Causalgia, the post-traumatic pain syndrome remains one of the most poorly understood and frequently misdiagnosed entities encountered in clinical practice. Ablation of the upper thoracic sympathetic trunk has been used for over a century with variable success for a variety of conditions. Endoscopic transthoracic techniques of ablation of the sympathetic trunk have the advantage of a minimally invasive approach with excellent visualization of the sympathetic trunk and rapid postoperative recovery. We discuss a case of causalgia in a 35 years old man with 15 years duration of symptoms (stage 2 Drucker) in whom nonoperative therapy has consisted of drug therapy (phenytion, amitriptyline, carbamazepine, beclofen, ibuprofen and diclofenac Na), intermittent sympathetic blocks and physiotherapy failed, but full degree of pain relief was achieved by thoracic T2-T3 sympathectomy endoscopically without any major complication. Endoscopic transthoracic techniques for sympathectomy are a major technical advance in the management of causalgia and pancreatic pain. The operation is safe, effective and well tolerated and leads to a high level of patient satisfaction. Further applications of this technique are inevitable and are likely to replace conventional open procedures.