Complications

Complications include pneumothorax, and intravascular and subarachnoid injection can be catastrophic complication (Figs. 13.12 and 13.13).

Figure 13.12 Sagittal cervical spine showing sympathetic nerves and ganglia.

RF lesioning of the stellate ganglion block can be performed via the anterior approach. The junction of the C7 transverse process with the vertebral body is identified with fluoroscopic guidance. A 54-cm RF 20-gauge needle with a 4 mm active tip is inserted at this junction. After bony contact is made, the needle is withdrawn slightly and 3-5 cc of the mixture of local anesthetic and contrast medium is injected. First a trial stimulation of 50 Hz and 0.9 V for sensory nerves and a stimulation of 2 Hz and 2 V for motor nerves is done to ensure that the recurrent laryngeal nerves and the phrenic nerves would not be affected by the RF lesioning. The RF lesioning is performed by heating at 80° C for 60 s or by pulsed radiofre-quency at 45 or 50°C for a longer period of time. Second lesioning at the medial aspect of the

Figure 13.12 Sagittal cervical spine showing sympathetic nerves and ganglia.

— Right common carotid artery

— Vertebral artery

— Cervicothoracic (stellate) ganglion

Figure 13.13 AP fluoroscopic image of a right stellate ganglion block with contrast dye.

transverse process and a third lesioning at the uppermost junction of the C7 transverse process and vertebral body may be performed if there is no stimulation of the motor and sensory nerves.

Lumbar Sympathetic Ganglion Block and Radiofrequency Lumbar Sympathetic Blocks

Indications

The stellate ganglion block is utilized for the diagnosis and treatment of complex regional pain syndromes of the lower extremity. The block may be utilized as well in clinical situations where increased lower extremity blood flow is warranted.

Anatomy

The lumbar plexus conducts the sympathetic innervation to the lower extremity. It encompasses the first three lumbar sympathetic ganglia. Fusion of the first and the second lumbar ganglia can be seen in many patients. The sympathetic chains run along the anterior portion of the vertebral bodies and are blocked from a posterior approach at L2 or L3 with diffusion cephalocaudad along the anterior portion of the vertebral bodies and the sympathetic chains.

Technique

A 22-gauge spinal needle is guided almost to the anterior line of the vertebral body, closely approximated to the vertebrae, aspirated, then a test dose given as above. The indications

Figure 13.14 Lumbar sympathetic block lateral and AP. Note the two patterns of spread on the AP. The more lateral column of dye is along the psoas muscle. The needle is advanced slightly, and the proper dye spread is observed closer to the vertebral body.

for the lower extremity are similar to those in the upper extremity. Complications include intravascular injection and viscus perforation (Fig. 13.14).

Radiofrequency Lesioning of the Lumbar Sympathetic Ganglion

Radiofrequency lesioning of the lumbar sympathetic ganglion is performed with the patient in the prone position. The spinous process of the vertebra just above the nerve to be blocked is identified, and a 150-mm 20-gauge radiofrequency needle with a 10 mm active tip is inserted in a sterile fashion at this point and advanced at a 35-40° angle to the skin. At a depth of about 2 in., the lateral portion of the L2 vertebral body is usually encountered, after which the needle is walked off the lateral portion of the L2 vertebral body. The needle is then advanced approximately 1/2 in. deeper to the anterior-lateral aspect of the vertebral body. The position of the needle is checked with contrast medium. After negative aspiration of CSF or blood, a trial stimulation at 50 Hz and 1 V is performed. The pain encountered should be localized to the lower back. If the pain is in the groin or in the lower extremity, the needle should be repositioned. Motor stimulation is then performed. If it is negative at 2 Hz and 3 V trial, a lesion is created for 60 s at 80° C.

Visceral Nerve Blockade Indications

There are a number of blocks that can be performed for visceral pain syndromes of the abdomen. These include the celiac plexus block, the hypogastric plexus block, and the ganglion impair block. There are a number of intraabdominal pain states that can be treated, including malignancy.

Celiac Plexus Block Anatomy

The celiac plexus is located at T12-L1. It receives sympathetic fibers from the greater, lesser, and least splanchnic nerves. The visceral afferents from the liver, pancreas, gall bladder, stomach, esophagus, spleen, kidneys, intestines, adrenals, and associated vasculature course through this plexus. Indications include pain secondary to malignancy and other chronic processes in one of the above structures.

Technique

There are several commonly used approaches performed in the prone position using fluoroscopy: retrocrural, transcrural, periaortic, and transaortic. Transabdominal approaches directed by computed tomography (CT) as well as a transgastric approach via upper endoscopy are other approaches to deliver analgesic and neurolytic medications to the plexus. The block is performed with the patient in the prone position (Fig. 13.15). Two 20-gauge, 13-cm styletted needles are inserted bilaterally to block both of the celiac ganglia, but on some occasions good spread to both sides is achieved with just using one needle. The needle entry point is just below the tip of the 12th rib, and with the help of fluoroscopic guidance, the needle is advanced until it hits the side of the L1 vertebra. The needle is withdrawn slightly and then redirected forward until it is in the area of the celiac plexus, avoiding the aorta and inferior vena cava. Radio-opaque dye is injected to confirm the correct placement of the needle, and then the appropriate mixture is injected. For a diagnostic block, 10-15 ml of 1% lidocaine or 3% 2-chloroprocaine is used on each side. For a therapeutic block, 10-15 ml of 0.5% bupi-vacaine is administered on each side and 10-12 ml of either absolute alcohol or 6.0% aqueous phenol is injected on each side for a neurolytic block.

Figure 13.15 Classic two-needle retrocrural technique.

Complications

Since the block causes dilatation of the upper abdominal vessels, venous pooling can occur, leading to hypotension. Since this can be exacerbated by preexisting dehydration, adequate intravenous hydration is needed before performing the block. Diarrhea is another common side effect. Other complications include bleeding due to aorta or inferior vena cava injury by

Kidney Diaphragm Retrocrural space Inf. vena cava Liver

Figure 13.15 Classic two-needle retrocrural technique.

Kidney Diaphragm Retrocrural space Inf. vena cava Liver

Celiac ganglia Abdominal aorta the needle, paraplegia from injecting phenol into the arteries that supply the spinal cord, sexual dysfunction (injected solution spreads to the sympathetic chain bilaterally), and lumbar nerve root irritation (injected solution tracks backward toward the lumbar plexus).

Hypogastric Plexus Block Indication

The hypogastric plexus block can be utilized for numerous lower abdominal pain states.

Located in the retroperitoneal space between the lower third of the fifth lumbar and the upper third of the first sacral vertebrae. It provides the sympathetic innervation to the pelvic organs such as the bladder, uterus, vagina, prostate, and rectum, as well as conducts nociceptive fibers. Pain arising from malignancy, postsurgical conditions, and chronic pelvic pain secondary to gynecologic or intestinal pathology can be effectively treated by this block (Fig. 13.16).

Technique

The block procedure is very similar in each of the targets mentioned above. A spinal needle is fluoroscopically guided to the desired anatomic location, and the position of the tip is further

Anatomy

Right greater and le; splanchnic ne

Left sympathetic trui

Left aorticorenal ganglia

Right common ili. artery and plexi

Right greater and le; splanchnic ne

Left sympathetic trui

Left aorticorenal ganglia

Right common ili. artery and plexi

Figure 13.16 Abdominal sympathetic nerves and ganglia.

Inferior mesenteric ganglion

Left common iliac artery and plexus

Superior hypogastric plexus

Intermesenteric plexus

Vagal trunks Celiac ganglia Left lesser splanchnic nerve Superior mesenteric ganglia and plexus Left aorticorenal ganglia

Figure 13.16 Abdominal sympathetic nerves and ganglia.

defined with the use of contrast material. The injectate may consist of local anesthetic for trial procedures or alcohol or phenol for neurolysis (de Leon-Casasola 2000).

Ganglion Impar Block Indication

The ganglion impar block can be utilized for perineal pain, most likely arising from the vagina and the rectum, including malignancy.

Anatomy

The ganglion impar is a solitary structure at the end of the sympathetic chains in the pelvis. It is just anterior to the sacrococcygeal junction. Visceral afferents from perineum, distal rectum, anus, distal urethra, distal 1/3 of vagina, and the vulva may project to the ganglion. Blocking it can be very effective for perineal pain secondary to pathology in one of the above structures. It is commonly blocked for pain from rectal cancer. It may be approached from beneath the tip of the coccyx, from the side of the sacrococcygeal junction, or transcoccygeal with a spinal needle under fluoroscopy (Fig. 13.17).

Figure 13.17 Fluoroscopic image of a ganglion impar block from the lateral approach at the sacrococcygeal junction.

Complications

A particular risk of the ganglion impar injection is perforation of the rectum and infection.

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