Syndromes Caused With Partial Postganglionar Paresis Of N. Sympathicus
The vegetative neural system adjusts the life functions of all organs. Among other, developmentally old, has narrow terms with the mental sphere of the affective and instinctive. 1913 years LERICHE recommend periarterijsku simpatektomiju at peripheral statics of profusions. JONNESCO 1916 carries out with success sympatektomy of the cervical trunk of n. sympathicus at the angina pectoris. HUNTER and ROYLE 1924, years cut the rame communicantes, revealing one of the most important indications of the sympathicus surgery – the removal of spasm of arteries. WHITE 1936 introduced preganglionar cutting, whose advantages still 1929 noticed FOERSTER (Bratislava). For the further development of the sympathicus surgery were responsible PEET and SMITHWICK.
The structure of the sympathetic system. The way for a vasoconstriction run from nucleus intermediolateralis over front root the spinal marrow, going as ramus communicans albus up to the truncus sympathicusa and, without interruption goes through it, and then goes further preganglionar in n. splanchnicus major. Finishing in the ganglion coeliacum – it goes (the dashed line) towards abdominal organs - postganglionari way. The same constrictor’s way finishes in the truncus simpatikus and as a postganglionar way enters in coronary veins of heart, etc. (H. Hellner – R. Nissen – K. Vossschulte: Textbook of surgery.) Connection of the nervous centre in the spinal marrow, and the nucleus intermediolateralis with theirs destinations in some organ is not direct. It consists of two neurons, one preganglionar and one postganglionar. (The role of the parasympathicus, which in relation to sympathicus has a subordinate role, is not a subject of the interest hereinto.) Preganglionar neuron, reach with marrow, starts from the lateral horn, abandoning the spinal marrow over front root, as a ramus communicans albus, coming such in one of ganglions of the truncus sympathicus, or go away through them to the second, some more peripheral located, e.g. to the ganglion coeliacum.
Postganglionar neuron starts there, where ceases the preganglionar. He starts of the appropriate ganglion as marrow poor ramus communicans griseus, mainly over peripheral somatic nerves or the over adventitia of arteries, finishing in the terminal reticulum of an executive organ. The sympathetic lateral chain of spinal marrow starts in eighth cervical segment, and finishes caudal in the third lumbar segments. Sympathetic preganglionic way for the head starts from the first and second front thoracic roots; for hands from 3–7 thoracic segments, so that between the second and the third thoracic ganglia can be cut preganglionar ways for hands and the second and the third lumbar ganglia for legs. Thoracic roots give also sympathetic fibers for pectoral and abdominal organs. From the lower segment, sympathetic nerves go in the leg over the tenth thoracic ganglion up to the second lumbar. Postganglionic ways for the hand come out from the ganglion cervicale medius and the ganglion stellatum (ganglion cervicale inferius and first thoracal ganglion); for legs from the fifth lumbar and upper three sacral ganglions.
For the surgery of the angina pectoris important are sympathetic nerves for the pain from the first to the fourth thoracic ganglia towards the heart. For the surgical treatment of essential hypertension we must take into consideration that the vasoconstrictors ways for abdominal organs only partially change theirs ways in thoracic ganglia of the truncus sympathicus. Preganglionar ways begin to flow, mostly, through the truncus sympathicus, building the nerva splanhnikus major and minor, changing theirs ways more peripherally (e. gr. in the plexus celiacus). Physiologic and patophysiologic conceives For surgeons are important to differ a preganglionic of a postganglionic paralyses in the vegetative system. A postganglionic paresis differs of a preganglionic, only with hyper-sensitization of the smooth musculature on the adrenaline and the considerable rise vasoconstrictor reactions of arteries on cold. In a postganglionic paresis lacks any coordination. On that was founded today generally accepted preganglionic cutting for the treatment of all postganglionic paresis. Neither any region of the body cannot be completely vegetative enervated - vegetative network establishes a certain autonomy, therefore every paresis is always partial (incomplete). How we have already seen the postganglionic paresis causes hypersensitive reaction the blood vessels on adrenalin in all cases where is increased its production, most frequently in stress. How postganglionic fibers do not have myelin shell cannot find distal part of cut nerve and cannot repair, for difference of preganglionaric. How the stress often cause increasesd production of adrenalin we will speak hereunto about stress paroxysmal hypertension, stress paroxysmal cephalalgias, stress anginas pectoris, etc. The treatment of these illnesses is only successful with preganglionaric blockade or cutting.
STRESS AND THE BRAIN During stress in the brain liberate so-called stressful hormones and nervous carriers (neurotransmitters), which enable the reaction of flight or struggles, which can be intensified at concomitant partial postganglionic paresis of the n. sympathicus. A result can be so called “the cerebral storm” which caused a panicky reaction. It can make perilous the paroxysmal hypertension caused with partial paresis of the postganglionic sympathicus. In the traumatic stress too strong activations of neurons can result in their death, because of the exaggerated entry of calcium in neurons. All this can lead to oversensitivity so-called the alarm centre in the brain (locus ceruleus), consecutively, the alarm centre can be activated spontaneously what lead to repeatedly attacks of panicky anxiety with concomitant paroxysmal cephalagias, anginas pectoris and hypertensions. Every traumatic stress can lead to disorder in function of different neurotransmitors of the system (dopaminergic, noradrenergic, serotoninergic, etc.).
THE PAROXISMAL HYPERTENSION CAUSED WITH A PARTIAL POSTGANGLIONARIC PARALYSIS OF THE N. SYMPATHICUS
Thanking to the progress realized in the production of pharmaceutical drugs with which we can more successfully treatment of an essential hypertension than with sympatectomy that is still ever a method of elections, used only in special, mostly hopeless cases. The paroxysmal hypertension caused with the partial paresis n. sympathicus we must treat it with operative cutting preganglionic n. sympathicus. Here is needed to point that vasoconstrictors’ reaction of blood vessels in stresses can lead to the harm of function many organs, what needs to investigate, and to these syndromes add news. The operational indication at essential hypertension is set up in cases when, in spite of the internist treatment and the absolute rest, ,blood pressure remains risen and that: systolic over 170, and diastolic over 105 mm Hg. Proxismal hypertension like essential can lead to heavy secondary changes on kidneys, with the bad function of secretion and high values of rest nitrogen. Ones diagnosed paroxysmal hypertension caused with the partial paresis postganglionic sympathicus needs operate as soon as it is possible. The same, in my opinion, worth for paroxysmal cephalalgias and anginas pectoris. As operational methods come in the consideration: supradiaphragmal or thoracolumbal simpatektomy at hypertension. In case of strong changes on kidneys sympatektomy needs complete with the subtotal adrenalektomy, as in essential hypertension.
Pars Thoracalis Truncus Sympathicus)
The thoracic portion of the sympathetic trunk (Fig. 3) consists of a series ganglia, which usually correspond in number to that of the vertebra; but, in cases of occasional coalescence of two ganglia, their number is uncertain. The thoracic ganglia rest against the heads of the ribs, and are covered by the costal pleura; the last two, however, are more anterior than others and are placed on the sides of the bodies of the eleventh and twelfth thoracic vertebra. The ganglia are small in size, and of a grayish color. The first, larger than others, is of an elongated form, and frequently blended with the inferior cervical ganglion. They are connected together by the intervening portions of the trunk.
Two rami communicantes, white and gray, connect each ganglion with its corresponding spinal nerve.
The branches of the upper five ganglia are very small; they supply filaments of the thoracic aorta and its branches. Twigs of the second, third, and fourth ganglia enter the posterior pulmonary plexus.
The branches from the lower seven ganglia are large, and white in color; they distribute filaments to the aorta, and unite to form the greater, the lesser, and the lowest splanchnic nerves.
The greater splanchnic nerve (n. splanchnicus major; great splanchnic nerve) is white in color, firm in texture, and of a considerable size; it is formed by branches from the fifth to the ninth or tenth thoracic ganglia, but the fibers in the higher roots may be traced upward in the sympathetic trunk as far as the first or second thoracic ganglion. It descends obliquely on the bodies of the vertebras, perforates the cruras of the diaphragm, and ends in the celiac ganglion. A ganglion (ganglion splanchnicum) exists opposite the eleventh or twelfth thoracic vertebra.
The lesser splanchnic nerve (n. splanchnicus minor) is formed by filaments of the ninth and tenth, and sometimes the eleventh thoracic ganglia, and of the cord between them. It pierces the diaphragm with the preceding nerve, and joins the aorticorenal ganglion.
The lowest splanchnic nerve (n. splanchnicus minimus; the lowest splanchnic nerve) arises from the last thoracic ganglion, and, piercing the diaphragm, ends in the renal plexus.
A striking analogy exists between the splanchnic and the cardiac nerves. The cardiac nerves are three in number; they arise from all three cervical ganglia, and are distributed to a large and important organ in the thoracic cavity. The splanchnic nerves, also three in number, are connected probably with all the thoracic ganglia, and are distributed to important organs in the abdominal cavity.
THE CASE OF THE PAROXISMAL HYPERTENSON CAUSED WITH PARTIAL PARESIS POSTGANGLIONIC SYPMPATHICUS
Until 1949 year healthy and very intelligent radio-technician, otherwise an emphasized sportsman, Erjavec Zvonimir, born in surroundings of Ptuj, R Slovenia, got sick on the lung tuberculosis with numerous complications, empyemas and the consumptive spondylitis of the thoracic spine, during serving punishment from 1949 till 1953 as political enemy of the socialistic system in Yugoslavia. Because of the tuberculosis and its complications he was cured over a decade in different sanatoriums in former, so called socialistic, Yugoslavia. 1958 years on he started in conditions of fear, knock-downs, affective reacting, more briefly said the stress, to feel intermittent intensive tachycardia and headaches, accompanied with paroxismal hypertension. In the beginning he was treated by physicians and authorised neurologists as DNV with sedatives of neurovegetative system. During the time in the clinical picture started to dominate symptoms of the paroxismal hypertensive crises: dizziness, headache, pain in breasts, throbbing, with an enormous rise of the blood pressure. Never did he have such attacks by night asleep, without the previous stress. 1959 and 1960 patient was in several occasions hospitalized in clinics of Faculty of medicine in Belgrade under diagnosing of pheochromocitoma. Pheochromocitoma was in several occasions excluded. Being a professional radio-technician, patient 1964 years suggested to me that of some “electric power-line" could have been broken in his organism that culprits his disturbances. After this was not difficultly to me, learning the surgery of the n. sympathicus for the specialist exam of the general surgery, set up the hypothesis about the preganglionic and postganglionic fibers of the n. sympathicus were during a long time with the scar’s changes of the surrounding tissue, stretching the trunkus sympathicus by hyperextensions of spine. Retractions of the scar’s tissue was impairing this and always anew originating this process. How the white preganglionic fibers have the myelin wrapping, and their way to ganglions is relatively short, they easily find the distal part and successfully grow in, quickly renewing activity. Postganglionic grey fibers have not myelin wrapping and once interrupted can not find theirs distal part, therefore they cannot renew function. During years occurs the partial postganglionic paralysis with oversensitivity of smooth musculature of arteries on the adrenaline with consecutive vasoconstrictors reactions of arteries peripherally.
Analogously the partial postganglionic paralysis of the n. sympaticus for the area of CNS, can result with a syndrome of the intermittent paroxismal stress headaches.
In the end I want point that these my observations, and opinion of the existence of miscellaneous syndromes caused by segmental partial postganglionic paralyses, have the hypothetically character, and that it demands further meticulous investigations.
Because of hypersensitive reaction on adrenalin with consecutive vasoconstriction of blood vessels after partial postganglionic paresis of the n. sympathicus, can ensue different syndromes as for example the paroxysmal stress hypertension, intermittent paroxysmal unilateral and bilateral headaches, intermittent paroxysmal anginas pectoris, etc. The treatment of all these syndromes is operative and consists in preganglionic cutting for it responsible nerve.
It has presented anatomy, pathogenesis, pathophysiology, and clinical picture of some disorders. One case is reported.
All syndromes of partial paresis of the postganglionic sympathicus can be treated with cutting preganglionic fibers.
1. H. Hellner – R. Nissen – K. Vossschulte: Textbook of Surgery. 2. Pro Mints, no. 1-2, 1998.