Pros & Cons Of Sympathectomy For RSD/CRPS ...
RSD/CRSP may adversely effect the Central Nervous System and your physician may recommend a sympathectomy as an innovative treatment for pain relief, says Alabama liability attorney Keith T. Belt .
Sympathectomy may be helpful in treating reflex sympathetic dystrophy (RSD), a condition that sometimes develops after injury. In RSD, the affected limb is painful (causalgia) and swollen. The color, temperature, and texture of the skin changes. These symptoms are related to prolonged and excessive sympathetic nervous system activity. Experts estimate that 10,000–20,0000 sympathectomy procedures are performed each year in the united States.
Sympathectomy for hyperhidrosis is accomplished by making a small incision under the armpit and introducing air into the chest cavity. The surgeon inserts a fiberoptic tube (endoscope) that projects an image of the operation on a video screen. The ganglia are cut with fine scissors attached to the endoscope. Laser beams may also be used to destroy the ganglia.
If only one arm or leg is affected, it may be treated with a percutaneous radiofrequency technique. In this technique, the surgeon locates the ganglia by a combination of x ray and electrical stimulation. The ganglia are destroyed by applying radio waves through electrodes on the skin.
A reversible block of the affected nerve cell (ganglion) determines if sympathectomy is needed. This procedure interrupts nerve impulses by injecting the ganglion with a steroid and anesthetic. If the block has a positive effect on pain and blood flow in the affected area, the sympathectomy will probably be helpful. The surgical procedure should be performed only if conservative treatment has not been effective. Conservative treatment includes avoiding exposure to stress and cold, and the use of physical therapy and medications.
Sympathectomy is most likely to be effective in relieving reflex sympathetic dystrophy if it is performed soon after the injury occurs. The increased benefit of early surgery must be balanced against the time needed to promote spontaneous recovery and responses to more conservative treatments.
The surgeon informs the patient about specific aftercare needed for the technique used. Doppler ultrasonography, a test using sound waves to measure blood flow, can help to determine whether sympathectomy has had a positive result. The operative site must be kept clean until the incision closes.
Side effects of sympathectomy may include decreased blood pressure while standing, which may cause fainting. After sympathectomy in men, semen is sometimes ejaculated into the bladder, possibly impairing fertility. After a sympathectomy is performed by inserting an endoscope in the chest cavity, some persons may experience chest pain with deep breathing. This problem usually disappears within two weeks. They may also experience pneumothorax (air in the chest cavity).
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CAUSE OF FAILURE AFTER SYMPATHECTOMY
1. Sympathectomy is analogous to the act of killing the messenger. The sympathetic nervous system has the critical job of properly controlling and preserving the circulation in different parts of the body, especially in the extremities. By paralyzing the system, the extremity will be more apt to have disturbance of circulation and is left unprotected from fluctuation in circulation.
Sympathectomy is similar to permanently removing the central heat and air-conditioning system and never replacing it because of malfunction.
Sympathectomy permanently damages the temperature regulatory system. The reason sympathectomy does not cause side effects other than ineffective control of pain as well as impotence and orthostatic hypotension is because it is invariably partial and incomplete.
2. Even after “complete” removal of the sympathetic plexus for the upper or lower extremities, the sympathetic nerves in the wall of the blood vessels are left intact.
3. The most common form (over 80%) of RSD is disuse RSD. In this situation, the sympathetic system is temporarily hyperactive. Proper conservative treatment would prevent any unnecessary invasive surgery (such as sympathectomy) in such patients.
4. Usually the patients that end up needing sympathectomy are the ones who suffer from ephaptic dystrophy. Sympathectomy in such cases cause a classic Cannon phenomenon. This physiological phenomenon refers to the fact that the end organ that is controlled by sympathetic nerve fibers will become uninhibited in its chemical dysfunction. As a result, even though the sympathetic fibers are not contributing to acetylcholine or become uninhibited with resultant increase of pain input.
In diabetic neuropathy RSD, sympathectomy dramatically relieves the pain for the first 1 to 3 years. Then deafferentation can Cannon phenomenon set in. As a result, invariably by the second to fifth year the patient ends up with a lot more pain. Sympathetic blocks repeated every 6 to 12 months yield similar results.
In patients who have had sympathectomy, thermography shows an increase of temperature in the focus of ephaptic nerve damage (Cannon phenomenon) with secondary increase of pain and discomfort.
5. There is a significant overlap in the border areas of sympathetic nerve dermatomes. As a result, the adjacent intact sympathetic nerves try to overcome the lack of sympathetic input. This contributes to the failure of long-term effects of sympathectomy.
6. Whereas the neiospinothalamic tract is quite consistent in its anatomical pattern, the sympathetic nerves and plexi are phylogenetically old, and show a marked individual variability in humans. This causes a problem at the time of surgery and results in the gray rami branching off and entering in a few adjacent areas of the sympathetic paravertebral chain. As a result, the removal of part of this chain does not guarantee a “complete” sympathectomy.
7. The sympathetic nervous system functions symmetrically and bilaterally. So the removal of a portion of this system on one side does not achieve a “total sympathectomy.
8. At times when patients undergo lumbar sympathectomy, we have noted that they may develop Horner’s syndrome on the same side or marked vasoconstriction of the hand on the same side, reflecting the complex and primitive connections of the sympathetic nervous system. Cooper has shown vasoconstriction in the hand during electrical stimulation of the lumbar sympathetic chain. We have noted development of de novo RSD in the ipsilateral hand in two patients after lumbar sympathetic block.
9. Repeated sympathectomies are no guarantee of success.
10. Another side effect of sympathectomy is that the patient loses motivation for physiotherapy and exercise. Because sympathectomy results in immediate relief in the first few months, the patient has less inclination or motivation to exercise and help improve the circulation of the extremity.
11. Even in the cases of rare and severe major causalgias, it makes more sense to resort to a morphine pump than to sympathectomy.
The application of sympathectomy in management of RSD should be strongly discouraged unless the patient suffering from RSD has a short life expectancy (less than 5 years), then sympathectomy makes sense and should be done.
About Belt Law Firm, P.C.
Belt Law Firm, P.C., is an Alabama law firm with extensive national experience in representing RSD/CRPS afflicted persons and handling RSD/CRPS cases with a focus on regional litigation in Alabama, Tennessee, Georgia, Florida, Arkansas, Mississippi, Texas, New Mexico, Colorado and Delaware. To learn more, call the firm toll-free at (888) 933-1514 or use its online form.