Surgical techniques: Dorsal cervico-thoracic sympathectomy

Surgical interruption of the cervical-thoracic sympathetic chain has been used for a spectrum of different purposes, but is now considered relatively rare. The current indications for cervical-thoracic sympathectomy include sympathetic-mediated skin hypersensitivity and allodynia related to complex regional pain syndrome (CRPS), and secondary vasoconstrictive upper extremity ischemia (Raynaud's phenomenon), both of which may occur in patients with thoracic outlet syndrome (TOS). While supraclavicular, transaxillary and open transthoracic approaches to sympathectomy exist, the vast majority of interventions on the upper thoracic sympathetic trunk are now performed in a minimally-invasive fashion through video-assisted thoracoscopic surgery (VATS). The purpose of this chapter is to outline a step-wise description of video-thoracoscopic cervico-thoracic sympathectomy as applied to patients with TOS, describing a thorough, flexible, and safe approach. Video-thoracoscopic sympathectomy offers the experienced surgeon a versatile and effective strategy to intervene in well-selected patients with CRPS or digital ischemia in association with TOS.