume of sympathicolytic agent administered was below 5 ml. In no case did the sympathicolytic agent extend caudally beyond the base plate of Th 3. No compensatory sweating of the back was observed in 5/78 (6.4 %) patients; here the sympathicolytic volume was above 5 ml and extended significantly caudally below the baseplate of T3.Transient miosis and ptosis was found in 8/78 (10.3 %) patients. In all of these patients, the volume of sympathicolytic agent administered was above 5 ml and it extended markedly cranially beyond the upper plate of T2. A mild to moderate recurrent sweating developed in 35/78 (44.9 %) patients, which was more marked if the volume of sympathicolytic administered was below 5 ml and slightly more pronounced on the left than on the right. Given a high level of satisfaction overall, 71/78 (91.0 %) patients said that they would undergo the intervention again. CONCLUSION For patients with primary, focal palmar hyperhidrosis CTSy represents a therapeutic option that offers good benefit and has few side effects. The amount and spatial distribution of the sympathicolytic agent has an influence on the therapeutic outcome and the side effects. KEY POINTS · CT-assisted thoracic sympathicolysis is a minimally invasive, low-complication therapy for treatment of severe forms of primary hyperhidrosis palmaris.. · CT-assisted thoracic sympathicolysis can usually be performed on an outpatient basis.. · The quantity and local distribution of the sympathicolytic agent has an influence on the therapeutic outcome and the side effects.. CITATION FORMAT · Andresen J, Scheer F, Schlöricke E et al. CT-assisted thoracic sympathicolysis for therapy of primary hyperhidrosis palmaris-retrospective analysis of the influence of the amount and position of the sympathetic agent on the therapeutic outcome and side effects. Fortschr Röntgenstr 2021; 193: 574 - 581.
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Affiliation(s)
| | - Fabian Scheer
- Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westküstenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg, Heide, Germany
| | - Erik Schlöricke
- Department of Visceral, Thoracic and Vascular Surgery, Westküstenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg, Heide, Germany
| | - Reimer Andresen
- Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westküstenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg, Heide, Germany
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Hong JH, Yi SW, Kim JS. Incidence of inadvertent intercostal or epidural spread during thoracic sympathetic ganglion block. Anesth Pain Med (Seoul) 2020; 15:486-491. [PMID: 33329853 PMCID: PMC7724114 DOI: 10.17085/apm.20052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 01/03/2023] Open
Abstract
Background Sympathetic blocks (SBs) have been used widely to relieve the symptoms of sympathetically maintained pain (SMP). The thoracic sympathetic ganglion is not separated from somatic nerves by muscles and connective tissue. The upper thoracic ganglion runs along the posterior surface of the vertebral column in close proximity to the adjacent epidural region. This anatomical difference leads to frequent epidural and intercostal spread in cases of thoracic SBs. The purpose of this study was to investigate the incidence of inadvertent intercostal and epidural injections during thoracic SBs. Methods Twenty-two patients who were suffering from complex regional pain syndrome or lymphedema after breast cancer surgery were managed with two or three times of thoracic SBs. Therefore, injections of 63 thoracic SBs from 22 patients were enrolled in this study. An investigator who did not attend the procedure evaluated the occurrence of intercostal or epidural spread using anteroposterior fluoroscopic images. Results The overall incidence of inadvertent intercostal or epidural spread of contrast was 47.5%. Among the inadvertent injections, intercostal spread (34.9%) was more frequent than epidural spread (12.6%). Only 52.5% of the thoracic SBs demonstrated successful contrast spread without any inadvertent spread. The mean difference in skin temperature between the blocked and unblocked sides was 2.5 ± 1.8ºC. Fifty-nine (93.6%) injections demonstrated more than 1.5ºC difference. Conclusions Thoracic SBs showed a high incidence (47.5%) of inadvertent epidural or intercostal injection. Thus, special attention is required for the diagnosis of SMP or the injection of any neurolytic agent around sympathetic ganglion.
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Affiliation(s)
- Ji Hee Hong
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Seung Won Yi
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Ji Seob Kim
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
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Hetta DF, Mohamed AA, Hetta HF, Abd EL‐Hakeem EE, Boshra MM, El‐Barody MM, Fattah Mohammad MA. Radiofrequency Thoracic Sympathectomy for Sympathetically Maintained Chronic Post‐Mastectomy Pain, a Preliminary Report: 6‐Month Results. Pain Pract 2020; 21:54-63. [DOI: 10.1111/papr.12933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/23/2020] [Accepted: 06/28/2020] [Indexed: 01/02/2023]
Affiliation(s)
- Diab Fuad Hetta
- Department of Anesthesia and Pain Management South Egypt Cancer Institute Assuit University Assiut Egypt
| | - Ashraf Amin Mohamed
- Department of Anesthesia and Pain Management South Egypt Cancer Institute Assuit University Assiut Egypt
| | - Helal F. Hetta
- Department of Internal Medicine University of Cincinnati College of Medicine Cincinnati Ohio U.S.A
- Department of Medical Microbiology and Immunology Faculty of Medicine Assiut University AssiutEgypt
| | - Essam Ezzat Abd EL‐Hakeem
- Department of Anesthesia and Intensive Care Assuit University Hospital Assuit University AssiutEgypt
| | - Madona Misheal Boshra
- Department of Anesthesia and Pain Management Department South Egypt, Cancer Institute Assuit University AssiutEgypt
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Frederico TN, da Silva Freitas T. Peripheral Nerve Stimulation of the Brachial Plexus for Chronic Refractory CRPS Pain of the Upper Limb: Description of a New Technique and Case Series. PAIN MEDICINE 2020; 21:S18-S26. [PMID: 32804227 DOI: 10.1093/pm/pnaa201] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Upper limb complex regional pain syndrome is an important cause of chronic pain, and its treatment is challenging. In this pilot case series, we preliminarily evaluated the feasibility, effectiveness, and safety of a new technique for brachial plexus neuromodulation in the treatment of this disease in patients refractory to conservative treatment. METHODS Between 2017 and 2018, 14 patients considered to be refractory to optimized conservative treatment were recruited to this study. In the first stage, patients were trialed for seven days with a new technique of implant of the brachial plexus. Patients with ≥50% pain relief in visual analog scale (VAS) score received a definitive implantation in the second stage. Follow-ups were conducted at pre-implant and 12 months using the Neuropathic Pain Scale, SF-32, and the visual analogic scale for pain. RESULTS After the initial trial, 10 patients had a pain reduction of ≥50% and received a permanent implant. At 12-month follow-up, VAS, Neuropathic Pain Scale, SF-12 physical and mental scores improved by 57.4% +/- 10% (P = 0.005), 60.2% +/- 12.9% (P = 0.006), and 21.9% +/- 5.9% (P = 0.015), respectively. CONCLUSIONS Our data suggest that this new technique of brachial plexus stimulation may have long-term utility in the treatment of painful upper limb complex regional pain syndrome. New more detailed comprehensive studies should be carried out to confirm our findings in a larger population and to further refine the clinical implementation of this technique.
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Won HJ, Choi HS, Park KH. Anatomic variations of the intrathoracic nerves and the neural connections of the second and third thoracic sympathetic ganglia to the brachial plexus. Clin Anat 2020; 34:590-595. [PMID: 32372452 DOI: 10.1002/ca.23619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 11/09/2022]
Abstract
INTRODUCTION This study investigated morphological variations of the intrathoracic nerves and the neural connections of the second and third thoracic sympathetic ganglia to the brachial plexus based on the existence of the intrathoracic nerves and the rami communicantes. MATERIALS AND METHODS Fifty thoracic sympathetic trunks from 26 Korean adult cadavers were used. RESULTS The first intrathoracic nerve connecting the first and second thoracic nerves was observed on 36 sides (72%), and the second intrathoracic nerve connecting the second and third thoracic nerves was found on three sides (6%). There were either one (62%) or two (10%) first intrathoracic nerves, and only one second intrathoracic nerve (6%). The neural connections of the second and third thoracic sympathetic ganglia to the first thoracic nerve were classified into three types based on the existence of the intrathoracic nerves: Type I (68%) had only the first intrathoracic nerve, Type II (26%) had no intrathoracic nerve, and Type III (6%) had both the first and second intrathoracic nerves. Types I, II, and III were further subdivided into 10, 6, and 3 types, respectively, according to the types of the rami communicantes arising from the second and third thoracic sympathetic ganglia. CONCLUSIONS Improved knowledge of the variations in intrathoracic nerves and upper thoracic sympathetic ganglia will be helpful to thoracic surgeons when they are disrupting the sympathetic supply to the hand for treating palmar hyperhidrosis, and contribute to successful diagnoses and treatments.
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Affiliation(s)
- Hyung-Jin Won
- Department of Anatomy, School of Medicine, Kangwon National University, Chuncheon, South Korea
| | - Hoon-Sung Choi
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon, South Korea
| | - Kyeong Han Park
- Department of Anatomy, School of Medicine, Kangwon National University, Chuncheon, South Korea
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Vanaclocha V, Sáiz Sapena N, Rivera M, Herrera JM, Ortiz-Criado JM, Monzó-Blasco A, Guijarro-Jorge R, Vanaclocha L. Selective block of grey communicantes in upper thoracic sympathectomy. A feasibility study on human cadaveric specimens. Br J Neurosurg 2019; 34:362-369. [PMID: 31353968 DOI: 10.1080/02688697.2019.1645297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Sympathetic chain interruption is the gold standard treatment for essential hyperhidrosis. Postoperative compensatory hyperhidrosis, the main reason for patients' dissatisfaction, is reduced by selectively lesioning white and grey rami communicantes (ramicotomy).Objective: To develop an endoscopic surgical technique that interrupts only T3 and T4 grey rami communicantes to minimize compensatory hyperhidrosis.Material and Methods: T3 and T4 grey rami communicantes ramicotomy in fifteen cold-preserved cadavers through a uniportal axillary endoscopic approach. The sympathetic chain, its ganglia, and white rami communicantes were left intact. On opening the chest, the sympathetic chain, rami communicantes and ganglia were dissected, photographed, measured and excised for histological examination.Results: Dissecting the grey rami communicantes is feasible as they consistently lie between the intercostal nerve and the homonymous sympathetic ganglion. At some levels, Kuntz nerves, as well as more than one grey ramus communicans, can be found. White rami communicantes are more medial, therefore damaging them can be avoided. Intercostal veins can be obstructive, but these can be controlled via coagulation or clipping if necessary.Conclusion: Uniportal endoscopic selective excision of the T3 and T4 grey rami communicantes is feasible without damaging the white rami communicantes, the sympathetic chain or its ganglia. Clipping the grey rami communicantes is technically possible but not reliable due to their thin diameter. This study confirms that T3 and T4 grey rami sympathetic block is technically feasible. Its application might reduce compensatory hyperhidrosis, but clinical studies are needed.
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Affiliation(s)
- Vicente Vanaclocha
- Department of Neurosurgery, Hospital General Universitario de Valencia, Valencia, Spain
| | - Nieves Sáiz Sapena
- Department of Anesthesiology, Hospital 9 de Octubre de Valencia, Valencia, Spain
| | - Marlon Rivera
- Department of Neurosurgery, Hospital General Universitario de Valencia, Valencia, Spain
| | - Juan Manuel Herrera
- Department of Neurosurgery, Hospital General Universitario de Valencia, Valencia, Spain
| | | | | | - Ricardo Guijarro-Jorge
- Department of Thoracic Surgery, Hospital General Universitario de Valencia, Valencia, Spain
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Zhu X, Kohan LR, Morris JD, Hamill-Ruth RJ. Sympathetic blocks for complex regional pain syndrome: a survey of pain physicians. Reg Anesth Pain Med 2019; 44:rapm-2019-100418. [PMID: 31055496 DOI: 10.1136/rapm-2019-100418] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/07/2019] [Accepted: 04/22/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Sympathetic blocks (SB) are commonly used to treat pain from complex regional pain syndrome (CRPS). However, there are currently no guidelines to assist pain physicians in determining the best practices when using and performing these procedures. METHODS A 32-question survey was developed on how SBs are used and performed to treat CRPS. The survey was conducted online via SurveyMonkey. The responses were statistically analyzed using descriptive statistics, and comparing academic versus non-academic, and fellowship versus non-fellowship-trained physicians. RESULTS A total of 248 pain physicians responded with a response rate of 37%. Forty-four percent of respondents schedule the first SB at the first clinic visit; 73% perform one to three consecutive blocks; over 50% will repeat the block if a patient receives at least 50% pain relief from the previous one lasting 1-7 days.Fifty-four percent of respondents perform stellate ganglion blocks (SGB) at the C6 vertebral level, 41% at C7; 53% perform lumbar sympathetic blocks (LSB) at L3 level, 39% at L2; 50% use fluoroscopy to guide SGB, 47% use ultrasound. More respondents from academic than non-academic centers use ultrasound for SGB. About 75% of respondents use a total volume of 5-10 mL for SGB and 10-20 mL for LSB. The most commonly used local anesthetic is 0.25% bupivacaine. About 50% of respondents add other medications, mostly steroids, for these blocks. CONCLUSION Our study showed a wide variation in current practice among pain physicians in treating CRPS with SBs. There is a clear need for evidence-based guidelines on when and how to perform SBs for CRPS.
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Affiliation(s)
- Xiaoying Zhu
- Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Lynn R Kohan
- Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Joshua D Morris
- Anesthesiology, Schneck Medical Center, Seymour, Indiana, USA
| | - Robin J Hamill-Ruth
- Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
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Vaseghi M, Barwad P, Malavassi Corrales FJ, Tandri H, Mathuria N, Shah R, Sorg JM, Gima J, Mandal K, Sàenz Morales LC, Lokhandwala Y, Shivkumar K. Cardiac Sympathetic Denervation for Refractory Ventricular Arrhythmias. J Am Coll Cardiol 2017. [PMID: 28641796 DOI: 10.1016/j.jacc.2017.04.035] [Citation(s) in RCA: 221] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cardiac sympathetic denervation (CSD) has been shown to reduce the burden of implantable cardioverter-defibrillator (ICD) shocks in small series of patients with structural heart disease (SHD) and recurrent ventricular tachyarrhythmias (VT). OBJECTIVES This study assessed the value of CSD and the characteristics associated with outcomes in this population. METHODS Patients with SHD who underwent CSD for refractory VT or VT storm at 5 international centers were analyzed by the International Cardiac Sympathetic Denervation Collaborative Group. Kaplan-Meier analysis was used to estimate freedom from ICD shock, heart transplantation, and death. Cox proportional hazards models were used to analyze variables associated with ICD shock recurrence and mortality after CSD. RESULTS Between 2009 and 2016, 121 patients (age 55 ± 13 years, 26% female, mean ejection fraction of 30 ± 13%) underwent left or bilateral CSD. One-year freedom from sustained VT/ICD shock and ICD shock, transplant, and death were 58% and 50%, respectively. CSD reduced the burden of ICD shocks from a mean of 18 ± 30 (median 10) in the year before study entry to 2.0 ± 4.3 (median 0) at a median follow-up of 1.1 years (p < 0.01). On multivariable analysis, pre-procedure New York Heart Association functional class III and IV heart failure and longer VT cycle lengths were associated with recurrent ICD shocks, whereas advanced New York Heart Association functional class, longer VT cycle lengths, and a left-sided-only procedure predicted the combined endpoint of sustained VT/ICD shock recurrence, death, and transplantation. Of the 120 patients taking antiarrhythmic medications before CSD, 39 (32%) no longer required them at follow-up. CONCLUSIONS CSD decreased sustained VT and ICD shock recurrence in patients with refractory VT. Characteristics independently associated with recurrence and mortality were advanced heart failure, VT cycle length, and a left-sided-only procedure.
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Affiliation(s)
- Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center, University of California, Los Angeles, California; Neurocardiology Research Center of Excellence at UCLA, Los Angeles, California.
| | - Parag Barwad
- Holy Family Heart Institute, Holy Family Hospital, Mumbai, India
| | | | - Harikrishna Tandri
- Johns Hopkins Heart and Vascular Institute, Johns Hopkins University, Baltimore, Maryland
| | - Nilesh Mathuria
- Baylor St. Luke's Medical Center/Texas Heart Institute, Baylor College of Medicine, Houston, Texas
| | - Rushil Shah
- Holy Family Heart Institute, Holy Family Hospital, Mumbai, India
| | - Julie M Sorg
- UCLA Cardiac Arrhythmia Center, University of California, Los Angeles, California
| | - Jean Gima
- UCLA Cardiac Arrhythmia Center, University of California, Los Angeles, California
| | - Kaushik Mandal
- Johns Hopkins Heart and Vascular Institute, Johns Hopkins University, Baltimore, Maryland
| | - Luis C Sàenz Morales
- Centro Internacional de Arritmias, Fundacion Cardio Infantil-Instituto de Cardiologia, Bogota, Colombia
| | - Yash Lokhandwala
- Holy Family Heart Institute, Holy Family Hospital, Mumbai, India
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, University of California, Los Angeles, California; Neurocardiology Research Center of Excellence at UCLA, Los Angeles, California
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Everett TH, Doytchinova A, Cha YM, Chen PS. Recording sympathetic nerve activity from the skin. Trends Cardiovasc Med 2017; 27:463-472. [PMID: 28619579 DOI: 10.1016/j.tcm.2017.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 05/02/2017] [Accepted: 05/03/2017] [Indexed: 01/09/2023]
Abstract
Sympathetic tone is important in cardiac arrhythmogenesis; however, methods to estimate sympathetic tone are either invasive or require proper sinus node function that may be abnormal in disease states. Because of the direct and extensive connections among various nerve structures, it is possible for the sympathetic nerves in the various structures to activate simultaneously. Therefore, we hypothesized that nerve activity can be recorded from the skin and it can be used to estimate the cardiac sympathetic tone. Preclinical studies in canines demonstrated that nerve activity is detectable using conventional ECG electrodes and can be used to estimate cardiac sympathetic tone. Subsequent clinical studies further supported this concept. In addition to studying the autonomic mechanisms of cardiac arrhythmia, these new methods may have broad application in studying both cardiac and non-cardiac diseases.
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Affiliation(s)
- Thomas H Everett
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN.
| | - Anisiia Doytchinova
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Yong-Mei Cha
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Peng-Sheng Chen
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
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16
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Vannucci F, Araújo JA. Thoracic sympathectomy for hyperhidrosis: from surgical indications to clinical results. J Thorac Dis 2017; 9:S178-S192. [PMID: 28446983 DOI: 10.21037/jtd.2017.04.04] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Sympathectomy and its variations have been performed in thoracic surgery for more than 100 years. However, its indications have undergone profound modifications in this period. Likewise, since then the surgical technique has also evolved dramatically up to the minimally invasive techniques worldwide accessible in present days. Currently, primary hyperhidrosis is, by far, the main indication for thoracic sympathectomy and this procedure is usually carried out thoracoscopically with excellent results. However, until today, hyperhidrosis is a part of thoracic surgery still surrounded by controversy, persisting as an open field over which some confusion still resides regarding its pathophysiology, terms definitions and operative approaches. The aim of this article is to provide a wide but easily comprehensible review of the theme, discussing and clarifying the major concepts with respect to its clinical presentation, all the presently available treatment options and strategies with their potential benefits and risks, the adequate patient selection for sympathectomy, as well as the postoperative clinical results.
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Affiliation(s)
- Fernando Vannucci
- Thoracic Surgery Department, Hospital Federal do Andaraí, Rio de Janeiro, Brazil.,Thoracic Surgery Department, Hospital Central da Polícia Militar (HCPM), Rio de Janeiro, Brazil
| | - José Augusto Araújo
- Thoracic Surgery Department, Hospital Federal do Andaraí, Rio de Janeiro, Brazil
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Street E, Ashrafi M, Greaves N, Gouldsborough I, Baguneid M. Anatomic Variation of Rami Communicantes in the Upper Thoracic Sympathetic Chain: A Human Cadaveric Study. Ann Vasc Surg 2016; 34:243-9. [PMID: 27116906 DOI: 10.1016/j.avsg.2016.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 02/06/2016] [Accepted: 04/14/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Hyperhidrosis is secondary to over activation of the sympathetic nervous system and surgical sympathectomy is the treatment of choice when other modalities have failed. This study investigated anatomic variation in the upper thoracic sympathetic chain and associated rami communicantes among cadaveric specimens. It considers the implications of these findings on surgical techniques to treat hyperhidrosis. METHODS The upper 4 thoracic sympathetic ganglia, intercostal nerves, and connecting rami were dissected, measured and mapped in 40 sides of 20 adult human cadavers. Ganglia location was recorded. The incidence, orientation, and distance travelled by rami communicantes was compared across different ganglionic levels and between sides. RESULTS The percentage of ganglia located below their associated intercostal space was 6.25% with stellate ganglions present in 70% of specimens and Kuntz fibers noted in 40%. There was a stepwise reduction in incidence of rami from superior to inferior placed ganglia. The number of rami identified across all levels was significantly greater on the right (P = 0.03). The horizontal distance between the sympathetic chain and union of the rami on the intercostal nerves was significantly greater on the right across all levels (P = 0.04). CONCLUSIONS There was substantial variation in the rami communicantes across the upper 4 ganglia and between right and left sides. Consideration of this variation should be given when planning surgical sympathectomy for hyperhidrosis particularly to avoid symptom recurrence.
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Affiliation(s)
- Elliot Street
- Department of Vascular Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Mohammed Ashrafi
- Department of Vascular Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Nicholas Greaves
- Department of Vascular Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | | | - Mohamed Baguneid
- Department of Vascular Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK.
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18
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Tulay CM. Sympathectomy for Palmar Hyperhidrosis. Indian J Surg 2016; 77:327-9. [PMID: 26730019 DOI: 10.1007/s12262-013-0822-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 01/15/2013] [Indexed: 11/30/2022] Open
Abstract
Palmar hyperhidrosis is an important situation that may cause emotional and work-related problems. Although local treatment and psychotherapy have been used for palmar hyperhidrosis, the choice of treatment for palmar hyperhidrosis is video-assisted thoracoscopic sympathectomy. Retrospective analysis of 120 bilateral thoracoscopic sympathectomies (60 patients) was done in this study. Earlier, 12 of 60 patients (20 %) had been operated on by other surgeons who used clipping method for palmar hyperhidrosis in different hospitals within 1 year. The procedure was performed under general anesthesia using single-lumen endotracheal tube. Sympathetic chain resection was performed between lower level of the second rib and upper level of the fourth rib. Intercostal blockage at three levels was performed, while thoracoscopic control of the injection sites was done. We observed improvement of symptoms in 95 %, mild compensatory sweating in 20 %, and excessive dryness of hands in 10 % in our patients.
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Affiliation(s)
- Cumhur Murat Tulay
- Department of Thoracic Surgery, Sanlıurfa Teaching and Research Hospital, Sanlıurfa, Turkey
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19
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Chan YH, Tsai WC, Shen C, Han S, Chen LS, Lin SF, Chen PS. Subcutaneous nerve activity is more accurate than heart rate variability in estimating cardiac sympathetic tone in ambulatory dogs with myocardial infarction. Heart Rhythm 2015; 12:1619-27. [PMID: 25778433 DOI: 10.1016/j.hrthm.2015.03.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND We recently reported that subcutaneous nerve activity (SCNA) can be used to estimate sympathetic tone. OBJECTIVE The purpose of this study was to test the hypothesis that left thoracic SCNA is more accurate than heart rate variability (HRV) in estimating cardiac sympathetic tone in ambulatory dogs with myocardial infarction (MI). METHODS We used an implanted radiotransmitter to study left stellate ganglion nerve activity (SGNA), vagal nerve activity (VNA), and thoracic SCNA in 9 dogs at baseline and up to 8 weeks after MI. HRV was determined based on time-domain, frequency-domain, and nonlinear analyses. RESULTS The correlation coefficients between integrated SGNA and SCNA averaged 0.74 (95% confidence interval [CI] 0.41-1.06) at baseline and 0.82 (95% CI, 0.63-1.01) after MI (P <.05 for both). The absolute values of the correlation coefficients were significantly larger than that between SGNA and HRV analysis based on time-domain, frequency-domain, and nonlinear analyses, respectively, at baseline (P <.05 for all) and after MI (P <.05 for all). There was a clear increment of SGNA and SCNA at 2, 4, 6, and 8 weeks after MI, whereas HRV parameters showed no significant changes. Significant circadian variations were noted in SCNA, SGNA, and all HRV parameters at baseline and after MI, respectively. Atrial tachycardia (AT) episodes were invariably preceded by SCNA and SGNA, which were progressively increased from 120th, 90th, 60th, to 30th seconds before AT onset. No such changes of HRV parameters were observed before AT onset. CONCLUSION SCNA is more accurate than HRV in estimating cardiac sympathetic tone in ambulatory dogs with MI.
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Affiliation(s)
- Yi-Hsin Chan
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, Taoyuan, Taiwan
| | - Wei-Chung Tsai
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung University College of Medicine, Kaohsiung, Taiwan
| | - Changyu Shen
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana; Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Seongwook Han
- Division of Cardiology, Department of Internal Medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea
| | - Lan S Chen
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Shien-Fong Lin
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Institute of Biomedical Engineering, National Chiao-Tung University, Hsin-Chu, Taiwan
| | - Peng-Sheng Chen
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
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Rocha RDO, Teixeira MJ, Yeng LT, Cantara MG, Faria VG, Liggieri V, Loduca A, Müller BM, Souza AC, de Andrade DC. Thoracic sympathetic block for the treatment of complex regional pain syndrome type I: A double-blind randomized controlled study. Pain 2014; 155:2274-81. [DOI: 10.1016/j.pain.2014.08.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 08/12/2014] [Accepted: 08/13/2014] [Indexed: 01/21/2023]
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21
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Robinson EA, Rhee KS, Doytchinova A, Kumar M, Shelton R, Jiang Z, Kamp NJ, Adams D, Wagner D, Shen C, Chen LS, Everett TH, Fishbein MC, Lin SF, Chen PS. Estimating sympathetic tone by recording subcutaneous nerve activity in ambulatory dogs. J Cardiovasc Electrophysiol 2014; 26:70-8. [PMID: 25091691 DOI: 10.1111/jce.12508] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 07/27/2014] [Accepted: 07/29/2014] [Indexed: 01/30/2023]
Abstract
INTRODUCTION We tested the hypothesis that subcutaneous nerve activity (SCNA) of the thorax correlates with the stellate ganglion nerve activity (SGNA) and can be used to estimate the sympathetic tone. METHODS AND RESULTS We implanted radio transmitters in 11 ambulatory dogs to record left SGNA, left thoracic vagal nerve activity (VNA), and left thoracic SCNA, including 3 with simultaneous video monitoring and nerve recording. Two additional dogs were studied under general anesthesia with apamin injected into the right stellate ganglion while the right SGNA and the right SCNA were recorded. There was a significant positive correlation between integrated SGNA (iSGNA) and integrated SCNA (iSCNA) in the first 7 ambulatory dogs, with correlation coefficient of 0.70 (95% confidence interval [CI] 0.61-0.84, P < 0.05 for each dog). Tachycardia episodes (heart rate exceeding 150 bpm for ≥3 seconds) were invariably preceded by SGNA and SCNA. There was circadian variation of both SCNA and SGNA. Crosstalk was ruled out because SGNA, VNA, and SCNA bursts had different timing and activation patterns. In an eighth dog, closely spaced bipolar subcutaneous electrodes also recorded SCNA, but with reduced signal to noise ratio. Video monitoring in additional 3 dogs showed that movement was not a cause of high frequency SCNA. The right SGNA correlated strongly with right SCNA and heart rate in 2 anesthetized dogs after apamin injection into the right stellate ganglion. CONCLUSIONS SCNA recorded by bipolar subcutaneous electrodes correlates with the SGNA and can be used to estimate the sympathetic tone.
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Affiliation(s)
- Eric A Robinson
- Division of Cardiology, Department of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana, USA
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Chen CK, Phui VE, Nizar AJ, Yeo SN. Percutaneous t2 and t3 radiofrequency sympathectomy for complex regional pain syndrome secondary to brachial plexus injury: a case series. Korean J Pain 2013; 26:401-5. [PMID: 24156009 PMCID: PMC3800715 DOI: 10.3344/kjp.2013.26.4.401] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 08/19/2013] [Accepted: 08/20/2013] [Indexed: 11/17/2022] Open
Abstract
Complex regional pain syndrome secondary to brachial plexus injury is often severe, debilitating and difficult to manage. Percuteneous radiofrequency sympathectomy is a relatively new technique, which has shown promising results in various chronic pain disorders. We present four consecutive patients with complex regional pain syndrome secondary to brachial plexus injury for more than 6 months duration, who had undergone percutaneous T2 and T3 radiofrequency sympathectomy after a diagnostic block. All four patients experienced minimal pain relief with conservative treatment and stellate ganglion blockade. An acceptable 6 month pain relief was achieved in all 4 patients where pain score remained less than 50% than that of initial score and all oral analgesics were able to be tapered down. There were no complications attributed to this procedure were reported. From this case series, percutaneous T2 and T3 radiofrequency sympathectomy might play a significant role in multi-modal approach of CRPS management.
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Affiliation(s)
- Chee Kean Chen
- Department of Anesthesiology, Kuching Specialist Hospital, Sarawak, Malaysia
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23
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Nourinezhad J, Gilanpour H, Radmehr B. Prenatal development of the fetal thoracic sympathetic trunk in sheep (Ovis aries). Auton Neurosci 2013; 177:154-62. [PMID: 23639816 DOI: 10.1016/j.autneu.2013.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 03/29/2013] [Indexed: 11/24/2022]
Abstract
This study aims at clarifying the detailed morphological and topographical changes of the thoracic part of the sympathetic trunk of sheep during fetal development. Bilateral micro-dissection of the thoracic sympathetic trunk was performed on 40 sheep fetuses aged 6-20 weeks (18 males and 22 females) under a stereomicroscope. The cervicothoracic ganglion (CTG) was observed on 75/80 sides (93.7%) and was composed of the caudal cervical and the first thoracic ganglia on 45/80 sides (56.2%), and of the caudal cervical and the first two thoracic ganglia on 30/80 sides (37.5%). The presence of the two last (12th-13th) thoracic ganglia was not constant. The influence of the sex, the side of the body, and the ages of the fetus on the morphology and topography of the thoracic sympathetic trunk in sheep were identified. In spite of the differences in the morphology and topography of the thoracic sympathetic trunk between early and late fetal developments, the morphology and topography of the older fetal thoracic sympathetic trunk tended to be similar to that of the adult sheep. To comprehend the comparative morphology of the fetal thoracic sympathetic trunk more completely, our results were compared with previous studies. Consequently, differences and similarities in the composition and position of the CTG, presence of single caudal cervical ganglion without fusion to the thoracic ganglia, and absence of the thoracic ganglia, and presence of splitting of the interganglionic branch were found among sheep, pig, and human fetuses. Therefore, sheep might be the appropriate animal model to be applied in human sympathetic nervous system.
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Affiliation(s)
- Jamal Nourinezhad
- Division of Anatomy and Embryology, Department of Basic Sciences, Faculty of Veterinary Medicine, Shahid Chamran University of Ahvaz, Iran.
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24
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Affiliation(s)
- Steven B Porter
- Departments of Anesthesiology and Orthopedic Surgery, Mayo Clinic, Jacksonville, FL 32224, USA
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25
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Dorsher PT. Acupuncture for Hot Flashes: Combining Traditional and Neurophysiologic Considerations for Effective Treatment. Med Acupunct 2012. [DOI: 10.1089/acu.2012.0920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Peter T. Dorsher
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Jacksonville, Florida
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Demey K, Nijs S, Coosemans W, Decaluwé H, Decker G, De Leyn P, Van Raemdonck D, Sermon A, Broos P, Lerut T, Nafteux P. Endoscopic thoracic sympathectomy for posttraumatic complex regional pain syndrome. Eur J Trauma Emerg Surg 2011; 37:597-604. [PMID: 26815471 DOI: 10.1007/s00068-011-0080-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2010] [Accepted: 01/28/2011] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Posttraumatic complex regional pain syndrome (CRPS) has a strongly negative impact on rehabilitation and activities of daily living. Treatment is most often unrewarding. AIM To analyze the efficacy of endoscopic thoracic sympathectomy (ETS) in reducing pain and disability associated with CRPS prospectively. PATIENT AND METHODS Over a 5-year period, 12 patients (7 females and 5 males; median age 46.5 [range 34-60 years]) with posttraumatic CRPS underwent unilateral ETS. The median duration of CRPS symptoms before ETS was 3.8 months (range 1.2-19.9). The sympathetic chain was resected from the 2nd to the 5th rib, and the nerve of Kuntz was severed. Median postoperative 16 months (range 12-40). Pain was assessed, at rest (passive) and during movement (active), using a visual analogue scale (VAS) from 0 to 10. RESULTS One patient (8%) suffered a hydrothorax and 3 patients (25%) complained of contralateral compensatory hyperhydrosis. At 1 month (n = 12), 2 months (n = 7), 6 months (n = 12), and 1 year (n = 12) after ETS, there was a significant decrease in passive and active VAS (P < 0.05). Ten out of the 12 patients (83%) needed fewer analgesics after surgery, and eight (67%) did not need analgesics at all. The median sleep duration improved significantly from a preoperative value of 2 h (range 1-7) to a postoperative value of 6.25 h (range 3.5-8) (P < 0.001). Overall, patient satisfaction was 83%. CONCLUSION ETS is effective at decreasing pain and improving quality of life, and should therefore be considered in the treatment of CRPS.
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Affiliation(s)
- K Demey
- Department of General Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - S Nijs
- Department of Traumatology, University Hospitals Leuven, Leuven, Belgium
| | - W Coosemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - H Decaluwé
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - G Decker
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - P De Leyn
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - D Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - A Sermon
- Department of Traumatology, University Hospitals Leuven, Leuven, Belgium
| | - P Broos
- Department of Traumatology, University Hospitals Leuven, Leuven, Belgium
| | - T Lerut
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - P Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
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Yoo HS, Nahm FS, Lee PB, Lee CJ. Early thoracic sympathetic block improves the treatment effect for upper extremity neuropathic pain. Anesth Analg 2011; 113:605-9. [PMID: 21778335 DOI: 10.1213/ane.0b013e3182274803] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The sympathetic nervous system has important roles in mediating many neuropathic pain conditions. A thoracic sympathetic block (TSB) is a useful therapeutic procedure for neuropathic pain in the upper extremities and thorax. However, no studies have examined the factors related to an improved therapeutic effect of TSB. In this study, we evaluated the influence of potential prognostic factors for a better TSB effect and identified clinically important prognostic factors. METHODS Percutaneous TSB was performed in 51 patients, under fluoroscopic guidance. Data collected for each patient included age, gender, body mass index, diagnosis, pain intensity, and symptom duration. The adjusted odds ratios and 95% confidence intervals for each variable were calculated by logistic regression. RESULTS TSB was more effective in patients with symptom durations of ≤1 year compared with >1 year (P = 0.006; odds ratio, 8.037; 95% confidence interval, 1.808-35.729). Patient age, gender, body mass index, diagnosis, and intensity of pre-TSB pain were not associated with TSB effectiveness. CONCLUSION The results showed that an earlier TSB produced a better outcome for patients with chronic pain syndrome. Thus, early TSB should be performed in patients with chronic pain in the upper extremities.
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Affiliation(s)
- Hyung Seok Yoo
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyung Hee University, Seoul, Korea.
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Ipsilateral Brachial Plexus Block and Hemidiaphragmatic Paresis as Adverse Effect of a High Thoracic Paravertebral Block. Reg Anesth Pain Med 2011; 36:198-201. [DOI: 10.1097/aap.0b013e31820d424c] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Pellerin M, Kimball Z, Tubbs RS, Nguyen S, Matusz P, Cohen-Gadol AA, Loukas M. The prefixed and postfixed brachial plexus: a review with surgical implications. Surg Radiol Anat 2010; 32:251-60. [DOI: 10.1007/s00276-009-0619-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 12/30/2009] [Indexed: 11/24/2022]
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Wasserman A, Brahn E. Systemic sclerosis: bilateral improvement of Raynaud's phenomenon with unilateral digital sympathectomy. Semin Arthritis Rheum 2009; 40:137-46. [PMID: 19878974 DOI: 10.1016/j.semarthrit.2009.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2009] [Revised: 08/10/2009] [Accepted: 08/24/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To demonstrate that unilateral digital sympathectomy, in patients with Raynaud's phenomenon (RP) and systemic sclerosis (SSc), may result in bilateral resolution of RP and digital ulcerations. METHODS We report a case of SSc and RP that had bilateral benefits from unilateral digital sympathectomy. A computer-assisted Medline/PubMed search of the medical literature was performed for 1960 through June 2009 using the keywords sympathectomy, Raynaud's phenomenon, systemic sclerosis, CREST, and digital ulcers. These searches were also combined with text words unilateral, ipsilateral, bilateral, digital sympathectomy, selective sympathectomy, autonomic nervous system, hyperhidrosis, etiology, pathogenesis, hypothesis, and treatment. Only pertinent literature, primarily in the English language, was included. RESULTS The majority of patients with SSc have RP and many suffer from digital ulcerations. Medical and behavioral management may have limited benefit and surgical intervention can be considered in recalcitrant cases, although efficacy data are sparse. We describe a man with limited SSc who underwent unilateral digital sympathectomy but manifested bilateral benefit. To our knowledge, this is the first published report of contralateral response with this procedure. The patient ultimately demonstrated these digital benefits when stressed with extreme cold and hypoxia while mountaineering. Despite the onset of high-altitude sickness and cerebral edema, his fingers remained unaffected while other mountaineers sustained severe frostbite or died of hypothermia. CONCLUSIONS Selective unilateral sympathectomy in SSc, for RP with digital ulcerations, can result in bilateral benefits despite intense challenge with cold and hypoxia.
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Affiliation(s)
- Amy Wasserman
- Division of Rheumatology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA 90095-1670, USA
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Zhang B, Li Z, Yang X, Li G, Wang Y, Cheng J, Tang X, Wang F. Anatomical variations of the upper thoracic sympathetic chain. Clin Anat 2009; 22:595-600. [PMID: 19418453 DOI: 10.1002/ca.20803] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The aim is to clearly delineate the upper thoracic sympathetic chains and neural connections between the chains and ventral rami of the thoracic nerves, and to provide an anatomical foundation for successful upper thoracic sympathicotomy for treating upper essential hyperhidrosis. The upper thoracic sympathetic chains, upper five intercostal nerves, and neural connections between them in 50 halves of 25 adult cadavers have been dissected, measured, and mapped. The stellate ganglion had an incidence of 80%. The second to the fourth thoracic sympathetic ganglia were commonly located in the corresponding intercostal spaces with the presence of 92%, 68%, and 50%, respectively. The incidence of the first and second intercostal rami was 40% and 6%, and that of the ascending or descending rami from the second, third and fourth ganglia was 54%, 24%, and 14%, respectively. Additional rami communicantes joined the ventral ramus of the 1st thoracic nerve proximal to the point where the latter gave a branch to the brachial plexus. The farthest horizontal distance from the sympathetic chain to the junction between the additional rami communicantes and the second to the fourth intercostal nerves was 29.1 mm. Only 16% of cadavers had similar anatomy bilaterally. Anatomical variations of the upper thoracic sympathetic trunk in relation to intercostal nerves, which may be one of the causes resulting in surgical failures and recurrences, were striking. Attention should be given to such anatomical variations when planning thoracic sympathicotomy.
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Affiliation(s)
- Bensi Zhang
- Department of Anatomy, Faculty of Basic Medicine, Dali University, Dali, Yunnan Province, China.
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Marhold F, Izay B, Zacherl J, Tschabitscher M, Neumayer C. Thoracoscopic and anatomic landmarks of Kuntz's nerve: implications for sympathetic surgery. Ann Thorac Surg 2009; 86:1653-8. [PMID: 19049766 DOI: 10.1016/j.athoracsur.2008.05.080] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Revised: 05/19/2008] [Accepted: 05/21/2008] [Indexed: 11/18/2022]
Abstract
BACKGROUND Kuntz's nerves (KN) have been blamed for surgical failures of endothoracic sympathectomy. The prevalence of these fibers, however, varies between the surgical (about 10%) and anatomic literature (about 80%). This clinically orientated cadaveric study was conducted to explain this discrepancy, to reveal possible reasons for the low thoracoscopic detection rate, and to define anatomic structures as possible landmarks of KNs. METHODS Video-assisted thoracoscopy was performed in 33 thoracic cavities of fresh human cadavers within 48 hours postmortem, followed by anatomic dissection of the first intercostal space. Kuntz's nerves and concomitant blood vessels were of special interest. Statistical analysis included frequencies and chi(2) tests. RESULTS Kuntz's nerves were identified in 12.1% by thoracoscopy, whereas anatomic dissection revealed KNs in 66.7% (p = 0.003). Subpleural veins (mean diameter, 2.2 +/- 0.9 mm) parallel to KNs were found in 81.8%. No collateral arteries were identified. Diameters of KNs were 1.4 +/- 0.7 mm; distances between the first thoracic ganglion and the middle of KNs were 9.7 +/- 3.0 mm. Thoracoscopic recognition of these Kuntz veins was higher than that of KNs (62.5% vs 18.2%, p < 0.005). CONCLUSIONS The low thoracoscopic detection rate of KNs may be due to the low color contrast of these small fibers. They have, however, most frequently concomitant subpleural veins that are easier to detect. These veins may serve as orientation landmarks of KNs and thus contribute to a more complete denervation improving the outcome of thoracoscopic sympathectomies.
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Affiliation(s)
- Franz Marhold
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
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Kopelman D, Hashmonai M. The correlation between the method of sympathetic ablation for palmar hyperhidrosis and the occurrence of compensatory hyperhidrosis: a review. World J Surg 2009; 32:2343-56. [PMID: 18797962 DOI: 10.1007/s00268-008-9716-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Upper dorsal sympathectomy achieves excellent long-term results in the treatment of primary palmar hyperhidrosis. Compensatory hyperhidrosis (CHH) remains an unexplained sequel of this treatment, attaining in a small percentage of cases disastrous proportions. It has been claimed that lowering the level of sympathectomy (from T2 to T3 and even T4), substituting resection by other means of ablation, and limiting its extend reduce the occurrence of this sequel. This review was designed to evaluate the validity of these claims. METHODS A MEDLINE search was performed for the years 1990--2006 and all publications about thoracoscopic upper dorsal sympathectomy for hyperhidrosis were retrieved. RESULTS The search identified 42 techniques of sympathetic ablation. However, pertinent data for the present study were reported for only 23 techniques with multiple publications found only for 10. The only statistically valid results from this review point that T2 resection and R2 transection of the chain (over the second rib) ensue in less CHH than does electrocoagulation of T2. Further comparisons were probably prevented due to the enormous disparity in the reported results, indicating lack of standardization in definitions. CONCLUSIONS The compiled results published so far in the literature do not support the claims that lowering the level of sympathetic ablation, using a method of ablation other than resection, or restricting the extend of sympathetic ablation for primary palmar hyperhidrosis result in less CHH. In the future, standardization of the methods of retrieving and reporting data are necessary to allow such a comparison of data.
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Affiliation(s)
- Doron Kopelman
- Department of Surgery B, Ha'emek Hospital, Afula, Israel
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Weksler B, Luketich JD, Shende MR. Endoscopic Thoracic Sympathectomy: At What Level Should You Perform Surgery? Thorac Surg Clin 2008; 18:183-91. [DOI: 10.1016/j.thorsurg.2008.01.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Singh B, Ramsaroop L. Upper limb sympathectomy: a historical reappraisal of the surgical anatomy. Clin Anat 2007; 20:863-7. [PMID: 17948288 DOI: 10.1002/ca.20549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- B Singh
- Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Congella, South Africa.
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36
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Ramos R, Moya J, Macia I, Morera R, Escobar I, Perna V, Rivas F, Masuet C, Saumench J, Villalonga R. Anatomical redistribution of sweating after T2–T3 thoracoscopic sympathicolysis: a study of 210 patients. Surg Endosc 2007; 21:2030-3. [PMID: 17353981 DOI: 10.1007/s00464-007-9262-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2006] [Revised: 11/12/2006] [Accepted: 12/01/2006] [Indexed: 11/25/2022]
Abstract
BACKGROUND The cutaneous influence areas of the different sympathetic ganglia have not been fully established to date. The aim of this study was to define the cutaneous influence area of sympathetic ganglia T2-T3. METHODS A total of 210 patients with primary hyperhidrosis (PH) underwent 420 thoracoscopic sympathicolysis procedures of ganglia T2-T3 in a prospective study. All completed a preoperative questionnaire and a second questionnaire 12 months after the operation. The questionnaires evaluated perspiration in the different body areas. Only the zones of anhidrosis were considered in delimiting the cutaneous expression of sympathetic ganglia T2-T3. RESULTS Redistribution of perspiration as reported by the patients comprised significant reduction in the palms, axillas, and soles, and an increase in the abdomen, back, and gluteal and popliteal regions. Regarding the incidence of anhidrosis by anatomical location, statistically significant changes were recorded in the head, hands, axillas, and soles (p < 0.001). CONCLUSIONS Bilateral upper thoracic sympathicolysis is followed by redistribution of body perspiration, with a clear decrease in the zones regulated by mental or emotional stimuli, and an increase in the areas regulated by environmental stimuli, though we are unable to establish the etiology of this redistribution.
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Affiliation(s)
- R Ramos
- Department of Thoracic Surgery and Unit of Human Anatomy and Embryology, Hospital Universitari de Bellvitge, School of Medicine, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain.
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Singh B, Ramsaroop L, Partab P, Moodley J, Satyapal KS. Anatomical variations of the second thoracic ganglion. Surg Radiol Anat 2005; 27:119-22. [PMID: 15800733 DOI: 10.1007/s00276-004-0304-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2003] [Accepted: 09/04/2004] [Indexed: 11/28/2022]
Abstract
In recent years the second thoracic ganglion has gained anatomical significance as an important conduit for sympathetic innervation of the upper extremity. Thoracoscopic excision of the second thoracic ganglion is now widely recognized as affording the most effective treatment option for palmar hyperhidrosis. This study recorded the incidence, location and associated additional neural connections of the second thoracic ganglion. Bilateral dissection of 20 adult cadavers was undertaken, and all neural connections of the second thoracic ganglion were recorded. Nineteen cadavers (95%) demonstrated additional neural connections between the first thoracic ventral ramus and second intercostal nerve. These were classified as either type A (47.5%) or type B (45%) using the intrathoracic ramus (nerve of Kuntz) between the second intercostal nerve and the ventral ramus of the first thoracic nerve as a basis on both right and left sides. The second thoracic ganglion was commonly located (92.5%) in the second intercostal space at the level of the intervertebral disc between the second and third thoracic vertebrae. Fused ganglia between the second thoracic and first thoracic (5%) and stellate (5%) ganglia were noted. These findings should assist the operating surgeon with a clear knowledge of the anatomy of the second thoracic ganglion during thoracoscopic sympathectomy with a view to improving the success rate for upper limb sympathectomy.
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Affiliation(s)
- B Singh
- Department of Surgery, Faculty of Health Sciences, Nelson R. Mandela School of Medicine, University of Kwa-Zulu Natal, PO Box 17039, 4013 Durban, South Africa
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Satyapal KS, Singh B, Partab P, Ramsaroop L, Pather N. Thoracoscopy: a new era for surgical anatomy. Clin Anat 2004; 16:538-41. [PMID: 14566905 DOI: 10.1002/ca.10174] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In this new era of minimal access surgery, advances in optics and illumination have established thoracoscopic sympathectomy as a pre-eminent procedure, including a safe and efficient technique for upper limb sympathectomy. The success of thoracoscopy will doubtless ensure that a greater number of these procedures will be carried out and will put some of the daunting technical challenges posed by traditional open surgical procedures to rest. The thoracoscopic era affords the surgical anatomist a new challenge: to move the teaching of living anatomy to a higher level.
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Affiliation(s)
- K S Satyapal
- Discipline of Anatomy, School of Basic and Applied Medical Sciences, University of Durban-Westville, Durban, South Africa.
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Ramsaroop L, Singh B, Moodley J, Partab P, Pather N, Satyapal KS. A thoracoscopic view of the nerve of Kuntz. Surg Endosc 2003; 17:1498. [PMID: 12802663 DOI: 10.1007/s00464-002-4555-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2002] [Accepted: 12/19/2002] [Indexed: 10/26/2022]
Abstract
The nerve of Kuntz and alternate neural pathways (ANPs) have long been considered crucial for upper limb sympathetic supply. However, at thoracoscopy, these structures are neither consistently identified nor searched for. This is probably reflective of the effectiveness of an isolated second thoracic ganglionectomy for upper limb sympathectomy. We present the case of a 19-year-old male who underwent a second thoracic ganglionectomy for palmar hyperhidrosis. On the left side, approximately 2.5 cm lateral to the typically located sympathetic chain, a filamentous structure (one-quarter the diameter of the sympathetic chain), identified as the nerve of Kuntz, was noted coursing across the neck of the second rib.
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Affiliation(s)
- L Ramsaroop
- Discipline of Anatomy, School of Basic and Applied Medical Sciences, University of Durban-Westville, Private Bag X54001, Durban, 4001, South Africa
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