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Selection of Hypertensive Patients for Thoracolumbar Sympathectomy
SELECTION OF HYPERTENSIVE PATIENTS FOR THORACOLUMBAR SYMPATHECTOMY An Analysis of Sixty-six Patients Obtaining Excellent Results J.
WILLIAM IhNTON,
JERE
W.
M.D., F.A.C.S.* AND M.D., F.A.C.S.t
I.ORD, JR.,
THE problem of the proper selection of patients suffering from essential hypertension for surgical intervention remains to be solved. All physicians and surgeons interested in the surgical management of hypertensive patients have observed some individuals obtaining what might be termed a "cure" of their hypertensive process in the same sense as "cure" of a gastric cancer is measured by the absence of all signs of malignant disease at a certain follow-up period, such as three, five or ten years. In the case of the hypertensives, the blood pressure has fallen to essentially normal levels (less than 160 systolic and 100 diastolic), the cardiac changes evidenced by the electrocardiogram and six foot heart plate have improved and similarly the eyegrounds and cerebral signs and symptoms havs been ameliorated. However, only a minority of cases subjected to sympathectomy obtain such outstanding relief, whereas the majority are improved moderately and some patients not at all. No single test or combination of tests has proved accurate to a high degree in the selection of patients in spite of considerable study in this direction. The authorsl reported on a set of rules or principles which, when coupled with clinical judgment, aided in the elimination of surgical failures and fatalities. However, it was pointed out that "the problem of determining which of the 312 patients, who were within the limits of the contraindication rules and who lived through the operative procedures, would derive excellent results and which ones would derive only fair results or no benefit, is a most difficult one." The present study is an attempt to obtain certain broad principles which may help in the selection of patients whose hypertensive process will respond dramatically to thoracolumbar sympathectomy. The study is based on an analysis of sixty-six patients who have done exceedingly well postoperatively and who have been followed for an average period
* Professor of Surgery, New York University Post-Graduate Medical School; Director of Surgery, Fourth (New York University) Surgical Division, Bellevue Hospital, New York City. t Assistant Professor of Surgery, New York University Post-Graduate Medical School; Assistant Attending Surgeon, University Hospital; Associate Visiting Surgeon, Fourth (New York University) Surgical Division, Hellevue Hospital, New York City. 727
728
.T. WILLIAM HINTON, JERE W. LORD, JR.
of twenty-four months, the shortest follow-up being twelve months imd the longest fivc years. For statistical purposes, the data on 437 consecutive patients undergoing thoracolumbar sympathectomy between February 1942 and June 1947 were reviewed and sixty-six of them were classified as having been returned to or near normal. There were thirty in-hospital deaths and fifty-three patients succumbed following discharge from the hospital, the time of death varying from one week to fivc years. Forty-seven patients have either been lost to follow-up or have been TABLE 1 SUMMARY OF TOTAL CASES
Total patients operated on, 437 In-hospital mortality ........ . Number discharged from hospital, 407 Out-of-hospital mortality, 1 to 5 years. Living patients, 354 Too short a follow-up or lost to follow-up ............. . Followed living patients, 307 Excellent results .................... . Total patients operated UpOll, 437 Excellent results ...... .
No. 30
Per Cent 6.9
53
13.0
47
13.0
66
21.0
66
15.0
TABLE 2 AGE AND SEX DISTRIBUTION AND KNOWN DUHATION OF THE HYPERTENSION IN THE SIXTY-SIX PATIENTS WITH EXCELLENT RESULTS
Age Average, 42 years Oldest, 58 years Youngest, 19 years Sex distribution Males, 21 Females, 45 Known duration of hypertension Average, 7 years Shortest, 4 months Longest, 23 years
followed for less than one year. Of the 307 living patients followed for one or more years, sixty-six have bcen markedly improved and might be classed as "cures" in terms of the two year average postoperative period of observation (Table 1). Let us examine the available data of the sixty-six patients from various viewpoints. The average age was 42 ycars, the oldest being 58 and the youngest 19 (Table 2). There were forty-five females and twenty-one males (Table 2). The known average duration of the)ypertensive process was seven years, whereas variations ranged from four months to twenty-
THORACOLUMBAR SYMPATHF~CTOMY IN HYPERTENSION
729
three years (Table 2). On the basis of the plus system of grading, 4 plus being more severe and 0 heing absent. or normal, we have classified the cerebral, eyegrounds, cardiae and renal status of each patient (Tables 3 and 4). The average total pluses \vas G, the extremes being 0 and 12 plus TABLE DEFINITIONS \VHICH
AID
;~
IN 'l'IIE SEI,ECTION OF CASES FOR THORACOLUMBAR SYMPATHECTOMY
In general in any system: o plus Normal 1 plus Slight or milel changes £ plusl 3 plus! Moderate changes 4 plus Cerebral: o plus 1 plus Z plus 3 plus 4 plus Eyes: o plus 1 plus Z plus 3 plus 4 plus Cardiac: o plus 1 plus £ plus
3 plus 4 plus Renal: o plus 1 plus £ plus 3 plus
4 plus
Advanced or marked changes No symptoms or signs Headaches and/or dizziness aT,,1 nervousness As above, plus nosebleeds and/or occipital headaches As above, plus paresthesias Stroke, encepalopathy, or coufusion. Normal Arteriolar As above, As above, As above,
narrowing and arteriovenous nicking plus hemorrhages and exudates plus papilledema
No symptoms or signs Slight symptoms and/or slight cardiac enlargement and slight c1eetrocardiographic ahanges :Moderate symptoms and/or moderate x-ray enlargement and moderate electrocardiographic changes Marked symptoms and/or marked enlargement and marked elcdrocardiographic changes Coronary occlusion or congestive heart failure Normal Nocturia, but concentration 1.0£4 or more and urea clearance 75 per cent or more Urea clearance 40 to 75 per cent, concentration 1.015 to 1.0~3 Urea clearance less than 40 per cent, concentrate less than 1.015, normal blood chemistry Persistent elevation of nonprotein nitrogen to 45 mg. or more and blood urea nitrogen to £.5 mg. or more.
(Table 5). In our study on the elimination of failures and fatalities, it was stated that a total of 11 pluses or more is sufficient evidence to reject the patient as too poor a risk for thoracolumbar sympathectomy. In this group of sixty-six patients, there was only one 12 plus and one
730
.1. WILLIAM HINTON, H;IU; W. LORD, JR.
10 plus, all others having 9 01' less. The 12 plus patient was a 5~~ year old white man who had a 4 plus cardiac status (an old coronary occlusion, a 3 plus fundal examination, a 3 plus cerebral status and a 2 plus renal examination. The preoperative blood pressure averaged 210/140 and was known to have been elevated for at least two years. Nine grains of sodium amy tal lowered the blood pressure to 170/110. The patient's symptoms were graded 3 plus and he was subjected to a Smithwick thoracolumbar sympathectomy. When examined two years postoperatively, his blood pressure averaged 180/95 and he was entirely asymptomatic. It is clear TABLE
4
RULES 'VHICH AID IN THE SELECTION OF CASES FOR THORACQI,UMBAR SYMPA'rHECTOMY
Contraindications to Thoracolumbar Sympathectom!J: Renal (1) 4 plus (2) 4 plus Cardiac in which congestive heart failure is unremitting or if coronary occlusion is within 3 months, (3) 4 plus Cerebral if confusion exists or if a stroke within 6 weeks (4) If there are two pluses other than eyes (5) If total count equals 11 or more pluses Indications for Thoracolumber Sympathectomy: (1) All cases are operable in which there is no contraindication rule (2) From the viewpoint of minimal involvement: Operation is probably advisable in patients with persistent hypertension associated with definite though minimal objective changes in anyone of the four systems TABLE
5
TOTAL PLUSES AND GRADING OF EYEGROUNDS IN THE SIXTY-SIX PATIENTS WITH EXCELLENT RESULTS
Average Total pluses for cerebral, eyegrounds, cardiac and renal status. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . .. 6 Grading of eyegrounds, 0 to 4 plus. . . . . . . . . . . . .. 1. 3
Maximum
Minimum
12 3 (3 patients)
o o
(16 patients)
that this patient is an exception to the rule that most individuals, with as advanced and widespread disease as he had, do poorly or at most are only moderately improved. From the point of view of the eyegrounds, there was no instance of malignant hypertension in the sixty-six patients and only three patients had 3 pluses. The average was 1.3 plus, sixteen patients exhibiting normal fundi (Table 5). Analysis of the cerebral status revealed five patients who had had attacks of encephalopathy or a hemiplegia, all of whom have been completely relieved of their major difficulty. None of this group exhibited
731
THORACOLUMBAR SYMPATHECTOMY IN HYPERTENSION
mental confusion preoperatively, a sign which is an absolute contraindication to operative intervention. From the cardiac point of view only one patient had had a coronary occlusion, the one described above. No patient had been at any time in congestive heart failure. The average preoperative change in the 6 foot heart plate was 1.~ plus and in the electrocardiogram 1.0 plus. Postoperatively there was significant improvement in the cardiac status as evidenced by decrease in the heart size (average 0.5 plus) and improvement in the electrocardiogram (average o.~ plus) (Table 6). TABLE
6
ELECTROCARDIOGRAM AND HEART PLATE IN THE SIXTY-SIX PATIENTS WITH EXCELLENT RESULTS
Preoperative Average
Postoperative Average
Electrocardiogram, 0 to 4 plus.
1.0
0.2
6 foot heart plate, 0 to 4 plus ..
1.2
0.5
TABLE
7
RENAL FUNCTION IN l'HE SIXTY-SIX PATIENTS WITH EXCELLENT RESULTS
Preoperative Average
o to 4 plus .....
1.2
TABLE
Maximum Plus 3 (2 patients)
8
BLOOD PRESSURE IN THE SIXTY-SIX PATIENTS WITH EXCELLENT RESULTS
Average
Preoperative Highest
Lowest
Postoperative Average
194 125
245 165
135 95
130 80
It is of considerable interest that the renal status of all sixty-six patients was good with the exception of two patients. The average was 1.~ plus and the two patients referred to above had 3 plus renal function, i.e., normal blood chemistries but ability to concentrate only to 1.013 and a urea clearance of less than 40 per cent (normal being 75 per cent or more) (Table 7). Many observers have recorded the fact that thoracolumbar sympathectomy improves renal function little if at all, and this study serves to emphasize that reasonably good renal function is a prerequisite to the attainment of an excellent postoperative result. The average level of the blood pressure preoperatively was 195 systolic and 1~5 diastolic, the extremes being ~45/165 and 135/95. Postoperatively, the average level was 130/80 (Table 8). In this group of sixty-six
732
J. WILLIAM HINTON, JERE W. LORD, JR.
patients, three had an average postoperative diastolic blood pressure level of 100 and in one patient the average was 105. However, these four patients were included because of the excellent improvement exhibited both objectively and subjectively. It is of interest that the sodium amy tal test showed an excellent response (diastolic fall of 30 points or more) in only 55 per cent of the patients, whereas in 75 per cent, the diastolic pressure fell below 100 mm. of mercury (Table 9). This data again emphasizes the relative inaccuracy of the sodium amy tal test other than being of general prognostic value. 2 TABLE
9
SODIUM AMYTAL TEST IN THE SIXTY-SIX PATIENTS WITH EXC~JL]'FJNT RESULTS
Excellent Response (Diastolic Fall of 30 points or more
Diastolic Fall Below 100 mm. Hg
55 per cent of patients
75 per cent of patients TABLE
10
SMITHWICK'S CLASSIFICATION O~' TYPES O~' BLOOD PRESSURE PUEOPERATIVELY IN TIlE SIXTY-SIX PATIENTS WITH EXC~JLLENT RESULTS
Type I (Pulse pressure less than 1/2 diastolic) Number of patients ....
21 TABLE
Type II Type HI (Pulse pressure O~ 10 (Pulse pressure '20 points more than or more points 1/2 diastolic) than 1/2 diaslolic) 22 23 11
GRADE OF SYMPTOMS BEFOUE AND AFTER OPERA'l"ION IN THE SIX'l'Y-SIX PATIENTS WITH EXCELLENT RESULTS
Symptoms graded 0 to 4 plus.
Preoperative Average 1.9
Postoperative Average 0.8
Smithwick3 has repeatedly emphasized that patients with narrow pulse pressures obtain better postoperative results than those with wide pulse pressures. We have been unable to confirm this finding and the data obtained in this study reveals the lack of correlation between pulse pressure and postoperative blood pressure levels. Twenty-one patients out of the group of sixty-six fell into Type l, twenty-three were of Type II and twenty-two patients showed Type III (Table 10). Symptoms play an important role in patients with essential hypertension~and most observers agree that thoracolumbar sympathectomy has a profound effect in lessening the patient's symptoms, perhaps more
THORACOLUMBAR SYMPATHECTOMY IN HYPERTENSION
733
so than any other form of treatment. The average level of preoperalive symptoms related to the hypertensive state was 1.9 plus, the extremes being 0 and 4 plus. Only two patients were entirely asymptomatic. Postoperatively, the average level of symptoms was O.S plus (Table ll). SUMMARY
In summary, what type of hypertensive patient presents the optimum picture for which thoracolumbar sympathectomy will effect a "cure" or at least an excellent result? From the data outlined in this analysis the following patient would present a so-called ideal pattern: 42 years of age, of either sex, with a known duration of hypertension for seven years, totaling 6 plus (possible maximum is 16 plus) in all four systems, i.e., cardiac, cerebral, eyegrounds and renal. Further, the renal function would be good (average 1.2 plus), the eyegrounds show minimal change (average 1.3 plus) and the cardiac status would be relatively good (average 1.1 plus). The cerebral status might range from normal to 4 plus (encephalopathy or hemiplegia) as long as there was no evidence of mental confusion. The patient would be bothered by symptoms to a moderate degree (average 1.9 plus). The above patient might look forward to a fall in his blood pressure from 195/125 to 130/S0 as determined at the twenty-four months' follow-up (average for the sixty-six patients). His symptoms would largely disappear and his heart would improve considerably. The mild eyeground changes would persist and renal function would not improve but also might not show further progression. Finally, he would be highly satisfied with his operation, believing that it was worthwhile and would follow the same course if he had the choice to make over again. Of the sixty-six patients, sixty-two considered the operation worthwhile, three were uncertain of the value, although objectively greatly improved, and one patient considered the whole procedure of no value. This individual has had a normal blood pressure postoperatively for two and one-half years but has not been relieved of her symptoms. REFERENCES 1. Hinton, J. W. and Lord, J. W., Jr.: The Selection of Patients for Thoracolumbar Sympathectomy: Description of a Set of Rules for the Elimination of Failures and • Fatalities. Ann. Surg.l£?7:681, 1948. 2. Hinton, J. W. and Lord, J. W., Jr.: The Prognostic Value of the Sodium Amytal Test in Hypertension Managed by Thoracolumbar Sympathectomy. New York State J. Med. 96:1015, 1946. 3. Smithwick, R. H.: The Surgical Treatment of Hypertension: Some Circumstances Under Which Lumbodorsal Splanchnicectomy Appears to be Inadvisable in Hypertensive Patients, New York State J. Med. 44:2693, 1944.
WILLIAM IhNTON,
JERE
W.
M.D., F.A.C.S.* AND M.D., F.A.C.S.t
I.ORD, JR.,
THE problem of the proper selection of patients suffering from essential hypertension for surgical intervention remains to be solved. All physicians and surgeons interested in the surgical management of hypertensive patients have observed some individuals obtaining what might be termed a "cure" of their hypertensive process in the same sense as "cure" of a gastric cancer is measured by the absence of all signs of malignant disease at a certain follow-up period, such as three, five or ten years. In the case of the hypertensives, the blood pressure has fallen to essentially normal levels (less than 160 systolic and 100 diastolic), the cardiac changes evidenced by the electrocardiogram and six foot heart plate have improved and similarly the eyegrounds and cerebral signs and symptoms havs been ameliorated. However, only a minority of cases subjected to sympathectomy obtain such outstanding relief, whereas the majority are improved moderately and some patients not at all. No single test or combination of tests has proved accurate to a high degree in the selection of patients in spite of considerable study in this direction. The authorsl reported on a set of rules or principles which, when coupled with clinical judgment, aided in the elimination of surgical failures and fatalities. However, it was pointed out that "the problem of determining which of the 312 patients, who were within the limits of the contraindication rules and who lived through the operative procedures, would derive excellent results and which ones would derive only fair results or no benefit, is a most difficult one." The present study is an attempt to obtain certain broad principles which may help in the selection of patients whose hypertensive process will respond dramatically to thoracolumbar sympathectomy. The study is based on an analysis of sixty-six patients who have done exceedingly well postoperatively and who have been followed for an average period
* Professor of Surgery, New York University Post-Graduate Medical School; Director of Surgery, Fourth (New York University) Surgical Division, Bellevue Hospital, New York City. t Assistant Professor of Surgery, New York University Post-Graduate Medical School; Assistant Attending Surgeon, University Hospital; Associate Visiting Surgeon, Fourth (New York University) Surgical Division, Hellevue Hospital, New York City. 727
728
.T. WILLIAM HINTON, JERE W. LORD, JR.
of twenty-four months, the shortest follow-up being twelve months imd the longest fivc years. For statistical purposes, the data on 437 consecutive patients undergoing thoracolumbar sympathectomy between February 1942 and June 1947 were reviewed and sixty-six of them were classified as having been returned to or near normal. There were thirty in-hospital deaths and fifty-three patients succumbed following discharge from the hospital, the time of death varying from one week to fivc years. Forty-seven patients have either been lost to follow-up or have been TABLE 1 SUMMARY OF TOTAL CASES
Total patients operated on, 437 In-hospital mortality ........ . Number discharged from hospital, 407 Out-of-hospital mortality, 1 to 5 years. Living patients, 354 Too short a follow-up or lost to follow-up ............. . Followed living patients, 307 Excellent results .................... . Total patients operated UpOll, 437 Excellent results ...... .
No. 30
Per Cent 6.9
53
13.0
47
13.0
66
21.0
66
15.0
TABLE 2 AGE AND SEX DISTRIBUTION AND KNOWN DUHATION OF THE HYPERTENSION IN THE SIXTY-SIX PATIENTS WITH EXCELLENT RESULTS
Age Average, 42 years Oldest, 58 years Youngest, 19 years Sex distribution Males, 21 Females, 45 Known duration of hypertension Average, 7 years Shortest, 4 months Longest, 23 years
followed for less than one year. Of the 307 living patients followed for one or more years, sixty-six have bcen markedly improved and might be classed as "cures" in terms of the two year average postoperative period of observation (Table 1). Let us examine the available data of the sixty-six patients from various viewpoints. The average age was 42 ycars, the oldest being 58 and the youngest 19 (Table 2). There were forty-five females and twenty-one males (Table 2). The known average duration of the)ypertensive process was seven years, whereas variations ranged from four months to twenty-
THORACOLUMBAR SYMPATHF~CTOMY IN HYPERTENSION
729
three years (Table 2). On the basis of the plus system of grading, 4 plus being more severe and 0 heing absent. or normal, we have classified the cerebral, eyegrounds, cardiae and renal status of each patient (Tables 3 and 4). The average total pluses \vas G, the extremes being 0 and 12 plus TABLE DEFINITIONS \VHICH
AID
;~
IN 'l'IIE SEI,ECTION OF CASES FOR THORACOLUMBAR SYMPATHECTOMY
In general in any system: o plus Normal 1 plus Slight or milel changes £ plusl 3 plus! Moderate changes 4 plus Cerebral: o plus 1 plus Z plus 3 plus 4 plus Eyes: o plus 1 plus Z plus 3 plus 4 plus Cardiac: o plus 1 plus £ plus
3 plus 4 plus Renal: o plus 1 plus £ plus 3 plus
4 plus
Advanced or marked changes No symptoms or signs Headaches and/or dizziness aT,,1 nervousness As above, plus nosebleeds and/or occipital headaches As above, plus paresthesias Stroke, encepalopathy, or coufusion. Normal Arteriolar As above, As above, As above,
narrowing and arteriovenous nicking plus hemorrhages and exudates plus papilledema
No symptoms or signs Slight symptoms and/or slight cardiac enlargement and slight c1eetrocardiographic ahanges :Moderate symptoms and/or moderate x-ray enlargement and moderate electrocardiographic changes Marked symptoms and/or marked enlargement and marked elcdrocardiographic changes Coronary occlusion or congestive heart failure Normal Nocturia, but concentration 1.0£4 or more and urea clearance 75 per cent or more Urea clearance 40 to 75 per cent, concentration 1.015 to 1.0~3 Urea clearance less than 40 per cent, concentrate less than 1.015, normal blood chemistry Persistent elevation of nonprotein nitrogen to 45 mg. or more and blood urea nitrogen to £.5 mg. or more.
(Table 5). In our study on the elimination of failures and fatalities, it was stated that a total of 11 pluses or more is sufficient evidence to reject the patient as too poor a risk for thoracolumbar sympathectomy. In this group of sixty-six patients, there was only one 12 plus and one
730
.1. WILLIAM HINTON, H;IU; W. LORD, JR.
10 plus, all others having 9 01' less. The 12 plus patient was a 5~~ year old white man who had a 4 plus cardiac status (an old coronary occlusion, a 3 plus fundal examination, a 3 plus cerebral status and a 2 plus renal examination. The preoperative blood pressure averaged 210/140 and was known to have been elevated for at least two years. Nine grains of sodium amy tal lowered the blood pressure to 170/110. The patient's symptoms were graded 3 plus and he was subjected to a Smithwick thoracolumbar sympathectomy. When examined two years postoperatively, his blood pressure averaged 180/95 and he was entirely asymptomatic. It is clear TABLE
4
RULES 'VHICH AID IN THE SELECTION OF CASES FOR THORACQI,UMBAR SYMPA'rHECTOMY
Contraindications to Thoracolumbar Sympathectom!J: Renal (1) 4 plus (2) 4 plus Cardiac in which congestive heart failure is unremitting or if coronary occlusion is within 3 months, (3) 4 plus Cerebral if confusion exists or if a stroke within 6 weeks (4) If there are two pluses other than eyes (5) If total count equals 11 or more pluses Indications for Thoracolumber Sympathectomy: (1) All cases are operable in which there is no contraindication rule (2) From the viewpoint of minimal involvement: Operation is probably advisable in patients with persistent hypertension associated with definite though minimal objective changes in anyone of the four systems TABLE
5
TOTAL PLUSES AND GRADING OF EYEGROUNDS IN THE SIXTY-SIX PATIENTS WITH EXCELLENT RESULTS
Average Total pluses for cerebral, eyegrounds, cardiac and renal status. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . .. 6 Grading of eyegrounds, 0 to 4 plus. . . . . . . . . . . . .. 1. 3
Maximum
Minimum
12 3 (3 patients)
o o
(16 patients)
that this patient is an exception to the rule that most individuals, with as advanced and widespread disease as he had, do poorly or at most are only moderately improved. From the point of view of the eyegrounds, there was no instance of malignant hypertension in the sixty-six patients and only three patients had 3 pluses. The average was 1.3 plus, sixteen patients exhibiting normal fundi (Table 5). Analysis of the cerebral status revealed five patients who had had attacks of encephalopathy or a hemiplegia, all of whom have been completely relieved of their major difficulty. None of this group exhibited
731
THORACOLUMBAR SYMPATHECTOMY IN HYPERTENSION
mental confusion preoperatively, a sign which is an absolute contraindication to operative intervention. From the cardiac point of view only one patient had had a coronary occlusion, the one described above. No patient had been at any time in congestive heart failure. The average preoperative change in the 6 foot heart plate was 1.~ plus and in the electrocardiogram 1.0 plus. Postoperatively there was significant improvement in the cardiac status as evidenced by decrease in the heart size (average 0.5 plus) and improvement in the electrocardiogram (average o.~ plus) (Table 6). TABLE
6
ELECTROCARDIOGRAM AND HEART PLATE IN THE SIXTY-SIX PATIENTS WITH EXCELLENT RESULTS
Preoperative Average
Postoperative Average
Electrocardiogram, 0 to 4 plus.
1.0
0.2
6 foot heart plate, 0 to 4 plus ..
1.2
0.5
TABLE
7
RENAL FUNCTION IN l'HE SIXTY-SIX PATIENTS WITH EXCELLENT RESULTS
Preoperative Average
o to 4 plus .....
1.2
TABLE
Maximum Plus 3 (2 patients)
8
BLOOD PRESSURE IN THE SIXTY-SIX PATIENTS WITH EXCELLENT RESULTS
Average
Preoperative Highest
Lowest
Postoperative Average
194 125
245 165
135 95
130 80
It is of considerable interest that the renal status of all sixty-six patients was good with the exception of two patients. The average was 1.~ plus and the two patients referred to above had 3 plus renal function, i.e., normal blood chemistries but ability to concentrate only to 1.013 and a urea clearance of less than 40 per cent (normal being 75 per cent or more) (Table 7). Many observers have recorded the fact that thoracolumbar sympathectomy improves renal function little if at all, and this study serves to emphasize that reasonably good renal function is a prerequisite to the attainment of an excellent postoperative result. The average level of the blood pressure preoperatively was 195 systolic and 1~5 diastolic, the extremes being ~45/165 and 135/95. Postoperatively, the average level was 130/80 (Table 8). In this group of sixty-six
732
J. WILLIAM HINTON, JERE W. LORD, JR.
patients, three had an average postoperative diastolic blood pressure level of 100 and in one patient the average was 105. However, these four patients were included because of the excellent improvement exhibited both objectively and subjectively. It is of interest that the sodium amy tal test showed an excellent response (diastolic fall of 30 points or more) in only 55 per cent of the patients, whereas in 75 per cent, the diastolic pressure fell below 100 mm. of mercury (Table 9). This data again emphasizes the relative inaccuracy of the sodium amy tal test other than being of general prognostic value. 2 TABLE
9
SODIUM AMYTAL TEST IN THE SIXTY-SIX PATIENTS WITH EXC~JL]'FJNT RESULTS
Excellent Response (Diastolic Fall of 30 points or more
Diastolic Fall Below 100 mm. Hg
55 per cent of patients
75 per cent of patients TABLE
10
SMITHWICK'S CLASSIFICATION O~' TYPES O~' BLOOD PRESSURE PUEOPERATIVELY IN TIlE SIXTY-SIX PATIENTS WITH EXC~JLLENT RESULTS
Type I (Pulse pressure less than 1/2 diastolic) Number of patients ....
21 TABLE
Type II Type HI (Pulse pressure O~ 10 (Pulse pressure '20 points more than or more points 1/2 diastolic) than 1/2 diaslolic) 22 23 11
GRADE OF SYMPTOMS BEFOUE AND AFTER OPERA'l"ION IN THE SIX'l'Y-SIX PATIENTS WITH EXCELLENT RESULTS
Symptoms graded 0 to 4 plus.
Preoperative Average 1.9
Postoperative Average 0.8
Smithwick3 has repeatedly emphasized that patients with narrow pulse pressures obtain better postoperative results than those with wide pulse pressures. We have been unable to confirm this finding and the data obtained in this study reveals the lack of correlation between pulse pressure and postoperative blood pressure levels. Twenty-one patients out of the group of sixty-six fell into Type l, twenty-three were of Type II and twenty-two patients showed Type III (Table 10). Symptoms play an important role in patients with essential hypertension~and most observers agree that thoracolumbar sympathectomy has a profound effect in lessening the patient's symptoms, perhaps more
THORACOLUMBAR SYMPATHECTOMY IN HYPERTENSION
733
so than any other form of treatment. The average level of preoperalive symptoms related to the hypertensive state was 1.9 plus, the extremes being 0 and 4 plus. Only two patients were entirely asymptomatic. Postoperatively, the average level of symptoms was O.S plus (Table ll). SUMMARY
In summary, what type of hypertensive patient presents the optimum picture for which thoracolumbar sympathectomy will effect a "cure" or at least an excellent result? From the data outlined in this analysis the following patient would present a so-called ideal pattern: 42 years of age, of either sex, with a known duration of hypertension for seven years, totaling 6 plus (possible maximum is 16 plus) in all four systems, i.e., cardiac, cerebral, eyegrounds and renal. Further, the renal function would be good (average 1.2 plus), the eyegrounds show minimal change (average 1.3 plus) and the cardiac status would be relatively good (average 1.1 plus). The cerebral status might range from normal to 4 plus (encephalopathy or hemiplegia) as long as there was no evidence of mental confusion. The patient would be bothered by symptoms to a moderate degree (average 1.9 plus). The above patient might look forward to a fall in his blood pressure from 195/125 to 130/S0 as determined at the twenty-four months' follow-up (average for the sixty-six patients). His symptoms would largely disappear and his heart would improve considerably. The mild eyeground changes would persist and renal function would not improve but also might not show further progression. Finally, he would be highly satisfied with his operation, believing that it was worthwhile and would follow the same course if he had the choice to make over again. Of the sixty-six patients, sixty-two considered the operation worthwhile, three were uncertain of the value, although objectively greatly improved, and one patient considered the whole procedure of no value. This individual has had a normal blood pressure postoperatively for two and one-half years but has not been relieved of her symptoms. REFERENCES 1. Hinton, J. W. and Lord, J. W., Jr.: The Selection of Patients for Thoracolumbar Sympathectomy: Description of a Set of Rules for the Elimination of Failures and • Fatalities. Ann. Surg.l£?7:681, 1948. 2. Hinton, J. W. and Lord, J. W., Jr.: The Prognostic Value of the Sodium Amytal Test in Hypertension Managed by Thoracolumbar Sympathectomy. New York State J. Med. 96:1015, 1946. 3. Smithwick, R. H.: The Surgical Treatment of Hypertension: Some Circumstances Under Which Lumbodorsal Splanchnicectomy Appears to be Inadvisable in Hypertensive Patients, New York State J. Med. 44:2693, 1944.