CERVICOTHORACIC SYMPATHECTOMY FOR RAYNAUDS SYNDROME

Raynaud's syndrome is a clinical entity characterized by episodic vasc ular spasm and digital ischemia occurring in response to cold or emoti onal stimuli. Most patients with Raynaud's syndrome are successfully m anaged with medical therapy. Surgical sympathectomy is rarely performe d and its use remains controversial. Of 3,219 patients seen with the d iagnosis of Raynaud's disease, phenomenon or syndrome over the last 10 years at Mayo Clinic, 20 cervical or thoracic sympathectomies were pe rformed in 14 (0.4%) patients. Of all patients who underwent cervico t horacic sympathectomy (68) for various reasons during the same time pe riod, 20,5% (14/68) were performed for Raynaud's syndrome. Surgical sy mpathectomy was reserved for those rare patients with persistent, seve re symptoms (pain, ulcer) despite intensive medical treatment. Surgica l therapy was also used for those few patients with occupations involv ing exposure to cold and disabling, refractory symptoms in hopes of al lowing them to return to work. Transaxillary (12 limbs) or supraclavic ular (8 limbs) exposure and resection of the sympathetic chain with T1 -T4 ganglions was usually performed. Initial resolution or improvement of symptoms was achieved in 19/20 (95%) of limbs. Both patients with digital ulceration healed. Although improved in some, persistent or re current symptoms were present in all patients after six months postope ratively. Increased sensitivity of digital vessels to circulating cate cholamines, nerve fiber regeneration or incomplete sympathectomy have been postulated to lead to recurrence. Five patients developed Horner' s syndrome postoperatively. A portion of the stellate ganglion was int entionally resected in 3 of the 5 patients. While cervicothoracic symp athectomy can be safely performed in patients with Raynaud's syndrome who do not respond to medical therapy and initial symptomatic relief c an be expected in most patients, the natural course of the disease app ears to be unaffected and significant long-term benefit remains unprov en.