Cardiovascular collapse developing during thoracoscopic thoracic sympathectomy

Cardiovascular collapse developing during thoracoscopic thoracic sympathectomy in a patient with essential palmar hyperhidrosis: A case report.  
Park SJ, Jee DL.

Department of Anesthesiology and Pain Medicine, College of Medicine, Yeungnam University, Daegu, Korea. djee@medical.yeungnam.ac.kr

Thoracoscopic thoracic sympathectomy (TTS) is usually a safe and uncomplicated procedure for treating essential palmar hyperhidrosis. However, we report a case of cardiovascular collapse that developed in a healthy patient undergoing TTS. The surgeon performed the left sympathectomy without incident. However, scarcely had an incision been made in the skin of the right chest when the patient developed sinus bradycardia and sudden, severe hypotension. Pulseless ventricular tachycardia occurred immediately thereafter, which rapidly progressed to ventricular fibrillation and cardiovascular collapse. The patient required resuscitation with 200 J of direct current shock defibrillation along with an intravenous injection of epinephrine 1 mg. She recovered without sequelae. We believe the Bezold-Jarisch reflex was triggered by pooling of venous blood and surgical stimuli, and the patient developed cardiovascular collapse as a result.

potential complications of hemorrhage, arrythmia, hypotension, pneumothorax, pain, persistent air leak

Thorascopic manipulation of the lung and mediastinal structures may result in cardiac arrhythmias. Electrical current from the cautery may initiate atrial or ventricular tachycardia or fibrillation. Sinus tachycardia may occur secondary to CO2 retention when insufflation techniques are used. A mediastinal shift with compromise of venous return to the heart may initiate a reflex sinus tachycardia. Vagal stimulation and air or CO2 embolism with insufflation techniques may lead to bradycardia or asystole. Hypotension may result from mediastinal tamponade, air or CO2 embolization, or hemorrhage. Hypercarbia, which results from CO2 insufflation, can result in hypertension and tacjycardia. Hemorrhage from the intracostal vessels may occur at the site of trocar placement.
Exposure of the thoracic sympathetic chain requires retraction of the lung apex away from the posterior chest wall. Improper instrumentation and the frequent presence of apical blebs or adhesions may result in a parenchymal lung injury and postoperative pneumothorax or persistent air leak.

The operative procedure and the potential complications of hemorrhage, arrythmia, hypotension, pneumothorax, pain, persistent air leak, inability to complete the procedure thoracoscopically, and death are reviewed with the patient.

Haimovici's Vascular Surgery

Edition: 5, illustrated

Published by Blackwell Publishing, 2004

Response to adrenaline after sympathectomy

None of the hands in this series
exhibited significant change in flow with A1 ,ug/min. With A ,ug/min, however,
eight of the thirteen hands now had 25 % or more vasoconstriction, the mean
for the group being 30 %. With i p,g no less than eight of the ten hands tested
had more than 25 % vasoconstriction.
Thus for the two groups receiving H and i ug adrenaline marked increases
in the mean responses from 11 to 30 % and from 16 to 44 %, respectively, were
observed after sympathectomy. The ratio of postoperative to preoperative
mean responses was about the same for both doses (2-7 and 2-8). The increased
response after sympathectomy is seen (Table 2) to be due especially to changes
in hands 3, 6, 9, 11, 12 and 13, which before operation had minimal constric-
tions but responded with marked reductions in blood flow after sympathectomy.
The altered behaviour of two of these hands is portrayed in Figs. 1 and 2.
Although some of the other seven hands also showed increased vasoconstric-
tion with a given dose of adrenaline after sympathectomy this increase was
less notable.
The paired differences between the hands before and after sympathectomy
are significant at the A .g/min (t = 3-03, P < 0-02), and the i ,ug/min (t = 3-55,
P < 0-01) levels. Of the six hands manifesting notable increases in sensitivity
to adrenaline three were sympathectomized by preganglionic section and three
by ganglionectomy.
J. Physiol. (I955) I29, 53-64
EFFECT OF ADRENALINE AND NORADRENALINE ON
BLOOD VESSELS OF THE HAND BEFORE AND AFTER
SYMPATHECTOMY
BY R. S. DUFF
From the Cardiological Department, St Bartholomew's Hospital and the
Sherrington School of Physiology, St Thomas's Hospital, London

Cerebral artery mass reduced by sympathetic denervation

Bevan RD, Tsuru H, Bevan JA.

Weights of matching right and left middle or posterior cerebral arteries and their main branches from the same animal were compared 8-10 weeks after unilateral denervation by superior cervical ganglionectomy. When compared in pairs, the denervated arterial systems weighed significantly less (mean 85%) than their innervated counterparts. This suggests that the sympathetic innervation exerts a trophic influence on extracerebral arteries.

PMID: 6362090 [PubMed - indexed for Medline
Stroke. 1983 May-Jun;14(3):393-6.

Patterns of reinnervation of denervated cerebral arteries

Eight weeks after ganglionectomy, these reinnervating nerve fibers formed a fairly dense plexus in a circular pattern in the circle of Willis. However, the reinnervation could not be observed in the arterial branches derived from the circle of Willis (middle cerebral artery and posterior cerebral artery) even 16 weeks after ganglionectomy. The present results clearly demonstrated the time course, distribution pattern and limitation of the reinnervation from the contralateral SCG following unilateral ganglionectomy. The fact that reinnervation could be observed only in the main cerebral arteries of the circle of Willis, in which the nerve plexus appeared to have a circular pattern, suggests a difference between the qualities of sympathetic innervation controlling the cerebral circulation in these arteries and the other arterial branches related to these differences in reinnervation capacity.

Exp Brain Res. 1991;86(1):82-9.Links

Patterns of reinnervation of denervated cerebral arteries by sympathetic nerve fibers after unilateral ganglionectomy in rats.

Handa Y, Nojyo Y, Hayashi M.

lobotomy is often associated with hyperhidrosis

"lobotomy is often associated with hyperhidrosis. Nerves from the hypothalamus apparently pass through the pons and medulla into the cervical spinal cord, since injury to certain areas of these structures results in anhidrosis of specific regions of the body surface.
Nerves leaving the ventral ramus of the spinals nerve cord pass through the chain of sympathetic ganglia so that from thoracic roots T2 to T4 the head and neck are innervated and from T2 to T8 the upper limbs are supplied.
There is some evidence of some innervation of the face and upper extremities from T1, even though autonomic function is presumed to arise only below the first thoracic root. For example, destruction of stellate ganglia (C8-T1 or T2) produces anhidrosis of the upper body and it's extremities. Despite these generalizations, the supply of nerves to small areas such as a finger may originate from as many as seven spinal segments. It may also be very important to recognize that the anatomy of the sympathetic chain is highly varied and that many nerves may bypass the ganglia entirely, thus accounting for numerous discrepancies in the literature concerning pathways and control.
List and Peet concluded from lesions at various levels that that section of the spinal cord and specific lesions within the cord result in loss of sweating in response to heat, but not to exogenous drugs. On the other hand, destruction of peripheral nerves by interruption of the nerve trunk results in loss of sweating in response to heat and drugs within two week.
Antiperspirants and Deodorants by Karl Laden

Edition: 2, illustrated, revised

Published by CRC Press, 1999, p.31

Autoregulation of cerebral blood flow in orthostatic hypotension

The most common patterns of cerebral response to OH are autoregulatory failure with a flat flow-pressure relationship or intact autoregulation with an expanded autoregulated range. The least common pattern is autoregulatory failure with a steep flow-pressure relationship. Patients with patterns 1 and 2 have an enhanced capacity to cope with OH, while those with pattern 3 have reduced capacity.
Stroke. 1998 Jan;29(1):104-11. Links
Autoregulation of cerebral blood flow in orthostatic hypotension.

Novak V, Novak P, Spies JM, Low PA.

Autonomic Disorders Center, Department of Neurology, Mayo Clinic and Foundation, Rochester, Minn. 55905, USA.

Intraneural activated T cells cause focal breakdown of the blood-nerve barrier

These findings demonstrate that activated T cells cause focal breakdown of the BNB, allowing circulating antimyelin antibody to enter the endoneurium with consequent focal demyelination.
Brain. 1995 Aug;118 ( Pt 4):857-68
Intraneural activated T cells cause focal breakdown of the blood-nerve barrier.

Spies JM, Westland KW, Bonner JG, Pollard JD.
Institute of Clinical Neurosciences, University of Sydney, NSW Australia.

a strong association of autonomic dysfunction and impaired cerebral autoregulation

Furthermore, we found a strong association of autonomic dysfunction and impaired autoregulation indicated by a correlation between the LF/HF ratio and Sx (p <>Drug and Alcohol Dependence
Volume 110, Issue 3, 1 August 2010, Pages 240-246

cervical ganglionectomy produces a significant reduction in the noradrenergic innervation of ip- silateral extraparenchymal arteries

Immediately following experimentation the cerebral vessels were examined
for the presence of noradrenergic fibers. The results of the study demonstrate that:
(1) superior cervical ganglionectomy produces a significant reduction in the noradrenergic innervation of ipsilateral extraparenchymal arteries;
(2) the peripheral sympathetic nervous system contributes to overall cerebral vascular resistance primarily by affecting resistance in extraparenchymal arteries; and
(3) as a result, it determines the contribution of the extraparenchymal arteries tooverall cerebral blood flow autoregulation.
1975;6;284-292 Stroke

interrupting sympathetic efferent fibers innervating the heart and baroreflex

The results suggest that cardiac sympathectomy induced by epidural anesthesia can suppress partially baroreceptor function by interrupting sympathetic efferent fibers innervating the heart during high levels of epidural anesthesia, but that lumbar sympathectomy during epidural anesthesia is unlikely to affect baroreceptor activity.
Baroreflex control of heart rate during cardiac sympathectomy by epidural anesthesia in lightly anesthetized humans.

Dohi S, Tsuchida H, Mayumi T
Anesth Analg 1983; 62:815-20.

Baroreflex sensitivity, measured as cardiac acceleration in response to nitroglycerin, was significantly lower (p < style="font-weight: bold;">The results suggest that baroreflex-mediated response to decreases in arterial pressure is dependent on the integrity of the sympathetic nervous system.

Baroreflex control of heart rate during high thoracic epidural anaesthesia. A randomised clinical trial on anaesthetised humans.
Goertz A, Heinrich H, Seeling W
Anaesthesia 1992; 47:984-7.

Sympathetic nervous system (SNS) modulation of immunity

Sypathetic nervous system (SNS) modulation of immunity. The role of the sympathetic nervous system in regulation of immunity is examined in mice that are chemically-denervated by injection of the neurotoxin 6-hydroxydopamine (6-OHDA). This results in a strain-dependant elevation of Th1 and Th2 cytokines and antibody titers. Denervation also results in a robust, but transient, expression of central Fos protein and corticotrophin releasing hormone, as well as an elevation in corticosterone levels in denervated mice. The interrelationships of this HPA axis activation, loss of peripheral sympathetics, and altered immune function is being explored.

Jan A. Moynihan
Associate Professor of Psychiatry, Microbiology and Immunology and of Oncology

Rice PA, Boehm GW, Moynihan JA, Bellinger DL, Stevens SY. Chemical sympathectomy alters numbers of splenic and peritoneal leukocytes. Brain Behav Immun. 16:62-73, 2002.

Rice PA, Boehm GW, Moynihan JA, Bellinger DL, Stevens SY. Chemical sympathectomy increases the innate immune response and decreases the specific immune response in the spleen to infection with Listeria monocytogenes. J Neuroimmunol 114:19-27, 2001.

Ultrastructural changes in the nerves innervating the cerebral artery after sympathectomy

The ultrastructure of the innervation of the anterior cerebral artery of the rat was studied in control animals and in animals after superior cervical ganglionectomy.
Fluorescence histochemistry shows a periarterial network of intensely fluorescent fibers which are divided into two groups, adventitial and periadventitial. The fluorescence begins to decrease 26 hours after, and completely disappears about 32 hours after, ganglionectomy.
Fine structural changes are first observed 18 hours after ganglionectomy, when the axoplasm of degenerating axons becomes electron dense. This density gradually increases up to about 32 hours. By 32 hours most axons with disintegrating axolemmas become inclusion bodies of the Schwann cells. At this stage, synaptic vesicles can still be distinguished as less dense areas, but the membrane structures of synaptic vesicles and mitochondria are difficult to recognize. The degenerating axons are gradually absorbed and by 38 hours dense, residual bodies are observed in the Schwann cells. Generally speaking, the degeneration occurs first in the adventitial fibers and then in the periadventitial fibers. The transient appearance of small, granular vesicles is noticed in axon terminals about 18 hours after denervation, although very few small, granular vesicles are seen in control tissue or at later stages of degeneration.
Cell and Tissue Research
Publisher Springer Berlin / Heidelberg
ISSN 0302-766X (Print) 1432-0878 (Online)
Issue Volume 109, Number 4 / December, 1970

Parasympathetic varicosity proliferation after sympathectomy

Parasympathetic innervation to eyelid smooth muscle inhibits sympathetic neurotransmission pre-junctionally without appreciable direct post-junctional effects. However, 5 weeks after sympathectomy, parasympathetic stimulation elicits substantial cholinergically mediated contractions. This study examined ultrastructural changes accompanying the conversion to parasympathetic excitation. In intact muscles, 64±9 nerve varicosities were encountered per 104 μm2. Most were close to muscle cells and not fully enclosed by supporting cells. Axo–axonal synapses were observed occasionally. Two days following sympathectomy, varicosity numbers were reduced by 97% and, relative to controls, remaining varicosities were farther from muscle cells and more frequently fully enclosed by supporting cells, but contained greater numbers of small spherical and large dense vesicles. By 6 weeks post-sympathectomy, numbers of varicosities per unit muscle volume increased to 14% of controls. These varicosities differed from those at 2 days in being closer to smooth muscle cells, less frequently enclosed, and having fewer small vesicles. These findings indicate that intact eyelid smooth muscle varicosities are predominantly sympathetic, but a small number of parasympathetic varicosities are present, some of which may form pre-junctional synapses with sympathetic nerves. Between 2 days and 6 weeks post-sympathectomy, varicosities increased in number and established appositions with smooth muscle cells. This suggests that parasympathetic nerves are capable of re-innervating an atypical smooth muscle target after sympathectomy, and that parasympathetic synaptogenesis is likely to contribute to conversion from pre-junctional inhibition to post-junctional excitation after sympathectomy.
Brain Research
Volume 786, Issues 1-2, 9 March 1998, Pages 171-180

noradrenaline-containing fibers around the cerebral arteries degenerated

There has been considerable controversy concerning the motor innervation of cerebral arteries. Bayliss et aL (1) and Hill and MacLeod (2) reported no evidence of any vascular response suggesting the existence of vasomotor nerves supplying the vessels of the brain. Dumke and Schmidt (3) also found little effect of sympathetic stimulation on cerebral blood flow, as did Carlyle and Grayson (4), who concluded that non-nervous autoregulation is the most important factor in the control of cerebral blood flow. The view of these authors (1-4) and others that vasomotor nerves are of minor importance in the regulation of cerebral blood flow has been supported in recent reviews (5-7), but these conclusions have been recently challenged by James et al. (8), who implicated vasomotor nerves in the responses of cerebral vessels to changes in blood CO2 levels. Earlier than this, Hiirthle (9) and Forbes and Cobb (10) had observed clear responses of cerebral arteries to motor nerve stimulation. Forbes and Cobb observed a constriction of cerebral arteries in response to sympathetic stimulation and a dilatation, which was blocked by atropine, in response to parasympathetic stimulation.
Meyer et al (11), using a preparation similar to that of Dumke and Schmidt (3), recently
observed a 22 to 30% reduction in internal carotid blood flow when the cervical sympathetic nerve was stimulated.

This work has clearly shown a dual adrenergic and nonadrenergic innervation of the anterior cerebral arteries of the rat. Two types of nerve fiber can be distinguished by their vesicle inclusions in tissue fixed in permanganate or, after treatment with 6-OHDA, in osmium or glutaraldehyde. The first type contained many small granular vesicles and degenerated after cervical sympathectomy. Fluorescent, noradrenaline-containing fibers were detected around the cerebral arteries; after sympathectomy, these fibers also degenerated. This suggests that the axons containing small granular vesicles are adrenergic.

Copyright © 1970 American Heart Association. All rights reserved. Print ISSN: 0009-7330. Online ISSN:
TX 72514
Circulation Research is published by the American Heart Association. 7272 Greenville Avenue, Dallas, 1970;26;635-646
Circ. Res.T. IWAYAMA, J. B. FURNESS and G. BURNSTOCK
From the Department of Zoology, University of Melbourne, Parkville 3052, Victoria, Australia.

This investigation was supported by grants from the National Heart Foundation of Australia and the Australian Research Grants Committee.
Received January 5, 1970. Accepted for publication March 9, 1970.

bradycardia and other cardiac complications are common side effects?

The most common side effects of sympathectomy are compensatory sweating, gustatory sweating and cardiac changes including decreasing heart rate, systolic-diastolic and mean arterial pressure. The mechanism of bradycardia and other cardiac complications that develop after thoracic sympathectomy are still unclear.

http://tipbilimleri.turkiyeklinikleri.com/abstract_54802.html

"It is a lie that sympatholysis may specifically cure patients

with unqualified "reflex sympathetic dystrophy". This was already stated by the father of sympathectomy, Rene Leriche, more than half a century ago.
...it is not an error. but a lie. While conceptual errors are not only forgivable, but natural to inexact medical science, lies, particularly when entrepreneurially inspired are condemnable and call for a peer intervention.

J. Neurology (1999) 246: 875-879

sympathectomy reduces fear - interferes with a range of emotional responses

"Experiements in animals demonstrate that sympathectomy may retard averse conditioning. (DiGusto and King, 1972), most likely because sympathectomy reduces fear."
Clinical Neuropsychology 2003

impairment of autoregulation after unilateral cervical sympathectomy

Although these findings argued against a neurogenic mechanism, James at al. (1969) reported impairment of autoregulation after unilateral cervical sympathectomy in the baboon. Gotoh et al. (1971/1972) observed impairment of autoregulation in patients with the Shy-Drager syndrome.
It was concluded that the autonomic nervous system plays an important role in the mechanism of autoregulation of CBF and that his mechanism is independent of the chemical control of the cerebral vessels. This was confirmed by direct observation of the pial vessels in cats, where separate sites of action in the vascular tree for autoregulation and chemical control were demonstrated; the autoregulatory reaction was located in pial arteries with a diameter larger than 50 μ, and the reaction to carbon dioxide in pial arteries of smaller diameter (Gotoh et al. 1975).
They concluded that the arteries operating in autoregulation were the larger ones with the dense innervation, while the smaller arteries with sparse innervation were involved in chemical control.
Coronna and Plum (1973) demonstrated the absence of CBF autoregulation in a patient with a Shy-Drager syndrome who had a postganglionic denervation....

Gotoh et al (1979) subsequently showed that autoregulation in patients with this syndrome was impaired irrespective of the localization of the damage to the cervical sympathetic nervous system (preganglionic, central, postganglionic) as judged by the eye instillation test.
Handbook of Clinical Neurology,

Vascular Diseases, Part I by P. J. Vinken, G. W. Bruyn, H. L. Klawans, and J. F. Toole

, Volume 53, Part 1

Elsevier Health Sciences, 1988

Orthodeoxia - an uncommon presentation folowing sympathectomy

P V van Heerden, P D Cameron, A Karanovic, M A Goodman. Anaesthesia and Intensive Care. Edgecliff:Oct 2003. Vol. 31, Iss. 5, p. 581-3
Abstract (Summary)

We present a case of orthodeoxia (postural hypoxaemia) which resulted from a combination of lung collapse/consolidation and blunted hypoxic pulmonary vasoconstriction due to partial interruption of the sympathetic nerve supply to the lung by bilateral thoracic sympathectomy.

Less common associations with orthodeoxia are atypical pneumonia3, trauma8, organophosphate poisoning10 and progressive autonomic failure12.

The surgical procedure, which interrupted both sympathetic trunks, probably resulted in "sympathectomy" of the lung with consequent vasoplegia of the pulmonary circulation and blunting of the HPV response.

The combination of areas of reduced ventilation in the lung, together with blunted HPV, resulted in profound oxygen desaturation in our patient when she sat up in bed.

As antibiotics and chest physiotherapy improved the collapse/consolidation of the lungs, the patient became less dependent on artificial means of maintaining pulmonary vascular tone, so that the noradrenaline and then the almitrine could be weaned without incident. Presumably there will be some return of sympathetic tone to the pulmonary circulation with time.

It was not the intention of the authors to describe all the physiological consequences of thoracotomy or thoracoscopy, with or without one-lung ventilation, in this short communication. Clearly these procedures on their own can have significant effects on lung physiology, quite apart from the unique confluence of factors producing orthodeoxia in the patient presented in this case report.
Copyright Australian Society of Anaesthetists Oct 2003

reduces the amount of adrenaline

Cervical sympathectomy
A form of surgery that is useful for some people with LQTS. It reduces the amount of adrenaline and its by-products produced and delivered to the heart by certain nerves (the left cervical ganglia). It involves operating on the left neck and removing or blocking these nerves

http://www.sads.org.uk/technical_terms.htm

sympathectomy greatly reduces ventilation

In conscious animals, cervical sympathectomy greatly reduces ventilation in normoxia and slightly affects ventilatory responses to hypoxia and hypercapnia, also suggesting an important role for these nerves in the control of breathing.
Eur Respir J 1998; 12: 177–184

The role of ANS in cerebral circulation and intracranial pressure

It is proposed that the autonomic innervation of brain vessels participates in the control not only of the cerebral circulation but also of associated intracranial pressure phenomena.
Blood Vessels 1974;11:2-31

Glycogen accumulation in Reissner's membrane following chemical sympathectomy

Acta Otolaryngol. 1978 Nov-Dec;86(5-6):314-30.
PMID: 213930 [PubMed - indexed for MEDLINE]

Hypoxaemia is of a major concern during thorascopic sympathectomy

The normal physiological response to massive atelectasis is an increase in pulmonary vascualr resistance (hypoxic pulmonary vasoconstriction) with re-routing of blood to well ventilated lung zones and consequent improvement of in PaO2. However, during endobronchial anaesthesia for thoracic sympathectomy there is an apparent failure of this compensatory mechanism. When more than 70% of the lung is atelectatic, compensation by hypoxic pulmonary vasonstriction appears to be ineffective. Furthermore, in in vitro and animal studies, inhalation anaesthetic agent have been shown to depress hypoxic pulmonary vasoconstriction.

In a study by Hartrey and colleagues, SpO2<95% style="font-weight: bold;">During carbon dioxide insufflation using endobronchial intubation, Hartrey and colleagues reported a decrease in systolic arterial pressure of >20 mm Hg in 21% of patients. Similarly, we have reported sudden hypotension and bradycardia after injudicious carbon dioxide insufflation.

In an interesting study of the delayed cardiac effects of T2-4 sympathectomy, Drott and colleagues demmonstrated significantly reduced heart rate at rest, and during both exercise and the recovery phase of the exercise.
Changes in the electrical axis and shortening of the QT interval have also been reported.

B. Fredman, D. Olsfanger, R. Jedeikin
British Journal of Anaesthesia 1997; 79: 113-119

Sympathectomy: "suppression of the neuroendocrine stress response"

p.254

Neuraxial blocks typically produce variable decrease in blood pressure that might be accompanied by a decrease in heart rate and cardiac contractility. These effects are generally proportional to the degree (level) of the sympathectomy. Vasomotor tone is primarily determined by sympathetic fibres arising from T5 to L1, innervating arterial and venous smooth muscle. Blocking these nerves causes vasodilation of the venous capacitance vessels, pooling of blood, and decreased vvenous terurn to the heart; in some instances, arterial vasodilation may also decrease systemic vascular resistance. The effects of arterial vasodilation may be minimized by compensatory vasoconstriction above the level of the block. A high sympathetic block not only prevents compensatory vasoconstriction but also blocks the sympathetic cardiac accelerator fibres that arise at T1-T4.
Profound hypotension may result from vasodilation combined with bradycardia and decreased contractility. These effects are further exaggerated if venous return is further compromised by a head-up position or from the weight of a gravid uterus. Unopposed vagal tone in some persons may explain cardiac arrest with spinal anesthesia.
p.261

The sympathetic system normally maintains some tonic vasoconstriction on the vascular tree. Loss off this tone following induction of anesthesia or sympathectomy frequently contributes to perioperative hypotension.
p.375

AV conduction abnormalities are usually manifested by abnormal ventricular depolarization (bundle-branch block) prolongation of the P-R interval (first degree AV block) failure of some atrial impulses to depolarize the ventricles (second degree AV block) or AV dissociation (third degree AV block or complete heart block).
p.428

Clinical anesthesiology By G. Edward Morgan, Maged S. Mikhail, Michael J. Murray
McGraw-Hill, Edition: 3 - 2002

Effect of sympathectomy on spinal cord blood flow

We conclude that adrenalectomy near-totally ablates the hypothermia-associated increase in RSCBF (regional spinal cord blood flow) measured in intact rats and that abdominal sympathectomy totally ablates it. This evidence complements morphological evidence for adrenergic innervation of the spinal cord vasculature.

Heart and Circulatory Physiology, Vol 260, Issue 3 827-H831, Copyright © 1991 by American Physiological Society

A. Iwai, W. W. Monafo and S. G. Eliasson
Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110.

The effects of vasoactive intestinal peptide on dura mater nitric oxide levels and vessel-contraction responses in sympathectomized rats

Nitric oxide (NO) and neurogenic inflammation in dura mater due to nociceptor activation has been implicated for pathophysiology of primary headache disorders. Development of migraine has also been observed in patients treated with ganglion blockage for sympathetic reflex dystrophy.

This study is intended to investigate the effects of VIP on dura mater NO levels and vessel-contraction responses in sympathectomized rats. In the experiments, 30 male rats in five groups

were used. Group 1 sympathectomized: under anesthesia, superior cervical sympathetic ganglion was removed via incision at the center line in the neck area. Group 2 sympathectomized + VIP: postoperative VIP of 25 ng/kg/day (0.2 ml) intraperitoneally administered to the rats exposed to the same operations for 5 days. Group 3 sham: ganglia and

nerves were exposed but not dissected. Group 4 control: no treatment was done. Group 5 VIP: only VIP was administered for 5 days. Sympathectomy induced a significant increase in dura mater NO levels and VIP decreased NO to control levels and increased the norepinephrine vessel-contraction responses of sympathectomized rats. VIP is an efficient NO modulator in superior cervical ganglionectomized rats.

J Mol Neurosci. 2010 Jun;41(2):288-93. Epub 2009 Nov 20.

http://www.ncbi.nlm.nih.gov/pubmed/19936638

Effect of cervical sympathectomy and circulatory hypoxia on time course of prostaglandin concentration in brain tissues

http://www.springerlink.c...ontent/j705306763158841/

Some workers suggest a possible "transmembrane" role of PG in the nervous system.

If the increase in the PG level during ischemia is regarded as a protective reaction, it must be admitted that no increase took place 1 day after CSE (cervical sympathectomy) and it was considerably weakened 7-40 days after CSE.

The effect of cerebral ischemia was virtually indistinguishable from the action of CSE itself.

It can be tentatively suggested that PGF plays the main role in the regulation of tone of the vascular wall and in the regulation of metabolism under conditions of ischemia when the sympathetic regulation is disturbed.

Surgical sympathectomy listed as neurologic disorder

Other neurologic disorders
- Idiopathic orthostatic hypotension
- Multiple sclerosis
- Parkinsonism
- Posterior fossa tumor
- Shy-Drager syndrome
- Spinal cord injury with paraplegia
- Surgical sympathectomy
- Syringomyelia
- Syringobulbia
- Tabes dorsales (syphillis)
- Wernicke's encephalopathy
Dizziness: Classification and Pathophysiology
The Journal of Manual and Manipulative Therapy, Vol. 12, No 4 (2004)

Post-sympathectomy neuralgia: hypotheses on peripheral and central neuronal mechanisms

Post-sympathectomy neuralgia is proposed here to be a complex neuropathic and central deafferentation/reafferentation syndrome dependent on: (a) the transection, during sympathectomy, of paraspinal somatic and visceral afferent axons within the sympathetic trunk; (b) the subsequent cell death of many of the axotomized afferent neurons, resulting in central deafferentation; and (c) the persistent sensitization of spinal nociceptive neurons by painful conditions present prior to sympathectomy. Viscerosomatic convergence, collateral sprouting of afferents, and mechanisms associated with sympathetically maintained pain are all proposed to be important to the development of the syndrome.

Author Keywords: Deafferentation; Central sensitization; Viscero-somatic convergence; Ectopic discharge; Sympathetically maintained pain

Pain
Volume 64, Issue 1, January 1996, Pages 1-9

Ectopic discharge in injured nerves: comparison of trigeminal and somatic afferent

Brain Research
Volume 579, Issue 1, 1 May 1992, Pages 148-151

hypotension-related poorer mental ability is also reflected in diminished cortical activity

EEG studies have demonstrated that the hypotension-related poorer mental ability is also reflected in diminished cortical activity. Contrary to convention, more recent research has suggested a deficient regulation of cerebral blood flow in persons with low blood pressure. In addition to reduced tonic brain perfusion, studies demonstrated insufficient adjustment of blood flow to cognitive requirements.

Chronically low blood pressure is accompanied by a variety of complaints including fatigue, reduced drive, faintness, dizziness, headaches, palpitations, and increased pain sensitivity [1–4]. In addition, hypotensive individuals report cognitive impairment, above all deficits in attention and memory.
Clin Auton Res. 2007 April; 17(2): 69–76.

increased sensitivity to adrenaline is produced by sympathectomy alone

"The increased sensitivity to adrenaline is produced by sympathectomy alone. I think sensory denervation makes no difference."

Vascular Reactivity Following Sympathectomy

Chapter Author: R. T. Grant

Ciba Foundation Symposium - Peripheral Circulation in Man

Book Series: Novartis Foundation Symposia

Published Online: 27 May 2008

Editor(s): G. E. W. Wolstenholme, Jessie S. Freeman

Print ISBN: 9780470714706 Online ISBN: 9780470715185

One patient with documented transection of the cord above T5 behaved like subjects after surgical sympathectomy

Increase in blood flow is generally followed by a rise in skin temperature but decrease in blood flow in response to the Gibbon-Landis procedure after sympathectomy is not necessarily accompanied by a fall in surface temperature. This poor correlation between skin temperature and blood flow confirms the previous report of Hoobler and co-workers and helps define the limits of usefulness of measurements
of skin temperature as an index of blood flow to the extremity.

The vasomotor responses to the Gibbon-Landis procedure (reflex response to warming) were studied in hemiplegic patients, subjects with "high transection" of the cord, and in sympathectomized patients.

One patient with documented transection of the cord above T5 behaved like subjects after surgical sympathectomy.
Of 11 sympathectomized limbs tested for vasodilatation in response to the Gibbon-Landis procedure, 4
showed no response, while 7 responded with decrease in blood flow (vasoconstriction).

Vasomotor Responses in the Extremities of Subjects with Various Neurologic Lesions
I. Reflex Responses to Warming
By WALTER REDISCH, M.D., FRANCISCO T. TANGCO, M.D., LOTHAR WERTHEIMER, M.D.,
ARTHUR J. LEWIS, M.D., J. MURRAY STEELE, M.D.
1957;15;518-524 Circulation

the pineal capability of producing antigonadal substance is suppressed by cervical ganglionectomy

Pineal glands of male hamsters 8 weeks after removal of both eyes or both superior cervical ganglia and those of untreated animals were studied by electron microscopy. In the blinded hamsters the reproductive organs were remarkably involuted, whereas the pinealocytes enlarged and were characterized by a tremendous hypertrophy of the smoothsurfaced endoplasmic reticulum, in the mesh of which some dense cored vesicles were distributed. In contrast the pinealocytes of ganglionectomized hamsters atrophied and were noted by a large number of lysosomes and sparsity of the agranular reticulum, the testes being significantly larger than the controls. The findings were interpreted to be compatible with the view that the pineal capability of producing antigonadal substance is augmented by blinding and is suppressed by cervical ganglionectomy due to the impairment of normal functioning of the pineal by denervation.

Fine structural changes in the hamster pineal gland after blinding and superior cervical ganglionectomy

Cell and Tissue Research
Volume 158, Number 3 / May, 1975

Effect of sympathectomy on the expression of NMDA receptors in the spinal cord

The expression of NMDA receptors in the intermediolateral (IML) region of the upper thoracic spinal cord, was studied in 3 week old rats. The effect of section of the cervical sympathetic nerve on neuronal cell number and receptor expression was examined up to two weeks after the operation. Age-matched sham-operated and unoperated animals were used as controls. It was shown using quantitative autoradiography with the NMDA receptor antagonist [(3)H]MK-801 (dizocilpine maleate), that there was a marked downregulation of receptors in all groups of animals, beginning at approximately 4 weeks of age. However after sympathectomy, which resulted in the death of 44% of neurones in the IML by 7 days, there was a significant increase in receptor density per neurone compared to sham-operated controls. In the control animals there was a significant increase in the Kd value of the binding between 21 and 24 days after birth indicating an increased expression of a low affinity receptor, but no such increase was seen after axotomy. The results are consistent with two populations of NMDA receptors being transiently expressed in the IML in developing animals, and the higher affinity receptor being down-regulated between 4 and 5 weeks of age. The presence of the high affinity receptor subtype may predispose neurones to die after axotomy.
J Neurol Sci (1999) 169: 156-60.
http://www.ionchannels.org/showabstract.php?pmid=10540025

haemodynamic instability during surgery

Rapid and excessive carbon dioxide insufflation into the closed chest cavity may create a tension pneumopthorax, displace the mediastinum, and compress the lungs and great vessels with consequent haemodynamic instability. During carbon dioxide insufflation using endobronchial intubation, Hartrey and colleagues reported a decrease in systolic arterial pressure of > 20 mm Hg in 21% of patients. Similarly, we have reported sudden hypotension and bradycardia after injudicious carbon dioxide insufflation.

In common with other surgical procedures, routine monitoring during thorascopic sympathectomy should include ECG, pulse oximetry and capnography. However, during thorascopic surgery, SpO2 and end-tidal carbon dioxide have the additional function of monitoring the surgical technique.
BJA 1997;79: 113-119

Sympathectomy-induced changes on the ventricular surface

Various investigators have shown that unilateral ganglionectomy or transection of the internal and external carotid nerves leads to a regenerative response in the ipsilateral superior cervical ganglion and to uninjured mature sympathetic neurons sprouting into bilaterally innervated shared target organs. In this study changes in the supraependymal neuronal network following unilateral and bilateral cervical sympathectomy on the infundibular floor of the third ventricle were studied by scanning electron microscopy in comparison with normal and sham-operated control animals. After unilateral cervical sympathectomy there was a great increase in the number of varicose nerve fibres on the infundibular floor as compared to the normal and sham-operated control animals. Not only was there an increase in the number of nerve fibres, but also their varicosities were substantially larger than those normally present on the ependymal surface. This study indicates the possible sympathetic projections from the superior cervical ganglia to the ependymal surface of the third cerebral ventricle.

http://www.ncbi.nlm.nih.gov/pubmed/17594665

Cerebral blood flow rose, while vascular resistance did not change after cervical sympathectomy

After bilateral cervical sympathectomy (n = 9), carotid chemoreceptor reflex stimulation induced significantly different (P less than 0.01) effects on cerebral blood flow, which rose by 42 +/- 8%, and cerebral vascular resistance, which did not change.

To determine whether the difference in effect was due to the sympathectomy or merely to the repetition of the stimulus, another group of dogs (sham; n = 6) that had intact sympathetic nerves were studied a second time. In "sham" dogs, the repeat response to carotid chemoreceptor stimulation also induced significantly different effects from those in dogs with sympathectomy.

Am J Physiol Heart Circ Physiol 238: H594-H598, 1980;
http://ajpheart.physiology.org/cgi/content/abstract/238/4/H594