The sympathetic nervous system (SNS) is one of the two divisions of the autonomic nervous system (ANS), the other being the parasympathetic nervous system (PNS), These systems largely work unconsciously in opposite ways to regulate many functions and parts of the body. Colloquially, the SNS governs the "fight or flight" response while the PNS controls the "rest and digest" response. The main overall end effect of the SNS is to prepare the body for physical activity, a whole-body response affecting many organ systems throughout the body to redirect oxygen-rich blood to areas of the body needed during intense physical demand.
The sympathetic nervous system is composed of many pathways that perform a variety of functions on various organ systems. The preganglionic neurons of the SNS arise from the thoracic and lumbar regions of the spinal cord (T1 to L2) with the cell bodies distributed in four regions of the gray matter in the spinal cord bilaterally and symmetrically. As opposed to the parasympathetic nervous system, the first order neurons of the SNS are short before synapsing on postsynaptic neurons found within sympathetic ganglia. Similar to the PNS, the neurotransmitter used at this junction is acetylcholine. This acetylcholine activates nicotinic receptors. These postganglionic neurons then travel to their effector sites and release the neurotransmitters epinephrine or norepinephrine, except for sympathetic innervation of sweat glands and the arrectores pili muscles, the small muscles attached to hair follicles, which use acetylcholine as their postganglionic neurotransmitter. These neurotransmitters act on adrenergic receptors. Among the adrenergic receptors are alpha-1 (coupled to a Gq and works through the IP3/Ca2+ pathway), alpha-2 (coupled to Gi and works through decreasing the cAMP pathway), and beta-1 and beta-2 (coupled to Gs and works through increasing the cAMP pathway). Whether beta-1 and beta-2 are excitatory or inhibitory depends on the tissue it is located on. These receptors are located on various parts of the body and regulate the actions of the SNS.
The functions of the sympathetic nervous system are expansive and involve many organ systems and various types of adrenergic receptors.
The effects in which SNS acts in direct contrast to the PNS function include the following:
Actions of SNS which do not oppose those of the PNS include the following:
Neurons of the peripheral autonomic nervous system, which includes both the sympathetic nervous system and parasympathetic nervous system, arise from neural crest cells that originate from between the neural and non-neural ectoderm. They form the dorsal neural folds as the folds themselves are forming the neural tube.
Aging has various effects on the sympathetic nervous system. Research has demonstrated that with increased age that baroreceptors of the heart decrease and become less sensitive; there is a compensatory increase in cardiovascular SNS activity and a reduction in PNS activity. However, both sympathetic and parasympathetic nervous activity to the iris decreases with aging, which is consistent with the general decline of peripheral somatic nerve function. It has also been shown that baseline levels of noradrenaline levels increase with age resulting in an elevated basal SNS activation, while the reactivity is reduced with aging. This increase in activation plays a role, among other disease processes, in both age-related hypertension and heart failure.
Horner syndrome is a complication born from interruption of the sympathetic innervation to the eye and adnexa at varying levels, most commonly of the neck, resulting in increased parasympathetic input. It presents with the classic triad of ipsilateral ptosis, pupillary miosis, and facial anhidrosis. It can be a complication of neck surgeries that damage the sympathetic input. There are even reports after minimally invasive thyroidectomy. For more information on Horner syndrome, please refer to our accompanying article.
Hyperhidrosis, otherwise known as excessive sweating, is a common indication for minimally invasive thoracic sympathectomy. Hyperhidrosis is excessive sweating beyond the organism’s physiological need to sweat to have a temperature within an adequate range. Removing the sympathetic input to the part of the body affected by hyperhidrosis is an acceptable and well-tolerated treatment. Thorascoposic sympathectomy can also be used to treat severe Raynaud syndrome, defined as episodic vascular spasms and digital ischemia secondary to cold or emotional stimuli.[
The clinical significance of the sympathetic nervous system is vast as it affects many organ systems. Of the many physiological and pathological processes, pheochromocytoma, erections and priapism, diabetic neuropathy, and orthostatic hypotension are described below.
Pheochromocytomas are tumors that arise from chromaffin cells present in the adrenal medulla or paraganglion cells that secrete excess amounts of catecholamines (norepinephrine, epinephrine). Because of this catecholamine release, the symptoms are largely that of sympathetic activation, such as hypertension, tachycardia/palpitations, hyperglycemia, and diaphoresis.
Erections are a product of parasympathetic activity. At resting state, the SNS predominates, and the penis remains flaccid. However, if the sympathetic fibers to the penis are damaged or compromised, a sustained erection of over 4 hours, called priapism, can occur and result in devastating consequences to the penis. This condition can be caused by spinal cord or cauda equina injury as the sympathetic input is damaged and the parasympathetic tone dominates. Nevertheless, SNS also contributes to the normal sexual function of a man. Sympathetic stimulation of the male genitals causes sperm emission which is sensed by the hypogastric nerve.
Diabetic autonomic neuropathy is one of the most common causes of sympathetic nerve neuropathy. This sympathetic denervation can lead to impaired myocardial coronary blood flow and reduced myocardial contractility. Diabetic neuropathy plays a crucial role in morbidity and mortality in patients with both type 1 and type 2 diabetes mellitus and causes dysfunction of many systems, including the heart, the Gastroenterol tract, the and genitourinary system, and sexuality. As it is well established that hyperglycemia is the primary driver of this diabetic complication, it is imperative for the clinician to establish early and sustained intensive glycemic control to prevent or delay the onset and slow the progression of autonomic dysfunction. However, this strategy seems to be more effective in type 1 versus type 2 diabetic patients.
Lastly, orthostatic hypotension is a common problem caused by the failure of noradrenergic neurotransmission. It is defined as a drop of systolic blood pressure by at least 20 mmHg or diastolic by 10 mmHg. It is caused by a wide variety of disease processes, including but not limited to pure autonomic failure, multiple system atrophy, and autonomic neuropathies that damage the SNS.
|||McCorry LK, Physiology of the autonomic nervous system. American journal of pharmaceutical education. 2007 Aug 15; [PubMed PMID: 17786266]|
|||Wehrwein EA,Orer HS,Barman SM, Overview of the Anatomy, Physiology, and Pharmacology of the Autonomic Nervous System. Comprehensive Physiology. 2016 Jun 13; [PubMed PMID: 27347892]|
|||Shibasaki M,Crandall CG, Mechanisms and controllers of eccrine sweating in humans. Frontiers in bioscience (Scholar edition). 2010 Jan 1; [PubMed PMID: 20036977]|
|||Strosberg AD, Structure, function, and regulation of adrenergic receptors. Protein science : a publication of the Protein Society. 1993 Aug; [PubMed PMID: 8401205]|
|||Young HM,Cane KN,Anderson CR, Development of the autonomic nervous system: a comparative view. Autonomic neuroscience : basic [PubMed PMID: 20346736]|
|||Pfeifer MA,Weinberg CR,Cook D,Best JD,Reenan A,Halter JB, Differential changes of autonomic nervous system function with age in man. The American journal of medicine. 1983 Aug; [PubMed PMID: 6881176]|
|||Shimazu T,Tamura N,Shimazu K, [Aging of the autonomic nervous system]. Nihon rinsho. Japanese journal of clinical medicine. 2005 Jun; [PubMed PMID: 15948378]|
|||Esler M,Hastings J,Lambert G,Kaye D,Jennings G,Seals DR, The influence of aging on the human sympathetic nervous system and brain norepinephrine turnover. American journal of physiology. Regulatory, integrative and comparative physiology. 2002 Mar; [PubMed PMID: 11832414]|
|||González-Aguado R,Morales-Angulo C,Obeso-Agüera S,Longarela-Herrero Y,García-Zornoza R,Acle Cervera L, Horner's syndrome after neck surgery. Acta otorrinolaringologica espanola. 2012 Jul-Aug; [PubMed PMID: 22502736]|
|||Hu X,Zhang X,Gan H,Yu D,Sun W,Shi Z, Horner syndrome as a postoperative complication after minimally invasive video-assisted thyroidectomy: A case report. Medicine. 2017 Dec; [PubMed PMID: 29310374]|
|||Khan Z,Bollu PC, Horner Syndrome 2019 Jan; [PubMed PMID: 29763176]|
|||Vannucci F,Araújo JA, Thoracic sympathectomy for hyperhidrosis: from surgical indications to clinical results. Journal of thoracic disease. 2017 Apr; [PubMed PMID: 28446983]|
|||Thune TH,Ladegaard L,Licht PB, Thoracoscopic sympathectomy for Raynaud's phenomenon--a long term follow-up study. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2006 Aug; [PubMed PMID: 16564187]|
|||Mubarik A,Aeddula NR, Cancer, Chromaffin Cell (Pheochromocytoma) 2019 Jan; [PubMed PMID: 30570981]|
|||Halls JE,Patel DV,Walkden M,Patel U, Priapism: pathophysiology and the role of the radiologist. The British journal of radiology. 2012 Nov; [PubMed PMID: 22960245]|
|||Alwaal A,Breyer BN,Lue TF, Normal male sexual function: emphasis on orgasm and ejaculation. Fertility and sterility. 2015 Nov; [PubMed PMID: 26385403]|
|||Freccero C,Svensson H,Bornmyr S,Wollmer P,Sundkvist G, Sympathetic and parasympathetic neuropathy are frequent in both type 1 and type 2 diabetic patients. Diabetes care. 2004 Dec; [PubMed PMID: 15562210]|
|||Verrotti A,Prezioso G,Scattoni R,Chiarelli F, Autonomic neuropathy in diabetes mellitus. Frontiers in endocrinology. 2014; [PubMed PMID: 25520703]|
|||Freeman R,Wieling W,Axelrod FB,Benditt DG,Benarroch E,Biaggioni I,Cheshire WP,Chelimsky T,Cortelli P,Gibbons CH,Goldstein DS,Hainsworth R,Hilz MJ,Jacob G,Kaufmann H,Jordan J,Lipsitz LA,Levine BD,Low PA,Mathias C,Raj SR,Robertson D,Sandroni P,Schatz I,Schondorff R,Stewart JM,van Dijk JG, Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clinical autonomic research : official journal of the Clinical Autonomic Research Society. 2011 Apr; [PubMed PMID: 21431947]|
|||Metzler M,Duerr S,Granata R,Krismer F,Robertson D,Wenning GK, Neurogenic orthostatic hypotension: pathophysiology, evaluation, and management. Journal of neurology. 2013 Sep; [PubMed PMID: 23180176]|