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General Thoracic Surgery > Thoracic Sympathectomy > Flashcards

Thoracic Sympathectomy Flashcards

1
Q

Indications for throacic dorsal sympathectomy

A
  • Hyperhidrosis
  • Complex regional pain syndrome (CRPS)
  • Raynaud’s phenomenon
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2
Q

Definition of hyperhidrosis

A

Excessive sweating that interferes with livelihood or quality of life

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3
Q

Incidence of hyperhidrosis

A

< 3%

(familial association)

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4
Q

Diagnostic criteria of hyperhidrosis

A
  • 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
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5
Q

Complex Regional Pain Syndrome (CRPS) includes what two disorders

A
  • Reflex sympathetic dystrophy (RSD, Type I)
  • Causalgia (Type II)
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6
Q

Presenting symptoms of CRPS

A
  • Pain
  • Hypersensitivity to minimal stimuli
  • Burning
  • Cutaneous muscular atrophy
  • Faigue and weakness
  • Vasomotor instability (sweating)
  • Patchy bone demineralization
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7
Q

Presenting signs of CRPS

A
  • Edema
  • Stiffness
  • Discoloration
  • Tenderness
  • Atrophy
  • Decreased motor function from flexion
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8
Q

Pathophysiology and Charcteristics of CRPS Type I

A

Type I: Reflex Sympathetic Dystrophy

  • Occurs after tissue trauma
  • Symptoms not confined to specific nerve or dermatomal distribution
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9
Q

Pathophysiology and Characteristics of CRPS Type II

A

Type II: Causalgia

  • Occurs after injury to peripheral nerve
  • Symptoms start within territory of injured nerve; may extend outside nerve distribution
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10
Q

Diagnostic modalities used to confirm CRPS

A
  • Autonomic testing
  • Bone scintigrophy (e/o bone demineralization)
  • X-ray
  • MRI
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11
Q

Presents with numb and cool extremity in response to stress or cool temperatures

A

Raynaud’s phenomenon

(abnormal vasoconstriction of digital arteries and arterioles)

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12
Q

Classic presentaion of Raynaud’s phenomenon

A

Sharply demarcated biphasic response (pallor and cyanosis)

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13
Q

Conservative, non-operative management of Hyperhidrosis

A
  • 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
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14
Q

TOC for patients refractory to conservative management

A

Thoracic dorsal sympathectomy

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15
Q

Conservative managment of CRPS

A
  • 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
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16
Q

TOC for CRPS refractory to conservative managment

A

Thoracic dorsal sympathectomy

17
Q

Patients with CRPS and Raynaud’s phenomenon should undergo ___ to ensure diagnosis and improvment prior to undergoing thoracic dorsal sympathectomy

A

Diagnostic sympathetic nerve block

18
Q

Surgical techique for Thoracic Dorsal Sympathectomy for Hyperhidrosis

A

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)
19
Q

Nomonclature for T-level isolation for hyperhidrosis

A

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)

20
Q

Surgical treatment for severe CRPS or Raynaud’s phenomenon

A
  • 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
21
Q

Disruption of C7 or C8 neural fibers during thoracic sympathectomy results in what complication

A

Horner’s syndrome

General Thoracic Surgery (36 decks)

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