Anatomical location of T2–3 sympathetic trunk and Kuntz nerve determined by transthoracic endoscopy

Abstract

<jats:p content-type="fine-print"><jats:italic>Object.</jats:italic> Bilateral subaxillary transthoracic endoscopic sympathectomy (TES) is a popular procedure of upper thoracic sympathectomy. The anatomical locations of the T-2 and T-3 sympathetic trunks, as viewed under the endoscope, are varied in the rib head areas. In this study, the authors investigated the more visible anatomical locations of the T-2 and T-3 sympathetic trunks, the so-called nerves of Kuntz, and intercostal rami by performing transthoracic endoscopy.</jats:p> <jats:p content-type="fine-print"><jats:italic>Methods.</jats:italic> Seventy patients with palmar hyperhidrosis undergoing bilateral TES (140 sides) via the anterior subaxillary approach were included in this study. The operative findings and video images of the T-2 and T-3 sympathetic trunks and ganglia were recorded and analyzed. The anatomical locations of the T-2 and T-3 sympathetic trunks along the horizontal axes of the rib heads were determined using a three-region system constructed by the authors. The area between the rib neck and the medial border of the rib head was equally divided into Region E (external half) and Region M (medial half). The area between the medial border of the rib head and the paravertebral ligament was defined as Region I.</jats:p> <jats:p content-type="fine-print">The incidence of the T-2 and T-3 sympathetic trunks found in Regions E, M, and I were 31.4 to 42.9%, 50 to 57.1%, and 7.1 to 11.4%, respectively, on the left side, and 24.3 to 34.3%, 57.1 to 65.7%, and 8.6 to 10%, respectively, on the right side. One right (1.4%) and six left (8.6%) Kuntz nerves originating from the T-3 sympathetic trunk were found in seven patients (10%). The intercostal ramus was found around the T-2 rib neck in 24 patients (34.3%), with 18 cases (25.7%) for each side. The intercostal ramus around the T-3 rib neck was found in 17 patients (24.3%): 12 (17.1%) on the right and nine (12.9%) on the left.</jats:p> <jats:p content-type="fine-print"><jats:italic>Conclusions.</jats:italic> These results indicate that approximately 90% of the T-2 or T-3 sympathetic trunks are located on the rib head. These findings may also be used to assist the surgeon in fluoroscopic guidance for locating the T-2 and T-3 sympathetic trunks during posterior percutaneous sympathectomy.</jats:p>

Thoracic sympathicolysis for primary hyperhidrosis

“…Several causes have been proposed for this syndrome, including the diffusion of the electric current from monopolar cautery, excessive traction of the sympathetic chain [15], and an erroneous localization of the second rib or anatomic distribution of the sympathetic chain [27,30,32]. Whatever the case, if sympathicolysis of T2 alone is performed, the incidence of this complication approaches zero, yet is sufficient to obtain anhydrosis in the event of palmar or facial hyperhidrosis [11].…”

In Reply

“…The endoscopic findings in patients not only can provide a better live anatomic location of the upper sympathetic trunk at which to perform sympathectomy by anterior subaxillary transthoracic endoscopy but also can offer a reasonable and predictable location of the sympathetic trunk to administer the dorsal percutaneous phenol injection (3). Although at present the reliability of endoscopic sympathectomy is superior to that of the injection procedure, the latter is a good alternative to the former, especially when the patient has adhesion between the lung and the pleura.…”

“…Based on my experience with thousands of patients treated with upper thoracic sympathectomy with the use of four different techniques (1,3,4) (dorsal open thoracic sympathetic ganglionectomy, dorsal percutaneous thoracic radiofrequency sympathectomy, subaxillary transthoracic endoscopic sympathectomy, and dorsal percutaneous thoracic phenol sympathicolysis), I think that there is room for developing an ideal technique of upper thoracic sympathectomy in the future. The present sonographic technology is useful for the detection of the ganglion in the wrist.…”

“…They are also influenced by the central neural mechanism. Therefore, PST fluctuates within a large range in different intraoperative situations while the patient is under local anesthesia (2,3). PST markedly decreases during emotional tension or surgical manipulation because of increased sympathetic tone, and it increases gradually only when a sufficient interruption of the sympathetic segment has been induced by phenol injection.…”

“…In fact, the thumb skin temperature of patients with PH is approximately 1°C colder than that of a healthy individual; after sympathectomy, however, it becomes approximately 2°C warmer than that of a healthy person. Consequently, PST is not useful or reliable as a guide for localizing the precise sympathetic target for phenol injection; it is useful only to indicate the final effect of a satisfactory phenol sympathicolysis procedure (2,3).…”