Surgical sympathectomy for reflex sympathetic dystrophy syndromes

Clinical presentation and surgical anatomy of sympathetic nerve injury during lumbar spine surgery: a narrative review

BACKGROUND AND OBJECTIVE

To highlight the surgical anatomy, procedural variations, presentation, and management of sympathetic nerve injury after surgery of the lumbar spine.

METHODS

PubMed and Google Scholar were searched for publications that were completed between 1951 and 2021. Relevant full-text articles published in the English language were selected and critically reviewed.

KEY CONTENT AND FINDINGS

Sympathetic injury is a highly variable postsurgical complication with a greater incidence after an anterior or oblique approach to the lumbar spine compared to posterior and lateral approaches. The direct and extreme lateral approaches reduce the need to disturb sympathetic nerves thus reducing the risk of complications. It can present in multiple manners, including complex regional pain syndrome (CRPS) and retrograde ejaculation. These complications can be transient and resolve spontaneously or be treated with medications, physical therapy, and spinal blocks. The severity of the conditions and extent of recovery can vary drastically, with some patients never fully recovering.

CONCLUSIONS

To access the lumbar spine, there are operational approaches and techniques that should be used to decrease the risk of intraoperative injury. It is crucial to understand the advantages and risks to different approaches and take the necessary steps to minimize complications. Early identification of dysfunction and adequate management of symptoms are imperative to effectively manage patients with lumbar sympathetic trunk and sympathetic nerve fiber injuries.

Long-Term Efficacy of T3 Versus T3+T4 Thoracoscopic Sympathectomy for Concurrent Palmar and Plantar Hyperhidrosis

BACKGROUND

More than 50% of patients with palmar hyperhidrosis (PAH) also have plantar hyperhidrosis (PLH). We compared the long-term results of T3 sympathectomy with those of combined T3+T4 sympathectomy among patients with concurrent PAH and PLH.

MATERIALS AND METHODS

We retrospectively analyzed the records of patients with concurrent PAH and PLH who underwent T3 alone or T3+T4 sympathectomy from January 1, 2012, to December 31, 2017. Preoperative and postoperative sweating (hyperhidrosis index) was evaluated through questionnaires, physical examination, and outpatient follow-up. The relief rates and hyperhidrosis index were used as outcome measures to compare the efficacy of the two approaches. Patients' satisfaction and side effects were also evaluated.

RESULTS

Of the 220 eligible patients, 60 underwent T3 sympathectomy (T3 group), and 160 underwent T3+T4 sympathectomy (T3+T4 group). Compared with the T3 group, the T3+T4 group showed higher symptom relief rates both for PAH (98.75% versus 93.33%, P = 0.048) and PLH (65.63% versus 46.67%, P = 0.01), and a greater postoperative decrease in both hyperhidrosis indices. The rate of severe compensatory hyperhidrosis also increased (10% versus 5%, P = 0.197), although the rates of overall satisfaction were comparable between the groups. The incidence of postoperative pneumothorax requiring chest tube placement and postoperative neuralgia was also similar. There were no cases of perioperative death, secondary operation, wound infection, or Horner syndrome in either group.

CONCLUSIONS

Compared with T3 alone, T3+T4 sympathectomy achieved a higher symptom relief rate and a lower hyperhidrosis index. T3+T4 sympathectomy may be a choice for the treatment of concurrent PAH and PLH; however, patients need to be informed that this kind of surgery may increase the risk of compensatory sweating.

Thoracic sympathectomy: a review of current indications

BACKGROUND

Thoracic sympathetic ablation was introduced over a century ago. While some of the early indications have become obsolete, new ones have emerged. Sympathetic ablation is being still performed for some odd indications thus prompting the present study, which reviews the evidence base for current practice.

METHODS

The literature was reviewed using the PubMed/Medline Database, and pertinent articles regarding the indications for thoracic sympathectomy were retrieved and evaluated. Old, historical articles were also reviewed as required.

RESULTS AND CONCLUSIONS

Currently, thoracic sympathetic ablation is indicated mainly for primary hyperhidrosis, especially affecting the palm, and to a lesser degree, axilla and face, and for facial blushing. Despite modern pharmaceutical, endovascular and surgical treatments, sympathetic ablation has still a place in the treatment of very selected cases of angina, arrhythmias and cardiomyopathy. Thoracic sympathetic ablation is indicated in several painful conditions: the early stages of complex regional pain syndrome, erythromelalgia, and some pancreatic and other painful abdominal pathologies. Although ischaemia was historically the major indication for sympathetic ablation, its use has declined to a few selected cases of thromboangiitis obliterans (Buerger's disease), microemboli, primary Raynaud's phenomenon and Raynaud's phenomenon secondary to collagen diseases, paraneoplastic syndrome, frostbite and vibration syndrome. Thoracic sympathetic ablation for hypertension is obsolete, and direct endovascular renal sympathectomy still requires adequate clinical trials. There are rare publications of sympathetic ablation for primary phobias, but there is no scientific basis to support sympathetic surgery for any psychiatric indication.

Spinal cord stimulation as treatment for complex regional pain syndrome should be considered earlier than last resort therapy

BACKGROUND

Spinal cord stimulation (SCS), by virtue of its historically described up-front costs and level of invasiveness, has been relegated by several complex regional pain syndrome (CRPS) treatment algorithms to a therapy of last resort. Newer information regarding safety, cost, and efficacy leads us to believe that SCS for the treatment of CRPS should be implemented earlier in a treatment algorithm using a more comprehensive approach.

METHODS

We reviewed the literature on pain care algorithmic thinking and applied the safety, appropriateness, fiscal or cost neutrality, and efficacy (S.A.F.E.) principles to establish an appropriate position for SCS in an algorithm of pain care.

RESULTS AND CONCLUSION

Based on literature-contingent considerations of safety, efficacy, cost efficacy, and cost neutrality, we conclude that SCS should not be considered a therapy of last resort for CRPS but rather should be applied earlier (e.g., three months) as soon as more conservative therapies have failed.

Endoscopic thoracic sympathectomy for posttraumatic complex regional pain syndrome

INTRODUCTION

Posttraumatic complex regional pain syndrome (CRPS) has a strongly negative impact on rehabilitation and activities of daily living. Treatment is most often unrewarding.

AIM

To analyze the efficacy of endoscopic thoracic sympathectomy (ETS) in reducing pain and disability associated with CRPS prospectively.

PATIENT AND METHODS

Over a 5-year period, 12 patients (7 females and 5 males; median age 46.5 [range 34-60 years]) with posttraumatic CRPS underwent unilateral ETS. The median duration of CRPS symptoms before ETS was 3.8 months (range 1.2-19.9). The sympathetic chain was resected from the 2nd to the 5th rib, and the nerve of Kuntz was severed. Median postoperative 16 months (range 12-40). Pain was assessed, at rest (passive) and during movement (active), using a visual analogue scale (VAS) from 0 to 10.

RESULTS

One patient (8%) suffered a hydrothorax and 3 patients (25%) complained of contralateral compensatory hyperhydrosis. At 1 month (n = 12), 2 months (n = 7), 6 months (n = 12), and 1 year (n = 12) after ETS, there was a significant decrease in passive and active VAS (P < 0.05). Ten out of the 12 patients (83%) needed fewer analgesics after surgery, and eight (67%) did not need analgesics at all. The median sleep duration improved significantly from a preoperative value of 2 h (range 1-7) to a postoperative value of 6.25 h (range 3.5-8) (P < 0.001). Overall, patient satisfaction was 83%.

CONCLUSION

ETS is effective at decreasing pain and improving quality of life, and should therefore be considered in the treatment of CRPS.

Evidence based guidelines for complex regional pain syndrome type 1

Background

Treatment of complex regional pain syndrome type I (CRPS-I) is subject to discussion. The purpose of this study was to develop multidisciplinary guidelines for treatment of CRPS-I.

Method

A multidisciplinary task force graded literature evaluating treatment effects for CRPS-I according to their strength of evidence, published between 1980 to June 2005. Treatment recommendations based on the literature findings were formulated and formally approved by all Dutch professional associations involved in CRPS-I treatment.

Results

For pain treatment, the WHO analgesic ladder is advised with the exception of strong opioids. For neuropathic pain, anticonvulsants and tricyclic antidepressants may be considered. For inflammatory symptoms, free-radical scavengers (dimethylsulphoxide or acetylcysteine) are advised. To promote peripheral blood flow, vasodilatory medication may be considered. Percutaneous sympathetic blockades may be used to increase blood flow in case vasodilatory medication has insufficient effect. To decrease functional limitations, standardised physiotherapy and occupational therapy are advised. To prevent the occurrence of CRPS-I after wrist fractures, vitamin C is recommended. Adequate perioperative analgesia, limitation of operating time, limited use of tourniquet, and use of regional anaesthetic techniques are recommended for secondary prevention of CRPS-I.

Conclusions

Based on the literature identified and the extent of evidence found for therapeutic interventions for CRPS-I, we conclude that further research is needed into each of the therapeutic modalities discussed in the guidelines.

Practical management of complex regional pain syndrome

Complex regional pain syndrome (CRPS) describes a diversity of painful conditions following trauma, coupled with abnormal regulation of blood flow and sweating, trophic changes, and edema of skin. The excruciating pain and diverse autonomic dysfunctions in CRPS are disproportionate to any inciting and recovering event. CRPS type I is formerly identified as "reflex sympathetic dystrophy." CRPS type II is the new term for "causalgia" that always coexists with documented nerve injury. The present diagnostic criteria of CRPS I and II depend solely on meticulous history and physical examination without any confirmation by specific test procedure (or gold standard). There are only few clinical studies with large-scale randomized trials of pharmacologic agents on the treatment of CRPS. Bisphosphonates have been studied in multiple controlled trials, based on theoretical benefit of bone resorption, to offer pain relief and functional improvement in patients with CRPS. Many current rationales in treatment of CRPS (such as topical agents, antiepileptic drugs, tricyclic antidepressants, and opioids) are mainly dependent on efficacy originate in other common conditions of neuropathic pain. There are additional innovative therapies on CRPS that are still in infancy. No wonder all the treatment of individual CRPS case nowadays is pragmatic at best. Although the interventional therapies in CRPS (such as nerve blockade, sympathetic block, spinal cord and peripheral nerve stimulation, implantable spinal medication pumps, and chemical and surgical sympathectomy) may offer more rapid response, yet it is still controversial with unpredictable outcome. Nevertheless, we need to start pain management immediately with the ambition to restore function in every probable case of CRPS. An interdisciplinary setting with comprehensive approach (pharmacologic, interventional, and psychological in conjunction with rehabilitation pathway) has been proposed as protocol in the practical management of CRPS. It is crucial to have a high sensitivity value combined with a fair specificity in revising diagnostic criteria of CRPS. The validation and consensus for new rationalized diagnostic criteria of CRPS could facilitate further research to enhance clinical outcome including quality of life. These endeavors to minimize suffering from CRPS would certainly be appreciated by many patients and their loved ones.

[From wheelchair dependency to the ability to walk: lumbar sympathectomy as a treatment for complex regional pain syndrome]

A 34-year-old woman developed walking disability with wheelchair dependency for more than 2 years due to chronic regional pain syndrome type II (CRPS II) in the feet. After excluding neurological and vascular disease, lumbar sympathectomy was performed on both sides. Surgical treatment was uneventful, and the patient's symptoms dramatically improved after 2 months. She is now able to walk some 500 m. This case illustrates the fact that surgical lumbar sympathectomy is an effective alternative or adjunct treatment even in fixed CRPS II.

Proprioceptive feedback enhancement induced by vibratory stimulation in complex regional pain syndrome type I: An open comparative pilot study in 11 patients

OBJECTIVE

Complex regional pain syndrome type I (CRPS-I) is now considered as a central nervous system disease with peripheral manifestations. CRPS-I may result from a mismatch between sensory input and motor output leading to a disorganization of motor programming in cortical structures. According to previous studies in the field of motor control, one efficient way to correct this mismatch could be a proprioceptive feedback enhancement. The goal of the present study was to determine whether vibratory stimulation by improving proprioceptive feedback may increase range of motion and minimize pain in patients with CRPS-I.

METHODS

An open non-randomized study was conducted in 11 patients with CRPS-I of the hand and wrist. Conventional rehabilitation sessions were given for 10 weeks. During each session, patients in the intervention group (n=7) received vibratory stimulation of the affected region; the remaining 4 patients served as the controls.

RESULTS

After 10 weeks, range-of-motion gains were about 30% larger and pain severity was about 50% lower in the intervention group than in the control group. A significant decrease in analgesic use occurred in the intervention group.

DISCUSSION

Vibratory stimulation may significantly improve range of motion and pain in patients with CRPS-I, probably by reestablishing consonance between sensory input and motor output at cortical level. Prospective randomized studies in larger numbers of patients are needed. Cross-over designs or simulated vibratory stimulation should be used to minimize bias.

Ten consecutive cases of complex regional pain syndrome of less than 12 months duration in active duty United States military personnel treated with spinal cord stimulation

Complex regional pain syndrome describes a constellation of symptoms that may involve the sympathetic nervous system. Emerging consensus recommends early intervention with spinal cord stimulation to facilitate physical therapy. Isolated case reports suggest this may be an effective treatment. Ten consecutive active duty United States military personnel with newly diagnosed complex regional pain syndrome underwent early intervention with spinal cord stimulation with favorable results, including decreased pain scores and decreased opioid intake. Six received injuries directly as a result of service in Iraq or Afghanistan. These patients also had posttraumatic stress disorder, but it did not interfere with successful pain control. Additionally, 6 of 10 patients continued on active duty.

Evaluation of plantar hyperhidrosis in patients undergoing video-assisted thoracoscopic sympathectomy

BACKGROUND

Sympathectomy is the treatment of choice for primary hyperhidrosis. One curious occurrence that is difficult to explain from an anatomophysiological point of view in cases of video-assisted thoracoscopic sympathectomy (VATS) for the treatment of palmar hyperhidrosis (PH) is the observed improvement in plantar hyperhidrosis (PLH). Nevertheless, current reports on VATS rarely describe the effect on PLH or just give superficial data. The aim of this study was to prospectively investigate, how surgery affects PLH in patients with PH and PLH over one-year period.

METHODS

From May 2003 to January 2004, 70 consecutive patients with combined PH and PLH underwent VATS at the T2, T3, or T4 ganglion level (47 women and 23 men, with mean age of 23 years).

RESULTS

Immediately after the operation, all the patients said they were free from PH episodes, except for two patients (2.8%) who suffered from continued PH. Compensatory hyperhidrosis (CH) of various degrees was observed in 58 (90.6%) patients after one year. Only 13 (20.3%) suffered from severe CH. There was a great initial improvement in PLH in 50% of the cases, followed by progressive regression, such that only 23.4% still presented that improvement after one year. The number of cases without overall improvement increased progressively (from 17.1% to 37.5%) and the numbers with slight improvement remained stable (32.9-39.1%). Of the 24 patients with no improvement after one year, 6 patients graded plantar sweating worse.

CONCLUSION

Patients with PH and PLH who undergo VATS to treat their PH present a good initial improvement in PLH that reduces to a lower level of improvement after the one-year period.

Advances in treatment of complex regional pain syndrome: recent insights on a perplexing disease

PURPOSE OF REVIEW

The paper is a critical appraisal of recent advances in the treatment of complex regional pain syndrome. Rapidly changing concepts related to the pathophysiology of this disease has transformed its current management and necessitates an updated review of the literature.

RECENT FINDINGS

Chronic regional pain syndrome is a perplexing disease that continues to challenge researchers with respect to its cause and treatment. Recent modification to diagnostic criteria has enabled clinicians to diagnose this disease in a more consistent fashion. Emerging data indicate a possible role of inflammation in the overall pathophysiology and have led to treatment trials with newer anti-inflammatory medications. Certain 'conventional' interventional techniques have been recently scrutinized. A few novel therapeutic options like graded imagery are also outlined.

SUMMARY

Enhanced insight into the pathophysiology of chronic regional pain syndrome has modified current clinical practice and the focus of research. Certain 'standard' therapeutic options for chronic regional pain syndrome have failed the test of time while others have prevailed. New options have recently been evaluated and have shown promising early results. Knowledge of recent advances in chronic regional pain syndrome will help pain physicians provide optimal care to these patients.

Sympathetic skin response: monitoring of CT-guided lumbar sympathetic blocks

PURPOSE

To prospectively evaluate accuracy of sympathetic skin response (SSR) for monitoring computed tomography (CT)-guided lumbar sympathetic blocks, with palpable temperature increase in the foot 30 minutes after injection serving as the reference standard.

MATERIALS AND METHODS

Institutional review board approval and written informed consent were obtained. Seventy individual lumbar sympathetic blocks were performed in 13 patients (six female, seven male; mean age, 45 years) with reflex sympathetic dystrophy of the foot. A 22-gauge needle was advanced to the sympathetic trunk at midlumbar level with CT fluoroscopic guidance, and 1 mL of iopamidol (200 mg of iodine per milliliter) and 5 mL of 0.5% bupivacaine were injected. SSR was monitored in both feet before and after bupivacaine injection. SSRs were activated with painless low-strength (5-20-mA) electrical stimuli. SSR ratio (SSR in the injected foot versus SSR in the contralateral foot) was calculated before injection and repeatedly at 1-minute intervals thereafter. Needle tip position and distribution of bupivacaine were measured on CT images. Receiver operating characteristic curves for SSR ratio were calculated until 7 minutes after injection. Logistic regression analyses adjusted for clustering were calculated for SSR ratio, injection parameters, needle tip position, and bupivacaine distribution.

RESULTS

Thirty minutes after injection, 83% of procedures were considered clinically successful. An SSR cutoff ratio of 1:10 was used, and sensitivity, specificity, and accuracy of SSR for prediction of clinical success were 84%, 92%, and 86%, respectively, 4 minutes after injection and 95%, 92%, and 94%, respectively, 7 minutes after injection. Needle tip position (P = .19), medial and lateral borders of bupivacaine distribution (P = .11 and .056), and distance between bupivacaine distribution and the vertebral body (P = .41) were not significantly different between successful and unsuccessful injections.

CONCLUSION

SSR can be used to correctly identify needle tip position in lumbar sympathetic blocks 6 and 7 minutes after injection.

Interventional Therapies in the Management of Complex Regional Pain Syndrome

Invasive procedures have long held a place in the therapeutic armamentarium for the management of complex regional pain syndrome (CRPS). However, this has evolved considerably, particularly as research into the mechanisms of CRPS has called into question long-held presumptions about the key role of sympathetic dysfunction in the syndrome. This review summarizes some of the key information currently available about interventional treatments, including nerve blocks, spinal cord and peripheral nerve stimulation, chemical and surgical sympathectomies, and deep brain stimulation. The potential roles for these procedures in facilitating functional rehabilitation goals that are primary to the treatment of CRPS are emphasized.

Management of Pediatric Patients With Complex Regional Pain Syndrome

This review summarizes current information about diagnosis and treatment of complex regional pain syndrome (CRPS) in children. Although it has been widely held that CRPS in children is intrinsically different from adults, there appear to be relatively few differences. However, there is a marked preponderance of lower extremity cases in children. Historically, psychological factors have been invoked to explain the genesis and persistence of CRPS in children, but the evidence is not compelling. Treatment outcome studies are limited but indicate that children generally respond to a primary focus on physical therapy. Multidisciplinary treatment reports are particularly encouraging. The general perception that children have a milder course may relate to the potentially greater willingness of children to actively participate in appropriately targeted treatment rather than to innate differences in the disease process itself. Recurrence rates appear higher than in adults, but response to reinitiation of treatment seems to proceed efficiently. Clinical judgment dictates the extent of medication or interventional therapy added to the treatment to facilitate rehabilitation. In many ways, the approach to the treatment of children mirrors that of adults, with perhaps greater restraint in the use of medications and invasive procedures. The rehabilitation of children with CRPS, like that of adults with CRPS, needs further rigorous investigation.

Treatment of complex regional pain syndrome type I of the hand with a series of intravenous regional sympathetic blocks with guanethidine and lidocaine

The aim of this study was to evaluate the efficacy of guanethidine and lidocaine in the treatment of complex regional pain syndrome (CRPS) type I of the hand. Seventeen patients, aged between 33 and 72 years, suffering from CRPS type I of the hand received two series of intravenous regional sympathetic block (Bier's block) sessions with guanethidine and lidocaine according to the following therapeutic protocol: (1) 5 sessions (once every second day) composed of intravenous regional administration of 15 mg guanethidine and 1 mg lidocaine/kg body weight each and (2) 20 sessions (twice a week) composed of intravenous regional administration of 10 mg guanethidine and 1 mg lidocaine/kg body weight each. Complete disappearance of pain and return of the normal function and movement of the extremity were achieved. No side effects were observed. The above-described therapeutic protocol method resulted in excellent pain relief and full restoration of both function and range of movement of the affected extremity in 17 patients suffering from CRPS type I of the hand.

Thoracoscopic sympathectomy for symptomatic arterial obstruction of the upper extremities

BACKGROUND

Severely symptomatic arterial insufficiency of the hand and upper extremities requires adequate treatment. Medical therapy and local care are usually unsuccessful, and thoracic sympathectomy can represent an effective procedure to control pain, to help ulcer healing, and to prevent or delay amputation.

METHODS

We performed 20 thoracoscopic sympathectomies in 15 patients (13 men and 2 women) with upper extremity ischemia. Mean age was 47 years (range 21 to 72 years). All patients were thought to have organic blockage of digital arteries. The condition was unilateral in 10 patients and bilateral in 5. Primary diagnosis was digital arteriosclerosis in 8 patients, Buerger's disease in 4 patients and the remaining 3 were drug abusers with severe ischemia due to accidental intraarterial injection of drugs. Eleven patients (73%) presented with terminal digital necrosis, gangrene, or ulceration of the fingers associated with severe pain. Four patients complained of coldness, pain, and some degree of soft tissue infection without permanent loss of tissue.

RESULTS

We performed 10 unilateral and five bilateral staged (mean interval was 3 months) thoracoscopic sympathectomies. We had two minor complications and no mortality. Mean duration of postoperative chest drainage was 2.5 +/- 0.4 days and mean postoperative hospital stay was 5.3 +/- 0.5 days. Follow-up ranged from 3 to 71 months, with a mean of 33 months. All patients demonstrated clinical benefit after operation.

CONCLUSIONS

Thoracoscopic sympathectomy in patients with severe ischemia of upper limb extremities permits optimal symptomatic control and maximum tissue salvage. Because the procedure is minimally invasive, safe, and associated with a low rate of complications, it should be considered earlier the natural course of this disease.