Sympathectomy is a surgical procedure that destroys nerves in the sympathetic nervous system. The procedure is performed to increase blood flow and decrease long-term pain in certain diseases that cause narrowed blood vessels. It can also be used to decrease excessive sweating. This surgical procedure cuts or destroys the sympathetic ganglia, which are collections of nerve cell bodies in clusters along the thoracic or lumbar spinal cord.
The autonomic nervous system controls such involuntary body functions as breathing, sweating, and blood pressure. It is subdivided into two components, the sympathetic and the parasympathetic nervous systems.
The sympathetic nervous system speeds the heart rate, narrows (constricts) blood vessels, and raises blood pressure. Blood pressure is controlled by means of nerve cells that run through sheaths around the arteries. The sympathetic nervous system can be described as the "fight or flight" system because it allows humans to respond to danger by fighting off an attacker or running away. When danger threatens, the sympathetic nervous system increases heart and respiratory rates and blood flow to muscles, and decreases blood flow to such other areas as skin, digestive tract, and limb veins. The net effect is an increase in blood pressure.
Sympathectomy is performed to relieve intermittent constricting of blood vessels (ischemia) when the fingers, toes, ears, or nose are exposed to cold (Raynaud's phenomenon). In Raynaud's phenomenon, the affected extremities turn white, then blue, and red as the blood supply is cut off. The color changes are accompanied by numbness, tingling, burning, and pain. Normal color and feeling are restored when heat is applied. The condition sometimes occurs without direct cause but is more often caused by an underlying medical condition, such as rheumatoid arthritis. Sympathectomy is usually less effective when Raynaud's syndrome is caused by an underlying medical condition. Narrowed blood vessels in the legs that cause painful cramping (claudication) are also treated with sympathectomy.
Sympathectomy may be helpful in treating reflex sympathetic dystrophy (RSD), a condition that sometimes develops after injury. In RSD, the affected limb is painful (causalgia) and swollen. The color, temperature, and texture of the skin changes. These symptoms are related to prolonged and excessive sympathetic nervous system activity.
Sympathectomy is also effective in treating excessive sweating (hyperhidrosis) of the palms, armpits, or face.
Experts estimate that 10,000–20,0000 sympathectomy procedures are performed each year in the united States.
Sympathectomy for hyperhidrosis is accomplished by making a small incision under the armpit and introducing air into the chest cavity. The surgeon inserts a fiberoptic tube (endoscope) that projects an image of the operation on a video screen. The ganglia are cut with fine scissors attached to the endoscope. Laser beams may also be used to destroy the ganglia.
If only one arm or leg is affected, it may be treated with a percutaneous radiofrequency technique. In this technique, the surgeon locates the ganglia by a combination of x ray and electrical stimulation. The ganglia are destroyed by applying radio waves through electrodes on the skin.
A reversible block of the affected nerve cell (ganglion) determines if sympathectomy is needed. This procedure interrupts nerve impulses by injecting the ganglion with a steroid and anesthetic. If the block has a positive effect on pain and blood flow in the affected area, the sympathectomy will probably be helpful. The surgical procedure should be performed only if conservative treatment has not been effective. Conservative treatment includes avoiding exposure to stress and cold, and the use of physical therapy and medications.
Sympathectomy is most likely to be effective in relieving reflex sympathetic dystrophy if it is performed soon after the injury occurs. The increased benefit of early surgery must be balanced against the time needed to promote spontaneous recovery and responses to more conservative treatments.
Patients should discuss expected results and possible risks with their surgeons. They should inform their surgeons of all medications they are taking, and provide a complete medical history. Candidates for surgery should have good general health. To improve general health, a surgical candidate may be asked to lose weight, give up smoking or alcohol, and get the proper amount of sleep and exercise . Immediately before the surgery, patients will not be permitted to eat or drink, and the surgical site will be cleaned and scrubbed.
The surgeon informs the patient about specific aftercare needed for the technique used. Doppler ultrasonography, a test using sound waves to measure blood flow, can help to determine whether sympathectomy has had a positive result.
The operative site must be kept clean until the incision closes.
Side effects of sympathectomy may include decreased blood pressure while standing, which may cause fainting. After sympathectomy in men, semen is sometimes ejaculated into the bladder, possibly impairing fertility. After a sympathectomy is performed by inserting an endoscope in the chest cavity, some persons may experience chest pain with deep breathing. This problem usually disappears within two weeks. They may also experience pneumothorax (air in the chest cavity).
Studies show that sympathectomy relieves hyperhidrosis in more than 90% of cases and causalgia in up to 75% of cases. The less invasive procedures cause very little scarring. Most persons stay in the hospital for less than one day and return to work within a week.
Morbidity and mortality rates
In 30% of cases, surgery for hyperhidrosis may cause increased sweating on the chest. In 2% of cases, the surgery may cause increased sweating in other areas, including increased facial sweating while eating. Less frequent complications include Horner's syndrome, a condition of the nervous system that causes the pupil of the eye to close, the eyelid to droop, and sweating to decrease on one side of the face. Other rare complications are nasal blockage and pain to the nerves supplying the skin between the ribs. Mortality is extremely rare, and usually attributable to low blood pressure.
Nonsurgical treatments include physical therapy, medications, and avoidance of stress and cold. These measures reduce or remove the likelihood of triggering a problem mediated by the sympathetic nervous system.
See also Neurosurgery .
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WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
A sympathectomy is usually performed by a general surgeon, neurosurgeon, or surgeon with specialty training in head and neck surgery.
Sympathectomy was traditionally performed on an inpatient under general anesthesia. An incision was made on the mid-back, exposing the ganglia to be cut. Recent techniques are less invasive. As a result, the procedure may be performed under local anesthesia in an outpatient surgical facility.
QUESTIONS TO ASK THE DOCTOR
- How will a sympathectomy affect daily activities after recovery?
- Is the surgeon board-certified?
- What alternative procedures are available?
- How many sympathectomy procedures has the surgeon performed?
- What is the surgeon's complication rate?