Thoracic Sympathectomy Flashcards
Indications for throacic dorsal sympathectomy
- Hyperhidrosis
- Complex regional pain syndrome (CRPS)
- Raynaud’s phenomenon
Definition of hyperhidrosis
Excessive sweating that interferes with livelihood or quality of life
Incidence of hyperhidrosis
< 3%
(familial association)
Diagnostic criteria of hyperhidrosis
- Focal sweating > 6 months
- Bilateral, symmetric sweating that impairs QOL
- Occurs at least once a week
- Starts prior to age 25
- Does not occur during sleep
- May be associated with family history
Complex Regional Pain Syndrome (CRPS) includes what two disorders
- Reflex sympathetic dystrophy (RSD, Type I)
- Causalgia (Type II)
Presenting symptoms of CRPS
- Pain
- Hypersensitivity to minimal stimuli
- Burning
- Cutaneous muscular atrophy
- Faigue and weakness
- Vasomotor instability (sweating)
- Patchy bone demineralization
Presenting signs of CRPS
- Edema
- Stiffness
- Discoloration
- Tenderness
- Atrophy
- Decreased motor function from flexion
Pathophysiology and Charcteristics of CRPS Type I
Type I: Reflex Sympathetic Dystrophy
- Occurs after tissue trauma
- Symptoms not confined to specific nerve or dermatomal distribution
Pathophysiology and Characteristics of CRPS Type II
Type II: Causalgia
- Occurs after injury to peripheral nerve
- Symptoms start within territory of injured nerve; may extend outside nerve distribution
Diagnostic modalities used to confirm Complex regional pain syndrome
- Autonomic testing
- Bone scintigrophy (e/o bone demineralization)
- X-ray
- MRI
Presents with numb and cool extremity in response to stress or cool temperatures
Raynaud’s phenomenon
(abnormal vasoconstriction of digital arteries and arterioles)
Classic presentaion of Raynaud’s phenomenon
Sharply demarcated biphasic response (pallor and cyanosis)
Conservative, non-operative management of Hyperhidrosis
- Drysol solution (aluminum chloride hexahydrate)
- Iontophoresis
- introducing ionized substances through skin via electical current)
- performed frequencly (weekly)
- adverse cutaneous symptoms (dryness)
- Botulinum toxin (duration 6-9 months)
- Glycopyrrolate
TOC for patients refractory to conservative management
Thoracic dorsal sympathectomy
Conservative managment of CRPS
- PT/OT
- Smoking cessation
- Medications:
- anticonvulsants
- bisphosphanates
- steroids
- calcitonin
- topical capsaicin
- Steroid injections
- Electrical nerve stimuation
- Regional sympathetic nerve blocks
- Dorsal column spinal cord stimulation
TOC for CRPS refractory to conservative managment
Thoracic dorsal sympathectomy
Patients with CRPS and Raynaud’s phenomenon should undergo ___ to ensure diagnosis and improvment prior to undergoing thoracic dorsal sympathectomy
Diagnostic sympathetic nerve block
Surgical techique for Thoracic Dorsal Sympathectomy for Hyperhidrosis
Thoracoscopic Sympathectomy
- 1-2 trocars
- Single lung ventilation
- Pleura overlying rib lateral to sympathetic chain incised 2-3 cm
- Dissecton of sympathetic chain and isolation (transection or clipping)
- Facial hyperhidrosis (T2 isolation)
- Palmer hyperhidrosis (T2-3 isolation)
- Axillary hyperhidrosis (T3-4 isolation)
Nomonclature for T-level isolation for hyperhidrosis
T level is from above that numbered rib to below teh subsequent rib
(e.g. T3 sympathectomy isolation involves the 3rd and below the 4th rib to exclude the T3 ganglia)
Surgical treatment for severe CRPS or Raynaud’s phenomenon
- First rib resection (transaxillary or posterior)
- Transaxillary preferred
- Posterior thoracoplasty reserved for recurrent or reoperative approaches
- Neurectomy (lysis of axillary and SC artery adventitial tissue)
- T1,2,3 gangion isolation (excision or clipping)
- Alternative surgical approach: VATS
Disruption of C7 or C8 neural fibers during thoracic sympathectomy results in what complication
Horner’s syndrome
