Vasospastic
conditions
Raynaud’s
syndrome
Raynaud’s
syndrome may be primary or secondary. The primary idiopathic form usually
occurs in young women and affects the upper extremities more than the lower. The
peripheral pulses are normal. The condition is attributable to abnormal
sensitivity in the direct response of the arterioles to cold. When cooled, these
vessels constrict and, as a result, the part (usually the fingers) becomes
blanched and incapable of finer movements. The capillaries then dilate and fill
with slowly flowing deoxygenated blood, the digits therefore becoming swollen
and dusky. As the attack passes off, the arterioles relax, oxygenated blood
returns into the dilated capillaries and the digits become red. Thus the
condition is recognised by the characteristic sequence of blanching, dusky
cyanosis and red engorgement, often accompanied by pain. In the idiopathic form,
superficial necrosis is very uncommon. Early cases must be distinguished from
chilblains and vascular disturbances sometimes associated with the
costoclavicular syndrome, and from the other causes of secondary Raynaud’s
syndrome.
Conservative
treatment
Protection
from cold and avoidance of pulp and nail-bed infections are part of the
conservative regimen that is advised for mild cases. The use of calcium
antagonists, such as nifedipine, may also have a role to play and electrically
heated gloves can be useful in winter. Sympathectomy has been discredited in
this condition.
Secondary
Raynauds syndrome
This
was previously called Raynaud’s disease (a term to be avoided). Although
peripheral vasospasm may be noted in atherosclerosis, thoracic outlet syndrome,
carpal tunnel, etc., the term secondary Raynaud’s syndrome is most often used
for a peripheral arterial manifestation of the collagen diseases, especially
progressive systemic sclerosis (scleroderma) and systemic lupus erythromatosis.
It may also follow the use of vibrating tools (when it is commonly known as
‘vibration white finger’), e.g. pneumatic road drills, mining borers and
chain saws, which vibrate at certain frequencies.
Treatment
Treatment
is directed primarily at the underlying condition, although the conservative
measures outlined above are often
Acrocyanosis
Acrocyanosis,
crurum puellarum frigidum4, may be confused with Raynaud’s
disease, but it is painless and is not paroxysmal. Affecting young females,
the cyanosis of the fingers and, especially, the legs may be accompanied by
paraesthesia and chilblains. In severe cases, sympathectomy may be tried. If
merely affecting the calves, a differential diagnosis is Bazin’s disease.
Preganglionic
cervicodorsal sympathectomy
Supraclavicular
method. Through a supraclavicular incision, the clavicular part of the
sternomastoid, the posterior belly of the omohyoid and the scalenus anterior
muscles are divided, the phrenic nerve being displaced medially. The subclavian
artery is exposed and depressed; the suprapleural fascia is divided so that the
dome of the pleura can be displaced downwards. The stellate ganglion is
identified as it lies on the first rib (Fig. 15.58). The sympathetic trunk is
traced downwards and divided below the third thoracic ganglion. All rami
communicantes associated with the second and third ganglia and the nerve of
Kuntz, a grey ramus running upwards from the second thoracic ganglion to the
first thoracic nerve, are meticulously divided. Occasionally, the approach is under
a high arching subclavian artery.
Transthoracic
method. This gives a greater exposure and facilitates the removal of the
sympathetic chain from the fifth ganglion up to the lower fringe of the stellate
ganglion. It tends to give better results than the supraclavicular method and
can be employed when that has failed. In women where cosmetic effects are a
consideration, the approach can be made via an axillary incision through the
third space (Hedley Atkins). The sympathetic chain is easily seen and after
dividing the pleura, it is dissected out, care being taken to avoid damage to
the intercostal vessels, which may cause tedious haemorrhage. Care should also
be taken, when making and suturing the approach wound, to avoid damage to the
nerve to seratus anterior, giving rise to ‘winging’ of the scapula.
Endoscopic
method. This seeks to achieve a sympathectomy via the transthoracic route using
a suitable endoscope, e.g. a cystoscope or laparoscope. A Verres needle is
passed via the axilla to induce a CO2 pneumothorax. A trochar and
cannula are then employed to introduce the endoscope. The sympathetic chain is
visualised and a coagulating electrode used to disrupt the ganglia. Some
surgeons carry out the procedure without using CD2, the lung being
simply deflated by the anaesthetist using a double-lumen endotracheal tube. The
endoscopic method is now the procedure of choice for cervicodorsal sympathectomy.
Lumbar
sympathectomy
Operative
method. Using a transverse loin incision, an extraperitoneal approach is used in
which the colon and peritoneum, to which the ureter clings, are stripped
medially so as to expose the inner border of the psoas muscle (Fig.
15.59). The
sympathetic trunk lies on the sides of the bodies of the lumbar vertebrae; on
the right side it is overlapped by the vena cava. Lumbar veins are apt to cross
the trunk superficially. The sympathetic trunk is divided on the side of the
body of the fourth lumbar vertebra. It is then traced upwards to be divided
above the large second lumbar ganglion, which is easily recognised by the number
of white rami which join it. Care should be taken not to mistake small lymph
nodes,
Chemical
method. This is contraindicated in patients taking anticoagulants. Under
radiographic fluoroscopic control, with the