Syndromes Caused With A Partial Postganglionic Paresis Of N. Sympathicus
The vegetative neural system adjusts life functions of all organs. Developmentally old, has narrow relations with the mental sphere of the affective and instinctive. 1913 years LERICHE recommend a periarterial sympathectomy at peripheral disturbances of profusions. JONNESCO 1916 carried out successfully sympathectomy of the cervical truncus sympathicus at an angina pectoris.
HUNTER and ROYLE 1924 years cut ramie communicants, revealing one of the most important indications of the surgery of sympathicus – removal of spasms of arteries. WHITE 1936 introduced preganglionic cutting, whose advantages still 1929 had noticed FOERSTER (Bratislava). For further development of the surgery of sympathicus were especially meritorious PEET and SMITHWICK.
The pass for vasoconstriction abandons nucleus intermediolateralis via the front root spinal marrow, going as ramus communicans albus up to the truncus sympathicus and without interruption goes through it, and then goes further preganglionic in the n. splanchnicus major. It finishes in the ganglion coeliacum, from that it goes (the dashed line) towards abdominal organs – postganglionic pass.
The same constrictive pass finishes in the truncus sympathicus and as the postganglionic pass enters in the coronary vessels of the heart. From the nucleus intermedio-lateralis arrive all constrictive passes on theirs pass towards the centre (shaded) in the central supranuclear connection for the diencephalon. Afferent passes for pain, enter the via back roots in the spinal marrow, cross the medial line and climb together with all ways of pain up to tractus spinothalamicus (the arrow).(H. Hellner – R. Nissen – K. Vossschulte: Textbook of surgery.)
Connection of the nervous centre in the spinal marrow, and the first of all cells of the lateral horn (nucleus intermediolateralis) with the reticular nervous net in organs are not direct. It consists of two neurons, which have their distribution place in one of the vegetative ganglions. We differ one preganglionic and one postganglionic neuron. (The role of the parasympathicus, which in relation to the sympathicus has a subordinate role, is not a subject of an interest hereinto.) Preganglionic neurons start from lateral horns, abandoning the spinal marrow over front roots, as with marrow enrich white communicants branches, and enter in one of ganglions of the truncus sympathicus on the spine, or arrive through these ganglions in some more peripheral located ganglion, so also in the ganglion celiacum.
Postganglionic neurons start there, where ceases preganglionic. Every of them starts from the appropriate ganglion as with marrow poor ramus communicans griseus, mainly over peripheral somatic nerves or over adventitial net of arteries, finishing in the terminal reticulum of executive organs.
The sympathetic lateral chain of spinal marrow starts at the man only in eighth cervical segment, and finishes caudal in third lumbar. From that clearly follows, that sympathetic preganglionic treads for the head originate from the first and the second front thoracic roots. Threads for arms start from 3–7 thoracic segments, therefore a lot of segments below than that answers to the motor and the sensitive innervations.
Thoracic roots give also sympathetic fibers for organs of the pectoral and venter cavity. From the lower segment, sympathetic nerves go in the leg over the 10 thoracic up to the 2d lumbar roots. Those ways do not abandon immediately appropriate the chain of the truncus sympathicus as gray communicants branches. They flow, under certain conditions, further along the net of the truncus sympathicus, up or down, and abandon only then ganglions. Postganglionic ways for arms come out, e.g., from the ganglion cervicale medius and the ganglion stellatum (ganglion cervicale inferior and first thoracic ganglion). Postganglionic fibers for the leg go from the 5. lumbar and upper three sacral ganglions of the truncus sympathicus.
From that follows that, as a rule, by cutting the truncus sympathicus between the 2d and the 3d thoracic ganglions interrupt all preganglionic ways of the centre towards the arm, and by the cutting between the 2d and the 3d lumbar ganglions interrupt all preganglionic ways for the leg.
Preganglionic ways are pulled out, postganglionic dashed. Between the 2d and the 3d thoracal ganglions of the trunkus sympathicus can be interrupt preganglionic ways for the arm, and between the 2d and the 3d lumbar ganglions preganglionic ways for legs. For the surgery of the sympathicus at an angina pectoris is important that sympathetic nerves for pain go from the first until the fourth thoracic ganglions towards the heart. For the surgical treatment of essential hypertension this must be taken into consideration; the vasoconstrictor ways for abdominal organs only partially change over in ganglions of the thoracic truncus sympathicus. Preganglionic ways flow, mostly, through the truncus sympathicus, making nervus splanhnicus major and minor, changing over much more peripherally (e.g. in the solar plexus celiacus).
Although certain pains are surely carried out over sympathetic ways (e.g. at abdominal colic and causalgia), it is possible, that these afferent ways do not belong to the right sympathetic, than the cerebrospinal system. Those afferent, so called ways for pain, go through ganglions of the truncus sympathicus and reach back roots over the ramie communicants. They cross, with other ways for the pain, the middle line of the spinal marrow and go up through the front lateral bundle.
Therefore at refractors pains we cut them with chordotomy. Contrary of it, vasoconstrictors pass through the supranuclear diencefal vasoconstrictor’s way, that described FOERSTER, that lies ventral of the pyramidal pathway (Fig. 1). Operative cutting of this way did not take root in the treatment of hypertension. Too big is the danger of a damage of environment.
Physiologic and pathophysiologic
For surgeons are important following understandings: in the central nervous system is well known difference between central and peripheral paralyses of pyramidal ways. The first causes spastic pareses, while damages of front horns or peripheral nerves cause a flaccid paralysis with a degeneration of muscles. Equally so is important, but less known, to differ preganglionic of postganglionic paralyses in the vegetative system. Postganglionic break differs of the preganglionic only with sensitization of the smooth musculature on adrenaline and considerable rise of vasoconstrictors’ reactions of arteries on the stimulus with cold.
So are, e.g., limbs, on which was carried out a postganglionic sympathectomy was so strong reacting with contraction of vessels on a stimulus with cold, that appeared necroses. We can say that at postganglionic paralyses lacks any coordination. On that was founded today a general accepted request, that the vegetative system needs to cut preganglionic.
Neither region of bodies is able to completely vegetative enervate. The independent vegetative neural network establishes certain autonomy. Therefore we speak in this work about partial paresis of postganglionic sympathicus, not complete. With the preganglionic sympathectomy we exclude harmful vasoconstrictor reflexes. With a preganglionic sympathectomy surgeons already long time successfully cure RAYNAUD disease, remove spastic components of an endangitis obliterans (WINNIWARTER-BUERGER disease), interrupt pains caused with causalgia, stop a development of SUDECK atrophy, improve essential hypertension and reduce the pain at an angina pectoris.
At all these diseases with preganglionic sympathectomy surgeons remove pathological spasms of arteries, regardless do they emerge primarily or secondarily.
THE STRESS AND THE BRAIN
(Pro Mints, 1-2, 1998.)
During a stress in the brain liberate so-called stressful hormones and nervous carriers (neurotransmitters), which enable a reaction of flight or struggle. Too much excitative neurotransmitters can result with “the cerebral storm” that causes panicky reactions. Later these panicky reactions can be activated in different, completely harmless, situations, which reminds of the stress.
In the traumatic stress too strong activations of neurons can result in their death because of an exaggerated entry of calcium in neurons. The organic changes of personality after traumatic experiences result with establishing new pathological relations between remaining neural cells (neurons). Expose to a stress can lead to oversensitivity so-called “alarm centre” in the brain (locus ceruleus). The alarm centre can be spontaneously activated in completely harmless situations, what can cause repeated attacks of panicky anxiety.
Exposure to a traumatic stress can result in a disorder of functions different neurotransmitters systems (dopaminergic, noradrenergic, serotoninergic systems, system of endogenous opiates, etc.)
PAROKSIZMALNA HYPERTENSION CAUSED WITH PARTIAL POSTGANGLIONIC PARALYSIS OF SYMPATHICUS
Thanking to the progress realized in the production of pharmaceutical preparations, which has enabled the more successfully internist treatment of essential hypertension, sympathectomy is, as methods of choices, stayed in use only in special, mostly hopeless cases. By that must be excluded nonessential forms of hypertension, primarily so called the white hypertension at the chronic illnesses of kidneys and various forms of hypertension at affection of suprarenal glands. (Cushing’s disease and pheochromocytoma with paroxysmal crises of blood pressure). The operational indication mostly sets up in cases when in spite of the internist treatment and the absolute rest blood pressure, it still remains systolic over 170, and diastolic over 105 mm Hg.
For estimation of condition are also important vasospastic and the sclerotic changes of eye background: bleedings, exudates and the edema of papilla. Measurement of the pressure in arteries of retinas enables very exactly judging of the condition of the cerebral arteries. Significant is the function of kidneys. The essential forms of hypertension which are already caused difficult secondary changes on kidneys, with the bad function of secretion and high values of the rest nitrogen, should not operate, as a pale hypertension too.
From an operation needs also to desist if was preceding attacks of an angina pectoris or cerebral attacks. It is not need to operate also when patients are older of 50 years, or when kidneys and the heart show signs of clear damage, and especially then, when on the eye background are revealed signs of difficult atherosclerosis of cerebral veins. In these cases an intervention is inoperative because of organic changes of arteries, because of which, the spastic component has lost its primary leading role in the pathological happening. Must take into account, as well as, that under these pathological circumstances the circulation requires a rise of pressure in order to the irrigation would be sufficient (hypertensions because of a need).
The operation is therefore recommended only in an stadium when is not possible to influence on the hypertension with medicaments, or if it was at very young individuals with a high diastolic pressure. Impressively acts a subjective end of difficulties (headache) after intervention, also even then when the blood pressure is not significantly and permanently reduced with operation.
Insignificant changes on the eyes’ backgrounds can completely disappear. Life becomes longer. As operational methods come in consideration a supradiaphragmal sympathectomy sec. PEET, a thoracolumbal sympathectomy sec. SMITHWICK, and an endoscopic electrosurgical cutting sec. KUX. The double-sided total resection of the truncus sympathicus sec GRIMSON in not justified. In case of strong changes in kidneys sympathectomy can be casually completed with the subtotal adrenalectomy.
PRESENTATION THE CASE OF THE PAROXISMAL HYPERTENSY CAUSED WITH A PARTIAL PARESIS OF THE N. SYMPATHICUS
Until 1949 year health and very intelligent and successful radio-technical engineer, a prominent sportsman, Erjavec Zvonimir, born in surroundings of Ptuj, Slovenia, serving time in a concentration camp for political prisoners, became ill of the lung tuberculosis with numerous complications, empyemas and a consecutive spondilitis of the thoracic spine. Because of the tuberculosis and its complications he was cured more than a decade in different sanatoriums in former Yugoslavia. 1958 years, in conditions of fear, knock-downs, affective reacting, more briefly said a stress, he became to feel intensive tachycardia and headache, accompanied with an intermittent paroxismal hypertension.
In the beginning he was treated by physicians and authorized neurologists as DNV with sedatives of neurovegetative system, diet and anti-hyperthensive drugs. During the time with clinical picture dominates symptomatology of paroxismal hypertensive crises: dizziness, headache, pain in breasts, throbbing, and an enormous rise of the blood pressure.
Described attacks of paroxysmal hypertension the patient never got asleep, by night, or spontaneously, without a previous stress. 1959 and 1960 years, patient was in several occasions hospitalized in Universities’ clinics in Belgrade under a suspicion on pheochromocytoma. Every time pheochromocytoma was excluded.
Being an excellent engineer, the radio-technician, patient 1964 years suggested to me possibility of breaking some “powerline” in his organism that could have been the culprit of his disturbances. After this, it would not have been difficultly to me, learning the surgery of the sympathicus for the specialist’s exam of the general surgery, set up the hypothesis about the permanent chronic interruption of the postganglionic sympathicus with cicatrices' changes of the surrounding tissue and consecutive stretching of the truncus sympathicus, either by it or by hyperextensions of the spine.
Retraction of the cicatrix also contributes to this process. How the white preganglionic fibers have the myelin covering, and theirs way to ganglions are relatively short, they can easily find the way into theirs distal parts and growing in, quickly renewing and establishing theirs activity. Postganglionic grey fibers have not the myelin covering and once interrupted can not find theirs way, they cannot renew function. During years occurs the partial postganglionic paralysis with an oversensitivity of the smooth musculature of arteries on the adrenaline, what leads to the rise vasoconstrictors’ reactions of arteries peripherally. Analogically this partial postganglionic paralysis of the n. sympathicus for the area of CNS results with a syndrome of an intermittent paroxysmal stress cephalalgias.
White and Smithwich 1941 years proved that vasomotor innervation’s way mostly approaches on arteries via appropriate nervous threads. Side-tracks in the surgery of the n. sympathicus - postganglionic cutting sympathetic threads with periarterial sympathectomy - discovered the effect of a partial postganglionic paralysis on extremities.
Ephemeral reactions of a vasoconstrictor’s natures emerge because oversensitivity on the adrenaline after such interventions that is identical to that which could emerge as a consequence of a break of the grey postganglionic fibers caused by already mentioned mechanism in various segments of innervations. This segmental partial postganglionic paralysis of this area leads to the syndrome of an intermittent paroxysmal stress cephalalgias.
At postganglionic paralyses lacks any coordination. How one region is not able total vegetative enervations, we speak about partial postganglionic paralysis.
1928 years Cannon proved that intensive excretion of adrenaline stands in the centre of reaction of security or necessities with that organism answers on the fear, pain, cold etc. We can say that any stronger outer excitement, as well as an emotional stress, can causes intensified excretion of adrenaline with consecutive spasms smooth musculatures of arteries in the innervation’s segment of the sympathetic postganglionic paralyses, with exception of a vasodilatation in the CNS.
ANGINA PECTORIS CAUSED WITH PARTIAL POSTGANGLIONIC PARALYSIS OF THE. N.SYMPATHICUS
Anglo-Saxon and Nordic literatures are published series successfully treated cases of an angina pectoris with sympathectomy.
THE STRESS AND THE HEART (Pro Mint, 1-2 1998)
At frequent stresses, excretion of stressful hormones adrenaline and nor-adrenaline burden the heart. It can eventually obtain irregularities in the heart functioning (heart arrhythmias), with not appearing pains in the area of heart, at rest and effort (anginas pectoris), and, in the end, a heart infarct. Individuals with heart disorders show the characteristic line of personality: they are very aspirational, more socialized, with a strong self-control feeling.
At work, they work more and longer of others, expressing strong feeling of responsibility and conscientiousness; not infrequently taking themselves too much obliged, and frequently sacrificing themselves to the family life. In the conflict situations are more optimistic and calmed. Additional risk factors in such individuals are the irregular nutrition, excessively smoking and taking of alcohol.
The STRESS AND METABOLISM (Pro Mint, 1-2 1998)
The negative stress can challenge different stoppages glands with internal excretion. An intensified function of the thyroid gland (the hyperthyroidism) is monitoring nervousness, insomnia, loss of the weight, strengthened sweating and throbbing, what can straighten results of stressful events. Certain people in a negative stress lose weight, while other can extravagantly eat. An exaggerated fatness can monitor some disorders of metabolism and provokes development of diabetes.
THE STRESS AND DIGESTIVE SYSTEM (Pro Mint, 1-2 1998)
Majority of individuals in a stress are afflicted with constipation because of effect of stressful hormones on the digestive system. The importance of negative feelings in creation of an ulcer disease is also proved. Ulcerous colitis has also certain relation with the stress.
THE STRESS AND THE IMMUNE SYSTEM (Pro Mint, 1-2 1998)
Excretion of stressful hormones of the suprarenal glands (cortisol) cause a suppression of the immune system, reducing defense abilities, so that such individuals are more receptive for different diseases, from common colds to much heavier diseases.
THE STRESS AND THE SEXUALITY (Pro Mint, 1-2 1998)
An appearance of an impotence, or frigidity, is not also irrelevant. Menstruations can become irregular, and absent. Premenstrual syndrome caused with an excretion of stressful hormones (aldosterone), can grow worse.
THE STRESS AND BEAUTY (Pro Mint, 1-2 1998)
Beauty and the health are twins. The negative stress can cause different changes on the skin (dirtiness, eczemas, rashes), and intensify feeling of sadness with often disfiguring face, especially lower lips, because stressful hormones cause a tightening of arteries weakening intradermal circulation.
THE STRESS AND A MENTALLY DISORDER (Pro Mint, 1-2 1998)
Pathological stresses, especially a psycho-trauma, have an importance in creations all functional mental disorders. In individuals with a genetic predisposition for schizophrenia, even so-called small life stresses can lead to development this disease. In the individual with a genetic affinity for depression, so-called middle life stresses can result with an appearance of depressing episodes. Stronger psycho-traumas even at individuals without any genetic predispositions for mental disorders can result with an appearance of a posttraumatic stress disorder. Anxiety and panicky reactions, disorders in fact, are regularly a result of experience stressful situations.
Causalgia and Sluder’s neuralgia can be also concomitant appearing at a syndrome of the partial postganglionic paresis.
In the end I would point out that these observations and thinking about the existence of miscellaneous syndromes caused by segmental partial postganglionic paralyses have in many cases still ever hypothetically character, demanding further meticulous investigations.
1. H. Hellner – R. Nissen – K. Vossschulte: Textbook of surgery. 2. Pro Mints, 1-2 1998