What Is Sympathectomy

Introduction

The nervous system acts as the body's communication system. It has two main parts: the Central Nervous System (CNS) with the brain and spinal cord, and the Peripheral Nervous System (PNS) with nerves and ganglia outside the CNS. The PNS is divided into the somatic nervous system, which handles voluntary actions, and the autonomic nervous system (ANS), which manages involuntary actions. It is called the “autonomic” nervous system, as it is responsible for many automatic functions in the body that happen without a person's conscious effort. This includes heart rate, blood pressure, digestion, respiration, urination and sweating.¹ The ANS splits into the Parasympathetic Nervous System (active during rest) and the Sympathetic Nervous System (activated during stress or emergencies). The sympathetic nervous system is particularly recognised for its involvement in the body's "fight or flight" response to stress or danger. In these situations, the sympathetic nervous system activates physiological responses, such as increasing heart rate, dilating pupils, and redirecting blood flow to deliver more blood to organs that need more oxygen or other responses, preparing the body for quick action.² If the nervous system becomes overly active or faces injury or trauma, it can lead to medical conditions that may impact the overall quality of life. In some cases, addressing these conditions may require the interruption of the sympathetic nerve pathway.

What does sympathectomy mean?

Sympathectomy is a procedure that involves removing or disrupting a part of the sympathetic nervous system. During this procedure, a small part of the sympathetic nervous system is either removed or adjusted. This helps manage how nerve signals travel through it, bringing balance and relief to the body. This permanent interruption of nerve signals alleviates discomfort or harm caused by excessive nervous system activity.³ After sympathectomy, the affected areas no longer respond as intensely to stimuli like sweating or blushing. This procedure is considered a last resort when alternative measures, such as antiperspirants or medications, prove ineffective.

Why is sympathectomy done?

Sympathectomy is indicated for specific medical conditions characterised by dysfunctional sympathetic nervous system activity. In 1889, Alexander of Liverpool was the first surgeon who performed the first cervical sympathectomy. At the time, indications for the surgery were epilepsy, exophthalmic goitre, and glaucoma. However, in the early 20th century, the practice gained broader recognition and application. More surgeons contributed to refining the techniques associated with sympathectomy. At first, sympathectomy was indicated for vascular disorders and diseases like Raynaud's disease, characterized by heightened sympathetic nervous system activity leading to blood vessel constriction. This results in increased sensitivity to cold temperatures and changes in skin colour. However, the procedure later expanded its application to treat hyperhidrosis, a condition triggered by faulty nerve signals, causing excessive sweating in the hands, face, underarms, and feet. It's also used for treating facial blushing and certain chronic pain conditions, like CRPS ( complex regional pain syndrome), often resulting from trauma or injury. Over time, improvements in both surgical methods and technology have significantly influenced the development of sympathectomy.⁴ Furthermore, various studies are actively investigating the potential applications of sympathectomy in addressing different disorders.⁵ This includes investigating its impact on psychological conditions and studying its role in certain neurological disorders. As research advances, more insights may emerge about the potential benefits and limitations of sympathectomy in these investigational areas.

What are the different types of sympathectomy?

There are various types, including both chemical and surgical approaches.⁶ The choice of the sympathectomy method depends on factors like the medical condition, the patient's overall health, and the surgeon's experience.

Surgical types:

• Open sympathectomy: This traditional surgical method involves making an incision and directly accessing the sympathetic nerves. The surgeon may resect or interrupt specific ganglia or nerves to achieve the desired effect, such as reducing excessive sweating.
• Endoscopic sympathectomy: A less invasive surgical approach, endoscopic sympathectomy involves using a thin, flexible tube with a camera (endoscope) to visualize and operate on the sympathetic nerves. This method typically results in smaller incisions and a faster recovery compared to open surgery.
• Thoracoscopic sympathectomy: A subset of endoscopic sympathectomy, thoracoscopic sympathectomy specifically focuses on the sympathetic nerves within the chest. It is often used to treat conditions like hyperhidrosis affecting the hands or face.

Chemical types:

• Chemical sympathectomy: This involves injecting a chemical agent, such as alcohol or phenol, near the sympathetic nerves to interrupt their function. This method is less common than surgical approaches but is sometimes used in specific cases.

What to consider before a sympathectomy

Before you agree to take the test or procedure, make sure that you are aware of the following:

• The name of the test or procedure
• The reason behind having the test or procedure
• What results to anticipate and their significance
• The potential risks and benefits associated with the test or procedure
• Any possible side effects or complications
• The scheduled time and location for the test or procedure
• Information about the person conducting the test or procedure and their qualifications
• Consideration of the consequences if you choose not to proceed with the test or procedure
• Any alternative tests or procedures that you might want to consider
• The expected timeline and method for receiving the results
• Contact information for any questions or issues after the test or procedure
• The financial considerations and how much you will be required to pay for the test or procedure.

What happens during sympathectomy?

Pre-operative assessment

• Patient Evaluation: Before the procedure, a thorough evaluation of the patient's overall health and medical history is conducted. This assessment helps determine the suitability of sympathectomy and ensures that the patient is well-prepared for the surgery.
• Informed Consent: The patient is provided with detailed information about the procedure, including potential risks and benefits. Informed consent is obtained, ensuring that the patient is aware of what to expect and agrees to undergo the sympathectomy.

The procedure

• Anaesthesia: The patient is administered anaesthesia to ensure they are comfortable and pain-free during the surgery. The type of anaesthesia (general or local) depends on the specific sympathectomy approach and the patient's medical condition.
• Access Points: Depending on the chosen surgical technique (open, endoscopic, or thoracoscopic), specific access points are determined. For instance, endoscopic sympathectomy involves small incisions, while open sympathectomy may require a larger incision. Access points are carefully chosen to minimize disruption and facilitate the surgeon's work.
• Sympathetic Chain Disruption: This interruption aims to address the underlying medical condition, such as hyperhidrosis or certain vascular disorders, by modifying the activity of the sympathetic nervous system.

What happens after a sympathectomy?

Recovery timeline

After the procedure, patients are moved to the recovery room for observation, where vital signs like blood pressure, pulse, and breathing are closely monitored. The duration in the recovery room depends on the procedure type and anaesthesia used. Once stable and alert, patients are transferred to their hospital room, where regular checks of incision sites continue to ensure proper healing. In most cases, patients can go home the day after surgery, but adherence to postoperative care instructions is crucial. 

Pain management

Patients may encounter pain or discomfort around incision sites, and pain management is achieved through prescribed medications. Healthcare providers typically suggest a combination of over-the-counter and prescription pain relievers. Patients are provided with detailed instructions on the correct use of medications, including dosage and frequency. Postoperative pain gradually diminishes for a week. Open communication is crucial, and patients are encouraged to report any persistent or unusual pain to their healthcare providers.

Follow-up and monitoring

Early follow-ups are scheduled to monitor recovery progress and address immediate concerns. These early appointments may be more frequent initially, gradually decreasing as recovery advances. Regular checks of incision sites are conducted to ensure proper healing, with a focus on addressing concerns such as infection or unusual swelling. Follow-up appointments also assess symptoms related to the treated condition, allowing healthcare providers to reinforce postoperative care instructions. 

Risks and complications

 General surgical risks

• Infection
• Bleeding
• Pain
• increased sweating in other areas of the body
• Damage to nerves and blood vessels
• Stroke or heart attack during the procedure
• Collapsed lung
• Pneumonia

Anesthesia risks

Complications related to anaesthesia, such as allergic reactions or respiratory issues, are general surgical risks.

Compensatory sweating

A common side effect of sympathectomy is compensatory sweating, where the body may start sweating excessively in other areas not targeted by the surgery.⁷ The severity varies among individuals, and while some may experience mild discomfort, others may find it more pronounced. Management strategies may include lifestyle adjustments, such as using antiperspirants or wearing breathable clothing.

Horner's syndrome

Horner's syndrome is a rare complication that can occur due to sympathetic nerve disruption during sympathectomy. It could lead to several symptoms, like ptosis (drooping eyelid), miosis (constricted pupil), and anhidrosis (lack of sweating) on the affected side of the face. The severity can differ, and sometimes, the symptoms may be temporary or improve over time. Managing it involves addressing specific symptoms, and in certain situations, observation may be needed instead of active intervention.

Success rates

Open surgical sympathectomy has shown high success rates, reaching up to 100%, with relatively low complication rates ranging between 2.5% and 5%. While the procedure is highly effective, there is a possibility of pain recurrence. However, reported rates of pain recurrence vary considerably, spanning from 0% to 33% in different series.⁸ These findings show the favourable success rates and manageable complication levels associated with open surgical sympathectomy.

Summary

Sympathectomy is an intervention targeting the sympathetic nervous system, which is responsible for automatic bodily functions. It becomes necessary when the nervous system is excessively active or injured, impacting one's quality of life. This procedure is typically a last resort, addressing conditions such as hyperhidrosis, Raynaud's disease, and chronic pain syndromes. Sympathectomy offers various surgical approaches, including open, endoscopic, and thoracoscopic methods, tailored to specific conditions. Chemical sympathectomy involving injected chemicals is less common. The process starts with a pre-operative assessment, making sure the patient is ready, followed by surgery where the sympathetic nerve chain is disrupted. Recovery varies, with patients often returning home the next day. Adequate pain management and postoperative care are vital. Despite associated risks like compensatory sweating, open surgical sympathectomy has high success rates, up to 100%, and low complication rates.