Disabling orthostatic hypotension caused by sympathectomies performed for hyperhidrosis: Difference between revisions

An otherwise healthy 38 year-old woman suffered from severe hyperhidrosis of the hands and the feet since childhood, because of which she felt socially withdrawn. Since medical treatment of the hyperhidrosis proved ineffective, she was referred to a clinic for neurovegetative surgery. Extensive sympathectomies were performed over a period of two years, as summarized in Fig. 1. Following thoracoscopic sympathetic ganglionotomies bilaterally at the upper thoracic levels (Th II- Th VI), the excessive sweating of the hands disappeared. In the following year the procedure was extended to the lumbar levels L II - L IV at the left, while interganglionary sympathicotomies at LII - LIV at the right were performed with a salutary effect on plantar hyperhidrosis. After these procedures abnormal sweating developed, located at both dorsal and ventral parts of the trunk. A further right-sided extension of the sympathectomies was performed at the levels Th VII - Th XII, including a re-ganglionotomy at Th VI and an interganglionary sympathicotomy at Th X - Th XII. This resulted in relief of the hyperhidrosis over the right hemi-thorax. Abnormal sweating of the left side of the trunk persisted, while palmar hyperhidrosis returned on the left for which the following procedure was performed on the left side: re-ganglionotomy at Th II - Th V, a ganglionotomy at Th VII - Th IX and an interganglionary sympathicotomy at Th III, IV, XI and XII. Two days before the last procedure she had played a field hockey game in the highest veteran league, indicating an excellent exercise tolerance. Directly following the last operation she complained of dizziness on standing, causing her to become severely disabled preventing her acutely from performing housekeeping duties <cite>VanLieshout</cite>.   

The sites of the lesions in the sympathetic thoraco-lumbar chain are indicated. For clarity the adrenergic innervation of the heart,  splanchnic vascular bed and adrenal medulla are shown on  the left side only.<br/>

.....  = interganglionary sympathicotomy <br/>

[[File:OrthostaticHypotension_Fig3.jpg | thumb | 300px | left | Figure 3. Finger blood pressure and heart rate responses upn active standing and passive head-up tilting in a 38-year old male with a cardiac transplant. Note marked difference in blood pressure adjustment in the first 15 s.]]

Patients with circumscribed anatomical lesions on the arterial baroreflex arc provide unique opportunity to study cardiovascular control in otherwise intact humans. Figure 4 provides a schematic drawing of the baroreceptor afferent and autonomic efferent pathways of the baroreflex arc with possible mechanisms of failure of cardiovascular resulting in a tendency to orthostatic hypotension and syncope.