Definition & Overview

Sympathectomy is the surgical procedure for cutting and cauterising the sympathetic nerve chain located along the spine to treat a variety of conditions related to excessive sweating and disorders of the nerve.

The sympathetic nervous system is responsible for a variety of unconscious bodily functions such as raising blood pressure, speeding up heart rate, and the ‘fight or flight’ instinct. Sympathetic nerves arise at the beginning of the first thoracic vertebra and extend to the second or third lumbar vertebra.

Before the advancement of endoscopic technology, this procedure is considered complicated and is associated with major surgical risks that even outweigh its potential benefits. With the use of endoscopy, it is now typically an outpatient procedure that does not require a hospital stay. The goal of the operation is to prevent the nerve signals from being transmitted from the brain to the affected areas.

Who Should Undergo and Expected Results

Patients with the following conditions are advised to undergo sympathectomy:

  • Hyperhidrosis - Characterised by excessive sweating in the palms of the hands, underarms, the face, and even the feet, this condition has a significant impact on the psychological state and social interaction of patients, especially in situations in which commercial antiperspirant products do not provide relief. Typically, patients have already tried other treatments like Botox injections and laser-assisted removal before resorting to this permanent surgical alternative.

  • Extreme facial blushing - Sympathectomy is also considered for people suffering from extreme facial blushing, which makes the patient uncomfortable in social settings.

  • Raynaud’s disease – This condition is characterised by the excessive reduction of blood flow into the fingers and toes in response to cold temperature. This causes discouloration of the affected parts and could lead to nail brittleness. It is caused by the hyperactivation of the sympathetic nerves, resulting in extreme vasoconstriction. If left untreated, the patient could experience skin and muscle atrophy, even gangrene.

  • Reflex sympathetic dystrophy – Patients with this condition experience severe pain and swelling of the skin that starts in one of the extremities and spreads to other parts of the body. Skin colour also changes. Over time, this condition could lead to disability and functional loss.
    Sympathectomy is a safe procedure with high satisfaction rating, especially among patients who suffer from social impacts of their conditions. Patients are allowed to go home a few hours after the procedure and can resume normal, daily activities after a few days. In patients suffering from hyperhidrosis, the result is felt almost immediately. There is very little scarring and discomfort following the procedure.

How is the Procedure Performed?

The patient is typically sedated during the whole procedure, with the administration of general anaesthesia. The physician makes one or more small incisions in the side of the chest, below the underarm. One lung is deflated to gain access to the sympathetic nerve chain. An endoscope is then inserted through the incision to locate the nerve chain and provide visual imaging of the surrounding parts. A special device is also inserted and used to cut and seal the sympathetic nerve chain at the level deemed appropriate. In some cases, the physician could also clamp the nerve instead of cutting it completely. Other related techniques include the use of laser beams to cut the nerve and the use of percutaneous radiofrequency, which destroys the affected ganglia using radio waves. The inserted tools are then retracted and the lung is inflated back before the incisions are closed with sutures.

Possible Risks and Complications

  • Excessive bleeding
  • Damage to nearby organs or tissues – This is a possible complication but is considered a rare occurrence with the use of advanced imaging techniques
  • Infection of the operative site
  • Compensatory hyperhidrosis - Though excessive sweating is no longer felt in the palms or underarms following the procedure, other parts like the leg or chest might develop this condition. This is often temporary though it is not unheard of for this condition to become permanent.
  • Pneumothorax - Air can collect and remain in the chest cavity following the procedure but this usually resolves itself after some time
  • Pain in the chest cavity during heavy breathing
  • Horner’s syndrome - This is caused by damaged nerves manifested by the drooping of the eyelid, constricted pupils, and decreased sweating in the face.
  • Fainting episodes – This complication is caused by decreased blood pressure while standing up

    References:

  • Kim BS, Bookland M, Hallo JI. Endoscopic thoracic sympathectomy. In: Jandial R, McCormick PC, Black PM, eds. Core Techniques in Operative Neurosurgery. Philadelphia, PA: Elsevier Saunders; 2011:chap 91.

  • Langtry JAA. Hyperhidrosis. In: Lebwohl MG, Heymann WR, Berth-Jones J, Coulson I, eds. Treatment of Skin Disease: Comprehensive Therapeutic Strategies. 4th ed. Philadelphia, PA: Elsevier Saunders; 2014:chap 105.

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