Percutaneous Full-Endoscopic C2 Ganglionectomy for the Treatment of Intractable Occipital Neuralgia: Technical Note.

BACKGROUND: The C-2 dorsal root ganglionectomy procedure can provide effective treatment for intractable occipital neuralgia (ON). However, the traditional microsurgery of C2 ganglionectomy needs a wide incision and significant paraspinous muscle dissection for adequate visualization. The indications of endoscopic spine surgery are ever expanding, with the development of endoscopic armamentaria and technological innovations. OBJECTIVE: To validate the feasibility of the approach and describe several operative nuances based on the authors' experience. In this paper, the authors describe a patient with intractable ON who was successfully treated with a percutaneous full-endoscopic C2 ganglionectomy. METHODS: We describe the case of an 83-yr-old female with a 2-yr history of left ON who did not respond to a series of treatments, including physical therapy, drug therapy, injection therapy, and radiofrequency therapy. After careful examination, we performed a percutaneous, full-endoscopic left C2 ganglionectomy. RESULTS: The patient was successfully treated with a percutaneous full-endoscopic ganglionectomy. Afterwards, her intractable and constant pain was relieved. There was no cerebrospinal fluid leakage, incision infection, neck deformity, or other complications. CONCLUSION: C2 ganglionectomy can be accomplished successfully using a full-endoscopic uniportal surgical technique under continuous irrigation, which has the advantages of excellent illumination and visualization, reduced surgery-related trauma, and reduced bleeding.

Abdominal Pain Associated With Anorexia Nervosa and Median Arcuate Ligament Syndrome: A Rare Condition Shadowed by a Postoperative Conversion Disorder.

Median arcuate ligament syndrome (MALS) is an often discounted and vexing condition that may go unnoticed in a population of patients with complex comorbid conditions or those with poor psychiatric health. We report a unique case of a patient with anorexia nervosa in whom the successful operation for MALS was briefly complicated by a postoperative conversion disorder.

Reperfusion Arrhythmias Increase after Superior Cervical Ganglionectomy Due to Conduction Disorders and Changes in Repolarization.

Pharmacological concentrations of melatonin reduce reperfusion arrhythmias, but less is known about the antiarrhythmic protection of the physiological circadian rhythm of melatonin. Bilateral surgical removal of the superior cervical ganglia irreversibly suppresses melatonin rhythmicity. This study aimed to analyze the cardiac electrophysiological effects of the loss of melatonin circadian oscillation and the role played by myocardial melatonin membrane receptors, SERCA2A, TNFα, nitrotyrosine, TGFß, KATP channels, and connexin 43. Three weeks after bilateral removal of the superior cervical ganglia or sham surgery, the hearts were isolated and submitted to ten minutes of regional ischemia followed by ten minutes of reperfusion. Arrhythmias, mainly ventricular tachycardia, increased during reperfusion in the ganglionectomy group. These hearts also suffered an epicardial electrical activation delay that increased during ischemia, action potential alternants, triggered activity, and dispersion of action potential duration. Hearts from ganglionectomized rats showed a reduction of the cardioprotective MT2 receptors, the MT1 receptors, and SERCA2A. Markers of nitroxidative stress (nitrotyrosine), inflammation (TNFα), and fibrosis (TGFß and vimentin) did not change between groups. Connexin 43 lateralization and the pore-forming subunit (Kir6.1) of KATP channels increased in the experimental group. We conclude that the loss of the circadian rhythm of melatonin predisposes the heart to suffer cardiac arrhythmias, mainly ventricular tachycardia, due to conduction disorders and changes in repolarization.

Avoidance of Vagal Response During Circumferential Pulmonary Vein Isolation: Effect of Initiating Isolation From Right Anterior Ganglionated Plexi.

BACKGROUND: Circumferential pulmonary vein isolation (CPVI) often cause unavoidable vagal reflexes during procedure due to the coincidental modification of ganglionated plexus which are located on pulmonary vein (PV) antrum. The right anterior ganglionated plexi (RAGP) which located at superoanterior area of right superior PV antrum is an essential station to regulate the cardiac autonomic nerve activities and is easily coincidentally ablated during CPVI. The aim of this study is to assess the effect of RAGP ablation on vagal response (VR) during CPVI. METHODS: A total of 80 patients with paroxysmal atrial fibrillation who underwent the first time CPVI were prospectively enrolled and randomly assigned to 2 groups: group A (n=40), CPVI started with right PVs at RAGP site; group B (n=40): CPVI started with left PVs first, and the last ablation site is RAGP. Electrophysiological parameters include basal cycle length, A-H interval, H-V interval, sinus node recovery time, and atrioventricular node Wenckebach point were recorded before and after CPVI procedure. RESULTS: During CPVI, the positive VR were only observed on 1 patient in group A and 25 patients in group B (P<0.001). A total of 21 patients with positive VR in group B needed for temporary ventricular pacing during procedure, while the only patient with positive VR in group A did not need for temporary ventricular pacing (P<0.001). Compared with baseline, basal cycle length, sinus node recovery time, and atrioventricular node Wenckebach point were decreased significantly after CPVI procedure in both groups (all P<0.05) and without differences between 2 groups. CONCLUSIONS: Circumferential PV isolation initiated from RAGP could effectively inhibit VR occurrence and significantly increase heart rate during procedure.

Dorsal Capsular Defect and Synovial Fistula to the Fourth Extensor Compartment: A Late Complication after Arthroscopic Dorsal Wrist Ganglionectomy.

Arthroscopic dorsal wrist ganglionectomy is demonstrably a safe procedure with recurrence rates comparable to open surgery. We present a patient with wrist pain following arthroscopic ganglion excision. MRI and arthroscopic findings showed a large dorsal capsular defect, synovial fistula to the fourth extensor compartment, and dorsal radiocarpal ligament resection. Ligament reconstruction and capsular imbrication resolved her symptoms. We postulate that this complication resulted from a large capsular resection. Because we feel that it can be difficult to judge the size of the debridement through an arthroscope, the need for adequate capsular resection in dorsal wrist ganglionectomy needs to be balanced by consideration of potential complications from more aggressive capsular debridement, and thus we feel that capsular resection should be limited to no more than 1 cm2.

Meningitis after invasive treatment of the trigeminal ganglion: two case reports and a review of the literature.

OBJECTIVES: The objective of this case is to report the rare complication of a meningitis after an invasive treatment of the trigeminal ganglion. METHODS: In this case report, two cases of meningitis due to oral streptococci are reported and a review of literature is presented. RESULTS AND DISCUSSION: This complication should be recognized as early as possible to prevent deterioration of the situation. Meningitis must be suspected when a patient reports headache and fever within days after an invasive treatment of the trigeminal ganglion.

[The experience with thoracoscopic sympathectomy for the treatment of distal lesions of limb arteries].

The study included 107 patients with distal lesions of limb arteries treated with the use of thoracoscopic sympathectomy. The best results in the early postoperative period were obtained in patients with Raynaud's disease. Modifications introduced into the methods of its treatment permitted to retain effectiveness of sympathectomy till the late postoperative period in 90% of the patients. Surgery for obliterative endarteritis and atherosclerosis was viewed as a possibility to preserve the supporting function of the limb. This purpose was attained in 73.2 and 62.5% of the patients respectively in the early and in 62 and 25% in the late postoperative periods.

Laparoscopic versus open celiac ganglionectomy in patients with median arcuate ligament syndrome.

OBJECTIVE: Median arcuate ligament syndrome (MALS) is a rare disorder characterized by abdominal pain and compression of the celiac artery. Traditional management consists of open MAL division, with or without arterial reconstruction. We present our outcomes using a laparoscopic approach and compare them to patients treated with open MAL division during the same period. METHODS: A retrospective medical records review of all patients with MALS treated at the University of California-Los Angeles from January 1999 to 2009 was performed. RESULTS: Fourteen patients with MALS were treated. All patients underwent an extensive preoperative gastrointestinal (GI) workup with 10 undergoing attempted laparoscopic division of the MAL and celiac ganglion (laparoscopic ganglionectomy [LG]). Two intraoperative conversions were performed for bleeding. Six patients were treated in the open surgery group (open ganglionectomy [OG]). There were no deaths or reoperations in either group. Median time to feeding was 1.0 vs 2.8 days (P≤.05) in the LG and OG groups, respectively, which was statistically significant. Median length of hospitalization was also significantly lower in the LG group compared with the OG group (2.3 vs 7.0 days; P≤.05). Eight patients had LG (100%) and 5 patients had OG (83%) and had immediate symptom resolution (postoperative day 1). Three patients with recurrent symptoms after LG underwent angiography demonstrating persistent celiac stenosis, then an angioplasty was performed. Median follow-up was 14.0 months (2-65 months) for all patients. Three patients who received LG (38%) and 3 patients who received OG (50%) had persistent pain at last follow-up. Six patients in the OG group (100%) and 7 patients in the LG group (88%) had ceased taking chronic oral narcotics at their last follow-up visit. CONCLUSION: Both laparoscopic and open MAL division and celiac ganglionectomy can be safely performed with minimal patient morbidity and mortality. Late recurrence is frequently seen; however, this seems to be milder than the presenting symptoms. The laparoscopic approach results in avoidance of laparotomy and was associated with shorter inpatient hospitalization and decreased time to feeding in our study. Optimal patient selection and prediction of clinical response in these patients remains a challenge.

The extent of laminectomy affects pain-related behavior in a rat model of neuropathic pain.

One of the unresolved questions in neuropathic pain research is whether we can prevent or reverse mechanical hyperalgesia by rhizotomy or ganglionectomy. However, one of the obstacles in answering that question is lack of a standardized surgical procedure used in experimental ganglionectomy. We tested the hypothesis that laminectomy performed during ganglionectomy induces lumbar column deformity. We further examined whether spinal deformity is a source of pain-related behavior. Five conditions were studied. Fifth and sixth lumbar (L5 and L6) ganglionectomy were performed in rats using either minimal or extensive laminectomy technique. Two other groups had minimal and extensive laminectomy without ganglionectomies. A final control group had no surgery. Sensory responsiveness of the plantar aspect of the hind paw was repeatedly tested, and a plain radiograph in anteroposterior projection was made to assess the extent of deformity by measurement of deformity angles. Hyperalgesia resulted in groups with extensive laminectomy regardless of performance or absence of ganglionectomy, while in groups with minimal laminectomy there was no increase in pain-related behavior. Lateral deformity of the spine was observed in rats with or without ganglionectomy, confirming that laminectomy can produce deformity. The extent of deformity was more pronounced in rats exposed to the extensive laminectomy. Our results indicate that laminectomy can produce spine deformity and that there is a direct relationship between the extent of laminectomy and the development of mechanical hypersensitivity. The data presented suggest that there is a need for standardization of laminectomy procedure in rat experimental pain models.

Robotic versus human camera holding in video-assisted thoracic sympathectomy: a single blind randomized trial of efficacy and safety.

Our objective is to compare surgical safety and efficacy between robotic and human camera control in video-assisted thoracic sympathectomy. A randomized-controlled-trial was performed. Surgical operation was VATS sympathectomy for hyperhidrosis. The trial compared a voice-controlled robot for holding the endoscopic camera robotic group (Ro) to human assisted group (Hu). Each group included 19 patients. Sympathectomy was achieved by electrodessication of the third ganglion. Operations were filmed and images stored. Two observers quantified the number of involuntary and inappropriate movements and how many times the camera was cleaned. Safety criteria were surgical accidents, pain and aesthetical results; efficacy criteria were: surgical and camera use duration, anhydrosis, length of hospitalization, compensatory hyperhidrosis and patient satisfaction. There was no difference between groups regarding surgical accidents, number of involuntary movements, pain, aesthetical results, general satisfaction, number of lens cleaning, anhydrosis, length of hospitalization, and compensatory hyperhidrosis. The number of contacts of the laparoscopic lens with mediastinal structures was lower in the Ro group (P<0.001), but the total and surgical length was longer in this group (P<0.001). Camera holding by a robotic arm in VATS sympathectomy for hyperhidrosis is as safe but less efficient when compared to a human camera-holding assistant.

Sympathicotomy affects cutaneous blood flow, temperature, and sympathicus-mediated reflexes.

OBJECTIVE: To study the sympathetically mediated effects of transthoracic endoscopic sympathicotomy (TES) in the treatment of severe primary palmar hyperhidrosis. MATERIALS AND METHODS: The effects of TES, on sympathetic ganglia at the thoracic level of 2-3, finger blood flow, temperature, and on heat and cold provocation were investigated. Middle cerebral artery (MCA) blood flow velocities were studied by transcranial Doppler. RESULTS: The finger blood flow increased by about 700% after TES and finger temperature by 7.0 +/- 0.5 degrees C. Several autonomic reflexes were dramatically affected. A finger pulp-shrinking test showed a major decrease after surgery. MCA mean blood flow velocities were not affected by TES. CONCLUSIONS: Besides the high success rate of good clinical effect of TES on palmar hyperhidrosis, major effects on local blood flow and temperature are elicited by TES. Complex autonomic reflexes are also affected. The patient should be completely informed before surgery of the side effects elicited by TES.

Evaluation of compensatory sweating after bilateral thoracoscopic sympathectomy for palmar hyperhidrosis.

The study is a retrospective review of 60 patients undergoing bilateral T2-T3 thoracoscopic sympathectomy for palmar hyperhidrosis in our department between 1997 and 2003. The study was based on a telephone questionnaire and medical chart review. Forty patients (67%) replied to the questionnaire and were included in the study. Postoperative complications, therapeutic results, patient satisfaction, and the severity of compensatory sweating (CS) were assessed. In all patients both palms were dry at the end of surgery. Postoperative complications included permanent unilateral Horner syndrome, wound infection, and residual pneumothorax resolving after thoracal drainage, in one patient each. CS with different severity occurred in 35 patients (87.5%). Six patients (15%) regretted undergoing the operation due to the extent and severity of the CS seriously affecting their quality of life. Thoracoscopic sympathectomy is a simple procedure with a high success rate. However, CS is a serious complication and a significant number of patients may regret undergoing the operation; a careful selection of patients and comprehensive explanation are advisable.

Interactive effects of testosterone and superior cervical ganglionectomy on attraction thresholds to volatile urinary odors in gonadectomized mice.

Volatile urinary odors contribute to mate recognition in mice after their detection by the main olfactory epithelium (MOE). We used a habituation/dishabitution task to ask whether the capacity of gonadectomized mice of both sexes to detect and investigate decreasing concentrations of volatile urinary odors from either breeding males or estrous females is modulated by administering androgen or estrogen and if so, whether any effects of these sex steroids are altered by disrupting the sympathetic innervation of the MOE via bilateral superior cervical ganglionectomy (SCGx). In tests given, beginning 51 days after gonadectomy without steroid treatment both male and female subjects detected even the lowest concentrations (1:120 and 1:160 dilutions by volume) of male urinary odors, provided they were SCGx as opposed to sham operated. In subsequent tests given after estradiol benzoate (EB) followed later by 5alpha-dihydrotestosterone (DHT) treatments, neither male nor female subjects detected low concentrations of male urinary odors regardless of whether or not their SCG's were intact. Administration of testosterone (T) prior to a final series of tests restored the ability of gonadectomized subjects of both sexes to detect low concentrations of male urinary odors regardless of their SCG status. This suggests that T, but not its neural metabolites estradiol, or DHT, facilitates responsiveness to low concentrations of male odors in mice of both sexes. In tests given 51 days after gonadectomy without steroid treatment most male and female subjects readily detected the three highest concentrations of estrous female urinary odors whereas SCGx males and females failed to detect the lowest concentrations of these odors. After treatment with EB and then with DHT, gonadectomized mice of both sexes generally failed to detect the three lowest concentrations of estrous female urinary odors regardless of their SCG status. After T treatment; however, subjects of both sexes again detected most dilutions of estrous female urine, provided their SCG's were intact. Again, these results suggest that T, but not estradiol or DHT, facilitates responsiveness to estrous female urinary odors. Provided such an activational effect of T is present, sympathetic, noradrenergic inputs to the MOE may enhance odorant contrast, as previously suggested [Nat. Neurosci. 2 (1999) 106], by reducing the responsiveness of olfactory neurons to low (1:120 and 1:160 dilutions) concentrations of some biologically significant odorants (e.g. male urinary odors) while facilitating their responsiveness to low to moderate (1:80 dilution) concentrations of others (e.g. estrous female urinary odors).

Application of spinal ablative techniques for the treatment of benign chronic painful conditions: history, methods, and outcomes.

STUDY DESIGN: The literature on current neuroablative techniques for treating benign chronic painful conditions is comprehensively reviewed. OBJECTIVE: To provide the reader with an understanding of the indications, techniques, and outcomes for the various ablative procedures used to treat chronic pain syndromes. SUMMARY OF BACKGROUND DATA: Neuromodulatory techniques are rapidly supplanting the traditional neuroablative procedures used to treat many types of pain. METHODS: A MEDLINE search was conducted for each of the following procedures: radiofrequency facet denervation, cordotomy, myelotomy, sympathectomy, DREZotomy, rhizotomy, and ganglionectomy. In the review of each article, special attention given to the outcome, length of follow-up, complications, and number of patients. Summaries of this data were compiled to provided historical perspective, current techniques, indications, and outcomes for each of the aforementioned procedures. The outcomes cited for each procedure generally represent the data from the three or four largest series with adequate follow-up length. RESULTS: The aforementioned procedures have 30% to 90% success rates, with success defined as at least a 50% reduction in perceived pain. These results tend to diminish with time. However, most are associated with a significant degree of morbidity and relatively high complication rates. In addition, many of the techniques lead to deafferentation pain syndromes. CONCLUSIONS: Ablative spinal techniques offer pain relief for many patients, but the use of these methods should be considered carefully in the light of available nondestructive procedures that may achieve similar goals with potentially lower morbidities.

Long-term assessment of percutaneous stereotactic thermocoagulation of upper thoracic ganglionectomy and sympathectomy for palmar and craniofacial hyperhidrosisin 1742 cases.

OBJECTIVE: We sought to determine the long-term outcome of percutaneous stereotactic thermocoagulation for upper thoracic ganglionectomy and sympathectomy in patients with palmar and craniofacial hyperhidrosis with the use of a three-dimensional system of coordinates for the location of the T2 and T3 ganglia on the basis of the findings in a cadaveric study. METHODS: From November 1986 to May 1998, upper thoracic ganglionectomy and sympathectomy with the use of percutaneous stereotactic thermocoagulation were performed in 1688 patients with palmar hyperhidrosis and 54 patients with craniofacial hyperhidrosis as outpatient surgical procedures based on a three-dimensional coordinate system for determining the location of the thermocoagulation point, which was developed by the authors in a cadaveric study. The technique requires only local anesthesia. RESULTS: After initial thermocoagulation, sweating stopped in 3465 (99.5%) of 3484 sides. Hyperhidrosis recurred within 2 to 59 months of treatment in 268 procedures. All patients in whom hyperhidrosis recurred were retreated successfully, resulting in a final success rate of 99.9%. Complications of treatment included pneumothorax in seven procedures (0.2%) and partial Horner's syndrome in five procedures (0.15%). Decreased plantar sweating was noted during follow-up in 92% of patients. CONCLUSION: The results of this study indicate that upper thoracic ganglionectomy and sympathectomy performed with the use of percutaneous thermocoagulation are a very effective treatment for palmar and craniofacial hyperhidrosis that provides excellent immediate and long-term results as well as a low complication rate. The method is also effective as a retreatment for recurrences. Our data also suggest that performing ganglionectomy and sympathectomy in both T2 and T3 is unnecessary, because the procedure had equal long-term effectiveness when performed in T2 alone.

Limited thoracoscopic ganglionectomy for primary hyperhidrosis.

Sympathetic ganglionectomy is universally accepted as an effective and enduring treatment for primary hyperhidrosis. However, the variable extent of the ganglionectomy to treat this condition has been reported to be associated with a troublesome compensatory hyperhidrosis in between 22% and 81% of patients. In this prospective evaluation of a limited second thoracic ganglionectomy this approach, in addition to always being effective for pallmar hyperhidrosis, proved useful in up to 90% of patients with associated axillary and plantar hyperhidrosis. A compensatory hyperhidrosis rate of 13% was noted, confirming that a limited ganglionectomy should be standard practice in the management of primary hyperhidrosis.

Reversal surgery for reducing the side effects of ETS. A case report.

Endoscopic sympathetic surgery has become a widespread surgery for handsweating and facial blushing all over the world. There are not many side effects in the normal train of the surgery, only lower body sweating is known to happen in some degree to nearly everyone. When the side effects exceed the expectation of the patient, she may demand the reversal of the surgery due to the regrets of the side effects. To better cope with this demand, we have developed an endoscopic method to restore the continuity of the sympathetic trunks. A typical course of recovery of one such reversal case is presented.

Neural mechanisms involved in the delay of gastric emptying and gastrointestinal transit of liquid after thoracic spinal cord transection in awake rats.

Spinal cord transection (SCT) delays gastric emptying (GE), and intestinal and gastrointestinal (GI) transit of liquid in awake rats. This study evaluates the neural mechanisms involved in this phenomenon. Male Wistar rats (N = 147) were fasted for 16 h and had the left jugular vein cannulated followed by laminectomy or laminectomy + complete SCT between T4 and T5 vertebrae. The next day, a test meal (1.5 ml of a phenol red solution, 0.5 mg/ml in 5% glucose) was administered by gavage feeding and 10 min later cervical dislocation was performed. Dye recovery in the stomach, and proximal, mid and distal small intestine was determined by spectrophotometry. SCT inhibited GE and GI transit since it increased gastric recovery by 71.3% and decreased mid small intestine recovery by 100% (P < 0.05). Subdiaphragmatic vagotomy, celiac ganglionectomy + section of the splanchnic nerves, i.v. hexamethonium (20 mg/kg) or yohimbine (3 mg/kg) prevented the development of the SCT effect on GE and GI transit. Pretreatment with i.v. naloxone (2 mg/kg), L-NAME (3 mg/kg) or propranolol (2 mg/kg) was ineffective. Bilateral adrenalectomy or guanethidine (10 mg/kg) increased the magnitude of the GE inhibition, while i.v. prazosin (1 mg/kg) or atropine (0.5 mg/kg) decreased the magnitude but did not abolish the GE inhibition. In summary, the inhibition of GI motility observed 1 day after thoracic SCT in awake rats seems to involve vagal and possibly splanchnic pathways.

Superior cervical ganglionectomy leads to dampening of amplitude of temperature rhythm in rats.

The circadian rhythm of body temperature (CRT) is a robust marker of the endogenous pacemaker function and is one of the most frequently studied rhythms. Melatonin, the main secretion of the pineal gland seems to have more of a thermomodulatory role in controlling the body temperature than having a direct role in thermoregulation. The sympathetic innervation to the pineal via the superior cervical ganglion determines the melatonin secretion, and superior cervical ganglionectomy (SCGx) decreases the secretion of melatonin. The present study was conducted on the Wistar rats (n = 12) to determine the role of melatonin in modulation of CRT. Adult male rats were either ganglionectomised (n = 6) or sham ganglionectomised (n = 6). Rectal temperature was recorded for CRT analysis. Cosinar analysis of the temperature record was done to get the acrophase, amplitude and mesor. Our results show that SCGx decreases the amplitude to the rhythm but has no effect on the mesor of the rhythm. Our study confirms that melatonin has little role to play in the thermoregulation and its role is mainly in thermomodulation.

Increased immunoreactive labeling of the spinal N-methyl-D-aspartate R1 receptors after dorsal root ganglionectomy in the rats.

The N-methyl-D-aspartate (NMDA) receptor plays an important role in the development of the autotomy after dorsal root ganglionectomy (DRGn). In this study, we further investigated the expression of the NMDAR1 in the spinal cord of the rats after right DRGn by immunohistochemical analyses. Computerized densitometric analysis of the NMDAR1 immunoreactivity was done and the integrated optical density (IOD) of the superficial laminae of the dorsal horn of the spinal cord was measured. The immunoreactive labeling of the NMDAR1 was increased in the cervical spinal cord ipsilateral to the DRGn from day 5 to 14 after DRGn. The ratio of the right/left IOD of the rats receiving DRGn was significantly higher than the rats in the sham-operated group and the control group (P<0.05). The expression of the NMDAR1 increased gradually to reach the peak at day 7 after DRGn (mean right/left IOD ratio=1.52), then decreased thereafter. The increased expression of the NMDAR1 at day 7 was suppressed by MK-801 (NMDA receptor antagonist) administered immediately after DRGn, but not by normal saline or 1,2,3,4-tetrahydro-6-nitro-2, 3-dioxo-benzo[f] quinoxaline-7-sulfonamide (NBQX, non-NMDA receptor antagonist). The results indicated that the expression of the NMDAR1 in the superficial laminae of the dorsal horn of the spinal cord was increased after DRGn and the time course was compatible with the onset and development of the autotomy induced by DRGn.