Keywords
Raynaud disease - Sympathectomy
INTRODUCTION
The treatment of Raynaud's symptoms of cold intolerance, pain, and ulceration that
are refractory to oral medication is an extremely difficult clinical problem [[1]]. Historically, cervicothoracic sympathectomy was a common treatment if conservative
treatment of symptoms was unsuccessful [[2]]. However, this treatment provided only temporary improvement, and in 1980 Flatt
et al. suggested the resection of the periarterial sympathetic fibers and digital
nerve branches to the common and proper digital arteries. This technique has provided
significant improvement in selected patients [[3]
[4]]. However, the associated incisions on the palmar surface of the hand typically
lead to redness, pain, edema, tenderness, and aesthetic problems. Surgical scars on
the palm may lead to not only functional but also aesthetic and psychological consequences,
particularly if they are located in areas of the body that are actively moving and
are exposed instead of covered by clothing [[5]
[6]]. Therefore, it is necessary to optimize scar formation by using appropriate incision
techniques and performing a careful follow-up to check the healing process. Minimal
incisions made for aesthetic purposes may lead to insufficient exposure of the operative
field. Therefore, we have performed a new incision technique over several recent years
in an attempt to obtain a sufficient operative field and improved aesthetic outcomes.
The objective of this study was to introduce a new incision technique for periarterial
sympathectomy of the hand and to compare the results of the new two-step incision
technique with those of the Koman incision by using objective questionnaire. We hypothesized
that periarterial sympathectomy of the palm performed with a two-step incision would
result in a more aesthetically acceptable and functional scar, reduced postoperative
pain, and earlier mobilization and discharge from the hospital.
METHODS
A total of 40 patients (17 men and 23 women) with intractable Raynaud's disease or
syndrome underwent surgery in our hospital, conducted by a single surgeon, between
January 2008 and January 2013. A retrospective study of periarterial sympathectomy,
based on chart review, was designed and conducted. All patients had a diagnosis of
Raynaud's disease or syndrome by a rheumatologist. They suffered from pain, ulcers,
or gangrene in the affected digits and were unresponsive to pharmacologic or other
conservative therapies. Pharmacologic interventions include alpha-blocking agents,
beta-blocking agents, and calcium channel-blocking agents. We evaluated preoperative
arteriography to assist with the decision for arterial reconstruction, and if possible,
revascularization procedures were also performed. In all cases in our study, angiography
showed multifocal arterial pathologic changes. A consecutive series of 40 Raynaud's
patients managed with periarterial sympathectomy was comprised of patients receiving
either a two-step incision or a Koman incision on the palm, as well as ulnar and radial
incisions on the wrist. Patients who had undergone extended sympathectomy or vessel
graft were excluded. The two-step incision technique was used in 28 selected patients
between January 2008 and January 2013. The twelve patients who had a Koman incision
served as the control group for comparison. All patients were admitted the day before
surgery, which is the present practice at our institution. We analyzed the period
that elapsed before return to work in order to evaluate the functional outcome.
Incision methods
In the Koman incision group, the incision was made in the middle of the palm as a
single transverse line ([Fig. 1A]). In the two-step incision group, the incision consisted of two separate incisions
in the proximal and distal palmar creases. The distal incision was made on the distal
palmar crease from the proximal continuation of the center of the long finger to that
of the little finger. The proximal incision was made on the proximal palmar crease
from the proximal continuation of the radial side of the index finger to that of the
ring finger. These incision lines can be modified to expose specific structures such
as narrowed arteries ([Fig. 1B]). In all cases, longitudinal incisions were also made at the volar wrist over the
radial and ulnar arteries. A straight skin incision over the ulnar artery, aligned
with the crest of the ulna, was made from the proximal wrist crease to 5 cm more proximally
([Fig. 1]). Next, the fascia overlying the arteries was incised and flexor carpi ulnaris was
retracted laterally and flexor digitorum superficialis was retracted medially. Another
skin incision for the radial artery, aligned with the edge of the brachioradialis
muscle, was extended from the proximal wrist crease to 5 cm more proximally. Next,
the fascia overlying the arteries was incised and brachioradialis was retracted laterally
and flexor carpi radialis was retracted medially.
Fig. 1 Incision method of periarterial sympathectomy
(A) Incision method for periarterial sympathectomy in the hand. Koman incision (red),
ulnar and radial incision (blue). (B) Incision method for periarterial sympathectomy
in the hand. Two-step incision (red), ulnar and radial incision (blue).
Postoperative management
Dressings were applied to minimize scar formation. Steri-strips were applied postoperatively
along the sutured incision line after the application of antibiotic powder. Each strip
was overlapped and attached without ointment so it could reinforce the subcuticular
and simple interrupted sutures. After the stitches were removed, placement of strips
was continued for six months.
Patient and observer scar assessment scale
Clinical evaluation of postoperative scars was performed in both groups one year after
surgery and postoperative management with self-drying silicone gel and adhesive strips
using the patient and observer scar assessment scale (POSAS). The POSAS consists of
two subscales: the patient scale (PS) and the observer scale (OS). The PS was compiled
by the patient, who rated scar pain, itch, color, stiffness, thickness, and surface.
All items were evaluated on a numerical rating scale ranging from 1 to 10 (with 10
indicating the worst imaginable scar or sensation). The observer completed the OS
using the same scale and rated scar vascularity, pigmentation, thickness, relief,
pliability, and surface area ([Table 1]). The OS was evaluated based on clinical experience and on references in the literature
such as the Vancouver scale. The total PS and OS scores were obtained by adding the
scores of each of the six items (range, 6-60), with higher scores indicating the worst
imaginable scar. Both the observer and the patient finally gave their overall opinion
on the appearance of the scar, assigning a score ranging from 1 to 10 [[7]
[8]].
Table 1 The patient and observer scar assessment scale
Wake Forest University rating scale
Symptoms such as pain, numbness, and cold intolerance were assessed in each patient
before and after undergoing periarterial sympathectomy using the Wake Forest University
rating scale (0, none; 1, mild; 2, moderate; 3, severe), with a higher score indicating
a greater intensity of symptoms.
Statistical analysis
Statistical analysis was performed using PASW ver. 18.0 (SPSS Inc., Chicago, IL, USA).
The Mann-Whitney U test was used to compare the POSAS and Wake Forest University rating
scale scores between the two groups. The Wilcoxon signed-rank test was used for comparing
preoperative and postoperative Wake Forest University rating scale scores in each
group. An independent t-test was used to compare the periods of hospitalization and
recovery before return to work between the two groups. A P-value of less than 0.05
was considered statistically significant.
RESULTS
Our patients were aged between 27 and 74 years, with a mean age of 53.1 years. The
majority of them were in their sixth and seventh decades (33% and 30%, respectively).
42% of patients were male. The number of smokers was five (three in the two-step incision
group and two in the Koman incision group).
Patient and observer scar assessment scale
The POSAS scores were lower on almost all of the items in the two-step incision group
than in the Koman incision group. Of note, the total PS score was 8.59 (range, 6-15)
in the two-step incision group, whereas it was 9.62 (range, 7-18) in the Koman incision
group. The total OS score was 11.79 (range, 7-20) in the two-step incision group and
11.84 (range, 8-20) in the Koman incision group. A significant difference was found
between the groups in total PS score (P=0.034), but not in total OS score (P=0.419)
([Table 2]). There were significant differences in PS scores on the parameters of pain (P=0.028),
color (P=0.045), and overall opinion (P=0.001) ([Table 3]) and in OS score in overall opinion (P=0.003) ([Table 4]). The other parameters were not significantly different between groups.
Table 2 Total POSAS scores in the Koman and two-step incision groups
Values are presented as the mean (range).POSAS, patient and observer scar assessment
scale.
Table 3 Total patient scale scores
Values are presented as the mean (range).
Table 4 Total observer scale scores
Values are presented as the mean (range).
Wake Forest University rating scale
In the Koman incision group, evaluation of patient symptoms with the Wake Forest University
rating scale indicated that patients experienced reduced pain (P<0.001) and numbness
(P=0.038) after periarterial sympathectomy surgery. Cold intolerance, however, was
not reduced significantly after the operation. In the two-step incision group, patients
experienced reduced pain (P<0.001) and numbness (P=0.028) after the surgery, but cold
intolerance was not significantly reduced.
The preoperative scores under the Wake Forest University rating scale showed that
the patients reported pain at a mean level of 2.41 in the Koman incision group and
2.27 in the two-step incision group. The mean numbness score was 1.75 in the Koman
incision group and 1.82 in the two-step incision group, and the mean cold intolerance
score was 2.23 in the Koman incision and 2.43 in the two-step incision group. Our
analysis found no significant difference between the preoperative scores in the Koman
and two-step incision groups.
One year after sympathectomy, the Wake Forest University rating scale scores demonstrated
that the patients reported pain at a mean level of 0.67 in the Koman incision group
and 0.56 in the two-step incision group. The mean numbness score was 0.89 in the Koman
incision group and 0.71 in the two-step incision group, and the mean cold intolerance
score was 1.54 in the Koman incision group and 1.67 in the two-step incision group.
There was no significant difference in postoperative scores between the Koman and
two-step incision groups ([Fig. 2]).
Fig. 2 Wake Forest University rating scale
The Wake Forest University rating scale before and after the operation in both groups.
Koman incision group (blue bars) and two-step incision group (orange bars). Pre-OP.,
preoperative; Post-OP., postoperative.
Period of hospitalization and return to work
The average postoperative hospitalization period was 13.74 days in the Koman incision
group and 11.42 days in the two-step incision group, and these periods were not significantly
different. The period of recovery prior to returning to work was different for the
two groups, with a mean of 34.15 days in the Koman incision group and 29.48 days in
the two-step incision group (P=0.03) ([Table 5]).
Table 5 Mean duration for recovery before return to work in Koman incision and two-step
incision groups
Values are presented as the mean (standard deviation).
Case 1
A 64-year-old woman had been suffering from skin necrosis on her right second finger
for several months. The patient had a history of Raynaud's syndrome, scleroderma,
dermatomyositis and pulmonary fibrosis. Angiography showed multifocal stenosis over
all proper digital arteries in the right hand. Conservative treatment was attempted
without success. Periarterial sympathectomy was performed over the common digital
arteries using the Koman incision and over the ulnar and radial arteries. Digital
artery reconstruction with the superficial vein in the wrist was performed over the
ulnar side of the right second finger. Cyanosis improved and the pain decreased post-surgery.
Capillary refilling also improved. The patient was discharged on the 13th postoperative
day. The patient was treated according to the above-mentioned wound and scar care
protocol for six months. The wound healed well but a clearly evident transverse scar
was formed in the palm ([Fig. 3]).
Fig. 3 Koman incision method with ulnar and radial incision
(A) Preoperative design by the Koman incision method on the palm and ulnar and radial
incision on the wrist. (B) Postoperative results after three days. (C) Postoperative
results after one year.
Case 2
A 36-year-old woman had been suffering from skin necrosis of the second and third
digits for several years. The patient also suffered from sensitivity to cyanosis in
cold temperatures. Periarterial sympathectomy was performed over the common digital
arteries using the two-step incision and ulnar and radial incisions. Postoperatively,
her symptoms were improved. The patient was discharged on the 11th postoperative day
and treated according to the wound care protocol for six months. After one year, the
scar was almost invisible and folded with the existing palmar crease ([Fig. 4]).
Fig. 4 Two-step incision method with ulnar and radial incision
(A) Preoperative design by the two-step incision method on the palm and ulnar and
radial incision on the wrist. (B) Postoperative results after three days. (C) Postoperative
results after one year.
DISCUSSION
Digital ischemia with subsequent gangrene and tissue necrosis caused by Raynaud's
syndrome remains a difficult treatment problem for rheumatologists and hand surgeons
[[9]
[10]]. Although several pharmacologic agents have been used successfully to improve symptoms,
some patients remain refractory to medical management [[11]
[12]]. During the past several decades, periarterial sympathectomy has been used as a
treatment option for improving the quality of life for patients suffering from severe
Raynaud syndrome [[13]
[14]]. Postoperative pain and scars are known complications of the Koman incision for
periarterial sympathectomy in the palm. These incisions leave a scar in the middle
of the palm, an area subject to crease formation when making a fist. In some cases,
an extra incision is required for visualizing the proximal common digital artery or
proper digital artery. To the best of our knowledge, this retrospective study is the
first to test whether periarterial sympathectomy in the palm performed through a two-step
incision has any benefits over the Koman incision technique.
To reduce confounding variables, a single surgeon performed all aspects of the procedure,
using the same operative techniques and the same protocol for wound dressing and scar
management in all patients. This is important, because methods of dressing and scar
management significantly affect scar formation [[7]].
Compared with the Koman incision method, our method of incision on the palmar crease
offers the following advantages. First, the two-step incision conceals the scar by
being placed at the proximal and distal palmar crease. Traditional incision inevitably
creates a scar that is visually distinct from the palmar crease. Second, our method
involves two separate incisions, which allows more extensive exposure of anatomical
structures than the Koman incision, especially of the superficial palmar arch and
common digital arteries. Third, the two separated curved incisions disperse the vector
of the scar in all directions, which can reduce its impact on the range of motion
of the finger. Thus, as well as palmar spreading, the post-surgical outcome results
in increased function and less pain when patients make a fist and unfold the palm.
As there is therefore very little effect of hand movement on wound healing, the stitches
can be removed early and patients can mobilize and return to work more quickly.
In this study, wrist incision for ulnar and radial artery commenced from, and skin
was preserved distal to, the proximal wrist crease. This was intended to reduce scar
contracture and web formation in the wrist, and it did not interfere with the operative
field.
Although reduced pain is one of the benefits that have been cited for this surgical
approach, none of the previously reported studies have directly measured pain as an
outcome. For this reason, our two-step incision was objectively assessed using several
parameters, including pain. The patient and observer scar assessment scale is reported
in the literature as a verified tool for the evaluation of linear scars [[15]
[16]]. The incision method for the wrist does not differ between the two-step and Koman
incision methods.
The damaging effect of cigarette smoking on digital perfusion and wound healing has
been reported in several studies [[17]
[18]]. Despite active counseling, five of 40 patients continued to smoke during the follow-up
period in the present study (three in the two-step incision group and two in the Koman
incision group). Three of these five patients had a healing period for a digital ulcer
of more than six months' duration (two in the two-step incision group and one in the
Koman incision group). Two of these five patients had active ulcers at follow-up (one
in each incision group). These results suggest a poor long-term outcome for patients
who continue to smoke. We strongly encourage smoking cessation but will perform periarterial
sympathectomy in patients who continue to smoke because we consider it to be a salvage
procedure.
The incidence of a single transverse palmar crease is 7%-10% in the general population
[[19]]. Because this would be a confounding factor in our analysis, patients with a single
transverse palmar crease were not included in this study. In these cases, a Koman
incision was performed on the palmar crease, which was not effectively different to
the procedure for a two-step incision, which is also performed on the palmar crease,
and so it had a similar effect on scar formation.
In the present study, patients in both groups reported decreased symptoms, most significantly
in the area of pain and numbness. These changes were associated with significant improvement
in digital micro-vascular perfusion, resulting in a resolution of ischemia. However,
cold intolerance did not improve significantly in either group. The fact that cold
intolerance, as assessed by the Wake Forest University rating scale, did not change
after periarterial sympathectomy is not surprising when considering the unchanged
total blood flow to the digits. Johnston et al. reported that cold intolerance persisted
in spite of adequate sympathetic denervation [[20]]. This indicates that nutritional blood flow and cutaneous perfusion are not enough
to improve cold intolerance following periarterial sympathectomy. An additional vessel
graft could perhaps improve cold intolerance, although additional studies would be
necessary to determine this.
The postoperative outcomes in the Koman incision group and the two-step incision group
were similar. We found that most patients' wounds recovered well and symptoms subsided.
Only two men (one in each incision group) reported no symptom reduction and continued
to experience digital ulcers and substantial pain. None of the patients suffered from
major complications. Taken together, these observations indicate that the two-step
incision could replace the Koman incision method.
Using the new incision technique, the scar at the palm was nearly invisible, being
well integrated into the natural palmar crease at one year after surgery. Both patients
and surgeons were more satisfied with the cosmetic appearance of the palm after wound
healing with the two-step incision method than with the Koman incision method. In
our experience, this new approach provides not only a more natural appearance, but
also greater functional improvement. Furthermore, it results in sufficient exposure
of anatomical structures and provides a wide surgical field.
