sympathectomy for pain

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C H A P T E R 195

Sympathectomy for PainANTONIO A. F. DE SALLES JOHN PATRICK JOHNSON

The popularity of surgical sympathectomy for thetreatment of pain has decreased over the years. Thisreduction reflects the improvement of medical man-agement and the development of less invasive andnondestructive surgical techniques: radiofrequency

percutaneous sympathectomy and dorsal column stim-ulation.13 The invasive nature of thoracic or lumbarsympathectomy, requiring thoracotomy, posteriorcostotransversectomy, large retroperitoneal dissection,or laparotomy, has made this approach less desirablefor treating mild cases of sympathetic-mediated pain(SMP). Severe cases of causalgia that failed to respondto all less invasive treatments are the ones that stillundergo the large, invasive approaches to the sympa-thetic chain. There is great interest in the endoscopicapproach to the sympathetic nervous system.46 In 1994,a symposium dedicated to thoracic endoscopic sympa-thectomy summarized the main clinical issues andtechnical advances of this technique.7 The thoracic and

lumbar sympathetic ganglia can be readily visualizedand severed or electrocoagulated through minimal inci-sions with the use of several endoscopic ports. Thischapter discusses the historical landmarks, rationale,results, and latest techniques for surgery of the sympa-thetic system to curtail SMP.

HISTORY

Claude Bernard and Brown Sequard described thephysiology of the sympathetic nervous system in 1852.Bernard showed that the removal of the stellate gangliain rabbits led to an increased temperature in that sideof the animals face, contrary to his own theory thatthe temperature should decrease. Gaskell and Langleymapped the sympathetic ganglia distribution, althoughin a rudimentary fashion, in 1859. The true segmentaldistribution of the sympathetic nervous system becameavailable only much later.4 When surgeons becameaware of the anatomic distribution and physiologicconsequences of this curious system, their creativeminds found numerous reasons to surgically intervenein the sympathetic nervous system.8 In 1889, Alexanderperformed the first cervical sympathectomy for thetreatment of epilepsy.9 The result was marginal, as were

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the results of several other surgical interventions inthe sympathetic system. Jaboulay and Jonnesco triedstellectomy for treatment of exophthalmic goiter in1896.10 Other applications with marginal results weredescribed in the late 1800s and early 1900s, including

glaucoma in 1889, trigeminal neuralgia in 1902, opticalnerve atrophy in 1905, and angioma of the externalcarotid artery in 1917.9

Leriche, the famous French vascular surgeon, dedi-cated his research to the enervation of large arteriessuch as the femoral and axillary arteries. He was inter-ested in surgical procedures to improve peripheral vas-cular insufficiency. He was a student of Jaboulay, whoin the late 1800s described the stripping of large arter-ies from their nerve supply to improve distal circula-tion. Leriche found that sympathectomy was a moreeffective procedure than artery denervation.11 Vascularsurgeons treating peripheral vascular insufficiencylargely used this procedure. Two Australian scientists,

Royle and Hunter, believed that sympathectomy im-proved spasticity. They thought that sympathetic fibersmaintained skeletal muscle tonus.8 Their work becamewidely know, but their results could not be repro-duced.12 The interest on the physiology of the sympa-thetic nervous system was greatly enhanced by thetheory of Royle and Hunter. The clinical observationsof Royle and Hunter were important to support thevascular effects of sympathectomy.

Similar to the operation of Royle and Hunter, an-other application of sympathectomy that fell into dis-use was for the treatment of arterial hypertension byresection of the splanchnic plexus.13, 14 Sympathectomywas settled as a treatment of peripheral vascular dis-

ease. In 1925, Adson and Brown described the posteriorapproach for removal of the second thoracic sympa-thetic ganglion. Davis and Kanavel reported the ante-rior approach to the upper thoracic sympathetic chainin the same year.8 Atkins developed the transaxillaryapproach in 1954.15 After 1920, sympathectomy alsogained acceptance for treatment of hyperhidrosisthrough the work of Kotzareff.9 Cloward16 describedthe dorsal midline approach to both sides of the sym-pathetic chain in 1969, and the approach gained popu-larity among neurosurgeons. After Wilkinson17 de-scribed the fluoroscopic approach to the thoracic


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sympathetic chain, Adler and coworkers18 described thecomputed tomography (CT)guided approach. Chuangand colleagues18 described a stereotactic approach tothe upper thoracic ganglia for treating hyperhidrosis.

In 1928, Spurling19 resected the stellate and first tho-racic ganglion for the treatment of causalgia of theupper extremity resulting from a partial lesion of theaxillary artery by a gunshot wound. He hypothesized

that vascular insufficiency of the arm led to the painand that posterior sympathectomy as described by Ad-son and Brown improved the circulation and pain.19

Since then, the treatment of causalgia and sympatheticdystrophy with sympathectomy has been encouraging.Rates of 59% to 74% for excellent results and of 9%to 17% for fair control of pain have appeared in theliterature.2022 The term causalgia was derived from twoGreek words, kausos, meaning heat, and algos, meaningpain.23 The term describing burning pain was coinedfrom the work of Weir Mitchell24 because of his detaileddescription of the syndrome after major nerve injuriesidentified during the United States Civil War, althoughPare probably described the first case of causalgia inthe 16th century.

NOMENCLATURE

Several terms have been used to describe pain relatedto the sympathetic nervous system, such as reflex sym-pathetic dystrophy, causalgia, and SMP. An organizednomenclature for the pain phenomenon is necessary toallow comparison of treatment results and to defineappropriate treatment for the various forms of painrelated to the sympathetic nervous system. The termsympathetic-mediated pain, introduced by Roberts in1986, is a general term indicating that surgery on thesympathetic nervous system may lead to importantcontrol of the patients chronic pain.25 The term reflexsympathetic dystrophy, describing a chronic pain syn-drome of a limb out of proportion in severity to theoriginal injury and implying sympathetic hyperactivity,became widely popular and often has been used in aninconsistent and misleading fashion.26 The same fatehas ensued for facial pain syndromes that are difficultto treat and that do not fall in the recognized diagnosesof facial pain such as trigeminal neuralgia, clusterheadaches, and anesthesia dolorosa. Certain types offacial pain also may be included in the category ofreflex sympathetic dystrophy,27 but facial pain syn-dromes are not included in the classification of com-plex regional pain syndrome.

A consensus workshop in 1993 suggested the termcomplex regional pain syndrome (CRPS).26 It describes avariety of painful situations that follow injury, appearregionally, have a distal predominance of abnormalfindings, exceed in magnitude and duration the ex-pected clinical course of the inciting event, often resultin significant impairment of motor function, and showvariable progression over time. CRPS is further dividedinto CRPS type I, which traditionally was referred toas reflex sympathetic dystrophy, and CRPS type II,

previously known as causalgia. The only differencebetween them is that type II has a known nerve injury.

Clinically, it is useful to define whether the CRPS isdependent or independent of the sympathetic activity.The terms SMP and sympathetic-independent pain(SIP) complement the term CRPS. Sympathectomy canhelp only patients with SMP and is contraindicatedfor patients with sympathetic-independent pain. The

challenge for the clinician is to determine whether aparticular patient with CRPS has SMP and, if so, prop-erly select patients for clinical or surgical treatment.For the purpose of this chapter oriented to the surgicalapproach, SMP is widely used, leaving the terminologyof CRPS for situations in which it becomes necessary.

PATHOPHYSIOLOGY OFSYMPATHETIC-MEDIATED PAIN

The pathophysiology of SMP is poorly understood.Some theories suggest ephaptic transmission betweensomatic afferents and sympathetic efferents at the levelof the spinal cord, leading to the release of chemicalmediators known to cause pain in inflammatory reac-tions, such as substance P, prostaglandin, and bradyki-nin. These substances produce the classic symptoms ofvascular instability and temperature changes.2831 Sup-porting this theory, the results of dorsal column stimu-lation in suppressing SMP appear to occur because ofstimulation-induced suppression of efferent sympa-thetic hyperactivity.2, 32, 33 Conversely, an experiment ofelectrical stimulation of distal sympathetic stumps aftersympathectomy for SMP reproduced presympathec-tomy pain.34 This classic, well-controlled experimentin humans with stimulation of the sympathetic chainbetween the second and third thoracic sympatheticganglia reproduced symptoms of SMP such as burning,tingling, and pricking sensations in the fingers, hand,or arm. Before the sensation of discomfort, subjectscould observe a pilomotor response over the entirearm and shoulder. After stimulation, a chronic achingsensation lasted for 24 hours. Patients undergoing sym-pathectomy for causalgia appear to have more of apainful response to stimulation than patients undergo-ing sympathectomy for other causes.34

Leriche35 developed the vicious cycle hypothesis toexplain causalgic pain, and Livingstone expanded it.36

Self-sustained, abnormal firing of loops in the dorsalhorn provoked by an irritative focus in small nerveendings or major nerve trunks activates central projec-tion fibers, leading to pain. Others also embraced thistheory, and the popular reflex sympathetic dystrophydenomination came to be. Resolution of pain with sym-pathetic blocks gives support to this theory. Bonica37

gave further support to this approach with his detailedaccounts of the syndrome variables and with specialemphasis on objective assessment of the efficacy ofblock techniques. Taken together, the studies of dorsalcolumn stimulation and stimulation of stumps of sym-pathectomized patients, as well as the results of sympa-thectomy and sympathetic blocks, support the hypoth-esis of ephaptic hyperactivity at the level of dorsal


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Chapter 195 Sympathectomy for Pain 3095

horn between sensory afferent and sympathetic effer-ent elements.

DIAGNOSTIC ASSESSMENTS ANDPATIENT EVALUATION

Clinical DiagnosisSMP must be differentiated from chronic pain syn-dromes with similar features but different maintainingfactors, such as secondary gain, psychological prob-lems, viral infections, neuropathic processes, and pe-ripheral nerve injury. True SMP implies that, despitemultiple triggering events in the pain syndrome, anabnormal response of the sympathetic system mediat-ing the pain can be documented. Although the clinicalfeatures of advanced cases of causalgia are easily iden-tifiable, mild cases are difficult to diagnose. Classically,SMP is associated with burning pain hypersensitivityin the distribution of the injured somatic nerve, signsof autonomic imbalance, and ultimately secondary tro-phic changes. Many patients do not have an identifi-able trauma triggering sympathetic dystrophy. In alarge series, 10% of the patients were diagnosed ashaving sympathetic dystrophy without a previous his-tory of trauma.38 This pattern has also been largelyidentified in smaller series.20 Sudecks atrophy and Su-decks syndrome focus on the associated osteoporosisobserved in late cases, an inconsistent finding that mayresult from a neurovascular reflex or disuse. Numerousmanifestations of the disorder by different causes andin different regions of the body have been reported. 3,27, 3942

The onset and progression of the SMP syndromeshave been divided in three stages. Stage I (i.e., early oracute) is characterized by constant, intense, and burn-ing pain that is disproportionate to the injury and thatis accompanied by vasomotor instability, edema, andswelling. Stage II (i.e., intermediate or dystrophy) ischaracterized by severe pain with skin sensitivity, shinyand discolored skin, and dystrophic nails. Stage III (i.e.,late or atrophic) shows signs of wasting, atrophy ofskin and subcutaneous tissues, stiffness of joints, andosteoporosis.38, 43

Wilkinson 44 mentioned several sympathetic painsyndromes. He grouped them as syndromes with prin-cipally SMP but little dystrophy or vasculopathy, in-cluding minor causalgia, shoulder-hand syndrome, and

T A B L E 1 9 5 1 Summary of 112 SympathectomyProcedures in Which Unilateral andBilateral Approaches Were Used in65 Patients

NO. OF NO. OFAPPROACH PATIENTS PROCEDURES

Unilateral 20 22Bilateral (staged) 11 22Bilateral (same day) 34 68

diabetic burning foot syndrome; syndromes with sig-nificant dystrophy and variable SMP, including majorcausalgia, reflex sympathetic dystrophy, and Sudecksatrophy; and syndromes with significant vasculopathyand variable SMP, including vasospasm of postacutevascular occlusion, peripheral occlusive vasculopathy,vasospastic vasculopathy such as Raynauds syn-drome, and Prinzmetals angina.17, 44

The clinical diagnosis of SMP must be always con-firmed by an objective test, usually relief of pain withsympathetic blockade.

Laboratory Tests

Although SMP is a clinical diagnosis confirmed withnerve block, certain laboratory studies may be confir-matory. Thermography may reveal a temperature dif-ference between extremities or regions in the sameextremity. Regular radiographs of the extremity inquestion may show patchy demineralization of epiphy-ses and the short bones of the hands and feet.45, 46 Softtissue swelling may be detected. In advanced phasesof the disease, fine-detail x-ray films show subperios-teal bone resorption, striation, and tunneling in thecortices, as well as large excavations and tunneling ofthe endosteal surface.47, 48 These changes are not specificfor SMP; they may occur in hyperparathyroidism, thy-rotoxicosis, and other conditions associated with rapidbone turnover.49, 50

A bone scintilogram usually reveals increased peri-articular uptake in the involved limb, and higher sensi-tivity may be achieved with triple-phase bone scan.5153

Kozin and collegues54 compared the sensitivity andspecificity of radiographs and scintilography in casesof reflex sympathetic dystrophy. The specificity of ra-diographs was 71% and that of scintilography was86%. The sensitivity of radiographs was 69% and thatof scintilography was 60%.54 Magnetic resonance im-aging (MRI) has been described as a more sensitivestudy than radiographic examination and radionuclideassessment for detection of changes in the bones ofpatients with SMP. It also has the advantage of de-tecting soft tissue changes such as edema and muscleatrophy. MRI allows a differential diagnosis betweenSMP and other bone lesions.55 Doppler flow studiesand plethysmography may also be used as adjunctivestudies, but they are not always reliable.56

Although the blood flow through the affected ex-tremity tends to be lower than the normal extremity instress conditions, in a warm and resting environment,the temperature of the affected extremity tends to ap-proach that of the normal extremity.56 Jeng and associ-ates57 observed an increase in cerebral blood flow afterT2 sympathectomy, and they suggested the possibilityof using such a surgical approach to improve cerebralblood flow in patients with cerebral vascular insuffi-ciency.

Patient Selection

Not all patients with SMP require sympathectomy.Early and frequent use of sympathetic blockade may


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carry the patient through a milder and self-limitedepisode of causalgic pain.58 Other clinical measures ofcontrolling pain must be exhausted before consideringsympathectomy. Withholding surgery too long, how-ever, my decrease chances of complete pain relief af-forded by a sympathectomy. The patients must have areliable and objective response to regional sympatheticblock encompassing the affected extremity. Good pain

relief with sympathetic nerve block confirms that thecomplex regional pain is mediated by the sympatheticnervous system. Blockade of 1-adrenergic receptorsby intravenously administered phentolamine correlateswith subjective pain relief.59 Use of saline as a placebocontrol minimizes the chance of a false response, andobjective findings such as temperature change shouldbe documented.60 Bier block with guanethidine can beemployed to provide regional sympathetic blockade.61

Guanethidine displaces norepinephrine in presynapticvesicles and prevents its reuptake. Reserpine also de-pletes norepinephrine stores by interfering with itsstorage, and it can be administered intra-arterially toachieve regional block.49, 50

Paravertebral sympathetic block is the most widelyused diagnostic and therapeutic modality for SMP.62, 63

For upper extremity pain, the target is the stellateganglion, which is readily accessible percutaneously.Although the sympathetic innervation to the arm ismainly from T2, anesthetic agents readily diffusethrough paravertebral space to block the sympatheticoutflow to the arm.64 The lower extremity sympatheticoutflow can be blocked at L2 and L3 levels, sources formost of the sympathetic innervation for the legs. Re-sults of the blockade must be carefully evaluated clini-cally by observing for Horners syndrome when theupper extremity is blocked and for changes in skintemperature and color when the upper or lower ex-tremity is blocked. Objective changes in temperatureand blood flow to the skin can be detected by carefulmeasurements.56 Patients must remain naive of the re-sult expected, and placebo must be used when there issuspicion of secondary gain. The visual digital scalemust be used as a hard record of the effects of thesympathetic blockade. Patients with unequivocal painrelief with sympathetic blockade are sympathectomycandidates.

SURGICAL TREATMENT

There are several approaches for upper thoracic andlower cervical sympathectomy and fewer options forsplanchnic and lumbar sympathectomy. The transaxil-lary and posterior paravertebral approaches are advo-cated by a few authorities for exposure of the upperthoracic and lower cervical ganglia. The most accept-able open procedure is the modification of MacKaysparavertebral approach described in 1955.65 Cloward66

described a similar approach in 1957. This approachhas the advantage of bilateral exposure through a sin-gle incision. It provides a more direct exposure of thesympathetic ganglia and their rami communicantes.16

The retroperitoneal flank approach is predominantlyused for the lumbar chain, and the splanchnic chain

is reached by means of a lower thoracic paramedianincision. This surgery involves rib removal and retrac-tion of the pleura.12 These procedures are frequentlytoo invasive for the patients symptoms, which is whyminimally invasive approaches to the sympathetic gan-glia are becoming prevalent. This section discusses en-doscopic approaches to the lower cervical, upper tho-racic, and lumbar sympathetic ganglia. The splanchnic

procedure is usually indicated for very debilitated pa-tients with cancer pain who are being treated mostlymedically or with phenol injection of the splanchnicchain.12

Thoracoscopic Sympathectomy

Jacobaeus67 first performed thoracic endoscopic proce-dures in 1910 for the diagnosis of pulmonary tubercu-losis and neoplastic diseases. Thoracoscopic sympa-thectomy procedures were originally described byHughes11 in 1942 and Kux61 in 1951, using a uretero-scope for the treatment of hyperhidrosis. Jacobaeus67

reported a series of more than 1400 endoscopic proce-

dures. There was little interest in this technique untilrecently.6, 6874 Minimally invasive treatment of sympa-thetic-mediated syndromes affecting the extremitieswith endoscopic techniques has expanded because ofthe refinement of techniques and clarification of theindications and applications.69, 7173, 7577 The most com-mon indications for thoracic sympathectomy includehyperhidrosis, SMP syndromes, Raynauds syndrome,postamputation syndrome (i.e., phantom pain), andrefractory cardiac tachyarrhythmias. Percutaneoussympathectomy procedures have limited efficacy, andthe long-term successes are not optimal.17, 68 Thoraco-scopic resection of the sympathetic ganglia appears tohave a lower incidence of morbidity than open thora-

cotomy or a posterior paraspinal approach. This resultmay reflect the magnified endoscopic view of the sym-pathetic chain and adjacent anatomy, leading to a moreprecise resection.6, 28, 74, 78 Subsequently, patient demandand improved satisfaction due to shortened hospitalstay with reduced costs and morbidity made minimallyinvasive thoracoscopic sympathectomy an attractivechoice for treatment of SMP syndromes of the upperextremities.

INDICATIONS

The thoracoscopic paraspinal approach is useful forsympathectomy and for biopsies and thoracic spinal

work. Besides the indications of sympathectomy forSMP, the most common indications for sympathectomyusing the endoscopic approach are discussed.

SympatheticMediated Pain Syndrome

Constant burning pain and atrophic skin changes inthe extremity are typical signs and symptoms of SMPsyndromes. Medical therapy with narcotics, neurolep-tics, or anticonvulsants usually has only limited useand temporary benefit. Similarly, stellate blocks pro-vide temporary relief, allowing the patient to pursuerehabilitation in an attempt to resolve the problem. A


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T1-4 sympathectomy provides good initial relief, butthere is a variable rate of recurrence that is difficult topredict.20, 49, 62

Vasculitis and Raynauds Syndrome

Ischemic vascular disorders have episodes of severe,painful skin blanching, primarily in the hands andfingertips, that are exacerbated by cold temperaturesor emotional response. Extreme cases may cause ische-mic and gangrenous ulceration of the digits. The initialtreatment is avoidance of cold and use of -adrenergicmedications that are effective for less severe cases.Refractory cases may achieve good initial relief fromsympathectomy, but the long-term results may besomewhat less optimal.6, 78, 79

Cardiac Arrhythmia

Malignant tachyarrhythmias may result from stressand sympathetic imbalance due to disproportionateleft-right sympathetic outflow.72, 80 A right stellate gan-glion block coupled with left stellate ganglion stimula-

tion lengthens the QT interval on the electrocardio-gram, and conversely, a left stellate ganglion blockwith right stellate ganglion stimulation shortens theQT interval. Accordingly, a left T1-4 sympathectomyproduces a -adrenergic effect that shortens the QTinterval and may reduce the incidence of medicallyrefractory tachyarrhythmias associated with danger-ous, prolonged QT interval syndromes. Despite thiscardiac function, the hemodynamics and catecholamineconcentrations may not be altered significantly aftersympathectomy.57, 80, 81

FIGURE 1951. Supine positioning of the patient undergoing sequential bilateral thoracoscopicsympathectomies. Right and left selective bronchi intubation is performed during the operation oneach side.

Hyperhidrosis

Palmar and axillary hyperhidrosis is the primaryindication for thoracoscopic sympathectomy. Hyper-hidrosis is characterized by excessive sweating, primar-ily in the hands, that is exacerbated by minor stressessuch as handshaking. The cause is unknown. Hyper-hidrosis has an incidence of approximately 1% in West-

ern populations, but the incidence may be higher inAsian populations.68 The sympathetic nervous systeminnervates eccrine sweat glands through cholinergicnerve fibers arising from the intermediolateral columnof the thoracic and upper lumbar spinal cord. Increasedsympathetic tone results in vasoconstriction, and skincooling exacerbates the excessive sweating.16, 78, 80 Stel-late ganglion blocks result in temporary drying anddecreased sweating in the ipsilateral hand and armpit.The warming effect is caused by increased blood flowthrough cutaneous arteriovenous fistulas and choliner-gic blockage. Resection of the T2-3 sympathetic gangliathat provide sympathetic innervation to the upper ex-tremity through the lower trunk of the brachial plexus

provides lasting relief from hyperhidrosis.16

Details ofthis syndrome and surgical approaches are discussedelsewhere in this volume.

SURGICAL AND ANESTHETIC CONSIDERATIONS

Endoscopic thoracic sympathectomy procedures re-quire an anesthesiologist and operating room staff fa-miliar with thoracic endoscopy. Double-lumen endotra-cheal tube placement for contralateral lung ventilationand ipsilateral lung deflation is essential. The patient


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FIGURE 1952. Lateral positioning of the patient undergoing right thoracoscopic sympathectomy isthe same as for a thoracotomy. Notice the exposure of the axillary region, including the upperintercostal spaces, which are important for the endoscope and instrumentation portals.

is positioned supine for bilateral thoracoscopic proce-dures (Fig. 1951), and the lateral decubitus position(Fig. 1952) can be used for unilateral procedures. Theoperating table positioning is important to allow thelung to fall away from the upper thorax and open theintercostal spaces for access into the thorax.

FIGURE 1953. View of the intrathoracic anatomy of the right upper thorax shows the location ofthe sympathetic ganglia and chain. Notice the subclavian artery and the first rib, landmarks fordetermination of the stellate ganglion.

Instruments

Thoracoscopic sympathectomy equipment and in-struments are similar to those used in general andobstetric-gynecologic procedures. A standard endo-scopic video-monitoring system with a 5- to 10-mm-


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diameter, rigid laparoscope is needed. Basic endoscopicsurgical instruments include 5-mm-diameter mini-Met-zenbaum scissors with monopolar electrocautery, a 10-mm-diameter curved hemostat, and a 5-mm-diametersuction-irrigator. Endoscopic vascular clips and a re-tractable fan-type retractor should be available ifneeded.

Ports and Port PlacementTwo or three ports are used to perform the sympa-

thectomy procedure. One port is for the endoscope,and one or two ports are for the instruments. Portinsertion is similar to chest tube placement, with a 2-cm skin incision and blunt dissection with a curvedhemostat over the rib into the thorax, avoiding theintercostal neurovascular bundle. The 15-mm-diameterports (Ethicon Flexi-path, Cincinnati, OH) are soft,flexible endoscopic cannulas inserted through the chestwall with an introducer. The anesthesiologist deflatesthe lung, and the first port is placed. The endoscope isplaced through the port in the fifth intercostal space inthe posterior axillary line. An instrument port is placedin the same fifth intercostal space. If another workingport is needed, it is placed in the fourth intercostalspace in the anterior axillary line.

Steps of the Procedure

The endoscope provides a panoramic view of theupper thoracic cavity, and the working ports can berearranged according to the surgeons preference (Fig.1953). A 0-degree endoscope usually provides goodvisualization for most sympathectomy procedures, butthe 30-degree endoscope lens occasionally is needed.Endoscopic exploration of the thoracic cavity is per-formed after the ports are placed, and any adhesionsto the parietal pleura are coagulated and divided,allowing the lung to be retracted. Additional lung re-traction can be accomplished by rotating or elevatingthe operating table so that the lung falls away from thevertebral column.

Important intrathoracic anatomic landmarks for asympathectomy are the first and second ribs. The sym-pathetic chain is a whitish, glistening, raised, longitudi-nal structure that courses over each rib head (see Fig.1953). The pleura overlying the sympathetic chainshould not be pressed excessively with endoscopic in-struments, because repetitive touch leads to pleuralhyperemia that obscures visualization of the chain. Thecephalad aspect of the sympathetic chain and limit ofthe surgical resection is the stellate ganglion. The stel-late ganglion is immediately below the subclavian ar-tery. Other major vascular structures, such as the azy-gous vein, subclavian veins, and the highest (supreme)intercostal artery and veins, should be avoided duringdissection of the sympathetic chain.

The sympathectomy begins with a pleural incisionover the sympathetic chain at T3 using curved scissorsand continuing cephalad above T2 but remaining shortof the inferior aspect of the stellate ganglion (Fig. 1954). The sympathetic chain is mobilized from T3 withscissors by dividing the rami communicantes at the T2-3 levels (Fig. 1955). It is important to maintain the

FIGURE 1954. Division of the rami communicants at each level(left) and division of the sympathetic chain at the inferior aspectof the stellate ganglion and T4 (right). Notice sectioning of thenerve of Kuntz, which is important to achieve sympathetic dener-

vation of the upper extremity, and preservation of the upper partof the stellate ganglion, which is important to avoid Hornerssyndrome.

FIGURE 1955. Detailed dissection of the rami communicantsfor complete release of the sympathetic chain to be removed.Notice the proximity to the intercostal vessels, which should beavoided during this dissection. The intercostal nerve must bepreserved to avoid postoperative chest wall deafferentation pain.


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T A B L E 1 9 5 2 Diagnosis of PatientsUndergoing ThoracoscopicSympathectomy

DISORDER NO. OF PATIENTS

Hyperhidrosis 48RSD/CRPS 12Raynauds syndrome 5

CRPS, complex regional pain syndrome; RSD, reflexsympathetic dystrophy.

dissection plane immediately beneath the sympatheticchain to avoid the underlying intercostal vessels. Ifbleeding is encountered, clip ligation or cautery of thevessel achieves the necessary meticulous hemostasis.Most intercostal vessels are small, but occasionally,they are enlarged or course over the sympathetic chainand require division.

A large ramus arising laterally from the T2 ganglionis the nerve of Kuntz, which is slightly larger than

other rami (see Fig. 1954). It provides important sym-pathetic innervation to the lower trunk of the brachialplexus.82 The nerve of Kuntz and the stellate ganglionare usually found beneath the fat pad that envelops thesubclavian artery (see Fig. 1953). The stellate ganglionshould remain undisturbed to avoid injury and possi-ble Horners syndrome. The dissected T2-3 sympa-thetic chain is then divided proximally and distallyand sent for histologic evaluation. The dissection bedis irrigated, and hemostasis is ensured. A 16-French(16F) chest tube is inserted and positioned endoscopi-cally through one of the ports. The instrument ports arethen removed, and the lung is re-inflated with positivepressure by the anesthesiologist. The port incisions are

closed in two layers using absorbable sutures and Steri-Strips. The operative procedure requires approximately1 hour, depending on the anatomic complexity of theindividual patient and the experience of the surgeon.

Postoperative Care

The chest tube is placed on 15 cm H2O of suctionuntil the patient reaches the recovery room, where thepatient is placed on a water-seal drainage system withsuction. A chest radiograph is obtained to ensureproper lung expansion, and one chest tube is removed,followed by a repeat chest radiograph. The procedureis repeated for the second chest tube. Pneumothorax isuncommon and requires chest tube replacement untilthe leak resolves. Oral analgesics are adequate for paincontrol, and the hospital stay is typically 1 or 2 days.

T A B L E 1 9 5 3 utcomes or 4 Patients with Hyperhidrosis

RELIEF OF PARTIAL RELIEF RECURRENT LOST TODISORDER SYMPTOM OF SYMPTOM SYMPTOMS FOLLOW-UP

Hyperhidrosis 47 1 0* 0

* Although no patients experienced recurrent palmar hyperhidrosis, 11 had mild compensatory sweating in the trunk,and 2 patients suffered gustatory sweating.

T A B L E 1 9 5 4 Patient Satisfaction andWillingness to Undergo a RepeatProcedure

PATIENT SATISFACTION WILLINGNESSDISORDER RATE (%) TO REPEAT (%)

Hyperhidrosis 96 98RSD/vasculitis 66 65

RSD, reflex sympathetic dystrophy.

Patients with chronic pain syndromes may require aslow taper of preoperative medications, which is man-aged on an outpatient basis.

OPERATIVE EXPERIENCE

Patient Population

The experience of the first 100 procedures performedat the University of CaliforniaLos Angeles (UCLA) is

presented. These data represent the use of moderntechnology and the learning curve resulting when us-ing the thoracic endoscopic approach. Sixty-five pa-tients underwent 112 thoracoscopic sympathectomyprocedures at UCLA Medial Center for sympathetic-mediated disorders between 1993 and 1999. The proce-dures were performed for unilateral or bilateral symp-toms. Twenty patients underwent unilateral proce-dures, and 11 patients with bilateral symptomsunderwent staged procedures several weeks apart inthe early part (19931995) of this series. In recent years,34 patients with bilateral symptoms had staged proce-dures on the same day (see Table 1951).

Outcome Analysis

The follow-up period was 6 months to 6 years, withassessment performed by a clinical examination or tele-phone interview, or both. An independent observercollected clinical outcome questionnaires, and a retro-spective analysis was performed. Patients with hyper-hidrosis were evaluated for the presence or absenceof sweaty palms, surgery-related complications, anddelayed-onset complications of compensatory hyper-hidrosis or gustatory sweating. Patients with pain dis-orders were evaluated with the Oswestry Pain Scale toquantify the severity of their preoperative and postop-erative symptoms. The incidence and severity of recur-rent pain symptoms were evaluated, and all patientswere questioned about their overall satisfaction andwillingness to undergo a repeat procedure.


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T A B L E 1 9 5 5 Outcomes for 17 Patients with Painand Vasculitis Disorders

NUMBER OF PATIENTS

Relief of Recurrence of Lost toDISORDER Symptoms Symptoms Follow-up

RSD/CRPS 7 4 1

Raynauds syndrome/vasculitis (5 patients) 4 1 0

CRPS, complex regional pain syndrome; RSD, reflex sympatheticdystrophy.

Results

Patients with hyperhidrosis were the largest grouptreated by thoracoscopic sympathectomy (Table 1952).They had very high success rates (Tables 1953 and1954), but they also had the highest complicationrates. Complications were usually related to compensa-tory hyperhidrosis manifested as sweating in the trunk

or torso. However, most patients were sufficiently satis-fied with the result, as indicated by their willingnessto repeat the procedure. Patients treated for pain syn-dromes or vascular disorders had a positive initialresponse to treatment (see Table 1952), however, out-comes were diminished for some patients after morethan 6 months by variable recurrence of symptoms(Tables 1955 and 1956; see also Table 1954). Theoverall satisfaction and willingness to repeat the opera-tive treatment was similarly decreased (see Table 1954). No patients had worsened pain symptoms aftersympathectomy. The hospital length of stay for thora-coscopic sympathectomy patients was usually 1 or 2days (Table 1957). The patients considered historicalcohorts at our institution who were treated with poste-rior paraspinal sympathectomies had a hospital lengthof stay that typically ranged from 3 to 6 days. Theoverall complication rates for thoracoscopic procedureswere also comparable with those of previous treatmentmodalities (Table 1958).

Complications

Complications from endoscopic sympathectomyprocedures are usually minor and self-limited. Horn-ers syndrome from injury to the stellate ganglion inthoracoscopic procedures occurred more often early inthe series, probably reflecting the learning curve for

T A B L E 1 9 5 6 utcomes or Pain and Vasculitis Disorders as Measured by the swestry Pain cale*

DISORDER PREOPERATIVE 1 MONTH POSTOPERATIVE 6 MONTHS POSTOPERATIVESTATUS STATUS (%) STATUS (%)

RSD/CRPS 42 92 65Raynauds

syndrome/vasculitis 51 96 88

* Oswestry Pain Scale score is derived from a 10-item questionnaire administered to each patient preoperatively and6 months postoperatively, with a scale of 1 to 100. Patient data are presented as a percentage of the mean.CRPS, complex regional pain syndrome; RSD, reflex sympathetic dystrophy.

T A B L E 1 9 5 7 Length of Stay after ThoracoscopicSympathectomy

UNILAT BILATSYMPATHECTOMY SYMPATHECTOMY

DURATION (DAYS) (DAYS)

Median 1 2Mean 1.5 1.8

Range 04 13

T A B L E 1 9 5 8 Postoperative omplications a terSympathectomy

COMPLICATION NO. OF PATIENTS

Horners syndromeTransient 7Permanent 1

Compensatory hyperhidrosis* 11Gustatory sweating 2Pneumothorax (requiring chest tube) 1

Pleural effusion (not requiring 4thoracocentesis or chest tube)Wound infection 1Intercostal neuralgia

Transient 3Permanent 1

Death 1

* Only patients with hyperhidrosis experienced compensatory sweatingsymptoms. An elderly patient with intractable Raynauds died. The patient suffered amyocardial infarction 1 month after an uncomplicated, unilateralsympathectomy.

endoscopic surgical techniques. Horners syndrome is

usually transient and rarely permanent. Endoscopicvisualization should minimize the incidence of Horn-ers syndrome, because only the rami caudal to thestellate that provide sympathetic innervation to theupper extremity are divided, with preservation of therostrally ascending fibers that innervate the ocular andpupillary muscles.49, 83 Intercostal neuralgia can resultfrom intercostal nerve injury during port placement orfrom pressure during the procedure. This problem hasbeen reduced with the use of soft, flexible ports and a5-mm endoscope. Hashmonai and colleagues76 citedthe lower incidence of intercostal neuralgia as the ma-jor difference between open supraclavicular and endo-scopic sympathectomy procedures; however, this re-


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Section VI Pain3102

port did not reflect the use of flexible ports and smallerinstruments.

Small pleural effusions do not require drainage butshould be followed with repeated chest radiographs.6,77, 83 Pneumothorax indicates a parenchymal or port-site leak. Most cases can be observed, although a largepneumothorax may require chest tube placement. Theone death that occurred in the series was several weeks

after surgery for severe Raynauds with significant pre-existing cardiovascular risk factors, and the patient wasdoing well after surgery.

Endoscopic Lumbar Sympathectomy

Open lumbar sympathectomy procedures have beenused effectively to treat lower extremity vasculitis andpain syndromes but are being supplanted by minimallyinvasive laparoscopic retroperitoneal techniques.84, 85

The most frequent indications for splanchnic sympa-thectomy procedures include lower extremity reflexsympathetic dystrophy (or CRPS) and Raynauds syn-drome. Pelvic and visceral pain syndromes have alsobeen treated with splanchnic sympathectomy, althoughless frequently. Similar to thoracoscopic sympathec-tomy, minimally invasive endoscopic techniques canreduce the surgical morbidity, hospital stay, and returnto activity due to small surgical incisions and reducedtissue injury.8688 A limited number of published reportswith small series suggest results similar to those foropen procedures, but reduced morbidity and hospital-ization are the major differences.1, 8991

PATIENT SELECTION

Patients with autonomic lower extremity pain syn-dromes require similar medical evaluation and man-

FIGURE 1956. Cross-sectional anatomy through the midlumbarlevel demonstrates where the retroperitoneal dissection occurs.Notice the expansion of the retroperitoneal space, with anteriordislocation of the kidney and lateral dislocation of the spleen.There is a direct approach to the anterolateral aspect of thevertebrae where the sympathetic chain is visualized. The patientis in the prone position.

FIGURE 1957. Lumbar retroperitoneal endoscopic exposure ofthe lumbar sympathetic chain for a sympathectomy. Notice thedirect reach of the sympathetic ganglia with this approach.

agement before consideration of a lumbar sympathec-tomy procedure. For most patients with lowerextremity pain syndromes, pelvic and lumbar imagingstudies are necessary to exclude other treatable disor-ders. Peripheral vascular abnormalities should be eval-uated with noninvasive methods or angiography toexclude treatable vascular lesions. Provocative testingwith anesthetic lumbar sympathetic blocks can provideconfirmation of diagnosis and useful predictive out-come assessment.

SURGICAL TECHNIQUE

The patient is placed in the prone position under gen-eral anesthesia, and ports are placed in the midaxillaryline at the level of the intended sympathectomy. Bluntdigital dissection is applied into the retroperitoneumto create an endoscopic working space with a balloontissue expander or direct carbon dioxide insufflation(Fig. 1956). Laparoscopic gas-tight ports are placedfor the endoscope and working ports. Exposure andresection of the lumbar sympathetic chain proceed in amanner similar to that for open procedures (Fig. 1957).

CONCLUSION

Minimally invasive endoscopic sympathectomy tech-niques have surgical goals that are similar to those foropen procedures with equivalent outcomes; however,the associated morbidity is substantially reduced be-cause of reduced tissue injury. We recommend thatsurgeons receive formal training for these procedures,including didactic and laboratory training, followed bywork with an experienced surgeon who performs theseoperations on a regular basis. These endoscopic proce-dures have learning curves that necessitate preciseknowledge of the anatomy and an understanding ofendoscopic surgical techniques.


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ACKNOWLEDGMENTS

We wish to thank Joe Bloch and Josh Emerson fortheir illustrations.

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