Surgery of the sympathetic nervous system.

This article reviews the innervation of the arterial system of the lower extremity, lumbar sympathectomy in vascular surgery, lumbar sympathectomy for digital gangrene and in the prevention of major amputation of the lower extremity and substance P's role in neurogenic inflammatory modulation. Long-term results of lumbar sympathectomy and direct arterial bypass surgery have also been reviewed. In addition to the pilomotor, sudomotor and vasomotor actions of the sympathetic nervous system via its neurotransmitters, the molecular basis of the chronic neurogenic inflammatory reaction have been addressed with special attention to the discovery of substance P in the lumbar sympathetic chain and ganglia of human beings.

Distal thigh/arm index as a predictor of success for lumbar sympathectomy.

Data from 90 lumbar sympathectomies were reviewed to assess the role of a distal thigh/arm Doppler systolic index (DTAI) and of external magnetic flowmeter (MCBF) measurements for predicting patient outcome following lumbar sympathectomy. The presenting symptoms included impending gangrene, gangrene, rest pain, nonhealing ulcers, and disabling claudication. Of the 90 cases, clinical improvement occurred in 57% of the limbs. Major amputation was not required in 73% of the limbs. The MCBF data showed variability which masked the relationship to the effects of sympathectomy. DTAI test results were significantly related to outcome. For DTAI > 0.6 (57 patients), improvement occurred in 70% of the limbs, with major amputation not required in 86% of the limbs. For DTAI < 0.6 (33 patients), improvement occurred in only 33% of the limbs, and major amputation was not required in 52% of the limbs. The Doppler systolic index has provided a noninvasive measure that can be used in conjunction with good clinical judgment for predicting the outcome of lumbar sympathectomy.