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Sono Guidede Stellate Ganglion

Alireza Moghtaderi,MD,FIPP
Physical Medicine and Rehabilitation Specialist
Fellow of Interventional Pain Practice

Block
Anatomy


The stellate ganglion refers to the ganglion formed by the fusion of the inferior cervical and the first thoracic ganglion as they meet anterior to the vertebral body of C7. It lies anterior to the prevertebral fasci and anterolateral to the longus colli muscle. Its alar fascial plane may communicate with the brachial plexus and the vertebral artery and it is in close proximity to the carotid sheath, phrenic nerve, and recurrent laryngeal nerve.

The stellate ganglion block can be performed in many ways. One of the most common ways to perform the stellate ganglion block is to perform it at the C6 level. Relatively large volumes (5-20ml) are injected 2mm superficial to the C6 tubercle. This is done to spread the solution downward to reach the stellate and upper thoracic ganglia. The stellate ganglion block can also be approached from at C7 with administration of a smaller volume; however, this approach increases the risk of vertebral artery injection and collapsed lung (pneumothorax). Another possible approach to this block is the posterior paravertebral approach. With this method the needle is walked off the upper thoracic lamina until correct needle placement is confirmed with fluoroscopy and contrast dye. Some physicians may also use ultra-sound guidance to decrease the chance of injury to vascular and soft tissue structures that are adjacent to the stellate ganglion.

You will be asked to lie down on your back with your neck slightly extended, your head rotated slightly to the side opposite of the block, with your mouth open. Your neck will be prepped and draped in a sterile manner before local anesthesia is administered at the point of entry of the needle into the skin. After your skin is anesthetized your physician will retract your sternocleidomastoid muscle and carotid artery as his or her index and middle fingers palpate your Chassignac’s tubercle. Your skin and
subcutaneous tissue will be pressed firmly onto the tubercle to reduce the distance between the skin surface and bone. This is done to reduce the chance of pneumothorax (collapsed lung) occurring. This may be mildly comfortable. Upon palpating these anatomical landmarks the needle is then advanced under fluoroscopy guidance until correct needle placement is obtained. Correct placement is also confirmed by administration of contrast dye. Once position is confirmed local anesthetic is administered.

A successful block is marked by profound pain relief and improved vascular flow to ipsilateral upper extremity. Local anesthetic is usually administered for diagnostic stellate ganglion block. For patients who have a documented response to administration of local anesthetic onto the stellate ganglion, a therapeutic block can be performed with administration of the neurolytic agent like phenol. Radioablation of the stellate ganglion is also another treatment modality for longer-lasting pain relief. Some patients may experience a constellation of symptoms known as Horner’s Syndrome (drooping of the upper eyelid, pupil constriction, and decreased sweating on the side that the block was preformed). This is normal and symptoms usually subside when the anesthetic wears of (usually ~4-6 hours after the block is preformed).

The procedure usually takes less than 15 minutes. Sometimes your physician will recommend intravenous sedation to make the procedure more comfortable. Your physician will monitor your pain and vital signs (pulse, blood pressure, temperature) after the procedure and place you in a sitting position to facilitate the spread of the anesthetic.


Benefit
Stellate ganglion block is a short, minimally invasive procedure that can effectively treat a wide array of conditions that have failed optimal medical management. These include providing relief for sympathetic-related pain in face, chest, and upper extremities, improving circulation in upper extremities and face, decreasing perspiration in upper extremities and face, decreasing hot flashes and associated sleep disturbances, and showing promise as a novel treatment for PTSD.


Risk

The risks for the procedure are typically low, but can include misplacement of the needle resulting in: bleeding, nerve injury, pneumothorax (collapsed lung), or esophageal perforation. Risks secondary to the spread of the anesthetic include: drug allergy, seizure (if the medication is injected into a blood vessel), brachial plexus block (numb arm on side of block that lasts as long as the life of the anesthetic injected), spinal or epidural block (transient weakness and/or numbness from neck down as long as the life of the anesthetic injected), hoarseness (from anesthetizing recurrent laryngeal nerve), and shortness of breath (from anesthetizing phrenic nerve). Lastly with any penetration of skin and soft tissues the risk of infection always exists. The most common side-effects related to the procedure are drooping of the upper eyelid, pupil constriction, and decreased sweating on the side that the block as well as voice becoming more hoarse. These side effects usually subside after the anesthetic wears off.


Ultrasound Technique:
at the level of c6 transverse process (bones not well visualized in this image), slowly scan the neck from medial to lateral in a transverse view
Using an in plane approach, insert a (preferably blunt) 21 g needle from lateral to medial. Be sure to avoid the brachial plexus (near the inter scalene location -usually anterior to the needle, and the exiting cervical nerve roots (usually hypoechoic). Your needle will wind up anterior to the longus colli muscle, and posterior to the carotid artery
Bupivicaine 0.25% 3ml, lidocaine 2% 2ml, +/- depomedrol/kenalog 40-80mg


Contraindication:
Anticoagulation therapy, pneumothorax (and pneumonectomy on contralateral side, recent cardiac infarction because the stallate ganglion cuts off the cardiac sympathetic fibers (accelerator nerves)
Glaucoma is a relative contraindication (provocation of glaucoma by repeated stellate ganglion block has been reported)
Caution with atrioventricular block and impairment of cardiac stimulus conduction as well.


Outcomes
After the block is preformed one of three things may occur:
1. Your pain is gone or greatly improved and stays that way for longer than the life of the anesthetic. This shows your physician that the block has therapeutic value for you and he or she can come up with a treatment plan that maximizes your pain control
2. Your pain is unchanged but, there is evidence of a sympathetic blockade. This is of diagnostic value to your physician and tells him or her that your pain is not responsive to a sympathetic block and he or she can try other treatment modalities to treat your pain.
3. Your pain is unchanged but there is no evidence of a sympathetic blockade. This indicates that the block was a technical failure.


Stellate ganglion blocks are a well-established treatment modality for providing relief from sympathetically-maintained pain syndromes; however, their utility does not end there. In conditions where there is decreased blood flow to the upper extremities, from causes such as arterial insufficiency, Raynaud’s phenomena and/or scleraderma, the stellate ganglion block has been documented to significantly increase blood flow, decrease the number of Raynaud attacks and ultimately provide symptom improvement. Another therapeutic indication is intractable angina for patients where maximal medical and surgical intervention (including optimal revascularization) have failed to provide pain relief. The stellate ganglion block can provide these patients relief as they cope with their advanced cardiovascular disease.

A recent study, suggests that the stellate-ganglion block, with minimal if any side effects, can provide relief from hot flushes and associated sleep dysfunction in breast cancer survivors. This study highlights that the long-term relief of symptoms obtained from the stellate ganglion block has the potential to not only improve quality of life, but also compliance with the anti-estrogen medications. These same authors have also found that some success can be achieved with treatment of PTSD with the stellate ganglion block as well. The benefits of stellate ganglion block can be temporary for some people and the amount and duration of pain relief vary from person to person. Some tend to have relief for weeks where others can benefit from the block for years. Fortunately, the procedure is a low risk, nonsurgical treatment that if successful the first time, will most likely continue to provide pain relief with repeat treatments.


آدرس مطب : اصفهان خیابان شمس آبادی چهارراه قصر ساختمان قصر نور واحد 305
تلفن : 32240068 - 031

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