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

Effect of botulinum toxin type A on quality of life measures in patients with excessive axillary sweating: a randomized controlled trial

BACKGROUND

Botulinum toxin type A (BTX-A) has been shown to be a safe and effective treatment for primary focal hyperhidrosis. However, the effect of BTX-A therapy on quality of life (QOL) in patients with this condition has only recently begun to be studied in controlled clinical trials.

OBJECTIVES

To assess the impact on QOL of BTX-A treatment in patients with bilateral primary axillary hyperhidrosis.

METHODS

A multicentre, randomized, double-blind, placebo-controlled trial enrolled 320 patients who exhibited persistent, bilateral, primary axillary hyperhidrosis sufficient to interfere with daily activities. These patients were treated with either 50 U BTX-A (Botox, Allergan, Inc., Irvine, CA, U.S.A.) or placebo in each axilla. QOL was assessed using the Hyperhidrosis Impact Questionnaire (HHIQ) at baseline and 1, 4, 8, 12 and 16 weeks post-treatment, as well as the Medical Outcomes Trust Short Form-12 Health Survey(SF-12) at baseline and 16 weeks post-treatment.

RESULTS

At baseline, participants reported a marked negative impact of hyperhidrosis on various measures, including emotional status, ability to participate in daily and social activities, productivity at work and number of clothing changes per day. During the post-treatment period, statistically and clinically significantly greater improvements in all of these parameters were observed for the BTX-A group compared with the placebo group (P < 0.01). The BTX-A group improvements were observed within 1 week of treatment, and were sustained with little or no decline throughout the 16-week follow-up period. Compared with the baseline HHIQ responses regarding treatment history, BTX-A treatment resulted in a greater level of overall treatment satisfaction than did many other hyperhidrosis treatments. In addition, patients treated with BTX-A exhibited statistically significantly greater improvement in the physical component summary score of the SF-12 at 16 weeks than did placebo-treated patients (P < or = 0.019).

CONCLUSIONS

Hyperhidrosis is associated with a substantial QOL burden; however, QOL is markedly improved with BTX-A treatment.

Defining the therapeutic role of local anesthetic sympathetic blockade in complex regional pain syndrome: a narrative and systematic review

OBJECTIVE

There is growing controversy on the value of blocking the sympathetic nervous system for the treatment of complex regional pain syndromes (CRPS). The authors sought to evaluate the efficacy of sympathetic blockade with local anesthetic in these syndromes. In addition, they performed a comprehensive review of the pathophysiology and other treatments for CRPS.

DESIGN

Systematic review of the literature was performed. MEDLINE was searched from 1966 through 1999. The authors identified only three randomized controlled trials (RCTs) that evaluated sympathetic blockade with local anesthetic, but because of differences in study design they were unable to pool the study data. The authors therefore included nonrandomized studies and case series.

INTERVENTIONS

Studies were included if local anesthetic sympathetic blockade was used in at least 10 patients. Studies were excluded if continuous infusion techniques, somatic nerve blocks, or combined sympatholytic therapies were evaluated.

OUTCOME MEASURES

Pain relief was classified as full, partial, or absent. The lack of a comparison group in the studies allowed only the calculation of distribution of the response categories, and the sum of the pooled rates does not equal 100%.

RESULTS

Twenty-nine studies were included that evaluated 1,144 patients. Nineteen studies were retrospective, 5 prospective case series, 3 RCTs, and 2 nonrandomized controlled studies. The quality of the publications was generally poor. Twenty-nine percent of patients had full response, 41% had partial response, and 32% had absent response. It was not possible to estimate the duration of pain relief.

CONCLUSIONS

This review raises questions as to the efficacy of local anesthetic sympathetic blockade as treatment of CRPS. Its efficacy is based mainly on case series. Less than one third of patients obtained full pain relief. The absence of control groups in case series leads to an overestimation of the treatment response that can explain the findings.

Surgical sympathectomy for reflex sympathetic dystrophy syndromes

PURPOSE

The purpose of this study was the assessment of the efficacy of thoracoscopic cervicodorsal and open lumbar sympathectomy for the reduction of pain severity and disability associated with reflex sympathetic dystrophy (RSD).

METHODS

From 1992 to 2000, 73 patients with RSD underwent 46 video-assisted thoracoscopic (first to fourth thoracic ganglion) or 37 surgical lumbar (first to fourth lumbar ganglion) sympathetic chain resections. The patients were referred from multidisciplinary pain clinics with documented sympathetically maintained pain syndrome on the basis of reproducible more than 50% reduction in pain severity score (0, no pain; 10, most severe pain imaginable) for more than 2 days after sympathetic block therapy. The mean duration of the RSD symptoms before sympathectomy was 26 plus minus 14 months (range, 6 to 100 months). Postoperative pain severity score, limb disability, and overall patient satisfaction were assessed by an independent third-party observer at a mean follow-up period of 30 months.

RESULTS

No operative mortality or serious morbidity (Horner's syndrome, bleeding that needed transfusion, wound infection) occurred. Transient (<3-month) postprocedural sympathalgia developed in one third of the patients for cervicodorsal sympathectomy and 20% of the patients for lumbar sympathectomy and was treated effectively with trigger point/proximal ganglion block therapy or transcutaneous electrical nerve stimulation. At 3 months after sympathectomy, 10% of the patients had conditions that were judged treatment failures with no reduction in pain severity or limb disability. The remaining patients testified to more than 50% pain reduction, with pain severity scores decreasing from a mean of 8.7 before surgery to 3.4 after sympathectomy. At 1 year, one quarter of the patients had continued significant pain relief (pain severity score, <3) and an additional 50% of the patients indicated continued but reduced pain severity and an increase in daily/work activities. Overall, patient satisfaction (willingness to have procedure again, benefit from sympathectomy) was 77% and was not significantly influenced by patient age, RSD duration/stage, or extremity involvement (lumbar, 84%; cervicodorsal, 72%).

CONCLUSION

Patients with RSD with a confirmed sympathetically maintained pain syndrome can realize long-term benefit from surgical sympathectomy. Procedural efficacy was similar for both upper limb and lower limb RSD syndromes, although the level of pain reduction did deteriorate with time. After sympathectomy, the patients with RSD had a low incidence rate (7%) of "new" complex regional pain or disabling compensatory sweating syndromes.

Gabapentin for neuropathic pain: systematic review of controlled and uncontrolled literature

OBJECTIVE

To assess the efficacy/effectiveness and side effects of gabapentin for the treatment of neuropathic pain.

DESIGN

Systematic review of the literature.

METHODS

Extensive search of several electronic databases located both controlled and uncontrolled studies. Efficacy was assessed through meta-analysis of randomized controlled trials (RCTs), whereas the effectiveness of gabapentin in uncontrolled studies was assessed via a novel system of dichotomous classification of "bad" versus "good" results.

FINDINGS

Thirty-five papers involving 727 patients with multiple neuropathic pain conditions met the inclusion criteria. The meta-analysis of the 2 high-quality, placebo-controlled RCTs showed positive effect of gabapentin in diabetic neuropathy and post-herpetic neuralgia. The addition of 2 low-quality, placebo-controlled RCTs did not alter the magnitude or direction of observed effect. The uncontrolled studies demonstrated positive effect on pain in different neuropathic syndromes, as well as benefit on different types of neuropathic pain; highest dose administered and rate-of-dose escalation showed wide variability between prescribers. Fewer and less severe side effects were reported in the uncontrolled studies.

CONCLUSIONS

Gabapentin seems to be effective in multiple painful neuropathic conditions. The variable prescribing patterns of the uncontrolled studies raise the suspicion that effectiveness may be reduced if one limits administration of the drug to very low doses, whereas rapid dose escalation may be associated with increased central nervous system side effects. Well-designed controlled trials may provide insight into differential symptom sensitivity to the drug.

Chemical sympathectomy for neuropathic pain: does it work? Case report and systematic literature review

OBJECTIVE

To determine if chemical sympathectomy successfully reduces limb neuropathic pain.

DESIGN

Systematic literature review of the effectiveness of phenol or alcohol sympathectomy for extremity neuropathic pain.

PATIENT

A 29-year-old female with complex regional pain syndrome of both lower extremities after back surgery who was submitted to bilateral lumbar chemical sympathectomy.

SEARCH STRATEGY

The Cochrane Database of Systematic Reviews, the Cochrane Controlled Trials Register, Medline, and EMBASE were systematically searched.

OUTCOME MEASURES

(1) For the patient in question: spontaneous pain, allodynia, pinprick hyperalgesia, pressure evoked pain; (2) For the literature review: meaningful versus nonmeaningful pain relief based on degree and duration (>2 weeks) of pain relief.

RESULTS

(1) The case reported experienced partial temporary relief of pain primarily related to selective modulation of allodynia, but not deep pain or pinprick hyperalgesia; (2) 44% of 66 patients in 13 studies that met the authors' inclusion criteria experienced meaningful pain relief. Whereas 19% experienced no meaningful relief, for the remaining 37% of the patients no conclusions regarding duration and degree of relief could be drawn due to poor reporting of outcomes.

CONCLUSIONS

Based on the case reported and systematic literature review, chemical sympathectomy seems to have at best a temporary effect, limited to cutaneous allodynia. Despite the popularity of chemical sympatholysis, only few patients and poorly defined outcomes are reported in the literature, substantiating the need for well-designed studies on the effectiveness of the procedure.