胸腔镜下交感神经链切断术治疗原发性手汗症疗效观察

目的观察比较胸腔镜下交感神经链切断术于T2及T3水平治疗原发性手汗症的治疗效果。方法应用电视胸腔镜交感神经链切断术治疗手汗症患者42例,其中25例行T2~4节段交感神经干切断术,17例行T3~4节段交感神经干切断术。术后1、6、12及24个月门诊及电话随访,观察患者手汗症复发情况及术后代偿性多汗的情况。结果全组术后手掌多汗症状立即消失,双手干燥温暖;术后3~6天出院,平均住院时间（4.1±0.8）天;无手术死亡和切口感染,术后随访期间无Horner s综合征出现,无复发病例;两种手术方式的代偿性多汗的发生率在各个观察期无明显差异（P〉0.05）;代偿性多汗严重程度在术后1个月随访时两组差异不明显,6个月及12个月时T2~4节段交感神经干切断术的代偿性多汗明显较T3~4节段交感神经干切断术严重（P〈0.05）。结论胸腔镜下交感神经干切断术治疗手汗症,术后无复发,T2切除节段及T3节段术后代偿性多汗情况无差异,但T2节段代偿性多汗较T3节段明显严重。     

Surgical sympathectomy of the heart in rodents and its effect on sensitivity to agonists

A new procedure for sympathetic denervation of the hearts of rats and guinea pigs is described. Bilateral removal of the inferior and medial cervical ganglia results in almost complete loss of catecholamines from atria and ventricles, disappearance of catecholamine-associated histofluorescence from the region of the sinoatrial node and marked depression of the chronotropic concentration-response curve for tyramine in right atria of both species. Seven days after bilateral sympathectomy, the chronotropic concentration-response curve for isoproterenol is shifted to the left by a factor of 3.3 in the rat and 1.7 in guinea-pig right atria. The chronotropic concentration-response curve for histamine was not shifted by sympathectomy in the guinea-pig right atrium. Inasmuch as the rat atrium does not respond to histamine, similar experiments could not be done in the rat. The inotropic concentration-response curve for isoproterenol in electrically driven left atria was not affected by 7 days of sympathectomy in either species. These results indicate that chronic surgical sympathectomy of the heart can be successfully accomplished in the rat and guinea pig. Such sympathectomy induces a postjunctional supersensitivity in guinea-pig right atria which is qualitatively and quantitatively similar to that described previously for chronic treatment with reserpine. Bilateral surgical sympathectomy provides a valuable tool for future investigations of the cellular basis of supersensitivity in the myocardium.     

颈交感神经阻断后脑瘫大鼠上肢肌电图的研究

为在肌电图上观察交感神经阻事痉挛性脑瘫大鼠肢体痉挛状态的改善情况，将３０只大白鼠做成骈挛性脑瘫模型，分成３组，随机选择１组采用颈总动脉周围交感神经网剥脱切除术，另１组采用颈上节交感神经切断术，于术后第８ｄ用ＤＡＮＴＥＣ肌电图仪测量３组大鼠上肢肱三头肌的Ｆ波。     

胸腔镜下交感神经链切除术治疗双手多汗症(12例报告)

目的评价内镜下胸交感神经链切除术治疗多汗症的临床效果。方法回顾性分析内镜下胸交感神经链切除术治疗12例多汗症的结果。结果12例术后多汗症均治愈，2例术后2d发生背部、双股部不同程度代偿性出汗，3～6个月后缓解，术后获得随访的10例未见复发。结论胸腔镜下交感神经链切除手术安全、疗效确切、创伤小，缩短住院时间。     

Neurosurgery (68)

Microinvasive transaxillary thoracoscopic sympathectomy: technical note. (Presbyterian University Hospital, Pittsburgh, PA) Neurosurgery 2000;46:1254–1258. This report describes a two‐port transaxillary thoracoscopic approach for thoracic sympathectomy that maximizes working space, improves manipulative ability, and enhances visualization of the surgical field. Positioning of the patients was optimized to displace the scapula posteriorly, widen the avenue of approach to the sympathetic ganglia, and create a more direct route to the target. The semi‐Fowler position permitted the lung apex to fall away from mediastinal structures, obviating a separate retraction port. A 30‐degree endoscope allowed an unobstructed view of surgical progress, and anatomic relationships were manipulated in a temporal sequence to facilitate dissection. Microinvasive transaxillary sympathectomy was performed successfully in 13 patients, all of whom had a good outcome without complications. Conclude the modifications implemented increase the speed and safety of thoracoscopic sympathectomy while minimizing complications. Comment by R. Ruiz‐López, MD. Thoracic sympathectomy is an accepted means of treating hyperhidrosis, Raynaud's disease, causalgia major and other autonomically mediated syndromes. The authors describe a two‐port transaxillary thoracoscopic approach that maximizes working space, improves manipulative ability, and enhances visualization of the surgical field, advocating a lateral decubitus semi‐Fowler position. A total of 13 patients were treated, 11 with reflex sympathetic dystrophy (complex regional pain syndrome type I (CRPS I)) and 2 with palmar hyperhidrosis. Interestingly, the authors excellent outcomes for CRPS I, not reflecting the experience of most practitioners. Thoracoscopic sympathectomy is evolving quickly since first described by Klux in 1951. From a technical standpoint, the authors describe a useful procedure of endoscopic thoracic sympathectomy that is worthy of further investigation as the series is limited to only 13 patients and in a larger series come complications would be encountered.     

Chemical lumbar sympathectomy in patients with chronic ischemia of the lower extremities

The efficiency of lumbar chemical sympathectomy made within the complex therapy for ischemic pain in the lower extremities was analyzed versus lumbar sympathectomy, made surgically, in 84 male and female patients aged 33-84. The below parameters were studied: the dynamics of painless-walking distance in patients with ischemia, stages IIa and IIb, and rest-pain intensity in patients with ischemia, stages III and IV, according to Fontaine. The regional hemodynamics was registered in all patients by Duplex scanning of lower-extremities vessels before manipulation and on days 5 and 10 after sympathectomy performed by chemical and surgical techniques. An increased distance of painless walking, reduced intensity of rest pain and better parameters of regional hemodynamics were observed in the study and control groups; they were of the unidirectional nature. Thus, sympathectomy, made by the chemical technique, is not inferior by its efficiency to surgical lumber sympathectomy.     

Adrenergic sensitivity of the sensory receptors modulating mechanical allodynia in a rat neuropathic pain model

This study focuses on changes in adrenergic sensitivity in untransected sensory axons that innervate an area of skin made neuropathic by transection of neighboring nerves. The segmental nerve injury model is favorable for this since all axons in the L5 and L6 nerves are transected whereas the L4 axons are intact. Earlier findings are that pain behaviors develop after this injury and that these beahviors are ameliorated by sympathectomy. The present study shows that behavior indicating mechanical allodynia can be rekindled after sympathectomy by intradermal norepinephrine and -2 but not -1 adrenergic ligands and the rekindling can be blocked by -2 but not -1 adrenergic antagonists. By contrast neither intradermal norepinephrine nor other adrenergic agonists or antagonists have any demonstrable effects in the normal or after either neuropathic surgery or sympathectomy alone. These data suggest that the combination of neuropathic surgery and sympathectomy results in an upregulation of active -2 adrenergic receptors on the undamaged sensory axons that provide the remaining sensory innervation to a neuropathic area partially denervated by segmental nerve lesions. These changes on undamaged axons presumably compliment similar changes on the transected axons and, thus play a role in the development of neuropathic pain.     

The effect of lumbar sympathectomy in the spinal nerve ligation model of neuropathic pain.

To evaluate the sympathetic dependency of pain behaviors in an animal model of neuropathic pain, the effect of surgical sympathectomy on the mechanical sensitivity of the hindpaw was examined in rats with L5 spinal nerve ligation. Mechanical sensitivity was determined by measuring foot withdrawal thresholds to mechanical stimulation with von Frey filaments applied to the base of the third or fourth toe. Tight ligation of the segmental L5 spinal nerve led to the development of mechanical hypersensitivity in the hindpaw. The effects of 2 different procedures of surgical lumbar sympathectomy on mechanical hypersensitivity were compared, limited (resection of sympathetic chain/ganglia L2 to L4 segments) and extensive (resection of L2 to L6 segments) sympathectomies. Mechanical hypersensitivity produced by L5 spinal nerve ligation was partially but significantly reduced by both sympathectomy procedures. In a separate group of rats, the L5 spinal nerve was ligated while irritating the neighboring L4 spinal nerve. This procedure produced a lesser degree of mechanical hypersensitivity, and subsequent sympathectomy had no effect on these animals. These data suggest that sympathectomy is effective in this model only when the animals show severe mechanical hypersensitivity.     

Sympathetic-independent bradykinin mechanical hyperalgesia induced by subdiaphragmatic vagotomy in the rat.

Bradykinin-induced mechanical hyperalgesia is sympathetically dependent and B(2)-type bradykinin receptor-mediated in the rat; however, a sympathetically independent component of bradykinin hyperalgesia is shown after subdiaphragmatic vagotomy. We evaluated the mechanism of this bradykinin-induced sympathetic-independent mechanical hyperalgesia. The dose-response curve for bradykinin mechanical hyperalgesia in sympathectomized plus vagotomized rats was similar in magnitude to that for sympathetically dependent bradykinin hyperalgesia in normal rats. Although bradykinin mechanical hyperalgesia was mediated by the B(2)-type bradykinin receptors after sympathectomy plus vagotomy, it had a much more rapid latency to onset. This hyperalgesia was significantly attenuated by inhibition of protein kinase A but not protein kinase C, similar to the hyperalgesia produced by prostaglandin E(2), an agent that directly sensitizes primary afferent nociceptors. However, unlike prostaglandin E(2)-induced mechanical hyperalgesia in normal rats, after sympathectomy plus vagotomy, bradykinin-induced hyperalgesia was not attenuated by inhibition of nitric oxide synthesis. Peripheral administration of a mu opioid agonist, [D-Ala(2),N-Me-Phe(4),Gly(5)-ol]-enkephalin, significantly attenuated bradykinin mechanical hyperalgesia after sympathectomy plus vagotomy. These data suggest that after sympathectomy plus subdiaphragmatic vagotomy, bradykinin acts directly on primary afferents to produce mechanical hyperalgesia via a novel protein kinase A-dependent signaling mechanism.     

Bradycardia and Permanent Pacing After Bilateral Thoracoscopic T2-Sympathectomy for Primary Hyperhidrosis

LAI, C.-L., et al. : Bradycardia and Permanent Pacing After Bilateral Thoracoscopic T2-Sympathectomy for Primary Hyperhidrosis. A 23-year-old woman with craniofacial hyperhidrosis underwent bilateral thoracoscopic T2-sympathectomy. Marked sinus bradycardia with a mean heart rate of 49 beats/min by Holter ECG monitoring occurred after the procedure and persisted for > 2 years. Normal sinus node function was found by an invasive electrophysiological study and unopposed vagotonia after sympathectomy was diagnosed. A permanent pacemaker was implanted. Although reduced heart rate is a common phenomenon after bilateral dorsal sympathectomy, intractable bradycardia with permanent pacing is rare. This patient demonstrates one of the potential cardiac complications of bilateral sympathectomy.     

Temporary sympathectomy in the treatment of chronic refractory angina

The aim of this study was to investigate the safety and efficacy of the two most commonly practiced temporary sympathectomy techniques in the treatment of chronic refractory angina. Fifty-nine consecutive refractory angina patients commencing outpatient temporary sympathectomy from November 1, 2000 to November 1, 2002, were prospectively audited for duration of pain relief and procedural complications over a two-year period. A total of 227 stellate ganglion blockades (SGB) and 100 paravertebral blockades (PVB) were performed on 59 chronic refractory angina (CRA) patients na?ve to sympathectomy. The mean period of pain relief obtained following SGB was 3.48 weeks (SD 3.38) and the mean relief following PVB was 2.80 weeks (SD 2.00). Mild, fully reversible complications occurred in 3% of SGB and 3% of PVB procedures, with one patient requiring overnight hospitalization. This study demonstrates that temporary sympathectomy may provide a safe and effective outpatient procedure in refractory angina patients when applied as part of holistic care.     

Are We Paying a High Price for Surgical Sympathectomy? A Systematic Literature Review of Late Complications

The purpose of this article was to systematically review the literature in order to assess (1) the current indications for surgical sympathectomy and (2) the incidence of late complications collectively and per indication. All types of upper or lower limb surgical sympathectomies are included. An extensive search strategy looked for controlled trials and observational studies or case series with an english abstract. Out of 1,024 abstracts from MEDLINE and 221 from EMBASE, 135 articles reporting on 22,458 patients and 42,061 procedures (up to april 1998) fulfilled the inclusion criteria. Weighted means were used to control for heterogeneity of data. No controlled trials were found. The main indication was primary hyperhidrosis in 84.3% of the patients. Compensatory hyperhidrosis occurred in 52.3%, gustatory sweating in 32.3%, phantom sweating in 38.6%, and horner's syndrome in 2.4% of patients, respectively, with cervicodorsal sympathectomy, more often after open approach. Neuropathic complications (after cervicodorsal and lumbar sympathectomy) occurred in 11.9% of all patients. Compensatory hyperhidrosis occurred 3 times more often if the indication was palmar hyperhidrosis instead of neuropathic pain (52.3% versus 18.2%), whereas neuropathic complications occurred 3 times more often if the treatment was for neuropathic pain instead of palmar hyperhidrosis (25.2% versus 9.8%). Surgical sympathectomy, irrespective of approach, is accompanied by several potentially disabling complications. Detailed informed consent is recommended when surgical sympathectomy is contemplated.     

Characteristics and associated features of persistent post-sympathectomy pain

OBJECTIVES: The aim of this study is to describe the incidence and characteristics of pain, sensory abnormalities, abnormal body sweating, and pathologic gustatory sweating in pain patients with persistent post-sympathectomy pain. METHODS: A retrospective chart review of a series of consecutive pain patients with persistent post-sympathectomy pain was performed. Inclusion criteria were: (1) sympathectomy performed for the indication of neuropathic pain, and (2) persistent pain after the procedure. Demographic data, patterns of pain before and after sympathectomy, patients' pain drawings, and incidence of pain had been collected concurrently at the time of referral. Additional data regarding sensory findings, surgical details of the sympathectomy, sweat patterns, and incidence of abnormal body sweating and pathologic gustatory sweating were extracted from the patients' charts or obtained in follow-up appointments. RESULTS: Seventeen adults (13 females and 4 males) with a mean age of 37 years (range 25-52) at the time of sympathectomy met the inclusion criteria. Five of the 17 patients experienced temporary pain relief for an average of 4 months (range 2-12 months), 3/17 retained the same pain as before the surgery, 1 patient was cured of her original pain but experienced a new debilitating pain, and 8/17 patients continued to have the same or worse pain in addition to a new or expanded pain. Pathologic gustatory sweating was present in 7/11 patients asked, and abnormal sweating (known as compensatory hyperhidrosis) in 11/13 patients asked. DISCUSSION: The present study does not allow for conclusions about the effectiveness of surgical sympathectomy for neuropathic pain. However, our findings indicate that if the pain persists after the procedure, the complications may be quite serious and at times worse than the problem for which the surgery was originally performed.     

胸腔镜下胸部交感神经切断术治疗手掌多汗症

胸腔镜下胸部交感神经切断术治疗手掌多汗症１２８例，其手术创伤小，手术方法简单、安全、手术时间短、术后恢复快，疗效可靠。本方法作为微外科术式对手掌多汗症病人而言是值得提倡的。     

Lumbar sympathectomy failed to reverse mechanical allodynia- and hyperalgesia-like behavior in rats with L5 spinal nerve injury

The L5 spinal nerve ligation model of neuropathic pain in rats has been proposed as a model for sympathetically maintained pain (SMP) based on the effects of surgical or chemical sympathectomy on nerve injury induced behavior. In an attempt to confirm that the lesion produces an animal model of SMP, surgical sympathectomies were independently conducted in two different laboratories (Johns Hopkins and University Kiel) using male Sprague-Dawley (n = 30) or Wistar rats (n = 14). The L5 spinal nerve was ligated or cut and ligated. Using von Frey hairs, paw withdrawal threshold and incidence of paw withdrawal were tested concurrently before and after the sympathectomy. The sympathectomy was either verified by (a) glyoxylic acid staining of peripheral blood vessels of the hindpaw or (b) skin temperature measurements of the hindpaws. To blind the experimenter, surgeries and behavioral tests were performed by two different investigators and a sham sympathectomy was performed at Johns Hopkins. Decreased paw withdrawal thresholds and increased frequencies of paw withdrawal on the lesioned side were observed after the L5 lesion. Thus, the L5 spinal nerve ligation resulted in behavioral signs of allodynia and hyperalgesia to mechanical stimuli. Lumbar surgical sympathectomy 1-3 weeks after the lesion or prior to lesion with bilateral removal of the sympathetic ganglia L2-L4, however, did not reverse or prevent the behavioral changes induced by the nerve injury. The lack of effect of the sympathectomies was independent of the testing paradigm used. Experiments in Wistar and Sprague-Dawley rats yielded the same results. Potential reasons for the discrepancies between the present study and earlier reports are discussed. These results indicate that an L5 spinal nerve injury rat model is not a reliable model for SMP.     

Treatment of Refractory Ischemic Pain from Chemotherapy-Induced Raynaud's Syndrome With Spinal Cord Stimulation

Abstract:   We report the successful treatment of refractory ischemic pain from cisplatin-induced Raynaud's syndrome with spinal cord stimulation after failed pharmacologic management and surgical sympathectomy.
Case Report: A 48-year-old man developed ischemic pain of the hands while undergoing cisplatin and gemcitabine chemotherapy for metastatic pancreatic carcinoma. After extensive pharmacologic management and surgical sympathectomy failed to provide adequate analgesia, the patient underwent a percutaneous spinal cord stimulation trial followed by permanent implantation and received significant pain relief prior to succumbing to his illness. Spinal cord stimulation provided effective therapy for refractory ischemic pain, even after failed sympathectomy.     

T2-4与T3-4交感神经链切断治疗手足多汗症术后代偿性出汗比较

目的:通过比较胸腔镜下T2-4与T3-4交感神经链切断治疗手足多汗症术后代偿性出汗发生情况,探讨其发生的可能机制.方法:手足多汗症患者146例,按不同手术方式分为T2-4组(行T2-4水平交感神经链切断术,共66例)与T3-4组(行T3-4水平交感神经链切断术,共80例).比较两组术后第1日、第6个月手术效果以及代偿性出汗发生部位和严重程度.结果:术后两组手汗治愈率100％,最常见代偿性出汗部位是背部和胸部.术后第1日T2-4组代偿性出汗发生率明显高于T3-4组(39％对比21％,P＜0.05),T2-4组出现2例重度代偿性出汗,T3-4组无重度者.术后6个月T2-4组代偿性出汗发生率依然明显高于T3-4组[24％ (16/66)对比11％ (9/80),P＜0.05].T2-4组仍有1例重度代偿性出汗患者.结论:降低胸交感神经链切断位置可减少代偿性出汗发生率和严重程度,T3-4切断术是一种较为理想的手术方式.代偿性出汗可能随时间有缓解趋势.     

Effects of sympathectomy in a model of causalgiform pain produced by partial sciatic nerve injury in rats

In a previous report we presented a novel behavioral model of neuropathic pain disorders, produced in rat by a unilateral ligation of about half of the sciatic nerve. The model is characterized by rapid onset of behaviors suggesting spontaneous pain and disordered responses to non-noxious and noxious stimuli. These include reduced withdrawal thresholds to repetitive touch in the partially deafferented skin ('touched-evoked hyperesthesia'), touch-evoked allodynia, reduced withdrawal thresholds to noxious thermal stimuli and exaggerated responses to noxious heat and mechanical stimuli ('thermal hyperalgesia'). Some of these disorders are seen at mirror image sites on the hind limb opposite the lesion. These disorder start within hours after partial nerve injury, last many months and are very similar to causalgia in humans following partial nerve injury. Since sympathetic efferent activity is known to aggravate causalgia in humans and sympathectomy is known to relieve it, we studied the effect of changing sympathetic outflow in the rat model. Reversible sympathectomy was carried out using guanethidine injected intraperitoneally in 3 experiments, each at a different time in relation to the partial nerve injury. We found that: (1) sympathectomy performed several months postoperatively alleviated the sensory disorders bilaterally; (2) sympathectomy prior to nerve injury partially prevented the appearance of thermal hyperalgesia but did not affect hyperesthesia to repetitive touch; and (3) sympathectomy at the time of nerve injury aggravated the sensory disorders during the first few days. As maintenance and production of the sensory disorders in this animal model depended on sympathetic nervous outflow, we conclude that the rats were suffering from a syndrome analogous to sympathetically maintained causalgia in man.     

胸腔镜下交感神经切除对血流动力学的影响

目的观察电视胸腔镜(video assisted thoracoscopic surgery，VATS)下胸交感神经切除术(transthoracic endoscopic sympathectomy，TES)时CO2人工气胸及手术操作对血流动力学的影响。方法对35例手汗症患者在气管插管全身麻醉情况下行胸腔镜下双侧胸交感神经切除。术中给予3～5cmH2O的CO2胸腔正压。观察记录患者麻醉前、诱导后、手术开始时、先后两侧胸交感神经切除时、胸交感神经切断后5min、10min心率(HR)、收缩压(SBP)、舒张压(DBP)、平均压(MAP)、中心静脉压(Cvp)、经皮氧饱和度(SpO2)变化。结果与麻醉前及手术开始时相比，术中HR明显减慢；与麻醉前相比，诱导后SBP、DBP、MAP明显下降，手术开始及以后各时点SBP、DBP、MAP平稳；CVP和SpO2平稳。结论在行胸腔镜下交感神经切除时。特别是在交感神经切断后能引起心率减慢。在3～5cmH2的CO2胸腔正压下行TES能在保证手术视野和操作的情况下将SBP、DBP、MAP、SpO2维持在正常范围。     

Vom Rollstuhl zur Gehfähigkeit

A 34-year-old woman developed walking disability with wheelchair dependency for more than 2 years due to chronic regional pain syndrome type II (CRPS II) in the feet. After excluding neurological and vascular disease, lumbar sympathectomy was performed on both sides. Surgical treatment was uneventful, and the patient’s symptoms dramatically improved after 2 months. She is now able to walk some 500 m. This case illustrates the fact that surgical lumbar sympathectomy is an effective alternative or adjunct treatment even in fixed CRPS II.