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440 Philip FINCH
history of sympathetic blockade and sympathectomy, for
it can provide valuable lessons in the use and abuse of an
interventional technique. e chapter will not act as a primer
for performing these blocks, except in outline, as more detailed
descriptions exist elsewhere [84, 106].
History
In 1889, the same year that the anatomy of the sympathetic
chain was described, the first surgical sympathectomy was
performed in the treatment of epilepsy! Surgical removal of the
stellate ganglion was then tried for varied conditions such as
exophthalmos, glaucoma, trigeminal neuralgia and even optic
atrophy. A more logical approach then prevailed following the
description by Leriche of periarterial stripping for Raynaud’s
disease and later for causalgia [60, 61].
It is of interest that there is a modern equivalent of this
technique in the treatment of refractory hand pain and
ulceration [54]. Likewise, causalgia (CRPS II), first described
by Mitchell in the American Civil War 1861–1865 [68] was
treated by sympathectomy in World Wars I and II [33, 62]
and in recent conflicts such as the Iran-Iraq War 1980–1988
[39].
Intravenous regional local anaesthetic blockade also has a long
history and was first described by Bier in 1908. Various drugs
which are active at the peripheral adrenergic receptor have
been added to local anaesthetic agents, and have been used
in regional techniques over the years, mainly in the treatment
of pain states such as CRPS. e results have not been
encouraging [48], despite early enthusiasm [37]. Again, the
placebo has been shown to be equally effective as drugs such
as guanethidine, which is now seldom used in the treatment
of CRPS. Direct blockade of the sympathetic chain with local
anaesthetic agents in the treatment of CRPS has also proved
no more efficacious when subjected to randomised placebo
controlled trials (RCT).
In a recent systematic review of RCTs and non-randomised
trials in the treatment of CRPS, only one-third of patients
reviewed responded fully to sympathetic blockade, which is
little different to a placebo response [17]. ese inconclusive
results were mirrored in a later study by the same authors
regarding short-term effects of sympathetic blockade in the
treatment of CRPS [16]. is author had previously found
that only approximately 50% of patients with CRPS respond
to sympathetic blockade with more than temporary thermo-
regulatory changes [28]. Longer-term sympatholysis such as
surgical sympathectomy produce such poor results that these
techniques have largely been abandoned in the treatment of
COSMETIC INDICATIONS FOR
SYMPATHETIC NEUROLYSIS
Anatomy of the cervicothoracic
chain
Endoscopic thoracic
sympathectomy
SYMPATHETIC BLOCKADE
AND SYMPATHECTOMY IN THE
TREATMENT OF PAIN STATES
CONCLUSION
REFERENCES
Figure 27.01 Rene Leriche
(1879 – 1955)
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441
The Sympathetic Chain
pain states such as CRPS. Unfortunately, instead
of the intended effects, complicating sequelae such
as compensatory sweating can be the only long-
term results of surgical ablation of the sympathetic
chain.
Kotzareff in 1920, successfully treated upper limb
hyperhidrosis by excision of the cervical ganglia
but unfortunately caused a Horner’s syndrome
in the process [55]. e thoracoscope is now
frequently used to access the upper thoracic ganglia
for the same indication, but unfortunately still
with unacceptable outcomes in some instances
[57]. In a recent extensive case series, there was a
3.8% incidence of Horner’s syndrome in patients
undergoing thoracoscopic sympathectomy [121].
is can be a devastating complication in a young
person.
ere are even suggestions that sympathectomy
may be helpful in the management of social phobic
reactions [100]. In fact, endoscopic sympathectomy
is recommended as the preferred treatment in severe,
“conservative therapy resistant” social phobia [52].
It would appear that not a lot has changed in over
100 years.
In 1924, Royle in Australia resected the lumbar
sympathetic chain both in animal models and
humans, hoping to modify skeletal muscle tone
in patients with spastic paralysis [91]. He noted
vasomotor effects and subsequently applied this
finding to the treatment of Raynaud’s disease [92].
oracoscopic sympathectomy for Raynaud’s
phenomenon has also been subjected to long-
term follow-up [101]. Unfortunately, symptoms
recurred in a substantial percentage of patients in
the follow-up period and many regretted having
the operation.
In more recent times, techniques for sympathetic
blockade have been modified with advances
in imaging. In the cervicothoracic, splanchnic
and lumbar regions, direct vision endoscopic
procedures have supplemented the use of the C-
arm image intensifier and computed tomography
(CT) guidance [27]. Also, novel techniques for
approaching the sympathetic ganglia have perhaps
improved the safety of sympatholytic interventions
[13]. However, the rationale for using sympatholysis
in the first place for the treatment of various
conditions is less than convincing and increasingly
subjected to critical evaluation. It is possible that
sympatholysis will eventually disappear from
treatment schedules proposed by pain physicians
and vascular and cosmetic surgeons alike, as its
true efficacy becomes better understood and the
rate of complications is rejected by both patients
and physicians.
Anatomical Basis of
Sympathetic Blocks
Much of the detailed anatomy of the sympathetic
chain will be examined in the sections relating
to specific techniques for the four main areas of
interest. ese include the cervicothoracic ganglia,
the splanchnic-coeliac plexus, the lumbar ganglia
and the superior hypogastric plexus.
e sympathetic nervous system has both central
and peripheral parts. e central component
includes the hypothalamus, midbrain, pons,
medulla and lateral columns of the spinal cord from
T1 to L2. e central component connects in the
thoraco-lumbar region to two ganglionated nerve
trunks extending from the first cervical level to the
coccyx. Preganglionic fibres, which are myelinated
fibres, ramify both cranially and caudally, so that
ongoing synaptic connections to the spinal nerves
can occur at both several segments above and below
the entry of the white rami into the chain.
Not all nerve fibres are efferent and mention must
be made of sympathetic afferents, which are largely
unmyelinated and traverse the coeliac ganglion
without synapse, some fibres crossing the midline,
and then travelling centrally via the splanchnic
nerves to the sympathetic ganglia and thence to the
sympathetic axonal cell bodies in the dorsal roots
T5–T10 [115]. It is these afferent fibres that are
blocked in neurolytic procedures for abdominal
cancer pain.
Sympathetic ganglia, which are said to number
five in the lumbar region, five in the sacral region
and three in the cervical region [88], however,
show considerable variability in position and
number and may even interconnect across the
midline [22, 79, 104, 112]. It is the variability in
the anatomy of the sympathetic ganglia that can
produce unpredictable results in techniques such as
radiofrequency sympatholysis of the lumbar chain.
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442 Philip FINCH
Sympatholysis and
Sympathetic Blockade in
Peripheral Vascular Disease
Possibly one of the less contentious uses of
sympathetic blockade, lumbar sympatholysis by
paravertebral block, became established in the
1920s after the work of Brunn and Mandl in
Vienna [23] and Royle in Australia [91]. Chemical
sympathectomy, which is popular to this day
for assisting in the healing of vascular ulcers and
relieving rest pain, is a safe procedure for the aged
and infirm. is simple technique can avoid the
need for general anaesthesia and is performed as
an outpatient procedure. Aqueous phenol 10%,
which was popularised by Haxton in 1949, has
largely replaced alcohol as it reduces the incidence
of neuritis. Its use for the upper thoracic chain has
been described [27], but has never achieved the same
popularity as lumbar chemical sympathectomy,
possibly due to the technical difficulty of nerve
blocks in the vicinity of the lung, the incidence
of side effects such as Horner’s syndrome and the
advent of direct vision thoracoscopic techniques
which can produce sympatholysis with a high
degree of certainty [57, 59].
Further refinements of the technique of percutaneous
lumbar sympatholysis have been claimed with the
use of CT guidance [26, 85]. In theory, the needle
Figure 27.03A Approach to the lumbar
sympathetic chain
Figure 27.02 Lumbar Sympathectomy
Figure 27.03B Lateral C-arm lumbar chemical
sympathectomy
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443
The Sympathetic Chain
tip can be placed onto the chain, avoiding adjacent
structures such as the kidney and lung. e spread
of contrast agent around the chain can be monitored
and the operator assured of an adequate neurolysis.
However, even with fast acquisition CT scanners,
the technique is undoubtedly more cumbersome
than chemical sympathectomy with a single needle
technique under image intensifier control [40].
Alternatives to the use of phenol 10% in the
treatment of peripheral vascular disease have been
described including radiofrequency techniques,
which are claimed to be as efficacious as phenol 6%
[75]. However, it is the author’s experience that
the discrete lesions produced by radiofrequency
electrodes cannot provide the certainty of
block provided by phenol 10%. More recently,
retroperitoneoscopic surgical sympathectomy
has been described for lower limb ischaemia
where reconstructive surgery is not indicated.
It has been claimed that retroperitoneoscopic
lumbar sympathectomy successfully combines the
advantages of minimally invasive surgery with the
effectiveness of the open procedure [3].
Attempts have been made to critically evaluate
the results of lumbar sympatholysis. In an earlier
study, using digital plethysmographic techniques,
Strandness concluded that lumbar sympathectomy
does not alter the physiological response to calf
muscle ischaemia and is probably of little use for
claudication [99]. Cousins, in a study of the results
of neurolytic sympathetic blockade, concluded that
the technique is an effective method of relieving rest
pain with a mean duration of sudomotor blockade
of approximately 6 months [21]. A subsequent
randomised prospective controlled trial supported
Strandnsess’ earlier conclusion and chemical
sympathectomy was not found to be beneficial in
the treatment of intermittent claudication [23].
Cross suggested that chemical sympathectomy
should be redefined as a pain relieving injection
suitable for treating ischaemic rest pain, which is
one of the major complaints of patients who are
not suited to reconstructive surgery.
Further prospective analysis has been conducted
of CT-guided lumbar sympathectomy, which is
proposed as an alternative to image intensifier
guided blocks [41]. Criteria for success included
doubling of the pre-interventional walking distance,
the disappearance of rest pain, or the healing of
ulcers. Approximately 50% of 83 patients in this
study showed improvement. However, despite
enhancing the ureters with intravenous contrast
medium, two patients developed ureteric strictures
probably due to injury from the neurolytic solution
(alcohol 96%).
Mention must be made of the treatment of
Raynaud’s phenomenon and frostbite. Adson in
1929 wrote that “the striking, maintained, and
unequivocal therapeutic effects of lumbar and
dorsal sympathetic ganglionectomy in Raynaud’s
disease seem to warrant the belief that surgical
control in this disease is an accomplished fact” [2].
However, in a recent long-term retrospective study
of thoracoscopic sympathectomy for Raynaud’s
phenomenon, 34 patients underwent thoracoscopic
sympathectomy and were assessed by questionnaire
with a median time to follow-up of 40 months [101].
Despite an immediate beneficial effect seen in 83%
of patients, symptoms recurred in 63%, gustatory
sweating occurred in 30% and 43% regretted
having the operation. ese results might suggest
that the surgical treatment of Raynaud’s disease is
far from accomplished. Perhaps sympathectomy
should be considered only as a salvage operation
to limit progressive gangrene and ulceration [109].
Lastly, sympatholysis is thought to have a place in
the treatment of frostbite — if performed early
[97].
Figure 27.03B A-P C-arm lumbar chemical
sympathectomy
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444 Philip FINCH
Sympatholysis in the
Treatment of Abdominal
Visceral Pain
e treatment of abdominal cancer pain by
sympathetic ablation procedures must be considered
as one of the successful uses of this technique.
Moore considers coeliac plexus blockade to be “the
most effective, least hazardous means of palliative
therapy for cancer of the upper intra-abdominal
viscera” [69]. However, the role of coeliac plexus
blockade for benign abdominal pain has never
been well established [66]. Kappis introduced
percutaneous splanchnic block in 1914, placing
drugs posterior and superior to the diaphragmatic
crura. As nociceptive afferents passing through the
coeliac plexus run in the splanchnic nerves before
reaching the sympathetic chain, this was a form of
indirect coeliac plexus block [83]. An analogous
situation is seen with the hypogastric plexus and
nociceptive afferents arising in pelvic cancers.
Lastly, blocks of the ganglion impar, which is the
fused termination of the sympathetic chains, can
be considered in the treatment of perineal pain
states.
But first, the anatomy of the coeliac plexus and
splanchnic nerves should be considered.
Anatomy of coeliac plexus
e coeliac plexus has highly variable anatomy and
is formed from the left and right coeliac ganglia.
It surrounds the coeliac artery and the base of the
superior mesenteric artery. e coeliac plexus lies
anterolateral to the aorta and has considerable
cephalocaudal variability [110]. It can be found
level with the T12/L1 disc space to the middle
of the vertebral body of L2. e left ganglia are
typically located slightly caudal to the right.
Anatomy of splanchnic nerves
e splanchnic nerves are considered to carry the
majority of the upper abdominal visceral nociceptive
afferents, especially those from the pancreas. ey
are therefore attractive as targets for nerve block
or ablation techniques. e greater splanchnic
nerve, which carries efferent preganglionic motor
fibres and unmyelinated afferent sensory fibres, is
usually formed by contributions from the T5 to
T10 sympathetic ganglia. ere is, like all matters
Figure 27.04 Splanchnic nerves
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445
The Sympathetic Chain
concerning the sympathetic nervous system,
considerable anatomical variability. e roots of
the greater splanchnic nerve may vary in number
from one to eight, four being the most common
number [9]. e nerve runs obliquely over the
ribs, approaching the spine and being more closely
applied on the left. After piercing the diaphragm,
the greater splanchnic nerve ends in the ipsilateral
coeliac ganglion.
e lesser splanchnic nerve is formed by rami from
the ninth and tenth thoracic ganglia and passes
through the diaphragm just inferior to the greater
splanchnic nerve to reach the aorticorenal ganglion.
e least splanchnic (T12) nerve is seldom seen in
anatomical dissections. (Figure 27.04)
A number of important structures lie in close
proximity to the splanchnic nerves, which run
caudally in a narrow compartment lateral to the
vertebral bodies. e parietal pleura of the lung
and the crura of the diaphragm form the lateral
wall. (Figure 27.05)
Many variations of this technique have been devised
over the years, mainly for palliation of pancreatic
cancer pain [117]. Neurolytic agents are deposited
anterior to the aorta over at least two segments (L1 to
L2). e various approaches have been compared and
found to give similar results [46]. Moore’s classical
description includes a bilateral posterior approach as
the ganglia are of course bilaterally represented [69].
Radiofrequency heat lesioning is not suited to the
coeliac plexus due to its diffuse structure and usually
quite substantial volumes of alcohol or phenol are
used as a neurolytic agent. Radiological guidance
includes C-arm fluoroscopy and CT.
An anterior, per abdominal, approach can also be
used with ultrasound or CT guidance. ere are
several advantages claimed for using CT guidance
Figure 27.05 Axial CT T11 – anatomy of adjacent
structures
Figure 27.06A Axial L1 approach to coeliac plexus
Figure 27.06B Sagital approach to coeliac plexus
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446 Philip FINCH
including increased accuracy in placement of the
injection needle and the spread of neurolytic agent,
which can be observed without the use of contrast
medium [108]. (Figure 27.06A and Figure 27.06B,
Figure 27.07A and Figure 27.07B)
Coeliac plexus blockade has been the subject of
several studies of efficacy and safety. ere have
been randomised controlled trials [45, 82, 116]
and meta-analyses [29] that indicate that coeliac
plexus neurolysis can provide long-lasting relief
of cancer-related abdominal pain. Its use in the
treatment of chronic benign abdominal pain is more
controversial [66]. Side effects such as diarrhoea and
hypotension are common and severe adverse effects
such as paraplegia and retroperitoneal abscess are
not unknown [1, 71].
Further, the use of neurolytic coeliac plexus
blockade for abdominal cancer pain has been
studied at different stages of the disease [25].
Contrary to previous views, that neurolytic blocks
should be retained to the end stages of the disease,
the results would suggest that sympathetic plexus
block should be considered earlier in the disease
process rather than later.
Splanchnic nerve neurolysis
Possibly a more precise method of blocking afferent
pain sensations from upper abdominal viscera,
splanchnic nerve neurolysis can be performed
in a number of ways. e relatively predictable
anatomy of the splanchnic nerves, especially their
relationship to the vertebral bodies of T11 and
T12, allow for precise needle placement using C-
arm fluoroscopy or CT [35, 83,]. (Figure 27.08A
and Figure 27.08B)
Curved blunt needles or radiofrequency cannulae
can be introduced under oblique projection of the
T11 or T12 vertebrae and by a vertebra-hugging
technique advanced to the anterior one-third of the
vertebral bodies as seen on lateral projection [32].
is technique avoids adjacent structures such as
the lung base [31]. Blunt tips may well reduce the
incidence of pleural or vascular puncture. Both
posterior, transcrural and anterior per abdomen
approaches have been described using CT guidance
[67]. Direct thoracoscopic techniques can also be
employed and perhaps provide even more certainty
to neurolysis of the splanchnic nerves.
Complications such as pneumothorax and diarrhoea
are fortunately rare. Severe diaphragmatic paralysis
has been described [89]. However, the use of alcohol
in the chest is perhaps less well controlled than
in the abdomen for coeliac plexus blockade. Few
data exist on the efficacy of splanchnic blockade.
Raj reported on 107 patients with 40% obtaining
excellent pain relief with radiofrequency neurolysis
[83]. Further trials are in progress and hopefully
will support earlier encouraging preliminary data.
Hypogastric Plexus
and Ganglion of Impar
Neurolysis
Some afferent pain sensations from the pelvic
viscera pass through the superior hypogastric
Figure 27.07A Coeliac plexus
Figure 27.07B Coeliac plexus
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447
The Sympathetic Chain
plexus providing a target for neurolytic blockade.
is is analogous to coeliac plexus blockade and
in a similar fashion many different approaches
have been considered since the first description of
hypogastric plexus block by Plancarte [80].
e superior hypogastric plexus is situated on the
anterior aspect of L5 to S1 disc and vertebral bodies
and lies below the aortic bifurcation. Important
structures just lateral to the plexus include the
internal iliac vessels and the ureter. (Figure 27.09)
Visceral pain probably originates in pelvic visceral
nociceptors [18], but the existence of the nociceptors
is controversial [8]. Visceral afferents pass without
synapse to the dorsal horn mostly between levels
T7 to L2. ese visceral afferents are termed
“sympathetic afferents”, but like the coeliac plexus
there is disagreement as to whether they constitute
part of the sympathetic nervous system, which is
primarily efferent in its activity. ere are a number
of possible autonomic pathways that transmit
pain sensation from the pelvis and not all of these
pathways pass through the hypogastric plexus.
is plexus is, however, reasonably accessible to
nerve block techniques as opposed to the presacral
plexus of nerves, and interruption of sympathetic
pathways, including the superior hypogastric
plexus, will provide pain relief.
Neurolysis of the superior
hypogastric plexus
Attempts at denervation of pelvic sympathetic nerves
date back to soon after the first description of the
sympathetic chain [47, 93]. Subsequently, surgical
presacral neurectomy was performed for severe
dysmenorrhoea. Part of the superior hypogastric
plexus was resected by various techniques and good
pain relief reported in 70% of patients in one large
retrospective series [6].
Figure 27.08A A A-P C-arm splanchnic nerve
Figure 27.08B Lateral C-arm splanchnic nerve
Figure 27.09 Hypogastric plexus
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448 Philip FINCH
Plancarte described hypogastric plexus block for
cancer pain using a blind (non-fluoroscopically
controlled) bilateral posterior approach [80].
(Figure 27.10)
However, this block can be difficult to perform
with C-arm fluoroscopy due to the high angles
of projection and the position of the pelvic crest.
Alternative techniques have been devised, including
a transdiscal [44, 102] and anterior (per abdomen)
approach [50]. Additionally, CT guidance has been
described and may assist positioning of the needle
tip by both posterior [105] and anterior approaches
[13].
Attempts at assessing efficacy have been limited.
Plancarte and others reported on 227 cancer
patients, with successful neurolysis occurring in
72% [81]. Also in a small series of patients blocked
by the transdiscal route, good pain relief was
reported in five of seven patients [30]. e use of
superior hypogastric plexus block for benign pain
has met with less success [8].
Ganglion of impar neurolysis
e ganglion of impar, which is the fused caudal
end of the sympathetic chain, lies over the ventral
surface of the coccyx in the retroperitoneum. Once
again, there is considerable anatomical variability
in a sympathetic nervous system structure. It can
lie in a number of positions relative to the anterior
surface of the coccyx [76].
Blockade of the ganglion is described to relieve
pain thought to be of sympathetic origin in the
perineum, bladder, ureter, cervix and rectum
[72, 111, 118]. What constitutes sympathetic as
opposed to somatic pain in this region is, however,
poorly described. Plancarte first described blockade
of the ganglion impar for cancer pain [80]. He
used a bent needle introduced between the coccyx
and the rectum. A number of variations on this
technique have subsequently been introduced
including transsacrococcygeal ligament [111],
cryoablation through the sacrococcygeal disc
[70] and a paramedial approach [65]. ese
alternative approaches have attempted to reach
this target without the attendant risks of puncture
of the rectum. Few data are available on efficacy.
Neurolysis of the ganglion impar has mainly been
used for cancer pain, but it has also been described
for sacral postherpetic neuralgia [65].
Cosmetic Indications for
Sympathetic Neurolysis
Severe primary hyperhidrosis and excessive facial
blushing can cause such misery that patients seek
surgical treatment in the form of sympathectomy.
Often these patients are less than 30 years of age
and complications, which can be significant, will
affect their lives for many years. Excessive palmar
sweating is currently treated with endoscopic
thoracic sympathectomy (ETS) when conservative
treatment fails – which is often the case. High
success rates are claimed [74, 86]. Other forms
of sympathetic chain ablation include the use
of laser and radiofrequency heat. In the case of
hyperhidrosis of the feet, some form of lumbar
chain neurolysis is considered, usually including
ganglia L2 to L4.
Extensions of the indications for this technique
have more recently included treatment of facial
sweating and blushing. It is even advocated for
social phobic disorders, which include fear of
scrutiny, fear of performing in public, fear of eating
with others because of trembling of the hands
(coffee cup neurosis), excessive blushing, sweating,
stuttering and trembling [95, 103]. Many would
consider sympatholysis for these conditions to be
Figure 27.10 Lateral C-arm hypogastric block
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449
The Sympathetic Chain
a lifestyle procedure and similar in some ways to
cosmetic aesthetic surgery [77].
Excessive palmar and axillary sweating can cause
social embarrassment, especially in young adults.
Certainly, excessive palmar sweating can cause
great difficulties with writing, as documents
become smeared. Plantar hyperhidrosis can also
cause significant problems including cutaneous
infections, trench foot, susceptibility to frostbite
due to moisture accumulation and aesthetic
problems due to sodden footwear [4].
Anatomy of the cervicothoracic chain
e stellate ganglion is usually composed of both
the inferior cervical and first thoracic ganglia.
Sympathetic fibres to the cranium, and especially
the eye, pass via the stellate ganglion and the cervical
sympathetic chain, synapsing with postsganglionic
fibres in the superior cervical ganglion. e stellate
ganglion lies anterolateral to the body of the seventh
cervical and lateral to the first thoracic vertebral
bodies. ere is marked anatomical variation in its
position, as with all sympathetic nervous system
structures [53]. (Figure 27.11)
e position of the cervical sympathetic chain can
also vary, lying within the carotid sheath in about
16% of cases in one cadaver study [63]. In the upper
chest, the sympathetic chain lies more laterally, in
close approximation to the head and neck of each
rib. On the left, the T2 ganglion lies adjacent to
the aortic arch and in the second intercostal space.
In about 16% of cases, the T3 ganglion is placed
anterior to the third rib, making it inaccessible
to direct posterior approaches for nerve block or
radiofrequency lesioning. As it progresses caudally,
the chain becomes more anterolateral to the
vertebral bodies. is relationship is maintained
into the lumbar region. (Figure 27.12, Figure
27.13A and Figure 27.13B)
Endoscopic thoracic
sympathectomy
Endoscopic thoracic sympathectomy (ETS) has
become the preferred method of upper thoracic
sympathectomy and was first described by Hughes
in 1942 [43]. Kux subsequently described a large
series in 1954 [56] and many authors have followed
[42, 58, 119, 121]. In the last two decades, video-
assisted fibre-optic endoscopy has vastly improved
the operating conditions for this procedure.
e main indication for ETS has been primary
hyperhidrosis. Usually, the upper thoracic ganglia,
including T2 and T3, are resected or destroyed by
diathermy [14]. Sometimes T2 to T4 are included.
Clipping is thought to offer some degree of
reversibility [19] and confining the sympathectomy
Figure 27.11 Stellate ganglion anatomy
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