ETS is misrepresented to patients: July 2012

Cell body reorganization in the spinal cord after elective surgery to treat sweaty palms

Sunday, July 29, 2012

It is well recognized that preganglionic sympathectomy involves division of cholinergic elements ad sensory fibers

It is well recognized that preganglionic sympathectomy involves division of cholinergic elements ad sensory fibers.
Theodore Cooper, Department of Surgery, St Louis University School of Medicine
Pharmacological Reviews, 1966 Vol. 18, No. 1. Part I

Friday, July 27, 2012

When sympathectomized rats were injected with the same carcinogen, 24 out of 38 developed tumors

"Lesions od the sympathetic nervous system have been shown to increase the incidence, induction, and take and growth, of tumors. In neurally intact rats which were infected with a known carcinogen, only 1 out of 30 developed a tumor. When sympathectomized (intentional sympathetic nerve interference) rats were injected with the same carcinogen, 24 out of 38 developed tumors. These results confirm that sympathetic block enhances tumor implantation."

"Clearly the autonomic nervous system in exquisitely sensitive to information from all parts of the nervous system and may affect many aspects of the immune response."

"Since immune response is initiated by the nervous system, this appears to be a likely place to look for the cause of disease."

Edward E. Cremata, Neural control of immunity, January/February, 1982 The Digest of Chiropractic Economics

1. Couhard, R. and P. Hein, Cancers de types divers provoqucs par lesion du sympathique, CR. Acad. Sci, 2434-2437, 1957.

2. Couhard, R. and F. Heitz, Production de tumeurs malìgncs consecutivas a des lesions des fibres sympaxhiqucs du neri sciatique chez le cobaye. CR. Amd. Scl", 244: 4-09-411, 1957.

3. Nayar, KK., Arthur, E. and Ballís, M4, Th: transmission of tumours induced in cockroaches by nerve severance, Experienria, 27: 183, 1971.

4. Champy, C.. Lesions neum-sympathìques precedam la canccrixation dans Patlaque de Porganìsmc par les substances cancerîgenes, C.R. Acad. Sci, 248: 3665-1666; 1959.

lnouye. T., Neuropalhologische Versuche ueber die organafñnîtact der bocsanígcn gcschwuclstc, Arrh. Jap. Chir., 1580-1594, 1959. www.usapr.org/paperpdfs/75.pdf

Norepinephrine activates pain pathways after nerve injury

According to MedicineNet, RSD involves "irritation and abnormal excitation of nervous tissue, leading to abnormal impulses along nerves that affect blood vessels and skin."

Animal studies indicate that norepinephrine, a catecholamine released from sympathetic nerves, acquires the capacity to activate pain pathways after tissue or nerve injury, resulting in RSD.

http://arthritis.about.com/od/rsd/a/rsd.htm

Thursday, July 26, 2012

Anthem medical policy for ETS surgery

Presence of medical complications or skin maceration with secondary infection; or
Significant functional impairment, as documented in the medical record.

Botulinum toxin is considered medically necessary in the treatment of secondary hyperhidrosis when the condition is related to surgical complications and both of the following criteria are met:

Presence of medical complications or skin maceration with secondary infection; and
Significant functional impairment, as documented in the medical record.

Treatment of primary axillary or palmar hyperhidrosis with endoscopic thoracic sympathectomy is consideredmedically necessary in the small subset of individuals with hyperhidrosis where both of the following criteria (1 and 2) have been met:

It has been adequately documented that all efforts at nonsurgical therapy have failed; and
Either of the following:

Presence of medical complications or skin maceration with secondary infection; or
Significant functional impairment, as documented in the medical records;

http://www.anthem.com/medicalpolicies/policies/mp_pw_a050005.htm

Wednesday, July 25, 2012

Correlating Dermatomal Level to Surface Landmarks

Table 3. Correlating Dermatomal Level to Surface Landmarks
Dermatomal Level	Surface Landmark	Comments
C8	Little finger	Cardioaccelerator fibers blocked (T1 to T4)
T1, T2	Inner aspect of the arm	Above fibers blocked but to lesser degree
T4	Nipple line, root of scapula	Cesarean section, Appendectomy, upper abdominal surgery
T7	Inferior border of scapula; Tip of xiphoid	Splanchnic (T5 to L1) blockage; lower abdominal surgery; T5 to T7 for thoracotomy or fractured ribs (at relevant interspace)
T10	Umbilicus	Usual level for LE procedures, hip surgery, TURP, vaginal delivery
L2 to L3	Anterior thigh	Appropriate for knee, foot surgery
S1	Heel of foot	Part of sacral plexus, difficult to block

http://www.nysora.com/test2/regional_anesthesia/neuraxial_techniques/3026-epidural-blockade.html

"sympathectomy of one side of the body leads to an increase in the development of tumors on the denervated side"

Coujard R, Heitz F. Cancerologic: Production de tumeurs malignes consecutives a des lesions des fibres sympathiques du nerf sciatique chez le Cobaye. C R Acad Sci 1957; 244: 409411.

This suggest that interference with the sympathetic nervous system (SNS) can lead to a compromise of the body's immune system [81–82]. Conversely, an immunological response can alter the response pattern of the sympathetic nervous system. [83]
http://www.chiro.org/LINKS/FULL/VERTEBRAL_SUBLUXATION_2.shtml

Monday, July 16, 2012

Management of reflex sweating in spinal cord injured patients

Reflex sweating can be a problem for cervical spinal cord injured patients. Patient comfort and skin breakdown have been the major concerns. Five patients were studied prospectively, using a patch containing 1.5mg of scopolamine. Patches were changed every third day. Each patient was carefully monitored before and after application of the patch for signs and symptoms of anticholinergic side effects such as dizziness, blurred vision and dry mouth. Patients were also monitored for changes in patch signs before and after use, including residual urine volumes, blood pressure, heart rate, and mental status. Our study indicates that topical scopolamine successfully controlled reflex sweating in 5 patients without anticholinergic side effects.

PMID:: 2742472; [PubMed - indexed for MEDLINE]; http://www.ncbi.nlm.nih.gov/pubmed/2742472

Saturday, July 7, 2012

Heart rate significantly decreased after bilateral but not after unilateral right sympathectomy

http://www.ncbi.nlm.nih.gov/pubmed/12643398

Friday, July 6, 2012

Sympathectomy or doxazosin, but not propranolol, blunt myocardial interstitial fibrosis

http://www.ncbi.nlm.nih.gov/pubmed/16216989

surgical and chemical sympathectomy can both modulate bone cell function

It is known that surgical and chemical sympathectomy can both modulate bone cell function. However, the sympathetic
nervous system (SNS) can give rise to both anabolic and catabolic effects [28-31] and its role in regulating bone remodeling is, therefore, controversial. For example, some researches reported that if bone is deprived of its sympathetic innervation, bone
deposition and mineralization is reduced and bone resorption increases [31], while in some other reports a sympathectomy impairs bone resorption [28].
Wei Fan BSc, MSc
Institute of Health and Biomedical Innovation
Faculty of Built Environment & Engineering
Queensland University of Technology

eprints.qut.edu.au/35722/7/35722b.pdf

Tuesday, July 3, 2012

Sustained Benefit (sic!) Lasting One Year from T4 Instead of T3-T4 Sympathectomy

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664277/

No statistically significant association between the CS with age, family history, type of HH and extent of TS

http://ejcts.oxfordjournals.org/content/34/3/514.full

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sympathectomy interrupts neural messages to many different organs, glands and muscles

Acquired cardiovascular disease following Sympathectomy

We found statistically significant differences (P < .05) in both time and frequency domains. Parameters that evaluate global cardiac autonomic activity (total power, SD of normal R-R intervals, SD of average normal R-R intervals) and vagal activity (rhythm corresponding to percentage of normal R-R intervals with cycle greater than 50 ms relative to previous interval, square root of mean squared differences of successive normal R-R intervals, high-frequency power, high-frequency power in normalized units) were statistically significantly increased after sympathectomy. Low-frequency power in normalized units, reflecting sympathetic activity, was statistically significantly decreased after sympathectomy. Low-/high-frequency power ratio also showed a significant decrease, indicating relative decrease in sympathetic activity and increase in vagal activity.

The Journal of Thoracic and Cardiovascular Surgery
Volume 137, Issue 3, March 2009, Pages 664-669

decline in external heart work due to sympathectomy both at rest and under exercise

the muscles that are supplied by these nerves shorten and tighten

This now well-established but generally under-appreciated principle of physiology is aptly known as 'Cannon's Law of Denervation Supersensitivity'. It describes the wide ranging effects of the complete loss of nerve inputs to a variety of bodily structures under experimental conditions. One of the many responses to nerves that are sick or dysfunctional (now termed Disuse Supersensitivity) is that the muscles that are supplied by these nerves shorten and tighten (due to the supersensitivity of both the muscle's specialized stretch receptors and motor nerve-muscle junctions), resulting not only in muscle spasm and stiffness which limit flexibility, but a whole sequence of pain compounding reactions. The two earliest are that localized taut bands of muscle fibers begin to compress the small specialized pain sensing (and now extra-sensitive) nerve fibers within the muscle (known as myofascial tender or trigger points) causing type 1 pain, and the compressed muscles do not allow proper blood flow in, or waste products to be removed. This leads to a build up of lactic acid, which further enhances the perception of pain through type 2 pain mechanisms. Continued and prolonged muscle shortening or contracture gradually leads to increased mechanical tension on the muscle's tendonous attachments to bone, causing all of the various tendonitis (types 1 & 2 pain) syndromes throughout the body. The end result is a truly vicious snowballing cycle of pain, with the muscle shortening further increasing pressure on the nerves.

www.northwestims.com/faq-4.html

Cannon's law of denervation tells us that if a post-ganglionic neurone has it's pre-ganglionic input removed, then it will become super-sensitive to the normal neurotransmitters that mediate that pre-ganglionic input. There is a variety of reasons for this, including up-regulation of receptors for the neurotransmitter(s), post-receptor effects, and impaired removal of neurotransmitters from the synapse

www.anaesthetist.com/anaes/patient/ans/

Most authors do not describe clinically significant capsular adhesions as a predominant finding in the chronic phase of this condition. Instead, pathologic data confirm an active process of hyperplastic fibroplasia and excessive type III collagen secretion that lead to soft-tissue contractures of the aforementioned structures (ie, the coracohumeral ligament, soft tissues of rotator interval, the subscapularis muscle, the subacromial bursae). However, these findings were observed in surgical patients who had severe and late-phase disease and cannot be applied to early phases of the disease.

From the chromosomal, cytochemical, and histologic points of view, the soft-tissue contractures are identical to those seen in a Dupuytren contracture of the hand. These contractures result in the classic progressive loss of ROM of the glenohumeral joint, which affects external rotation and abduction, then flexion, adduction, and extension (in descending order of severity). Despite these histopathologic similarities, the favorable and regressive outcome of adhesive capsulitis differs from the unfavorable and progressive outcome of Dupuytren disease.

http://emedicine.medscape.com/article/326828-overview#a0104

cervical sympathectomy is a psychosurgery

decreased conditioning-related activity in insula and amygdala after autonomic denervation

The degree to which perceptual awareness of threat stimuli and bodily states of arousal modulates neural activity associated with fear conditioning is unknown. We used functional magnetic neuroimaging (fMRI) to study healthy subjects and patients with peripheral autonomic denervation to examine how the expression of conditioning-related activity is modulated by stimulus awareness and autonomic arousal. In controls, enhanced amygdala activity was evident during conditioning to both "seen" (unmasked) and "unseen" (backward masked) stimuli, whereas insula activity was modulated by perceptual awareness of a threat stimulus. Absent peripheral autonomic arousal, in patients with autonomic denervation, was associated with decreased conditioning-related activity in insula and amygdala. The findings indicate that the expression of conditioning-related neural activity is modulated by both awareness and representations of bodily states of autonomic arousal.

http://www.ncbi.nlm.nih.gov/pubmed/11856537

All patients except one suffered from compensatory sweating

Complications in patients with palmar hyperhidrosis treated with transthoracic endoscopicsympathectomy.

Neurosurgery. 1997 Jul ;41 (1):110-3; discussion 113-5 9218302

OBJECTIVE: To assess the complications in a group of patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy. The extraordinarily high incidence of postoperative compensatory hyperhidrosis in our series is stressed and explained. METHODS: The retrospective study included chart reviews and outpatient assessments. Seventy-two patients underwent T2 or T2-T3 endoscopic sympathectomy for primary palmar hyperhidrosis. Patients' hyperhidrosis severity, precipitating factors, postoperative complications, surgical results, and satisfaction were assessed. Severity of palmar hyperhidrosis and compensatory hyperhidrosis was classified by two grading scales. RESULTS: The success rate of sympathectomy was 93%. All patients except one suffered from compensatory sweating,which was the main cause of patients' dissatisfaction postoperatively. Seventeen percent of the patients (12 of 72 patients) experienced new symptoms of gustatory sweating (facial sweating associated with eating). Twenty-one patients experienced other complications, including pneumothorax, Horner's syndrome,nasal obstruction, and intercostal neuralgia.

our ignorance of the mechanisms of primary hyperhidrosis and of the effect of sympathetic ablation

Segmental myoclonus was associated with thoracic sympathectomy

Spinal myoclonus was associated with laminectomy, remote effect of cancer, spinal cord injury, post-operative pseudomeningocele, laparotomy, thoracic sympathectomy, poliomyelitis, herpes myelitis, lumbosacral radiculopathy, spinal extradural block, and myelopathy due to demyelination, electrical injury, acquired immunodeficiency syndrome, and cervical spondylosis.

http://www.ncbi.nlm.nih.gov/pubmed/3753263

Spinal myoclonus is typically associated with a localized area of damaged tissue (focal lesion). The injured area may include direct damage of the spinal cord or may cause abnormal changes in the function of the spinal cord.

http://www.wemove.org/myo/myo_pc.html

Spinal myoclonus following a peripheral nerve injury: a case report

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526081/

RESPONSE TO SYMPATHETIC BLOCKADE DEPENDS ON THE DEGREE OF SYMPATHETIC TONE BEFORE THE BLOCK

Denervation of preganglionic cardiac accelerator fibres leaving the cord at T1-T5 results in minimal vasodilatory consequences. Changes however in heart rate, left ventricular function and myocardial oxygen demand may occur due to high thoracic epidural blockade and are discussed below.

The major determinant of heart rate is the balance between sympathetic and parasympathetic systems with the latter predominating. A high thoracic epidural anaesthesia (TEA) covering the cardiac segments (T1-T4) produces small but significant reductions in heart rate4-8. During cardiac sympathetic denervation, parasympathetic cardiovascular responses, including those involved in baroreflexes, may dominate.

Individual cardiovascular response to different levels of sympathetic blockade varies widely, depending on the degree of sympathetic tone before the block.
Anaesth Intensive Care 2000; 28: 620-635
B. T. VEERING*, M. J. COUSINS†
Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands and Department of Anaesthesia and
Pain Management, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales

Effects of upper abdominal sympathectomy on gastric acid, serum gastrin, and catecholamines

Selective upper abdominal sympathectomy increased basal acid output in rats but was without effect on stimulated acid output, serum gastrin concentration, and gastric mucosal histidine decarboxylase activity. The sympathectomy was verified by fluorescence histochemistry and determination of tissue catecholamines. A drastic reduction in tissue noradrenaline, adrenaline, and dopamine levels occurred after sympathectomy, and fluorescence microscopy showed a complete loss of adrenergic nerve fibers. Vagotomy reduced catecholamine levels in the stomach wall by 50% but did not affect the catecholamine content in the pancreas and small bowel. Surprisingly, combined vagotomy and upper abdominal sympathectomy resulted in lower catecholamine levels than sympathectomy alone in extragastric but not in gastric tissues.

http://www.ncbi.nlm.nih.gov/pubmed/6515311

painful vasospastic condition in the right arm following surgical sympathectomy on the left side

Patients who have undergone sympathectomy are not suitable controls. Why?

Hemodynamic changes in vertebral and carotid arteries were observed after sympathicotomy for PH

Patients with sympathectomy are not suitable controls for sleep study. Why?

Exclusions:
Patients with permanent pacemaker, non-sinus cardiac arrhythmias, peripheral vasculopathy or neuropathy, severe lung disease, status postbilateral cervical or thoracic sympathectomy, finger deformity that precludes adequate sensor application, using a-adrenergic receptor blockers, or alcohol or drug abuse during the last 3 years.
Evaluation of a Portable Device Based on Peripheral Arterial Tone for Unattended Home Sleep Studies
The clinic sleep laboratory of the Technion Sleep Medicine Centre, Israel
http://chestjournal.chestpubs.org/content/123/3/695.long
CHEST March 2003 vol. 123 no. 3 695-703

MSAC Application no 1130, Assessment Report

These gustatory phenomena were quite different from physiologic gustatory sweating

In a series of 100 bilateral upper dorsal sympathectomiesperformed for palmar hyperhidrosis, gustatory sweating and othergustatory phenomena were reported by 68 of 93 patients (73%),followed up for an average of 11/2 years. These gustatory phenomenawere quite different from physiologic gustatory sweating: awide range of gustatory stimuli caused a variety of phenomenain varied locations. There was a negative correlation betweenthe incidence of these phenomena and the occurrence of Horner'ssyndrome after sympathectomy. Analysis of our observations,and of clinical and experimental work of others, leads to theconclusion that gustatory phenomena after upper dorsal sympathectomyare the result of preganglionic sympathetic regeneration orcollateral sprouting with aberrant synapses in the superiorcervical ganglion.

http://archneur.ama-assn.org/cgi/content/abstract/34/10/619

cervical sympathectomy is a psychosurgery

the muscles that are supplied by these nerves shorten and tighten

www.northwestims.com/faq-4.html

www.anaesthetist.com/anaes/patient/ans/

http://emedicine.medscape.com/article/326828-overview#a0104

The courts have become the sole policing body for the medical profession

Major lawsuits, with the major judgments that go with them, may not completely keep negligent physicians from practicing, but they are the one way that currently exists to deter these individuals from practicing their inept brand of medicine. "

Over the years, we have given a lot of thought to why the medical profession adheres to this code of silence. What is it about this profession that causes it to protect its own at the expense of the public?"

Harvey F. Wachsman: Lethal Medicine

Publisher: Henry Holt & Co