Sympathetic Ganglion Blockade for Extremities Stellate Ganglion Block

Indications

The stellate ganglion block is utilized for the diagnosis and treatment of complex regional pain syndromes of the upper extremity. The block may be utilized as well in clinical situations where increased upper extremity blood flow is warranted. The block can be effective for pain in the head and neck, upper extremity, and upper thoracic dermatomes. Clinically, the most common indications in the upper extremity include chronic regional pain syndrome, malignancy, and vascular insufficiency and hyperhydrosis.

Anatomy

The stellate ganglion is the most caudal sympathetic ganglion affecting the head and neck. It is also one of the more cephalad ganglion affecting the upper limb. It is formed by the fusion of the inferior cervical ganglion (C7) and the first thoracic ganglion (T1) and star shaped, yielding its name. It is located in the anterior part of the neck, and the classic block is performed from anterior directed toward the lateral process of C6, "Chassignac's" tubercle, on the affected side.

Technique

Stellate Ganglion Block: Anterior Approach

Although the ganglion is located caudal to the C6, this anterior approach provides a higher level of safety. The important vascular structures are retracted laterally as a 22-gauge 1.5-in. needle is advanced to the tubercle. After contact with bone, it is withdrawn slightly and aspirated and then a test dose of the LA is given. If there are no untoward effects after a minute the remaining LA is injected slowly with frequent aspiration checks. The patient is brought to a 30° head-up position after the injection block to increase caudal migration of the local anesthetic.

Stellate Ganglion Block: Posterior Approach

The posterior approach to the stellate ganglion is performed with the patient in the prone position. The block is approached lateral to the spinous process of the T1-T2 vertebrae. A 22-gauge 10-cm needle is inserted 4 cm lateral to the spinous process of T1-T2. The lamina of the vertebra is contacted after which the needle is slightly withdrawn and redirected laterally and inferiorly to be adjacent to the anterolateral aspect of the vertebral body; then, 5-7 cc of local anesthetic solution is injected. If there is an inflammatory component, then a total of 80 mg of depot steroid can be used for the initial block, followed by 40 mg of depot steroid for successive blocks.

Stellate Ganglion Block: Vertebral Body Approach

With this approach, the patient is placed in the supine position with the cervical spine placed in a neutral position. The point of injection of the local anesthetic is at the junction of the transverse process of C7 and the vertebral body medial to the carotid pulsations. This procedure is done with a 22-gauge 3.5-in. spinal needle. Neurolysis of the stellate ganglion can also be performed with 6.5% phenol or alcohol.

Skin temperature in the blocked extremity should elevate a few degrees due to vasodilatation. Horner's syndrome and recurrent laryngeal nerve paralysis and hoarseness are common side effects. It should be noted that pneumothorax is the most common complication with a stellate ganglion block done with a posterior approach.

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