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Reoperative Digital Sympathectomy in Refractory Raynaud's Phenomenon

Dorafshar, Amir H. M.D.; Seitz, Iris A. M.D., Ph.D.; Zachary, Lawrence M.D.

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Plastic and Reconstructive Surgery: January 2009 - Volume 123 - Issue 1 - p 36e-38e
doi: 10.1097/PRS.0b013e3181905725
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Sir:

Raynaud's phenomenon is a condition associated with episodic vasospasm of the digital arteries. Current therapeutic modalities provide limited benefit, but more recently, the use of botulinum toxin type A has been demonstrated to be an effective temporary treatment option.1 Digital artery sympathectomy is the surgical treatment of choice for Raynaud's syndrome patients with digital ulcerations and rest pain when conservative therapy has failed.2 However, a number of patients will have recurrent and persistent symptoms even after digital artery sympathectomy, here termed refractory Raynaud's phenomenon. We present the efficacy of reoperative digital sympathectomy in the treatment of patients with refractory Raynaud's phenomenon.

Institutional review board approval for the study was obtained. A retrospective telephone follow-up survey of patients who had failed nonsurgical treatment for refractory Raynaud's phenomenon and were undergoing reoperative digital sympathectomy was completed by the senior author. Severity of symptoms, functional activity, cold sensitivity, healing of ulcerations, and patient satisfaction were surveyed.

Three female patients, aged 34 to 64 years (mean age, 49 years), who had failed nonsurgical treatment for refractory Raynaud's phenomenon and were undergoing reoperative digital sympathectomy in a total of 16 fingers from 1995 to 2005 were evaluated. Average time to recurrence of symptoms after the initial digital artery sympathectomy was 6 years (range, 2 to 8 years), and the duration of symptoms until reoperative digital sympathectomy was performed was 41 weeks (range, 6 to 104 weeks). After an average follow-up period of 1 year after the reoperation for 16 fingers, all patients reported improvement in symptom severity (Levine Symptom Severity Scale score, 3.5 versus 1.7; range, 1 to 5), functional status (Levine Functional Status Scale score, 3.7 versus 2.5; range, 1 to 5) (Fig. 1),3 cold sensitivity (McCabe Cold Sensitivity Severity Scale score, 354 versus 120; range, 0 to 400) (Fig. 2),4 and overall symptoms (abbreviated Wake Forest University Symptom Scale score, 3.7 versus 1.2; range, 0 to 9) in the affected fingers when comparing preoperative versus postoperative status. Fifteen fingers had preoperative ulcerations that completely healed postoperatively after an average period of 3 months. All patients were very satisfied with the results of surgery and would recommend reoperative digital sympathectomy for treatment of refractory Raynaud's phenomenon.

Fig. 1.
Fig. 1.:
The Levine Severity of Symptoms and Functional Severity Scale demonstrated improved symptoms and functional disability scores after versus before reoperative digital sympathectomy for refractory Raynaud's phenomenon.
Fig. 2.
Fig. 2.:
The McCabe Cold Sensitivity Scale showed improved cold sensitivity scores after versus before reoperative digital sympathectomy for refractory Raynaud's phenomenon.

The treatment of patients who have refractory Raynaud's phenomenon following a digital artery sympathectomy continues to be a challenging problem for the treating rheumatologist or hand surgeon. McCall et al. introduced reoperative digital sympathectomy in one patient with scleroderma, but to our knowledge, this is the first report that has evaluated the efficacy of reoperative digital sympathectomy for the treatment of patients with refractory Raynaud's phenomenon.5 In this article, we have shown that reoperative digital sympathectomy may provide refractory patients with an improvement in symptom severity, functional activity, cold sensitivity, and ulcerative healing after 1 year of follow-up.

Recurrent disease presented 6 years after initial digital sympathectomy in this series. Recurrent scar tissue formation and perivascular sympathetic regrowth can be hypothesized as the main causes of refractory Raynaud's phenomenon. The purpose of reoperative digital sympathectomy in this surgical approach is to decompress the digital vessels by excising the re-accumulated scar tissue and to denervate any possibly regrowing sympathetic fibers.

This study presents an efficacious treatment approach for patients with refractory Raynaud's phenomenon who have failed all conservative treatment approaches, including temporization with botulinum toxin type A, and have persistent symptoms and nonhealing ulcerations.

DISCLOSURE

The authors have no financial interests to disclose and there were no external sources of funding provided for this project.

Amir H. Dorafshar, M.D.

Iris A. Seitz, M.D., Ph.D.

Lawrence Zachary, M.D.

Section of Plastic and Reconstructive Surgeons

University of Chicago

Chicago, Ill.

REFERENCES

1. Van Beek AL, Lim PK, Gear AJL, et al. Management of vasospastic disorders with botulinum toxin A. Plast Reconstr Surg. 2007;119:217.
2. Flatt AE. Digital artery sympathectomy. J Hand Surg. 1980;5:550.
3. Levine DW, Simmons BP, Koris MJ, et al. A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J Bone Joint Surg (Am). 1993;75:1585.
4. McCabe SJ, Mizgala C, Glickman L. The measurement of cold sensitivity of the hand. Am J Hand Surg. 1991;16:1037.
5. McCall TE, Petersen DP, Wong LB. The use of digital artery sympathectomy as a salvage procedure for severe ischemia of Raynaud's disease and phenomenon. J Hand Surg (Am). 1999;24:173–177.

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