C H A P T E R 195
Sympathectomy for Pain
ANTONIO A. F. DE SALLES ■ JOHN PATRICK JOHNSON
The popularity of surgical sympathectomy for the
treatment of pain has decreased over the years. This
reduction reflects the improvement of medical man-
agement and the development of less invasive and
nondestructive surgical techniques: radiofrequency
percutaneous sympathectomy and dorsal column stim-
ulation.1–3 The invasive nature of thoracic or lumbar
sympathectomy, requiring thoracotomy, posterior
costotransversectomy, large retroperitoneal dissection,
or laparotomy, has made this approach less desirable
for treating mild cases of sympathetic-mediated pain
(SMP). Severe cases of causalgia that failed to respond
to all less invasive treatments are the ones that still
undergo the large, invasive approaches to the sympa-
thetic chain. There is great interest in the endoscopic
approach to the sympathetic nervous system.4–6 In 1994,
a symposium dedicated to thoracic endoscopic sympa-
thectomy summarized the main clinical issues and
technical advances of this technique.7 The thoracic and
lumbar sympathetic ganglia can be readily visualized
and severed or electrocoagulated through minimal inci-
sions with the use of several endoscopic ports. This
chapter discusses the historical landmarks, rationale,
results, and latest techniques for surgery of the sympa-
thetic system to curtail SMP.
HISTORY
Claude Bernard and Brown Sequard described the
physiology of the sympathetic nervous system in 1852.
Bernard showed that the removal of the stellate ganglia
in rabbits led to an increased temperature in that side
of the animal’s face, contrary to his own theory that
the temperature should decrease. Gaskell and Langley
mapped the sympathetic ganglia distribution, although
in a rudimentary fashion, in 1859. The true segmental
distribution of the sympathetic nervous system became
available only much later. 4 When surgeons became
aware of the anatomic distribution and physiologic
consequences of this curious system, their creative
minds found numerous reasons to surgically intervene
in the sympathetic nervous system.8 In 1889, Alexander
performed the first cervical sympathectomy for the
treatment of epilepsy.9 The result was marginal, as were
the results of several other surgical interventions in
the sympathetic system. Jaboulay and Jonnesco tried
stellectomy for treatment of exophthalmic goiter in
1896.10 Other applications with marginal results were
described in the late 1800s and early 1900s, including
glaucoma in 1889, trigeminal neuralgia in 1902, optical
nerve atrophy in 1905, and angioma of the external
carotid artery in 1917.9
Leriche, the famous French vascular surgeon, dedi-
cated his research to the enervation of large arteries
such as the femoral and axillary arteries. He was inter-
ested in surgical procedures to improve peripheral vas-
cular insufficiency. He was a student of Jaboulay, who
in the late 1800s described the stripping of large arter-
ies from their nerve supply to improve distal circula-
tion. Leriche found that sympathectomy was a more
effective procedure than artery denervation.11 Vascular
surgeons treating peripheral vascular insufficiency
largely used this procedure. Two Australian scientists,
Royle and Hunter, believed that sympathectomy im-
proved spasticity. They thought that sympathetic fibers
maintained skeletal muscle tonus.8 Their work became
widely know, but their results could not be repro-
duced.12 The interest on the physiology of the sympa-
thetic nervous system was greatly enhanced by the
theory of Royle and Hunter. The clinical observations
of Royle and Hunter were important to support the
vascular effects of sympathectomy.
Similar to the operation of Royle and Hunter, an-
other application of sympathectomy that fell into dis-
use was for the treatment of arterial hypertension by
resection of the splanchnic plexus.13, 14 Sympathectomy
was settled as a treatment of peripheral vascular dis-
ease. In 1925, Adson and Brown described the posterior
approach for removal of the second thoracic sympa-
thetic ganglion. Davis and Kanavel reported the ante-
rior approach to the upper thoracic sympathetic chain
in the same year.8 Atkins developed the transaxillary
approach in 1954.15 After 1920, sympathectomy also
gained acceptance for treatment of hyperhidrosis
through the work of Kotzareff.9 Cloward16 described
the dorsal midline approach to both sides of the sym-
pathetic chain in 1969, and the approach gained popu-
larity among neurosurgeons. After Wilkinson 17 de-
scribed the fluoroscopic approach to the thoracic
3093
3094 Section VI ■ Pain
sympathetic chain, Adler and coworkers18 described the
computed tomography (CT)–guided approach. Chuang
and colleagues18 described a stereotactic approach to
the upper thoracic ganglia for treating hyperhidrosis.
In 1928, Spurling19 resected the stellate and first tho-
racic ganglion for the treatment of causalgia of the
upper extremity resulting from a partial lesion of the
axillary artery by a gunshot wound. He hypothesized
that vascular insufficiency of the arm led to the pain
and that posterior sympathectomy as described by Ad-
son and Brown improved the circulation and pain.19
Since then, the treatment of causalgia and sympathetic
dystrophy with sympathectomy has been encouraging.
Rates of 59% to 74% for excellent results and of 9%
to 17% for fair control of pain have appeared in the
literature.20–22 The term causalgia was derived from two
Greek words, kausos, meaning heat, and algos, meaning
pain.23 The term describing burning pain was coined
from the work of Weir Mitchell24 because of his detailed
description of the syndrome after major nerve injuries
identified during the United States Civil War, although
Pare probably described the first case of causalgia in
the 16th century.
NOMENCLATURE
Several terms have been used to describe pain related
to the sympathetic nervous system, such as reflex sym-
pathetic dystrophy, causalgia, and SMP. An organized
nomenclature for the pain phenomenon is necessary to
allow comparison of treatment results and to define
appropriate treatment for the various forms of pain
related to the sympathetic nervous system. The term
sympathetic-mediated pain, introduced by Roberts in
1986, is a general term indicating that surgery on the
sympathetic nervous system may lead to important
control of the patient’s chronic pain.25 The term reflex
sympathetic dystrophy, describing a chronic pain syn-
drome of a limb out of proportion in severity to the
original injury and implying sympathetic hyperactivity,
became widely popular and often has been used in an
inconsistent and misleading fashion.26 The same fate
has ensued for facial pain syndromes that are difficult
to treat and that do not fall in the recognized diagnoses
of facial pain such as trigeminal neuralgia, cluster
headaches, and anesthesia dolorosa. Certain types of
facial pain also may be included in the category of
reflex sympathetic dystrophy, 27 but facial pain syn-
dromes are not included in the classification of com-
plex regional pain syndrome.
A consensus workshop in 1993 suggested the term
complex regional pain syndrome (CRPS).26 It describes a
variety of painful situations that follow injury, appear
regionally, have a distal predominance of abnormal
findings, exceed in magnitude and duration the ex-
pected clinical course of the inciting event, often result
in significant impairment of motor function, and show
variable progression over time. CRPS is further divided
into CRPS type I, which traditionally was referred to
as reflex sympathetic dystrophy, and CRPS type II,
previously known as causalgia. The only difference
between them is that type II has a known nerve injury.
Clinically, it is useful to define whether the CRPS is
dependent or independent of the sympathetic activity.
The terms SMP and sympathetic-independent pain
(SIP) complement the term CRPS. Sympathectomy can
help only patients with SMP and is contraindicated
for patients with sympathetic-independent pain. The
challenge for the clinician is to determine whether a
particular patient with CRPS has SMP and, if so, prop-
erly select patients for clinical or surgical treatment.
For the purpose of this chapter oriented to the surgical
approach, SMP is widely used, leaving the terminology
of CRPS for situations in which it becomes necessary.
PATHOPHYSIOLOGY OF
SYMPATHETIC-MEDIATED PAIN
The pathophysiology of SMP is poorly understood.
Some theories suggest ephaptic transmission between
somatic afferents and sympathetic efferents at the level
of the spinal cord, leading to the release of chemical
mediators known to cause pain in inflammatory reac-
tions, such as substance P, prostaglandin, and bradyki-
nin. These substances produce the classic symptoms of
vascular instability and temperature changes.28–31 Sup-
porting this theory, the results of dorsal column stimu-
lation in suppressing SMP appear to occur because of
stimulation-induced suppression of efferent sympa-
thetic hyperactivity.2, 32, 33 Conversely, an experiment of
electrical stimulation of distal sympathetic stumps after
sympathectomy for SMP reproduced presympathec-
tomy pain.34 This classic, well-controlled experiment
in humans with stimulation of the sympathetic chain
between the second and third thoracic sympathetic
ganglia reproduced symptoms of SMP such as burning,
tingling, and pricking sensations in the fingers, hand,
or arm. Before the sensation of discomfort, subjects
could observe a pilomotor response over the entire
arm and shoulder. After stimulation, a chronic aching
sensation lasted for 24 hours. Patients undergoing sym-
pathectomy for causalgia appear to have more of a
painful response to stimulation than patients undergo-
ing sympathectomy for other causes.34
Leriche35 developed the vicious cycle hypothesis to
explain causalgic pain, and Livingstone expanded it.36
Self-sustained, abnormal firing of loops in the dorsal
horn provoked by an irritative focus in small nerve
endings or major nerve trunks activates central projec-
tion fibers, leading to pain. Others also embraced this
theory, and the popular reflex sympathetic dystrophy
denomination came to be. Resolution of pain with sym-
pathetic blocks gives support to this theory. Bonica37
gave further support to this approach with his detailed
accounts of the syndrome variables and with special
emphasis on objective assessment of the efficacy of
block techniques. Taken together, the studies of dorsal
column stimulation and stimulation of stumps of sym-
pathectomized patients, as well as the results of sympa-
thectomy and sympathetic blocks, support the hypoth-
esis of ephaptic hyperactivity at the level of dorsal

horn between sensory afferent and sympathetic effer-
ent elements.
DIAGNOSTIC ASSESSMENTS AND
PATIENT EVALUATION
Clinical Diagnosis
SMP must be differentiated from chronic pain syn-
dromes with similar features but different maintaining
factors, such as secondary gain, psychological prob-
lems, viral infections, neuropathic processes, and pe-
ripheral nerve injury. True SMP implies that, despite
multiple triggering events in the pain syndrome, an
abnormal response of the sympathetic system mediat-
ing the pain can be documented. Although the clinical
features of advanced cases of causalgia are easily iden-
tifiable, mild cases are difficult to diagnose. Classically,
SMP is associated with burning pain hypersensitivity
in the distribution of the injured somatic nerve, signs
of autonomic imbalance, and ultimately secondary tro-
phic changes. Many patients do not have an identifi-
able trauma triggering sympathetic dystrophy. In a
large series, 10% of the patients were diagnosed as
having sympathetic dystrophy without a previous his-
tory of trauma.38 This pattern has also been largely
identified in smaller series.20 Sudeck’s atrophy and Su-
deck’s syndrome focus on the associated osteoporosis
observed in late cases, an inconsistent finding that may
result from a neurovascular reflex or disuse. Numerous
manifestations of the disorder by different causes and
in different regions of the body have been reported.3,
27, 39–42
The onset and progression of the SMP syndromes
have been divided in three stages. Stage I (i.e., early or
acute) is characterized by constant, intense, and burn-
ing pain that is disproportionate to the injury and that
is accompanied by vasomotor instability, edema, and
swelling. Stage II (i.e., intermediate or dystrophy) is
characterized by severe pain with skin sensitivity, shiny
and discolored skin, and dystrophic nails. Stage III (i.e.,
late or atrophic) shows signs of wasting, atrophy of
skin and subcutaneous tissues, stiffness of joints, and
osteoporosis.38, 43
Wilkinson 44 mentioned several sympathetic pain
syndromes. He grouped them as syndromes with prin-
cipally SMP but little dystrophy or vasculopathy, in-
cluding minor causalgia, shoulder-hand syndrome, and
TABLE 195–1 ■ Summary of 112 Sympathectomy
Procedures in Which Unilateral and
Bilateral Approaches Were Used in
65 Patients
NO. OF NO. OF
APPROACH PATIENTS PROCEDURES
Unilateral 20 22
Bilateral (staged) 11 22
Bilateral (same day) 34 68
Chapter 195 ■ Sympathectomy for Pain 3095
diabetic burning foot syndrome; syndromes with sig-
nificant dystrophy and variable SMP, including major
causalgia, reflex sympathetic dystrophy, and Sudeck’s
atrophy; and syndromes with significant vasculopathy
and variable SMP, including vasospasm of postacute
vascular occlusion, peripheral occlusive vasculopathy,
vasospastic vasculopathy such as Raynaud’s syn-
drome, and Prinzmetal’s angina.17, 44
The clinical diagnosis of SMP must be always con-
firmed by an objective test, usually relief of pain with
sympathetic blockade.
Laboratory Tests
Although SMP is a clinical diagnosis confirmed with
nerve block, certain laboratory studies may be confir-
matory. Thermography may reveal a temperature dif-
ference between extremities or regions in the same
extremity. Regular radiographs of the extremity in
question may show patchy demineralization of epiphy-
ses and the short bones of the hands and feet.45, 46 Soft
tissue swelling may be detected. In advanced phases
of the disease, fine-detail x-ray films show subperios-
teal bone resorption, striation, and tunneling in the
cortices, as well as large excavations and tunneling of
the endosteal surface.47, 48 These changes are not specific
for SMP; they may occur in hyperparathyroidism, thy-
rotoxicosis, and other conditions associated with rapid
bone turnover.49, 50
A bone scintilogram usually reveals increased peri-
articular uptake in the involved limb, and higher sensi-
tivity may be achieved with triple-phase bone scan.51–53
Kozin and collegues54 compared the sensitivity and
specificity of radiographs and scintilography in cases
of reflex sympathetic dystrophy. The specificity of ra-
diographs was 71% and that of scintilography was
86%. The sensitivity of radiographs was 69% and that
of scintilography was 60%.54 Magnetic resonance im-
aging (MRI) has been described as a more sensitive
study than radiographic examination and radionuclide
assessment for detection of changes in the bones of
patients with SMP. It also has the advantage of de-
tecting soft tissue changes such as edema and muscle
atrophy. MRI allows a differential diagnosis between
SMP and other bone lesions.55 Doppler flow studies
and plethysmography may also be used as adjunctive
studies, but they are not always reliable.56
Although the blood flow through the affected ex-
tremity tends to be lower than the normal extremity in
stress conditions, in a warm and resting environment,
the temperature of the affected extremity tends to ap-
proach that of the normal extremity.56 Jeng and associ-
ates57 observed an increase in cerebral blood flow after
T2 sympathectomy, and they suggested the possibility
of using such a surgical approach to improve cerebral
blood flow in patients with cerebral vascular insuffi-
ciency.
Patient Selection
Not all patients with SMP require sympathectomy.
Early and frequent use of sympathetic blockade may
3096 Section VI ■ Pain
carry the patient through a milder and self-limited
episode of causalgic pain.58 Other clinical measures of
controlling pain must be exhausted before considering
sympathectomy. Withholding surgery too long, how-
ever, my decrease chances of complete pain relief af-
forded by a sympathectomy. The patients must have a
reliable and objective response to regional sympathetic
block encompassing the affected extremity. Good pain
relief with sympathetic nerve block confirms that the
complex regional pain is mediated by the sympathetic
nervous system. Blockade of ␣1-adrenergic receptors
by intravenously administered phentolamine correlates
with subjective pain relief.59 Use of saline as a placebo
control minimizes the chance of a false response, and
objective findings such as temperature change should
be documented.60 Bier block with guanethidine can be
employed to provide regional sympathetic blockade.61
Guanethidine displaces norepinephrine in presynaptic
vesicles and prevents its reuptake. Reserpine also de-
pletes norepinephrine stores by interfering with its
storage, and it can be administered intra-arterially to
achieve regional block.49, 50
Paravertebral sympathetic block is the most widely
used diagnostic and therapeutic modality for SMP.62, 63
For upper extremity pain, the target is the stellate
ganglion, which is readily accessible percutaneously.
Although the sympathetic innervation to the arm is
mainly from T2, anesthetic agents readily diffuse
through paravertebral space to block the sympathetic
outflow to the arm.64 The lower extremity sympathetic
outflow can be blocked at L2 and L3 levels, sources for
most of the sympathetic innervation for the legs. Re-
sults of the blockade must be carefully evaluated clini-
cally by observing for Horner’s syndrome when the
upper extremity is blocked and for changes in skin
temperature and color when the upper or lower ex-
tremity is blocked. Objective changes in temperature
and blood flow to the skin can be detected by careful
measurements.56 Patients must remain naive of the re-
sult expected, and placebo must be used when there is
suspicion of secondary gain. The visual digital scale
must be used as a hard record of the effects of the
sympathetic blockade. Patients with unequivocal pain
relief with sympathetic blockade are sympathectomy
candidates.
SURGICAL TREATMENT
There are several approaches for upper thoracic and
lower cervical sympathectomy and fewer options for
splanchnic and lumbar sympathectomy. The transaxil-
lary and posterior paravertebral approaches are advo-
cated by a few authorities for exposure of the upper
thoracic and lower cervical ganglia. The most accept-
able open procedure is the modification of MacKay’s
paravertebral approach described in 1955.65 Cloward66
described a similar approach in 1957. This approach
has the advantage of bilateral exposure through a sin-
gle incision. It provides a more direct exposure of the
sympathetic ganglia and their rami communicantes.16
The retroperitoneal flank approach is predominantly
used for the lumbar chain, and the splanchnic chain
is reached by means of a lower thoracic paramedian
incision. This surgery involves rib removal and retrac-
tion of the pleura.12 These procedures are frequently
too invasive for the patient’s symptoms, which is why
minimally invasive approaches to the sympathetic gan-
glia are becoming prevalent. This section discusses en-
doscopic approaches to the lower cervical, upper tho-
racic, and lumbar sympathetic ganglia. The splanchnic
procedure is usually indicated for very debilitated pa-
tients with cancer pain who are being treated mostly
medically or with phenol injection of the splanchnic
chain.12
Thoracoscopic Sympathectomy
Jacobaeus67 first performed thoracic endoscopic proce-
dures in 1910 for the diagnosis of pulmonary tubercu-
losis and neoplastic diseases. Thoracoscopic sympa-
thectomy procedures were originally described by
Hughes11 in 1942 and Kux61 in 1951, using a uretero-
scope for the treatment of hyperhidrosis. Jacobaeus67
reported a series of more than 1400 endoscopic proce-
dures. There was little interest in this technique until
recently.6, 68–74 Minimally invasive treatment of sympa-
thetic-mediated syndromes affecting the extremities
with endoscopic techniques has expanded because of
the refinement of techniques and clarification of the
indications and applications.69, 71–73, 75–77 The most com-
mon indications for thoracic sympathectomy include
hyperhidrosis, SMP syndromes, Raynaud’s syndrome,
postamputation syndrome (i.e., phantom pain), and
refractory cardiac tachyarrhythmias. Percutaneous
sympathectomy procedures have limited efficacy, and
the long-term successes are not optimal.17, 68 Thoraco-
scopic resection of the sympathetic ganglia appears to
have a lower incidence of morbidity than open thora-
cotomy or a posterior paraspinal approach. This result
may reflect the magnified endoscopic view of the sym-
pathetic chain and adjacent anatomy, leading to a more
precise resection.6, 28, 74, 78 Subsequently, patient demand
and improved satisfaction due to shortened hospital
stay with reduced costs and morbidity made minimally
invasive thoracoscopic sympathectomy an attractive
choice for treatment of SMP syndromes of the upper
extremities.
INDICATIONS
The thoracoscopic paraspinal approach is useful for
sympathectomy and for biopsies and thoracic spinal
work. Besides the indications of sympathectomy for
SMP, the most common indications for sympathectomy
using the endoscopic approach are discussed.
Sympathetic–Mediated Pain Syndrome
Constant burning pain and atrophic skin changes in
the extremity are typical signs and symptoms of SMP
syndromes. Medical therapy with narcotics, neurolep-
tics, or anticonvulsants usually has only limited use
and temporary benefit. Similarly, stellate blocks pro-
vide temporary relief, allowing the patient to pursue
rehabilitation in an attempt to resolve the problem. A

T1-4 sympathectomy provides good initial relief, but
there is a variable rate of recurrence that is difficult to
predict.20, 49, 62
Vasculitis and Raynaud’s Syndrome
Ischemic vascular disorders have episodes of severe,
painful skin blanching, primarily in the hands and
fingertips, that are exacerbated by cold temperatures
or emotional response. Extreme cases may cause ische-
mic and gangrenous ulceration of the digits. The initial
treatment is avoidance of cold and use of ␣-adrenergic
medications that are effective for less severe cases.
Refractory cases may achieve good initial relief from
sympathectomy, but the long-term results may be
somewhat less optimal.6, 78, 79
Cardiac Arrhythmia
Malignant tachyarrhythmias may result from stress
and ‘‘sympathetic imbalance’’ due to disproportionate
left-right sympathetic outflow.72, 80 A right stellate gan-
glion block coupled with left stellate ganglion stimula-
tion lengthens the QT interval on the electrocardio-
gram, and conversely, a left stellate ganglion block
with right stellate ganglion stimulation shortens the
QT interval. Accordingly, a left T1-4 sympathectomy
produces a ‘‘␤-adrenergic effect’’ that shortens the QT
interval and may reduce the incidence of medically
refractory tachyarrhythmias associated with danger-
ous, prolonged QT interval syndromes. Despite this
cardiac function, the hemodynamics and catecholamine
concentrations may not be altered significantly after
sympathectomy.57, 80, 81
FIGURE 195–1. Supine positioning of the patient undergoing sequential bilateral thoracoscopic
sympathectomies. Right and left selective bronchi intubation is performed during the operation on
each side.
Chapter 195 ■ Sympathectomy for Pain 3097
Hyperhidrosis
Palmar and axillary hyperhidrosis is the primary
indication for thoracoscopic sympathectomy. Hyper-
hidrosis is characterized by excessive sweating, primar-
ily in the hands, that is exacerbated by minor stresses
such as handshaking. The cause is unknown. Hyper-
hidrosis has an incidence of approximately 1% in West-
ern populations, but the incidence may be higher in
Asian populations.68 The sympathetic nervous system
innervates eccrine sweat glands through cholinergic
nerve fibers arising from the intermediolateral column
of the thoracic and upper lumbar spinal cord. Increased
sympathetic tone results in vasoconstriction, and skin
cooling exacerbates the excessive sweating.16, 78, 80 Stel-
late ganglion blocks result in temporary drying and
decreased sweating in the ipsilateral hand and armpit.
The warming effect is caused by increased blood flow
through cutaneous arteriovenous fistulas and choliner-
gic blockage. Resection of the T2-3 sympathetic ganglia
that provide sympathetic innervation to the upper ex-
tremity through the lower trunk of the brachial plexus
provides lasting relief from hyperhidrosis.16 Details of
this syndrome and surgical approaches are discussed
elsewhere in this volume.
SURGICAL AND ANESTHETIC CONSIDERATIONS
Endoscopic thoracic sympathectomy procedures re-
quire an anesthesiologist and operating room staff fa-
miliar with thoracic endoscopy. Double-lumen endotra-
cheal tube placement for contralateral lung ventilation
and ipsilateral lung deflation is essential. The patient
3098 Section VI ■ Pain

FIGURE 195–2. Lateral positioning of the patient undergoing right thoracoscopic sympathectomy is
the same as for a thoracotomy. Notice the exposure of the axillary region, including the upper
intercostal spaces, which are important for the endoscope and instrumentation portals.

is positioned supine for bilateral thoracoscopic proce- Instruments

dures (Fig. 195–1), and the lateral decubitus position
(Fig. 195–2) can be used for unilateral procedures. The
operating table positioning is important to allow the
lung to fall away from the upper thorax and open the
intercostal spaces for access into the thorax.
Thoracoscopic sympathectomy equipment and in-
struments are similar to those used in general and
obstetric-gynecologic procedures. A standard endo-
scopic video-monitoring system with a 5- to 10-mm-

FIGURE 195–3. View of the intrathoracic anatomy of the right upper thorax shows the location of
the sympathetic ganglia and chain. Notice the subclavian artery and the first rib, landmarks for
determination of the stellate ganglion.
 Chapter 195 ■ Sympathectomy for Pain 3099

diameter, rigid laparoscope is needed. Basic endoscopic

surgical instruments include 5-mm-diameter mini-Met-
zenbaum scissors with monopolar electrocautery, a 10-
mm-diameter curved hemostat, and a 5-mm-diameter
suction-irrigator. Endoscopic vascular clips and a re-
tractable fan-type retractor should be available if
needed.
Ports and Port Placement
Two or three ports are used to perform the sympa-
thectomy procedure. One port is for the endoscope,
and one or two ports are for the instruments. Port
insertion is similar to chest tube placement, with a 2-
cm skin incision and blunt dissection with a curved
hemostat over the rib into the thorax, avoiding the
intercostal neurovascular bundle. The 15-mm-diameter
ports (Ethicon Flexi-path, Cincinnati, OH) are soft,
flexible endoscopic cannulas inserted through the chest
wall with an introducer. The anesthesiologist deflates
the lung, and the first port is placed. The endoscope is
placed through the port in the fifth intercostal space in
the posterior axillary line. An instrument port is placed
in the same fifth intercostal space. If another working
port is needed, it is placed in the fourth intercostal
space in the anterior axillary line.
Steps of the Procedure
The endoscope provides a panoramic view of the
upper thoracic cavity, and the working ports can be
rearranged according to the surgeon’s preference (Fig.
195–3). A 0-degree endoscope usually provides good
visualization for most sympathectomy procedures, but
the 30-degree endoscope lens occasionally is needed. FIGURE 195–4. Division of the rami communicants at each level
Endoscopic exploration of the thoracic cavity is per- (left) and division of the sympathetic chain at the inferior aspect
formed after the ports are placed, and any adhesions of the stellate ganglion and T4 (right). Notice sectioning of the
nerve of Kuntz, which is important to achieve sympathetic dener-
to the parietal pleura are coagulated and divided, vation of the upper extremity, and preservation of the upper part
allowing the lung to be retracted. Additional lung re- of the stellate ganglion, which is important to avoid Horner’s
traction can be accomplished by rotating or elevating syndrome.
the operating table so that the lung falls away from the
vertebral column.
Important intrathoracic anatomic landmarks for a
sympathectomy are the first and second ribs. The sym-
pathetic chain is a whitish, glistening, raised, longitudi-
nal structure that courses over each rib head (see Fig.
195–3). The pleura overlying the sympathetic chain
should not be pressed excessively with endoscopic in-
struments, because repetitive touch leads to pleural
hyperemia that obscures visualization of the chain. The
cephalad aspect of the sympathetic chain and limit of
the surgical resection is the stellate ganglion. The stel-
late ganglion is immediately below the subclavian ar-
tery. Other major vascular structures, such as the azy-
gous vein, subclavian veins, and the highest (supreme)
intercostal artery and veins, should be avoided during
dissection of the sympathetic chain.
The sympathectomy begins with a pleural incision
over the sympathetic chain at T3 using curved scissors
and continuing cephalad above T2 but remaining short
of the inferior aspect of the stellate ganglion (Fig. 195– FIGURE 195–5. Detailed dissection of the rami communicants
for complete release of the sympathetic chain to be removed.
4). The sympathetic chain is mobilized from T3 with Notice the proximity to the intercostal vessels, which should be
scissors by dividing the rami communicantes at the T2- avoided during this dissection. The intercostal nerve must be
3 levels (Fig. 195–5). It is important to maintain the preserved to avoid postoperative chest wall deafferentation pain.
3100 Section VI ■ Pain
TABLE 195–2 ■ Diagnosis of Patients
Undergoing Thoracoscopic
Sympathectomy
DISORDER NO. OF PATIENTS
Hyperhidrosis 48
RSD/CRPS 12
Raynaud’s syndrome 5 RSD/vasculitis
CRPS, complex regional pain syndrome; RSD,
sympathetic dystrophy.
dissection plane immediately beneath the sympathetic
chain to avoid the underlying intercostal vessels. If
bleeding is encountered, clip ligation or cautery of the
vessel achieves the necessary meticulous hemostasis.
Most intercostal vessels are small, but occasionally,
they are enlarged or course over the sympathetic chain
and require division.
A large ramus arising laterally from the T2 ganglion
is the nerve of Kuntz, which is slightly larger than
other rami (see Fig. 195–4). It provides important sym-
pathetic innervation to the lower trunk of the brachial
plexus.82 The nerve of Kuntz and the stellate ganglion
are usually found beneath the fat pad that envelops the
subclavian artery (see Fig. 195–3). The stellate ganglion
should remain undisturbed to avoid injury and possi-
ble Horner’s syndrome. The dissected T2-3 sympa-
thetic chain is then divided proximally and distally
and sent for histologic evaluation. The dissection bed
is irrigated, and hemostasis is ensured. A 16-French
(16F) chest tube is inserted and positioned endoscopi-
cally through one of the ports. The instrument ports are
then removed, and the lung is re-inflated with positive
pressure by the anesthesiologist. The port incisions are
closed in two layers using absorbable sutures and Steri-
Strips. The operative procedure requires approximately
1 hour, depending on the anatomic complexity of the
individual patient and the experience of the surgeon.
Postoperative Care
The chest tube is placed on 15 cm H2O of suction
until the patient reaches the recovery room, where the
patient is placed on a water-seal drainage system with
suction. A chest radiograph is obtained to ensure
proper lung expansion, and one chest tube is removed,
followed by a repeat chest radiograph. The procedure
is repeated for the second chest tube. Pneumothorax is
uncommon and requires chest tube replacement until
the leak resolves. Oral analgesics are adequate for pain
control, and the hospital stay is typically 1 or 2 days.
TABLE 195–3 ■ Outcomes for 48 Patients with Hyperhidrosis
RELIEF OF
DISORDER SYMPTOM
Hyperhidrosis 47
* Although no patients experienced recurrent palmar hyperhidrosis, 11 had mild compensatory sweating in the trunk,
and 2 patients suffered gustatory sweating.
TABLE 195–4 ■ Patient Satisfaction and
Willingness to Undergo a Repeat
Procedure
PATIENT SATISFACTION WILLINGNESS
DISORDER RATE (%) TO REPEAT (%)
Hyperhidrosis 96 98
66 65
reflex RSD, reflex sympathetic dystrophy.
Patients with chronic pain syndromes may require a
slow taper of preoperative medications, which is man-
aged on an outpatient basis.
OPERATIVE EXPERIENCE
Patient Population
The experience of the first 100 procedures performed
at the University of California–Los Angeles (UCLA) is
presented. These data represent the use of modern
technology and the learning curve resulting when us-
ing the thoracic endoscopic approach. Sixty-five pa-
tients underwent 112 thoracoscopic sympathectomy
procedures at UCLA Medial Center for sympathetic-
mediated disorders between 1993 and 1999. The proce-
dures were performed for unilateral or bilateral symp-
toms. Twenty patients underwent unilateral proce-
dures, and 11 patients with bilateral symptoms
underwent staged procedures several weeks apart in
the early part (1993–1995) of this series. In recent years,
34 patients with bilateral symptoms had staged proce-
dures on the same day (see Table 195–1).
Outcome Analysis
The follow-up period was 6 months to 6 years, with
assessment performed by a clinical examination or tele-
phone interview, or both. An independent observer
collected clinical outcome questionnaires, and a retro-
spective analysis was performed. Patients with hyper-
hidrosis were evaluated for the presence or absence
of sweaty palms, surgery-related complications, and
delayed-onset complications of compensatory hyper-
hidrosis or gustatory sweating. Patients with pain dis-
orders were evaluated with the Oswestry Pain Scale to
quantify the severity of their preoperative and postop-
erative symptoms. The incidence and severity of recur-
rent pain symptoms were evaluated, and all patients
were questioned about their ‘‘overall satisfaction’’ and
‘‘willingness to undergo a repeat procedure.’’
PARTIAL RELIEF RECURRENT LOST TO
OF SYMPTOM SYMPTOMS FOLLOW-UP
1 0* 0
 Chapter 195 ■ Sympathectomy for Pain 3101

TABLE 195–5 ■ Outcomes for 17 Patients with Pain TABLE 195–7 ■ Length of Stay after Thoracoscopic
and Vasculitis Disorders Sympathectomy

NUMBER OF PATIENTS UNILAT BILAT

SYMPATHECTOMY SYMPATHECTOMY
Relief of Recurrence of Lost to DURATION (DAYS) (DAYS)
DISORDER Symptoms Symptoms Follow-up
Median 1 2
RSD/CRPS 7 4 1 Mean 1.5 1.8
Raynaud’s syndrome/ Range 0–4 1–3
vasculitis (5 patients) 4 1 0

CRPS, complex regional pain syndrome; RSD, reflex sympathetic

dystrophy.
TABLE 195–8 ■ Postoperative Complications after
Sympathectomy
Results COMPLICATION NO. OF PATIENTS
Patients with hyperhidrosis were the largest group
Horner’s syndrome
treated by thoracoscopic sympathectomy (Table 195–2). Transient 7
They had very high success rates (Tables 195–3 and Permanent 1
195–4), but they also had the highest complication Compensatory hyperhidrosis* 11
rates. Complications were usually related to compensa- Gustatory sweating 2
Pneumothorax (requiring chest tube) 1
tory hyperhidrosis manifested as sweating in the trunk Pleural effusion (not requiring 4
or torso. However, most patients were sufficiently satis- thoracocentesis or chest tube)
fied with the result, as indicated by their willingness Wound infection 1
to repeat the procedure. Patients treated for pain syn- Intercostal neuralgia
dromes or vascular disorders had a positive initial Transient 3
Permanent 1
response to treatment (see Table 195–2), however, out- Death† 1
comes were diminished for some patients after more
than 6 months by variable recurrence of symptoms * Only patients with hyperhidrosis experienced compensatory sweating
(Tables 195–5 and 195–6; see also Table 195–4). The symptoms.
† An elderly patient with intractable Raynaud’s died. The patient suffered a
overall satisfaction and willingness to repeat the opera- myocardial infarction 1 month after an uncomplicated, unilateral
tive treatment was similarly decreased (see Table 195– sympathectomy.
4). No patients had worsened pain symptoms after
sympathectomy. The hospital length of stay for thora-
coscopic sympathectomy patients was usually 1 or 2
days (Table 195–7). The patients considered historical endoscopic surgical techniques. Horner’s syndrome is
cohorts at our institution who were treated with poste- usually transient and rarely permanent. Endoscopic
visualization should minimize the incidence of Horn-
rior paraspinal sympathectomies had a hospital length
er’s syndrome, because only the rami caudal to the
of stay that typically ranged from 3 to 6 days. The
stellate that provide sympathetic innervation to the
overall complication rates for thoracoscopic procedures
upper extremity are divided, with preservation of the
were also comparable with those of previous treatment
rostrally ascending fibers that innervate the ocular and
modalities (Table 195–8).
pupillary muscles.49, 83 Intercostal neuralgia can result
from intercostal nerve injury during port placement or
Complications
from pressure during the procedure. This problem has
Complications from endoscopic sympathectomy been reduced with the use of soft, flexible ports and a
procedures are usually minor and self-limited. Horn- 5-mm endoscope. Hashmonai and colleagues76 cited
er’s syndrome from injury to the stellate ganglion in the lower incidence of intercostal neuralgia as the ma-
thoracoscopic procedures occurred more often early in jor difference between open supraclavicular and endo-
the series, probably reflecting the learning curve for scopic sympathectomy procedures; however, this re-

TABLE 195–6 ■ Outcomes for Pain and Vasculitis Disorders as Measured by the Oswestry Pain Scale*

DISORDER PREOPERATIVE 1 MONTH POSTOPERATIVE ⬎ 6 MONTHS POSTOPERATIVE

STATUS STATUS (%) STATUS (%)

RSD/CRPS 42 92 65
Raynaud’s
syndrome/vasculitis 51 96 88

* Oswestry Pain Scale score is derived from a 10-item questionnaire administered to each patient preoperatively and
6 months postoperatively, with a scale of 1 to 100. Patient data are presented as a percentage of the mean.
CRPS, complex regional pain syndrome; RSD, reflex sympathetic dystrophy.
3102 Section VI ■ Pain

port did not reflect the use of flexible ports and smaller
instruments.
Small pleural effusions do not require drainage but
should be followed with repeated chest radiographs.6,
77, 83
Pneumothorax indicates a parenchymal or port-
site leak. Most cases can be observed, although a large
pneumothorax may require chest tube placement. The
one death that occurred in the series was several weeks
after surgery for severe Raynaud’s with significant pre-
existing cardiovascular risk factors, and the patient was
doing well after surgery.

Endoscopic Lumbar Sympathectomy

Open lumbar sympathectomy procedures have been
used effectively to treat lower extremity vasculitis and
pain syndromes but are being supplanted by minimally
invasive laparoscopic retroperitoneal techniques.84, 85
The most frequent indications for splanchnic sympa-
thectomy procedures include lower extremity reflex
sympathetic dystrophy (or CRPS) and Raynaud’s syn-
drome. Pelvic and visceral pain syndromes have also
been treated with splanchnic sympathectomy, although
less frequently. Similar to thoracoscopic sympathec-
tomy, minimally invasive endoscopic techniques can
reduce the surgical morbidity, hospital stay, and return
to activity due to small surgical incisions and reduced
tissue injury.86–88 A limited number of published reports
with small series suggest results similar to those for
open procedures, but reduced morbidity and hospital-
ization are the major differences.1, 89–91
PATIENT SELECTION
Patients with autonomic lower extremity pain syn-
dromes require similar medical evaluation and man-
FIGURE 195–7. Lumbar retroperitoneal endoscopic exposure of
the lumbar sympathetic chain for a sympathectomy. Notice the
direct reach of the sympathetic ganglia with this approach.
agement before consideration of a lumbar sympathec-
tomy procedure. For most patients with lower
extremity pain syndromes, pelvic and lumbar imaging
studies are necessary to exclude other treatable disor-
ders. Peripheral vascular abnormalities should be eval-
uated with noninvasive methods or angiography to
exclude treatable vascular lesions. Provocative testing
with anesthetic lumbar sympathetic blocks can provide
confirmation of diagnosis and useful predictive out-
come assessment.
SURGICAL TECHNIQUE
The patient is placed in the prone position under gen-
eral anesthesia, and ports are placed in the midaxillary
line at the level of the intended sympathectomy. Blunt
digital dissection is applied into the retroperitoneum
to create an endoscopic working space with a balloon
tissue expander or direct carbon dioxide insufflation
(Fig. 195–6). Laparoscopic gas-tight ports are placed
for the endoscope and working ports. Exposure and
resection of the lumbar sympathetic chain proceed in a
manner similar to that for open procedures (Fig. 195–7).

FIGURE 195–6. Cross-sectional anatomy through the midlumbar
level demonstrates where the retroperitoneal dissection occurs.
Notice the expansion of the retroperitoneal space, with anterior
dislocation of the kidney and lateral dislocation of the spleen.
There is a direct approach to the anterolateral aspect of the
vertebrae where the sympathetic chain is visualized. The patient
is in the prone position.
CONCLUSION
Minimally invasive endoscopic sympathectomy tech-
niques have surgical goals that are similar to those for
open procedures with equivalent outcomes; however,
the associated morbidity is substantially reduced be-
cause of reduced tissue injury. We recommend that
surgeons receive formal training for these procedures,
including didactic and laboratory training, followed by
work with an experienced surgeon who performs these
operations on a regular basis. These endoscopic proce-
dures have learning curves that necessitate precise
knowledge of the anatomy and an understanding of
endoscopic surgical techniques.

ACKNOWLEDGMENTS
We wish to thank Joe Bloch and Josh Emerson for
their illustrations.
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