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Cold Sensitivity as a New Side Effect After Sympathicotomy for Hyperhidrosis

2005; Elsevier BV; Volume: 80; Issue: 6 Linguagem: Inglês

10.1016/j.athoracsur.2004.07.003

1552-6259

Eric G. Lowe, Philip D. Allmendinger, Robert Lowe,

Biomedical and Chemical Research

Extremity cold sensitivity is a previously unreported side effect of thoracoscopic sympathicotomy. We report a case of a young man who underwent thoracoscopic sympathicotomy for hyperhidrosis, after which cold sensitivity developed in his sympathicotomized right hand and arm. When exposed to cold, the right hand and forearm become numb and the skin temperature drops to uncomfortable levels, while the left extremity remains comfortably warm. Extremity cold sensitivity is a previously unreported side effect of thoracoscopic sympathicotomy. We report a case of a young man who underwent thoracoscopic sympathicotomy for hyperhidrosis, after which cold sensitivity developed in his sympathicotomized right hand and arm. When exposed to cold, the right hand and forearm become numb and the skin temperature drops to uncomfortable levels, while the left extremity remains comfortably warm. Thoracoscopic sympathicotomy (simple sectioning of the sympathetic trunk) offers an alternative to the more invasive thoracoscopic sympathectomy (dissection and excision of a portion of the sympathetic chain) and has been recognized as an effective means of treating severe upper-extremity hyperhidrosis [1Drott C. Gothberg G. Claes G. Endoscopic procedures of the upper-thoracic sympathetic chain a review.Arch Surg. 1993; 128: 237-241Crossref PubMed Scopus (101) Google Scholar]. We report a case of a patient who underwent thoracoscopic sympathicotomy and experienced a previously unreported increase in cold sensitivity in the sympathicotomized hand and arm.A 25-year-old man presented with severe bilateral palmar, axillary, and plantar hyperhidrosis. The patient had previously tried multiple topical drying agents and iontophoresis without success. These agents either demonstrated no noticeable clinical improvement or were deemed too cumbersome for long-term therapy. The patient had no significant past medical history, was otherwise healthy with no prior surgical history, and was on no medications. The patient’s family history is significant for primary Raynaud’s phenomenon (PRP) in his mother, maternal grandfather, and one maternal aunt.After a discussion of the risks and benefits of the surgical treatment, the patient decided that unilateral upper extremity dryness would allow him to function more comfortably in his medical career. He did not want to lose all thermoregulatory sweating from his head because of athletic hobbies, so he underwent unilateral right-sided thoracoscopic sympathicotomy. The right sympathetic chain was divided with electrocautery over the neck of both the second and third ribs, and the procedure was uncomplicated.Immediately after the surgery, the right hand was palpably warmer than the left, and right palmar sweating was absent. Subsequently, the patient described anhidrosis of the right face, scalp, neck, and the lateral surface of the right upper arm, right forearm, and right hand consistent with the expected surgical result. Within the first 6 months, the only other effect noted was increased gustatory sweating on the right face and scalp, a previously well-described side effect.During the winter, 8 to 10 months postoperatively, the patient became aware of a severe sensitivity to cold in the sympathicotomized hand and arm. In cold temperatures his right hand and forearm became much colder than the left side, often to the point where the right hand became stiff and numb while the left hand was still comfortably warm. The patient is a triathlete and an avid runner, and he first became aware of the symptoms while running outside in cold weather. Since that time he has noted that his right hand can become uncomfortably cold even in air-conditioned rooms in the summertime or when holding a cold beverage. Anhidrosis of the hand, lateral arm, right face, and right scalp persists.An infrared skin temperature thermometer was used to examine the average skin temperature of the patient’s hand and arm. A mean skin temperature was calculated by using five anatomic locations on the hand and three on the arm for each measurement. After the patient sat warmly dressed in a 20.5°C room for 1 hour, the sympathicotomized hand was 3.6°C warmer than the left hand. However, after jogging for 20 minutes in −1.0°C weather, the skin of the sympathicotomized hand was 11.9°C colder than the left hand.When the patient is in a warm environment, there is no perceptible difference between the capillary refill or Allen tests between the two hands. However, when the patient is exposed to cold, the capillary refill of his sympathicotomized hand is 4 to 5 seconds longer than that of the left hand, and the Allen test demonstrates a markedly delayed refill.CommentDividing the sympathetic innervation to a limb should remove the underlying tone of sympathetic vasoconstriction along with denervating the sweat glands. The expected result is a dry limb that is warmer than base line. In the patient we describe, this situation holds in warm environments; however, the temperature difference quickly reverses when the patient is exposed to cooler temperatures.A possible explanation for this phenomenon might involve the presence of residual sympathetic innervation in the sympathicotomized extremity. Investigations using tyramine infusions after endoscopic sympathicotomy have demonstrated the retention of a vasoconstrictive response in the sympathicotomized extremity, indicating the presence of viable postganglionic sympathetic innervation of the vascular bed [4Eisenach J.H. Clark E.S. Charkoudian N. et al.Effects of chronic sympathectomy on vascular function in the human forearm.J Appl Physiol. 2002; 92: 2019-2025PubMed Google Scholar]. The initial postoperative rise in skin temperature and anhidrosis indicates dissociation of the extremity from central sympathetic regulation; however, we cannot rule out the development of accessory reflex or control mechanisms or the evolution of irregular pathways through nerve regeneration and sprouting.The fact that cold sensitivity has not yet been reported in patients who underwent partial resection of the sympathetic chain and stellate ganglion may indicate that simply dividing the trunk leaves behind enough nerve tissue for aberrant regeneration to occur. However, it may also indicate that sympathectomy patients have never been queried directly about cold sensitivity. By undergoing only unilateral surgery, our index patient was in an unusual situation, and the ability to directly compare one arm to the other might have helped him to notice the development of this paradoxical cold sensitivity.Before this side effect is attributed to the specifics of sympathicotomy as a surgical technique, further comparison among patients who have undergone sympathectomy and sympathicotomy would clearly be warranted. This comparison might also prove instructive in helping to define a possible anatomic basis for the pathophysiology of cold sensitivity as a side effect.An alternate explanation for this patient’s side effect may relate to the patient’s strong family history of PRP. A genetic role has been demonstrated in the etiology of PRP [2Freedman R.R. Mayes M.D. Familial aggregation of primary Raynaud’s disease.Arthritis Rheum. 1996; 39: 1189-1191Crossref PubMed Scopus (66) Google Scholar], and a genetic predisposition towards cold reactivity in this patient may have been uncovered by the sympathicotomy. The pathogenesis of PRP involves α-adrenergic receptors [3Freedman R.R. Baer R.P. Mayes M.D. Blockade of vasospastic attacks by alpha 2-adrenergic but not alpha 1-adrenergic antagonists in idiopathic Raynaud’s disease.Circulation. 1995; 92: 1448-1451Crossref PubMed Scopus (68) Google Scholar] that are known to up-regulate and down-regulate their expression by many factors, including their degree of stimulation. If the adrenergic receptors in this patient’s right arm were up-regulated in response to the decreased sympathetic stimuli after the sympathicotomy, the arm might have become hypersensitive to any endogenous circulating catecholamines released during periods of cold stress or exercise. Further study using selective adrenergic agents might better elucidate the specific role of up-regulated receptors in this situation.This is the first patient at our institution that has reported an extreme cold-sensitivity reaction as a side effect of thoracoscopic sympathicotomy for hyperhidrosis. However, in a retrospective review of our last 20 consecutive patients who underwent sympathicotomy, we found 25% responded that they had noted an increase in cold sensitivity in their sympathicotomized hand(s) and arm(s), indicating this may not be an isolated incident. Although most of these patients noted the increase in cold sensitivity to be only a mild inconvenience, we have not yet objectively quantified their reaction to cold.The cold sensitivity experienced by the index patient may present a significant side effect to an elective procedure, especially in a patient with a strong family history of PRP or a patient whose vocation or avocation involves cold exposure. Until further information is available, we believe that the potential for cold sensitivity should be mentioned when the possible side effects of sympathicotomy are discussed. Thoracoscopic sympathicotomy (simple sectioning of the sympathetic trunk) offers an alternative to the more invasive thoracoscopic sympathectomy (dissection and excision of a portion of the sympathetic chain) and has been recognized as an effective means of treating severe upper-extremity hyperhidrosis [1Drott C. Gothberg G. Claes G. Endoscopic procedures of the upper-thoracic sympathetic chain a review.Arch Surg. 1993; 128: 237-241Crossref PubMed Scopus (101) Google Scholar]. We report a case of a patient who underwent thoracoscopic sympathicotomy and experienced a previously unreported increase in cold sensitivity in the sympathicotomized hand and arm. A 25-year-old man presented with severe bilateral palmar, axillary, and plantar hyperhidrosis. The patient had previously tried multiple topical drying agents and iontophoresis without success. These agents either demonstrated no noticeable clinical improvement or were deemed too cumbersome for long-term therapy. The patient had no significant past medical history, was otherwise healthy with no prior surgical history, and was on no medications. The patient’s family history is significant for primary Raynaud’s phenomenon (PRP) in his mother, maternal grandfather, and one maternal aunt. After a discussion of the risks and benefits of the surgical treatment, the patient decided that unilateral upper extremity dryness would allow him to function more comfortably in his medical career. He did not want to lose all thermoregulatory sweating from his head because of athletic hobbies, so he underwent unilateral right-sided thoracoscopic sympathicotomy. The right sympathetic chain was divided with electrocautery over the neck of both the second and third ribs, and the procedure was uncomplicated. Immediately after the surgery, the right hand was palpably warmer than the left, and right palmar sweating was absent. Subsequently, the patient described anhidrosis of the right face, scalp, neck, and the lateral surface of the right upper arm, right forearm, and right hand consistent with the expected surgical result. Within the first 6 months, the only other effect noted was increased gustatory sweating on the right face and scalp, a previously well-described side effect. During the winter, 8 to 10 months postoperatively, the patient became aware of a severe sensitivity to cold in the sympathicotomized hand and arm. In cold temperatures his right hand and forearm became much colder than the left side, often to the point where the right hand became stiff and numb while the left hand was still comfortably warm. The patient is a triathlete and an avid runner, and he first became aware of the symptoms while running outside in cold weather. Since that time he has noted that his right hand can become uncomfortably cold even in air-conditioned rooms in the summertime or when holding a cold beverage. Anhidrosis of the hand, lateral arm, right face, and right scalp persists. An infrared skin temperature thermometer was used to examine the average skin temperature of the patient’s hand and arm. A mean skin temperature was calculated by using five anatomic locations on the hand and three on the arm for each measurement. After the patient sat warmly dressed in a 20.5°C room for 1 hour, the sympathicotomized hand was 3.6°C warmer than the left hand. However, after jogging for 20 minutes in −1.0°C weather, the skin of the sympathicotomized hand was 11.9°C colder than the left hand. When the patient is in a warm environment, there is no perceptible difference between the capillary refill or Allen tests between the two hands. However, when the patient is exposed to cold, the capillary refill of his sympathicotomized hand is 4 to 5 seconds longer than that of the left hand, and the Allen test demonstrates a markedly delayed refill. CommentDividing the sympathetic innervation to a limb should remove the underlying tone of sympathetic vasoconstriction along with denervating the sweat glands. The expected result is a dry limb that is warmer than base line. In the patient we describe, this situation holds in warm environments; however, the temperature difference quickly reverses when the patient is exposed to cooler temperatures.A possible explanation for this phenomenon might involve the presence of residual sympathetic innervation in the sympathicotomized extremity. Investigations using tyramine infusions after endoscopic sympathicotomy have demonstrated the retention of a vasoconstrictive response in the sympathicotomized extremity, indicating the presence of viable postganglionic sympathetic innervation of the vascular bed [4Eisenach J.H. Clark E.S. Charkoudian N. et al.Effects of chronic sympathectomy on vascular function in the human forearm.J Appl Physiol. 2002; 92: 2019-2025PubMed Google Scholar]. The initial postoperative rise in skin temperature and anhidrosis indicates dissociation of the extremity from central sympathetic regulation; however, we cannot rule out the development of accessory reflex or control mechanisms or the evolution of irregular pathways through nerve regeneration and sprouting.The fact that cold sensitivity has not yet been reported in patients who underwent partial resection of the sympathetic chain and stellate ganglion may indicate that simply dividing the trunk leaves behind enough nerve tissue for aberrant regeneration to occur. However, it may also indicate that sympathectomy patients have never been queried directly about cold sensitivity. By undergoing only unilateral surgery, our index patient was in an unusual situation, and the ability to directly compare one arm to the other might have helped him to notice the development of this paradoxical cold sensitivity.Before this side effect is attributed to the specifics of sympathicotomy as a surgical technique, further comparison among patients who have undergone sympathectomy and sympathicotomy would clearly be warranted. This comparison might also prove instructive in helping to define a possible anatomic basis for the pathophysiology of cold sensitivity as a side effect.An alternate explanation for this patient’s side effect may relate to the patient’s strong family history of PRP. A genetic role has been demonstrated in the etiology of PRP [2Freedman R.R. Mayes M.D. Familial aggregation of primary Raynaud’s disease.Arthritis Rheum. 1996; 39: 1189-1191Crossref PubMed Scopus (66) Google Scholar], and a genetic predisposition towards cold reactivity in this patient may have been uncovered by the sympathicotomy. The pathogenesis of PRP involves α-adrenergic receptors [3Freedman R.R. Baer R.P. Mayes M.D. Blockade of vasospastic attacks by alpha 2-adrenergic but not alpha 1-adrenergic antagonists in idiopathic Raynaud’s disease.Circulation. 1995; 92: 1448-1451Crossref PubMed Scopus (68) Google Scholar] that are known to up-regulate and down-regulate their expression by many factors, including their degree of stimulation. If the adrenergic receptors in this patient’s right arm were up-regulated in response to the decreased sympathetic stimuli after the sympathicotomy, the arm might have become hypersensitive to any endogenous circulating catecholamines released during periods of cold stress or exercise. Further study using selective adrenergic agents might better elucidate the specific role of up-regulated receptors in this situation.This is the first patient at our institution that has reported an extreme cold-sensitivity reaction as a side effect of thoracoscopic sympathicotomy for hyperhidrosis. However, in a retrospective review of our last 20 consecutive patients who underwent sympathicotomy, we found 25% responded that they had noted an increase in cold sensitivity in their sympathicotomized hand(s) and arm(s), indicating this may not be an isolated incident. Although most of these patients noted the increase in cold sensitivity to be only a mild inconvenience, we have not yet objectively quantified their reaction to cold.The cold sensitivity experienced by the index patient may present a significant side effect to an elective procedure, especially in a patient with a strong family history of PRP or a patient whose vocation or avocation involves cold exposure. Until further information is available, we believe that the potential for cold sensitivity should be mentioned when the possible side effects of sympathicotomy are discussed. Dividing the sympathetic innervation to a limb should remove the underlying tone of sympathetic vasoconstriction along with denervating the sweat glands. The expected result is a dry limb that is warmer than base line. In the patient we describe, this situation holds in warm environments; however, the temperature difference quickly reverses when the patient is exposed to cooler temperatures. A possible explanation for this phenomenon might involve the presence of residual sympathetic innervation in the sympathicotomized extremity. Investigations using tyramine infusions after endoscopic sympathicotomy have demonstrated the retention of a vasoconstrictive response in the sympathicotomized extremity, indicating the presence of viable postganglionic sympathetic innervation of the vascular bed [4Eisenach J.H. Clark E.S. Charkoudian N. et al.Effects of chronic sympathectomy on vascular function in the human forearm.J Appl Physiol. 2002; 92: 2019-2025PubMed Google Scholar]. The initial postoperative rise in skin temperature and anhidrosis indicates dissociation of the extremity from central sympathetic regulation; however, we cannot rule out the development of accessory reflex or control mechanisms or the evolution of irregular pathways through nerve regeneration and sprouting. The fact that cold sensitivity has not yet been reported in patients who underwent partial resection of the sympathetic chain and stellate ganglion may indicate that simply dividing the trunk leaves behind enough nerve tissue for aberrant regeneration to occur. However, it may also indicate that sympathectomy patients have never been queried directly about cold sensitivity. By undergoing only unilateral surgery, our index patient was in an unusual situation, and the ability to directly compare one arm to the other might have helped him to notice the development of this paradoxical cold sensitivity. Before this side effect is attributed to the specifics of sympathicotomy as a surgical technique, further comparison among patients who have undergone sympathectomy and sympathicotomy would clearly be warranted. This comparison might also prove instructive in helping to define a possible anatomic basis for the pathophysiology of cold sensitivity as a side effect. An alternate explanation for this patient’s side effect may relate to the patient’s strong family history of PRP. A genetic role has been demonstrated in the etiology of PRP [2Freedman R.R. Mayes M.D. Familial aggregation of primary Raynaud’s disease.Arthritis Rheum. 1996; 39: 1189-1191Crossref PubMed Scopus (66) Google Scholar], and a genetic predisposition towards cold reactivity in this patient may have been uncovered by the sympathicotomy. The pathogenesis of PRP involves α-adrenergic receptors [3Freedman R.R. Baer R.P. Mayes M.D. Blockade of vasospastic attacks by alpha 2-adrenergic but not alpha 1-adrenergic antagonists in idiopathic Raynaud’s disease.Circulation. 1995; 92: 1448-1451Crossref PubMed Scopus (68) Google Scholar] that are known to up-regulate and down-regulate their expression by many factors, including their degree of stimulation. If the adrenergic receptors in this patient’s right arm were up-regulated in response to the decreased sympathetic stimuli after the sympathicotomy, the arm might have become hypersensitive to any endogenous circulating catecholamines released during periods of cold stress or exercise. Further study using selective adrenergic agents might better elucidate the specific role of up-regulated receptors in this situation. This is the first patient at our institution that has reported an extreme cold-sensitivity reaction as a side effect of thoracoscopic sympathicotomy for hyperhidrosis. However, in a retrospective review of our last 20 consecutive patients who underwent sympathicotomy, we found 25% responded that they had noted an increase in cold sensitivity in their sympathicotomized hand(s) and arm(s), indicating this may not be an isolated incident. Although most of these patients noted the increase in cold sensitivity to be only a mild inconvenience, we have not yet objectively quantified their reaction to cold. The cold sensitivity experienced by the index patient may present a significant side effect to an elective procedure, especially in a patient with a strong family history of PRP or a patient whose vocation or avocation involves cold exposure. Until further information is available, we believe that the potential for cold sensitivity should be mentioned when the possible side effects of sympathicotomy are discussed.