Stellate Ganglion Block

Dr. Jay M. Panchaldrjaypanchal@gmail.com

IntroductionStellate ganglion block is utilized in the

diagnosis and management of various vascular disorders and sympathetically mediated pain in the upper extremity, head, and neck. Physicians per form this procedure with or without the aid of fluoroscopy.

IndicationPain syndromes

Complex regional pain syndrome type I and II  Refractory angina  Phantom limb pain  Post herpatic neuralgia Post radiation neuritis Herpes zoster Shoulder/hand syndrome Angina

Vascular insufficiency

Raynaud's syndrome Scleroderma Frostbite Obliterative vascular disease Vasospasm Trauma Emboli 

Accidental intra arterial injection Menier’s syndrome associated with vascular disease

  It has also been in dicated as immediate therapy for

pulmo nary embolus , hyperhidrosis of upper limb.

ContraindicationAbsolute contraindication patient refusal, local infection, allergic reaction to lo cal anesthetics, and primary and second ary coagulopathy. Relative contraindication

Recent cardiac infarc tion or a severe cardiac conduction block- to prevent possible deterioration of car diac function.

  Glaucoma- Repeated stellate ganglion blocks have been reported

to aggravate it. 

Anatomy

The stellate ganglion refers to the ganglion formed by the fusion of the inferior cervical and the first thoracic ganglion . It is present in 80% of subjects.It measures approximately 2.5 cm long, 1 cm wide, and 0.5 cm thick(anteroposterior diameter).

It is usually located posteriorly in the chest in front of the neck of the first rib and may extend to the seventh cervical (C7) vertebral bodies . If the inferior cervical ganglion and first thoracic ganglion are not fused, the inferior cervical ganglion lies in front of the C7 tubercle, and the first thoracic ganglion rests over the neck of the first rib.

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, and against which the carotid artery may be compressed by the finger. 

Relations of stellate ganglionAnterior The structures anterior to the ganglion include the skin and subcutaneous tissue, the sternocleidomastoid muscle ,vertebral artery and the carotid sheath. The dome of the lung lies anterior and inferior to the ganglion.

MedialThe vertebral body of C7, oesophagus and thoracic duct lie medially. 

Posterior Structures posterior to the ganglion  include the prevertebral fascia, longus colli muscle, brachial plexus sheath and neck of the first rib. 

LateralScalene muscle

Preganglionic sympathetic fibers originate from cell bodies in the antero lateral column of the spinal cord. Nerves supplying the head and neck arise from the first and second thoracic spinal seg ments. Fibers destined to the upper ex tremities are traceable from the second through the ninth thoracic segments (T2–T9).

The preganglionic axons leave the T1 and T2 ventral roots, pass through the white rami communicans, join the sym pathetic chain, and ultimately synapse at the inferior (stellate), middle, or superior cervical ganglion .

Postganglionic sympathetic fibers from stellate ganglion pass the gray rami and join C6,C7,C8 and T1 nerevs in most cases.Most of the sympathetic fibers for the head and neck travel along the common and then internal or external carotid artery. Some of the fibers, however, leave the stellate ganglion, form the vertebral plexus, and innervate cranial structures supplied by the vertebral plexus.

Preblock ProcedurePatient must have normal clotting values and give written

informed consent. For the clinical evaluation of sympathetic component involvement

in patient’s disease process,patient should be assessed by increment in pain on cooling the local area for about 1.5-2 ‘C.

  Intravenous access should be ensured and emergency

resuscitation kit should be kept ready. Patient is monitored with electrocardi ography, pulse-oximetry, and

blood pres sure throughout the procedure. The skin temperatures are recorded in the distal portion of both the upper extremities in mirror-image locations.

TechniquePosition of patient:- supine with the neck extended, the head rotated to the side opposite the block.

Without image guidance: Anterior paratrecheal approach at C6 level Anterior paratrecheal approach at C7 level

Anterior paratrecheal approach at C6 level: point of needle puncture:- 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.  The trachea and carotid pulse are gentely retracted to allow identification of the most prominent cervical transeverse process (chassaignac tubercle) at C6 ,the level of cricoid cartilage. the carotid sheath is moved laterally, and the trachea medially, before a 25-30mm 23-25 G needle is directed anteroposteriorly perpendicularly down on to the tubercle. once it has encountered bone , needle is with drawn 2-3 mm .if this is not done there is high incidence of upper limb somatic blockade. blocking agent in 10-12 ml volume is injected after negative aspiration test.

Anterior paratrecheal approach at C7 level:point of needle puncture:- between the trachea and the carotid

sheath at the level of two fingerbredths lateral to the suprasternal notch and two fingerbredths superior to the clavicle 

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

the needle insertion is two fingerbredths lateral to the suprasternal notch and two fingerbredths superior to the clavicle.this identifies the transverse process of C7 , immediately below chassaignac tubercle at C6.

the sternocledomastoid and carotid sheath are moved laterally before needle is directed anteroposteriorly perpendicularly down onto transeverse process.

once it has encountered bone the needle is withdrown 3-4 mm.Blocking agent in 10-12 ml volume is injected after negative

aspiration test.this approach to the ganglion’s actual location at C7 risks both

pneumothorax and vertebral artery puncture.

With image guidance: Anterior paratrecheal approach at C6 level Anterior paratrecheal approach at C7 level Lateral/anterolateral trans scalenic

approach

Either USG GUIDED or FLUOROSCOPIC GUIDED or CT GUIDED

Image guided anterior paratracheal approachesUSG guided After 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 technique With 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.

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.

Image guided lateral/anterolateral trans scalenic approach

Fluoroscopic Lateral/anterolateral trans scalenic approach

The fluoroscopy beam is directed in an anteroposterior direction until the C5–C6 disc is well visualized(Fig. A).

Figure A A) The C-arm is in the anterio-posterior position with caudal angula

tion to optimize disc view with flattened endplates.

This usually requires caudocranial angulations of the C-arm. The C-arm is then rotated obliquely, ipsilateral to the side where blockade is desired. The rota tion must occur to allow adequate visu alization of the neural foramina ( Fig. B & C).

Figure B Figure CB) The C-arm is rotated in an oblique C)Final needle placement

at the base C7manner until the neural foramina are seen uncinate process of left

side

A skin wheal is raised at the surface point where the junction of the uncinate process and the vertebral body of C 7 is seen on the fluoroscope. Under real-time imaging, a single pass is made with a 25-gauge spinal needle to contact bone at this point. Care should be exercised to avoid passage of the nee dle toward the neural foramina and the thecal sac, which is exposed posteriorly; the disc located cephalad; and the esoph agus, which resides medial to the ultimate target point. In its final position, the nee dle tip comes to rest at the junction be tween the uncinate process and the verte bral body of C 7 (Fig. D).

Figure D D) Stellate Ganglion

Block - final position, with contrast injection

The stylet is removed, the extension set is attached, and 1 to 2 ml of radio-opaque contrast is injected to vi sualize the longus colli muscle.

The syringe containing the contrast is ex changed with the one that contains the lo cal anesthetic. After ensuring that nega tive aspiration is performed, a 0.5-mL test dose is injected to rule out intravascu lar injection into the vertebral artery.

The value of this test dose in providing early warning if intra-arterial injection is ques tionable, as seizures can occur immediate ly, even with very small volumes of local anesthetic.

This is followed by slow injec tion of blocking agent onto the ganglion. Three to six-eight milliliters of blocking agent usually is adequate for caudal spread to at least the first thorac ic segment.

Meaningful verbal contact should be maintained, and the patient should be urged to respond verbally without mov ing the head-neck so as to allow recogni tion of any adverse reaction should it oc cur. Concomitant hemodynamic moni toring is crucial as well.

If stable in the recovery area for 30 to 60 minutes and tolerating clear liq uids without aspiration, the patient is discharged home with an escort.

 USG guided and CT guided Lateral/anterolateral trans scalenic

approach is performed in the same way.

Advantages of Lateral/anterolateral trans scalenic approach over Anterior paratrecheal approaches

Eliminates pressing or pushing the vascular system out of the way

Eliminates pressing on the Chassaignac tubercle, which can be uncomfortable and even painful to patients

Minimizes the chance of intravascular injectionMinimizes the chance of esophageal perforation Minimizes the chance of recurrent laryngeal nerve paralysis Reduces the volume of blocking agent needed to cover lower

cervical through upper thoracic areas Most important, can easily be learned by traineesThe experience obtained in this technique suggests that in

addition to efficacy, the technique is safe but also eas ily learned.

 However, theoretically, in the individual with emphysematous

bullous pleura, an oblique C7 insertion to the base of the un cinate process can lead to a pneumotho rax.

Expected result

Patients usually develop Horner’s 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.

Blocking agents used

Local anaesthetic agents like Lignocaine(1%) in volume of 10 -12 ml by anterior paratracheal

approach 6-8 ml by Lateral/anterolateral trans

scalenic approach  Bupivacaine(0.25%) in volume of 10 -12 ml by anterior

paratracheal approach 6-8 ml by Lateral/anterolateral trans

scalenic approach   Studies with Bupivacaine(0.25%) have shown its minimum duration

of action for 6 hrs, but large inter individual variabilities have been observed regarding this duration of action.

  Other Local anaesthetic agents like ropivacaine ,mepivacaine can

also be used.

  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 Horner’s syndrome also. So its use should be limited to patients with short life expectancy and where benefits of pain relief outweigh the disadvantage of Horner’s syndrome.

Considering inter individual variabilities regarding response to various blocking agents,

It has been suggested that after evaluating the response to successful diagnostic block,

Temporary pain relief is obtained from repeated local anaesthetic sympathetic blocks or, neurolyic procedures should be considered.

Some patients may respond to series of 6 to 12 blocks.  Other blocking agents which can be used and/or under

studies are Fentanyl Ketamine Clonidine Steroids (like Depomedrol,Triamcinolone)

Complications Misplaced needle 

Haematoma from vascular trauma 

Carotid trauma Internal jugular vein trauma Neural injury (recurrent laryngeal nerve)Vagus injury Brachial plexus roots injury Pulmonary injury Pneumothorax Haemothorax Chylothorax (thoracic duct injury)Oesophageal perforation 

Infection 

Soft tissue (abscess) Neuraxial (meningitis) Osteitis

Spread of local anaesthetic

Intravascular injection:Carotid artery Vertebral artery Internal jugular vein 

Neuraxial/brachial plexus spread:Epidural blockIntrathecal Brachial 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. Lateral/Anterolateral Trans sclenic approach with image guidance

has higher success rate without significant permanent side effects due to precise location of Stellate ganglion 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.