Thoracic Sympathetic Blockade Research Articles

Perfusion index as an early predictor of hypotension following spinal anesthesia for cesarean section

Introduction: Hypotension is a common complication after spinal anesthesia for cesarean delivery which is caused by sympathetic block 1. This can result in adverse maternal and fetal outcomes. Hence prevention and early treatment of spinal hypotension early has been a key research area in obstetric anesthesia. Intermittent non-invasive blood pressure measurement is the standard practice that fails to detect episodes of hypotension in a timely fashion. Methods: Noninvasive PI and blood pressure were measured in 109 healthy parturients undergoing elective cesarean section under spinal anesthesia. Results: PI appeared to increase significantly and more quickly in parturients with significant hypotension. Discussion: Findings may be due to the thoracic sympathetic blockade. Conclusion: Perfusion index can be a useful tool to early predict hypotension following spinal anesthesia for cesarean section. Response to ephedrine can be quickly assessed by the change in the PI which helps to decide on further boluses of ephedrine. Effect on the vascular tone by oxytocin is significant with 5IU bolus, though it does not cause a significant blood pressure drop.

CT-guided thoracic sympathetic blockade for palmar hyperhidrosis: Immediate results and postoperative quality of life

The purpose of this study was to evaluate the results, complications, and degree of satisfaction among patients who underwent a CT-guided percutaneous puncture thoracic sympathetic blockade. A total of 186 patients underwent CT-guided thoracic sympathetic blockade based on case histories and a prospective pre- and postoperative questionnaire survey. The study sample was composed of 93 patients with an age range from 18 to 34years and a diagnosis with primary palmar hyperhidrosis (severe in some patients). Percutaneous puncture thoracic sympathetic blockade guided by CT was performed under local anesthesia in all patients. Heart rate (HR), non-invasive blood pressure (NIBP), arterial oxygen saturation (SPO2), perfusion index (PI), and palmar temperature (T) were monitored before and after treatment. Follow-up included a questionnaire on life quality and degree of satisfaction. Ten minutes after treatment, the SPO2, PI, and temperature all raised remarkably ([92.75±2.02]% vs. [98.85±1.09]%, [1.55±0.69]% vs. [8.60±0.94]%, [30.95±1.27]°C vs. [35.75±0.55]°C, respectively, P<0.001). The therapeutic success rate was 96.7%. No operative mortality was recorded. No complications were observed, except transient bradycardia in one patient and transient injection site pain in 25 patients. Of the 89 patients who were monitored over a period of 6–12months through follow-up interviews and questionnaires, 46% developed compensatory hyperhidrosis, 87.6% reported improvement in their quality of life. CT-guided percutaneous puncture thoracic sympathetic blockade is a safe, effective, and minimally invasive technique for the treatment of palmar hyperhidrosis. Despite the high rate of compensatory hyperhidrosis, it produces a high rate of patient satisfaction.

Diagnosis and Treatment of Symptomatic Carpal Bossing.

Carpal bossing is an osseous formation at the dorsal portion of the quadrangular joint, which rarely becomes symptomatic. However, in some patients it causes pain, restricted mobility and can lead to complications like tendon rupture, inflammatory and degenerative joint disease. In this article, we present our experiences with this rare disorder in order to improve diagnostic and therapeutic proceedings. This is a multicenter and interdisciplinary observation made by orthopaedic surgeons and radiologists in the years 2010 to 2015. Retrospective observational study. The follow up period was 2 years. In the observed time period, eight patients were diagnosed with symptomatic carpal bossing. Symptoms were pain at palmar flexion and limited mobility of the wrist in combination with a palpable protuberance over the quadrangular joint. All patients underwent X-ray, CT and MRI examinations. A conservative treatment strategy was initiated for 6 weeks in all patients, followed by a wedge resection when symptoms were persisting and disabling. After the conservative treatment schedule, five patients were asymptomatic. Three patients had persisting pain and were thus recommended for surgery. In the postoperative course, two patients were asymptomatic. One patient developed a type 1 complex regional pain syndrome (CRPS) in the first postoperative year, which was successfully treated with pain-adapted physiotherapy, pharmacotherapy with analgesics and calcitonin, and a triple CT-guided thoracic sympathetic nerve blockade. Carpal bossing is a mostly asymptomatic entity, which in our experience gets symptomatic due to direct trauma or repetitive stress, especially in competitive racket sports players. It can be diagnosed by thorough clinical examination and multimodal diagnostic imaging. Conservative treatment comprises an excellent prognosis, however surgery, either wedge resection or arthrodesis, must be considered if the response is not positive after 6 weeks.

Oximetry-derived perfusion index as an early indicator of CT-guided thoracic sympathetic blockade in palmar hyperhidrosis

To test the hypothesis that the oximetry-derived perfusion index (PI) recorded in the index finger may provide earlier objective evidence for correct positioning of the needle tip during computed tomography (CT)-guided thoracic sympathetic blockade than skin temperature in palmar hyperhidrosis. Forty-four CT-guided thoracic sympathetic blockades were prospectively performed in both hands of 22 patients. Prior to chemical blockade, PI and skin temperature were recorded at 1 min intervals until 20 min after lidocaine injection. Repeated measures analysis of variance was used to assess the potency of PI and skin temperature over time. Using a 100% increase in the PI as the threshold and symptom relief within 20 min as the reference standard, the sensitivity and specificity for predicting a successful injection were calculated. Thirty-seven (84%) sympathetic blockade procedures were clinically successful. For successful cases, the PI increased as early as 1 min after the blockade of the sympathetic chain (p < 0.05), whereas the skin temperature showed statistical significance 1 min later (p < 0.05). The PI can be used to indicate a successful CT-guided sympathetic blockade with 97% sensitivity and 100% specificity 3 min after lidocaine injection. The PI, a more marked and sensitive indicator than changes in skin temperature, can be used to indicate a successful CT-guided sympathetic blockade with satisfying sensitivity and specificity, 3 min after lidocaine injection in palmar hyperhidrosis.

Effects of high thoracic epidural sympathetic blockade for the treatment of severe chronic heart failure due to dilated cardiomyopathy

Objective Beta blockers and angiotensin-converting enzyme inhibitors are known to attenuate the remodelling process in chronic heart failure, but the high mortality after heart failure must be resolved. We aimed to evaluate the eff ects of using high thoracic epidural sympathetic blockade (HTESB) as an adjunctive treatment to conventional therapy on the regression of left ventricular remodelling in chronic heart failure due to dilated cardiomyopathy.Methods We studied 40 patients with severe chronic heart failure due to dilated cardiomyopathy. These patients were randomly divided into two groups with equal size, and treated either by conventional therapy or HTESB as an adjunctive therapy (HTESB therapy) for 30 days. Echocardiography was performed before and after treatment.Results HTESB therapy was found to reduce left ventricular end-diastolic internal dimension by 5.3 mm, left atrial dimension by 7.6 mm, right ventricular dimension by 5.0 mm and right atrial dimension by 10.5 mm (P < 0.01). No discernable changes were observed in patients treated by conventional therapy. Moreover, HTESB therapy produced a greater increase in ejection fraction (11.2% vs. 2.2%) and more signifi cant improvement to NYHA class than conventional therapy (P < 0.05).Conclusions These data demonstrate that the use of HTESB as an adjunctive therapy to conventional therapy in severe chronic heart failure due to dilated cardiomyopathy was associated with reduction in cardiac chamber dimension and increase in left ventricular systolic function. These benefi cial eff ects on remodelling may lead to better prognosis.

Bilateral thoracic sympathetic block for refractory polymorphic tachycardia

Extensive evidence has established a link between sympathetic nervous system hyperactivity, ventricular arrhythmias, and sudden cardiac death. For this reason, cardiac sympathectomy is often beneficial in the treatment of patients at high risk for ventricular ectopy, although it involves an invasive procedure associated with potential morbidity. We report a case in which we used guided lytic thoracic sympathetic block in a patient with underlying cardiomyopathy and refractory polymorphic ventricular tachycardia. A 74-yr-old African American male with ischemic cardiomyopathy presented with refractory episodes of ventricular tachycardia despite maximal medical therapy involving antiarrhythmic drugs and previous interventions, including endovascular epicardial ablation and open cryoablation via sternotomy. During his inpatient admission, the patient developed sustained ventricular tachycardia associated with cardiac depression requiring vasopressors. An open thoracoscopic sympathectomy was considered as a possible treatment, but in our view, the patient would not tolerate this procedure. As an alternative, the pain medicine team successfully performed a lytic thoracic sympathetic block. Subsequently, the patient demonstrated a period of clinical improvement with no apparent morbidity related to the procedure. Lytic thoracic sympathetic blockade is a novel technique for the treatment of sympathetically mediated ventricular tachycardia, and it is less invasive than other types of cardiac sympathectomy. Additional studies are required to evaluate this treatment as a viable alternative in patients at high risk for ventricular ectopy. This report suggests the feasibility of this approach and the potential for minimal morbidity in cases of refractory ventricular arrhythmias.

Late Postoperative Harlequin Syndrome Coexisting With Horner Syndrome After Thoracic Epidural Anesthesia

A patient who underwent left mastectomy under thoracic epidural anesthesia developed transient ipsilateral well-demarcated hemifacial erythema, sweating, and contralateral Horner syndrome postoperatively. All the clinical features subsided and had completely resolved within 24 hours after the cessation of patient-controlled epidural analgesia with bupivacaine 0.05% and fentanyl 0.5%. We believe that the reason for the excessive highlevel thoracic sympathetic blockade that led to this concomitant syndrome was cephalad spread of local anesthetic.

Ambulante CT-gestützte thorakale Sympathikusblockade als zusätzliche Therapieoption bei komplexem regionalen Schmerzsyndrom Typ I nach Sportverletzungen

Also after bagatelle trauma, some patients can develop a complex regional pain syndrome (CRPS). The limb concerned usually shows a marked temperature difference to the contralateral side. Apart from a doughy swelling, the patient is impaired in particular by burning pain and a restricted range of motion. The objective of the present study was to examine the influence of early thoracic sympathetic nerve blockade on the basis of clinical and quantified blood flow parameters. In 7 young patients (average age 17.7 [15 - 21] years) with a clinically developing type 1 CRPS after sport injuries (mountain bike, bike, skateboard, hockey and go-kart accidents), occult injury and ligament lesions were ruled out using conventional imaging and MRI. In addition to pain-adapted physiotherapy and pharmacotherapy with analgesics and calcitonin, sympathetic nerve blockade was performed three times at two-day intervals. The CT-assisted puncture was performed in the prone position at the level of the intervertebral space of the 2nd/3 rd thoracic vertebral bodies. In the correct paravertebral position, a 10-cm long, 22 G Seibel-Grönemeier needle was used for the successive injection of 6 - 10 ml Carbostesin 0.5 %. By adding a small amount of contrast medium, it was possible to visualise clearly the distribution of the sympathicolytic agent in the control scan in each case. Before and after the intervention, colour-coded duplex sonography (CCDS) of the affected limb arteries was performed on all patients. The injection needle was correctly placed in all patients, without complications. The medication mixture was observed to have distributed properly. After the intervention, all patients reported the immediate onset of marked pain relief, whereby they recovered fully over the further course. The increase in peripheral blood flow was shown by a significant improvement in flow in the CCDS. Outpatient CT-assisted temporary sympathetic nerve blockade is an effective and low-complication therapeutic option for the supportive treatment of patients with CRPS.

Ambulante CT-gestützte thorakale Sympathikusblockade als zusätzliche Therapieoption bei komplexem regionalen Schmerzsyndrom Typ I nach Sportverletzungen

Also after bagatelle trauma, some patients can develop a complex regional pain syndrome (CRPS). The limb concerned usually shows a marked temperature difference to the contralateral side. Apart from a doughy swelling, the patient is impaired in particular by burning pain and a restricted range of motion. The objective of the present study was to examine the influence of early thoracic sympathetic nerve blockade on the basis of clinical and quantified blood flow parameters. In 7 young patients (average age 17.7 [15-21] years) with a clinically developing type 1 CRPS after sport injuries (mountain bike, bike, skateboard, hockey and go-kart accidents), occult injury and ligament lesions were ruled out using conventional imaging and MRI. In addition to pain-adapted physiotherapy and pharmacotherapy with analgesics and calcitonin, sympathetic nerve blockade was performed three times at two-day intervals. The CT-assisted puncture was performed in the prone position at the level of the intervertebral space of the 2nd/3rd thoracic vertebral bodies. In the correct paravertebral position, a 10-cm long, 22 G Seibel-Grönemeier needle was used for the successive injection of 6-10 ml Carbostesin 0.5 %. By adding a small amount of contrast medium, it was possible to visualise clearly the distribution of the sympathicolytic agent in the control scan in each case. Before and after the intervention, colour-coded duplex sonography (CCDS) of the affected limb arteries was performed on all patients. The injection needle was correctly placed in all patients, without complications. The medication mixture was observed to have distributed properly. After the intervention, all patients reported the immediate onset of marked pain relief, whereby they recovered fully over the further course. The increase in peripheral blood flow was shown by a significant improvement in flow in the CCDS. Outpatient CT-assisted temporary sympathetic nerve blockade is an effective and low-complication therapeutic option for the supportive treatment of patients with CRPS.

Excision of sympathetic ganglia and the rami communicantes with histological confirmation offers better early and late outcomes in Video assisted thoracoscopic sympathectomy

BackgroundVideo-Assisted Thoracoscopic Sympathectomy (VATS) is an established minimally invasive procedure for thoracic sympathetic blockade in patients with hyperhidrosis, facial flushing and intractable angina. Various techniques using clips, diathermy and excision are used to perform sympathectomy. We present our technique of excision of the sympathetic chain with histological proof and the analysis of the early and late outcomes.MethodsWe evaluated 200 procedures in 100 consecutive patients, who underwent Video Assisted Thoracoscopic Sympathectomy by a single surgeon in our centre between September 1996 to March 2007. All patients had maximum medical therapy prior to surgery and were divided into 3 groups based on indications, Group 1(hyperhidrosis: 48 patients), Group 2 (facial flushing: 26 patients) and Group 3(intractable angina: 26 patients). The demography and severity of symptoms for each group were analysed. The endpoints were success rate, 30 day mortality, complications and patient's satisfaction.Results99 patients had bilateral VATS sympathectomy and 1 had unilateral sympathectomy. The conversion rate to open was 1(1%). All patients had successful removal of ganglia proven histologically with no perioperative mortality in our series. The complications included pneumothorax (5%), acute coronary syndrome (2%), transient Horner's syndrome (1%), transient paraesthesia (1%), wound infection (4%), compensatory hyperhidrosis (18%), residual flushing (3%) and wound pain (5%). There were five late deaths in the intractable angina group at a mean follow up of 36.7 months. Overall success rates of abolishing the symptoms were 96.3%, 87.5% and 95.2% for Group 1, 2 and 3 respectively.ConclusionExcision of the sympathetic chain with histological confirmation during VATS sympathectomy is a safe and effective method in treating hyperhidrosis, facial flushing and intractable angina with good long term results and satisfaction.

Usefulness of galvanic skin reflex monitor in CT-guided thoracic sympathetic blockade for palmar hyperhidrosis

Computed tomography (CT)-guided thoracic sympathetic blockade with ethanol was performed while monitoring sympathetic nerve activity, with an alternating current (AC) galvanic skin reflex (GSR) monitor, in a patient with palmar hyperhidrosis in whom endoscopic thoracic sympathectomy was impossible because of pleural adhesion. Sweating was suppressed after the thoracic sympathetic blockade, and the monitor showed a significant increase in skin resistance. The effect of sympathetic blockade could be evaluated directly and in real time using a GSR monitor.

Sympathectomy for Acute Pulmonary Embolism

Sympathectomy for Acute Pulmonary Embolism In Response: We appreciate Dr. Stratmann’s letter underlining potentially beneficial effects of unilateral stellate ganglion block by citing reports from the 1940s and 50s. We are aware of reports considering blockade of the cervicothoracic sympathetic ganglion being a therapeutic or supportive option during pulmonary embolism (PE) in humans. In 1964, Nolte and Hagelsten (1) in Germany reported an improvement by bilateral stellate ganglion block during pulmonary embolism. However, even if performed bilaterally, sympathetic blockade is restricted to the level of T1 or T2. In contrast, in our experimental study in awake, chronically instrumented sheep, we investigated the effects of the complete bilateral blockade of the thoracic sympathetic nervous system. To analyze the effects of sympathetic activation/sympathetic blockade achieved by thoracic epidural anesthesia during PE was the primary purpose of our study. Thus, we did not primarily intend to establish an animal model for the development of new therapeutic principles in the clinical setting of PE in man, and therefore completely consent to Dr. Stratmann that establishment of thoracic epidural sympathetic blockade in patients under effective anticoagulative or thrombolytic therapy is problematic. However, in patients having an epidural catheter already inserted (e.g. perioperative patients) the occurrence of PE may be effectively treated, either by using an epidural catheter at thoracic levels or by extending lumbar blockade to thoracic levels, when the catheter is implanted at lumbar segments. Studies to evaluate the effectiveness of thoracic sympathetic blockade in the setting of PE in man have to be performed. Nevertheless, the idea of testing stellate ganglion block animal models of PE as proposed by Dr. Stratmann seems very interesting. However, uni- or bilateral blockade of the stellate ganglion in awake, spontaneous breathing sheep would be extremely hard to perform; we feel that this is impossible in our experimental model of PE. Uli R. Jahn, MD Hans-G. Bone, MD Hugo Van Aken, MD, PhD Christoph Schmidt, MD Michael Booke, MD

Thoracic Epidural Bupivacaine Attenuates Supraventricular Tachyarrhythmias After Pulmonary Resection

Supraventricular tachyarrhythmias after pulmonary surgery are well described. Some investigators suggest that tachyarrhythmias after thoracic operations may result from the relative sympathotonic status produced by injury to the cardiac parasympathetic nerves. We examined whether postoperative thoracic sympathetic blockade by thoracic epidural bupivacaine might reduce the tachyarrhythmias after pulmonary resection. Fifty patients with lung cancer were randomized to receive epidural bupivacaine (Group B) or epidural morphine (Group M). Patients in Group B were given 6 to 10 mL of 0.25% bupivacaine epidurally, followed by epidural infusion at 3 to 5 mL/h for 3 days, and patients in Group M were given 2 to 3 mg morphine epidurally, followed by morphine infusion at a rate of 0.2 mg/h. Tachyarrhythmias were diagnosed by using the continuous heart rate trend and arrhythmia trend with a central monitoring system. Postoperative analgesia was not statistically different between groups. However, the incidence of postoperative tachyarrhythmias in Group B was significantly less than in Group M (1 of 23 vs 7 of 25, P = 0.0497, Fisher’s exact test). The continuous infusion of thoracic epidural bupivacaine can reduce supraventricular tachyarrhythmias compared with epidural morphine infusion, presumably because of attenuation of the sympathotonic status after pulmonary resection.

Thoracic sympathetic block: A new approach

Although a number of approaches to the thoracic sympathetic ganglia are described, the risk of pneumothorax generally precludes this procedure for other than neurolytic ablation. The approach that is described uses the principle of inserting a needle in a direction away from a potential complication by taking advantage of very consistent anatomy. Making use of 2 radiologic landmarks, the tubercle of the costotransverse articulation and the costovertebral articulation, when superimposed, allows a line when subtended from the costotransverse articulation to the observer that is parallel to the neck of the rib. The triangular space formed by the reflection of the parietal pleura, which lies anteromedial to the costotransverse articulation and before its reflection onto the mediastinum, provides a relatively safe passage for a needle that is directed to its target at the costovertebral articulation. In the author's experience, the frequency of pneumothorax is less than 1%, and it has occurred only when the foregoing radiologic landmarks due to pathology are poorly discerned. The technique should increase the usefulness of thoracic sympathetic ganglion blockade for diagnostic, prognostic, and therapeutic use. Copyright © 2001 by W.B. Saunders Company

Measurement of Sympathetic Blockade: Effect of Epidural and Spinal Anesthesia

Consultant in Anesthesiology Akureyri Central HospitalAkureyri, IcelandDirectorklaus.kirno@medfak.gu.seProfessorDepartment of Cardiothoracic Anesthesiology and Intensive CareAssociate ProfessorDepartment of Clinical NeurophysiologySahlgrenska University HospitalUniversity of GöteborgGöteborg, SwedenIn Reply:—We appreciate the interest and comments expressed by Drs. Introna, Blair, Martin, and Yodlowski. We fully agree that indirect methods of measuring sympathetic nerve activity can provide useful, qualitative information. Quantification of sympathetic nerve activity, however, is difficult with these techniques.The main issue raised by Introna et al. is whether a high thoracic epidural anesthesia (TEA) completely inhibits cardiac sympathetic activity. Based on studies measuring heart rate variability, these authors are convinced that TEA with T1–T5 sensory blockade does not result in complete cardiac sympathetic blockade. However, a comparative study of heart rate variability, cardiac norepinephrine spillover, and muscle sympathetic nerve activity in humans by Kingwell et al. 1invites some caution because it showed heart rate variability to be dependent on multiple factors in addition to cardiac sympathetic nerve activity and not directly related to cardiac norepinephrine spillover.The degree of thoracic sympathetic blockade was not specifically addressed in our recent study, 2which was primarily aimed at evaluating sympathetic function caudal to the TEA-induced sensory blockade and showed no sign of sympathetic blockade. However, previous microneurographic studies of lumbar epidural and spinal anesthesia have shown a fairly close relation between the extent of sensory and sympathetic blockade. 3,4Because the nerves to internal organs are not accessible to microneurographic recording in humans, we previously used biochemical measurements of nerve transmitter release to quantify cardiac sympathetic nerve activity. 5We used an isotope dilution technique with radiolabeled norepinephrine to demonstrate that TEA prevented the sympathetically mediated surgical stress response during coronary artery bypass surgery. Although this finding could be explained by an afferent nociceptive blockade or an efferent blockade of cardiac sympathetic nerve fibers, supportive evidence for the existence of a cardiac sympathetic blockade after TEA has been provided by Taniguchi et al. , 6who directly measured efferent cardiac sympathetic nerve activity after TEA in an experimental study on cats. Our recent finding 2that vasomotor and sudomotor reflexes were abolished in the hands but remained in the feet after TEA also suggests a thoracic sympathetic blockade. Therefore, although we agree with Introna et al. that “sympathetic fibers above and below the segment of epidural anesthesia could travel cephalad or caudad within the sympathetic chain” and “continue to innervate the heart,” we remain convinced that TEA can abolish sympathetic reflexes within thoracic segments.

The anterior approach for thoracic sympathetic ganglion block using a curved needle

AbstractFollowing cadaveric study, 20 patients suffering from Complex Regional Pain Syndrome (CRPS) underwent upper thoracic ganglion sympathetic blockade using a new anterior approach. Five patients obtained a favorable response to the diagnostic block. All five cases had pain relief following successful radiofrequency ablation to the second and third thoracic sympathetic ganglion using the anterior approach. Only one case of pneumothorax was reported which was treated conservatively. The anterior approach was technically easier to perform, and outcomes were comparable to the classical posterior approach.

Physiology and pathophysiology of thoracic sympathetic blockade

Sympathetic innervation of the heart and lung is mediated by fibres originating from the thoracic segments T1–4. Sympathetic stimulation in healthy subjects causes coronary vasodilation, whereas stenotic coronary arteries show vasoconstriction in response to sympathetic stimulation. Thus, in patients at risk of ischaemia, high thoracic epidural anaesthesia (TEA) should dilate constricted coronary vessels, decrease heart rate and myocardial metabolism, and improve cardiac function by reducing pre- and afterload and optimizing oxygen availability. The pulmonary effects include an improved postoperative diaphragmatic function in lambs and humans and enhanced respiratory function parameters. Hypoxic pulmonary vasoconstriction, an important mechanism for the maintenance of adequate oxygenation after induction of general anaesthesia, is not affected by TEA in dogs. Beneficial effects of epidural sympathetic blockade on myocardial perfusion and function, and on pulmonary parameters, can only be achieved by a thoracic blockade, whereas lumbar epidural anaesthesia may exert adverse effects due to a compensatory increase of thoracic sympathetic activity.

神経ブロック 安全で確実な神経ブロック手技の追求 胸腔鏡下胸部交感神経遮断

神経ブロック 安全で確実な神経ブロック手技の追求 胸腔鏡下胸部交感神経遮断

神経ブロック 安全で確実な神経ブロック手技の追求 胸腔鏡下胸部交感神経遮断術

神経ブロック 安全で確実な神経ブロック手技の追求 胸腔鏡下胸部交感神経遮断術

Efficacy of thoracic sympathetic ganglion block and prediction of complications: clinical evaluation of the anterior paratracheal and posterior paravertebral approaches in 234 patients.

In the 10 years from 1980 to 1989, a total of 234 patients underwent 557 thoracic sympathetic ganglion blocks. The block was performed by the anterior paratracheal approach in 129 cases and by the posterior paravertebral approach in 428 cases. The procedures for using these two approaches are presented here. The efficacy of thoracic sympathetic ganglion blockade was evaluated as follows; marked efficacy was defined by the complete control of sweating in the palms, moderate efficacy was defined by a decrease in palmar sweating which persisted for at least one week, and minor efficacy was defined by a decrease in sweating followed by recurrence of hyperhidrosis within one week with maintenance of palmar warmth. in addition, the results were retrospectively reviewed in relation to the age and sex of the patients, the technique used, the laterality of the block, the disease treated, the doses of local anesthetic and neurolytic agents, and the number of blocks. The posterior approach was significantly more successful than the anterior approach, and the treatment of both T2 and T3 by the posterior approach was significantly more effective than the treatment of either nerve alone by the same approach ( P < 0.01). The efficacy rate was significantly lower for hyperhidrosis than for the other diseases ( P < 0.01). Complete cessation of hyperhidrosis was significantly less common in the over-60 age group ( P < 0.01). Regarding the dose of neurolytic, the complete cessation of hyperhidrosis was achieved significantly more frequently with doses of 2.5 ml or higher than with lower doses ( P < 0.01) when both T2 and T3 wee treated by the posterior approach. A dose-dependent response if hyperhidrosis was noted at dose levels higher than 2.5 ml. Thoracic sympathetic ganglion blockade was only occasionally associated with complications, and no serious complications were observed. Before injecting the neurolytic agent, a mixture of contrast medium and local anesthetic was injected to determine the three-dimensional distribution of the contrast and to assess the scope of the analgesia produced by the local anesthetic. Significant complications could thus be avoided.