Stellate Ganglion Block

STELLATE GANGLION BLOCK

dr. Nur Surya Wirawan, Mkes, Sp.An-KMN

Miles Day MD, FIPP Evidence based medicine, Sympathetic Blocks 2008

Introduction

The sympathetic paravertebral ganglia form three groups:1 . Cervical ganglia,2. Thoracic and upper two, or three, lumbar ganglia, and3. Lower lumbar and all of the sacral ganglia The Cervical sympathetic nerve form cervical ganglion :Superior Middle The inferior cervical ganglion, located at the C7-8 level, fuses with the first thoracic ganglion to form the cervicothoracic ganglion (the stellate ganglion)

P. Prithvi Raj Pain Management Chapter 151

Preganglionic sympathetic fibers originate from cell bodies in the anterolateral column of the spinal cord. Nerves supplying the head and neck arise from the first and second thoracic spinal segmentsThe preganglionic axons leave the T1 and T2 ventral roots, pass through the white rami communicans, join the sympathetic chain, and ultimately synapse at the inferior (stellate), middle, or superior cervical ganglion .Stellate ganglion block is utilized in the diagnosis and management of various vascular disorders and sympathetically mediated pain in the upper extremity, head, and neck.

Axons of pre- and postganglionic sympathetic neurons leaving the ganglia form two sets of branches: the medial, mostly preganglionic, branches that innervate the viscera (via preaortic ganglia), and the lateral postganglionic branches that rejoin the spinal nerves and travel with them to the body wall where they innervate peripheral blood vessels, sweat glands, and arrectores pilorum muscles

The sympathetic nervous system (SNS) directly controls involuntary human homeostatic activities The involuntary system controls numerous body functions such as sweating, the functions of the intestines and internal organs, dilation and contracting of the pupils in the eye, and blood flow through various tissues and has a major role in neuropathic, vascular, and visceral pain

Sympathetically mediated pain occurs when the sympathetic component of the autonomic nervous system is dysfunctional The sympathetic block appears to interrupt and reset the dysfunctional autonomic nervous system, while the resulting analgesia also permits more aggressive rehabilitation

IndicationsUpper extremity CRPS Sympathetic pain of head and neck/ Phantom limb painAcute herpes zoster pain / Post herpetic neuralgiaPain secondary to neoplastic infiltration, Paget's disease.Arterial embolism/ Venous insufficiencyFrostbite

IndicationsUpper extremity CRPS Sympathetic pain of head and neck/Phantom limb painAcute herpes zoster pain / Post herpetic neuralgiaPain secondary to neoplastic infiltration, Paget's disease.Arterial embolism/ Venous insufficiencyFrostbite

IndicationsUpper extremity CRPS Sympathetic pain of head and neck/Phantom limb painAcute herpes zoster pain / Post herpetic neuralgiaPain secondary to neoplastic infiltration, Paget's disease.Arterial embolism/ Venous insufficiencyFrostbite

IndicationsUpper extremity CRPS Sympathetic pain of head and neck/Phantom limb painAcute herpes zoster pain / Post herpetic neuralgiaPain secondary to neoplastic infiltration, Paget's disease.Arterial embolism/ Venous insufficiencyFrostbite

IndicationsUpper extremity CRPS Sympathetic pain of head and neck/Phantom limb painAcute herpes zoster pain / Post herpetic neuralgiaPain secondary to neoplastic infiltration, Paget's disease.Arterial embolism/ Venous insufficiencyFrostbite

IndicationsUpper extremity CRPS Sympathetic pain of head and neck/Phantom limb painAcute herpes zoster pain / Post herpetic neuralgiaPain secondary to neoplastic infiltration, Paget's disease.Arterial embolism/ Venous insufficiencyFrostbite

contraindicationsAnti-coagulant therapy, coagulopathyPatients refusal to give consent Recent MIHeart BlockGlaucoma

Preblock ProcedurePatient must have normal clotting values and give written informed consent.Intravenous access should be ensured and emergency resuscitation kit should be kept ready.Patient is monitored with electrocardiography, pulse-oximetry, and blood pressure throughout the procedure. The skin temperatures are recorded in the distal portion of both the upper extremities in mirror-image locations.

Technique

Position of patient:- supine with the neck extended,

TechniqueCONVENTIONAL TECHNIQUEThe patient is placed in the supine position The neck slightly extended The head is keep straight and the mouth slightly open.

The point of needle puncture is located between the trachea and the carotid sheath at the level of the cricoid cartilage and Chassaignac's tubercle.

Cutaneous anaesthesia is obtained with a skin wheal of local anaesthetic.

Conventional TechniqueAlthough the ganglion lies at the level of the C7 vertebral body, the needle is inserted at the level of C6 to avoid piercing the pleura. Chassaignac's tubercle , This is the anterior tubercle of the transverse process of the sixth cervical vertebra, which lies lateral to and at a slightly higher level than the posterior tubercle

Conventional techniqueThe sternocleidomastoid and carotid artery are retracted laterally as the index and middle fingers palpate Chassaignac's tubercle. The skin and subcutaneous tissue are pressed firmly onto the tubercle to reduce the distance between the skin surface and bone, and in an attempt to push the dome of the lung out of the path of the needle. When properly performed, this manoeuvre is uncomfortable for the patient.

Conventional TechniqueThe needle is directed onto the tubercle, and then redirected medially and inferiorly toward the body of C6. After the body is contacted, the needle is withdrawn 1-2 mm. This brings the needle out of the belly of the longus colli muscle, which sits posterior to the ganglion and runs along the anterolateral surface of the cervical vertebral bodies. The needle is then held immobile.

Conventional TechniqueA 10 ml control syringe charged with local anaesthetic is attached to the needle and aspiration is performed to rule out intravascular placement. A 0.5 ml test dose is performed to rule out intra arterial injection into the vertebral artery. Seizures can occur immediately, even with very small volumes of local anaesthetic into vertebral artery.The remainder of the anaesthetic (5-10 ml) is injected in with intermittent aspiration. The patient is placed in the head up 30 degree after injection to facilitate the spread of anaesthesia inferiorly to the stellate ganglion.

With image guidance: Anterior paratrecheal approach at C6 level Anterior paratrecheal approach at C7 level Either USG GUIDED or FLUOROSCOPIC GUIDED or CT GUIDED

Image guided anterior paratracheal approachesUSG guidedAfter aseptic preparation of the skin, the transducer is placed on the neck to enable cross sectional visualization of anatomical structures. The carotid artery, internal jugular vein, thyroid gland, trachea, esophagus (if left SGB was performed), longus colli covered with the prevertebral fascia, root of C6, and transverse process of C6 are all visualized. The transducer was then gently pressed between the carotid artery and trachea to retract the carotid artery laterally and to position the transducer close to the longus colli (Fig. 1).

Figure 1.Ultrasound image of the left neck at the level of C6 before stellate ganglion block. CA, carotid artery; C6, root of C6; LC, longus colli muscle; TP, transverse process of C6; TH, thyroid gland; ES, esophagus

A 1.0-inch, 25-gauge long-bevel needle is paratracheally inserted toward the middle of the longus colli, while staying within the ultrasound beam plane. The endpoint for injection was the ultrasound image demonstrating the tip of needle upto the prevertebral fascia in the longus colli. After negative aspiration, blocking agent is injected. The injection and spread (including longitudinal spread) of agent were visualized in real time (Fig. 2). The needle is withdrawn, and pressure is held for 5-10 minutes.

Figure 2.Ultrasound image during C6- stellate ganglion block injection at the prevertebral fasica in the longus colli muscle; white arrow indicates the preve rtebral fascia distended with blocking agent. CA, carotid artery; C6, root of C6; LC, longus colli muscle; TP, transverse process of C6; TH, thyroid gland; ES, esophagus; LA, local anesthetic.

Fluoroscopic guided techniqueWith the patient in the supine position, the C6, C7 vertebral body is identified under fluoroscopy. After the administration of local anestheisa, a 25-gauge spinal needle is directed in the anteroposterior (AP) plane toward the junction of the vertebral body and the ipsilateral transverse process (see image below). When bone is reached, the needle is aspirated, and a small amount of iodinated contrast material (eg, Omnipaque 180) is injected to rule out an intravascular or intraspinal needle tip placement.Once the needle has been positioned, blocking agent is slowly injected, and the patient is monitored for signs of a sympathetic block. The needle is with drawn, and pressure is held for 5-10 minutes.

Fig. Anteroposterior (AP) image demonstrates correct needle placement at the junction of the body and the transverse process of C6. Contrast material has been injected to document extravascular location of the needle tip.

Lateral

CT-guided technique By using CT scanning or CT fluoroscopy, the head of the first rib is identified, as well as the adjacent vertebral artery and vein. Under sterile conditions, the skin and needle track are anesthetized, and a 25-gauge spinal needle is maneuvered onto the head of the first rib, as close to the vertebral body as possible.The physician should take care to avoid the vertebral vessels (see image below).

Computed tomography fluoroscopic image shows the correct placement of a 25-gauge needle on the head of the first rib.

The needle tip should be placed on the cortex to minimize the likelihood of intravascular placement, and after negative aspiration a small amount of iodinated contrast material is injected to confirm an extravascular location of the needle tip (see image below).

Contrast material has been injected to confirm the extravascular location of the needle tip (same patient as in image above).

Once the needle is in place, a small amount of blocking agent is injected.The needle is withdrawn, and pressure is held for 5-10 minutes.

Expected result

Patients usually develop Horners syndrome,stuffynose and increased temperature(1.5`C) on the ipsilateral side of the block (face and upper extremity) within 5 minutes after the procedure.

Phenol(3%) Racz et al. had demonstrated longer duration of block than above , with mixture of 2.5ml Phenol(6%) + 2.5ml (0.5% Bupivacaine) + 80mg Depomedrol This regime had not shown any unwanted permanent side effect associated with use of other neurolytic agents.

Alcohol(25%)

3 ml Alcohol(50%) + 3ml (0.25% Bupivacaine) + 40mg Depomedrol.

Absolute alcohol 1 1.5 ml of absolute alcohol is indicated for permanent block but it produces permanent Horners syndrome also. So its use should be limited to patients with short life expectancy and where benefits of pain relief outweigh the disadvantage of Horners syndrome.

Complications

Misplaced needle

Haematoma from vascular traumaCarotid traumaInternal jugular vein traumaNeural injury(recurrent laryngeal nerve)Vagus injuryBrachial plexus roots injuryPulmonary injuryPneumothoraxHaemothoraxChylothorax (thoracic duct injury)Oesophageal perforation

Infection

Soft tissue (abscess)Neuraxial (meningitis)Osteitis

Spread of local anaesthetic

Intravascular injection:Carotid arteryVertebral arteryInternal jugular vein

Neuraxial/brachial plexus spread:Epidural blockIntrathecalBrachial plexus anaesthesia or injury (intraneural injection)

Local spread:Horseness (recurrent laryngeal nerve)Elevated hemidiaphragm (phrenic nerve)

SummaryStellate ganglion block is useful to denervate sympathetic component involved in upper limb,head and neck disease conditions.Careful evaluation of sympathetic involvement in disease process should be done before deciding to perform block.Blocking agent type, dose and subsequent blocks should be decided on the basis of response to primary block.After even successful stellate ganglion block patient should be monitored for side effects.