Dr. Jay M.

Panchal
drjaypanchal@gmail.com

Introduction
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. Physicians perform this procedure with or without the aid of fluoroscopy.

Indication
Pain 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 Meniers syndrome associated with vascular disease

It has also been indicated as immediate therapy for pulmo-

nary embolus , hyperhidrosis of upper limb.

Contraindication
Absolute contraindication

patient refusal, local infection, allergic reaction to local anesthetics, and primary and secondary coagulopathy.
Relative contraindication

Recent cardiac infarction or a severe cardiac conduction block- to prevent possible deterioration of cardiac 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). 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.

It is usually located posteriorly in the chest

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 ganglion

Anterior 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. Medial The 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. Lateral Scalene muscle

 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 segments. Fibers destined to the upper extremities are traceable from the second through the ninth thoracic segments (T2T9). The 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 .

 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 Procedure
Patient must have normal clotting values and give written informed

consent.

For the clinical evaluation of sympathetic component involvement in

patients disease process,patient should be assessed by increment in pain on cooling the local area for about 1.5-2 C. should be kept ready.

Intravenous access should be ensured and emergency resuscitation kit 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 mirrorimage locations.

Technique
Position 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 ganglions 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 approaches USG 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 C6stellate 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 C5C6 disc is well visualized(Fig. A).

Figure A A) The C-arm is in the anterio-posterior position with caudal angulation 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 rotation must occur to allow adequate visualization of the neural foramina ( Fig. B & C).

Figure B B) The C-arm is rotated in an oblique manner until the neural foramina are seen

Figure C C)Final needle placement at the base C7 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 realtime 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 needle toward the neural foramina and the thecal sac, which is exposed posteriorly; the disc located cephalad; and the esophagus, which resides medial to the ultimate target point. In its final position, the needle tip comes to rest at the junction between the uncinate process and the vertebral 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 radioopaque contrast is injected to visualize the longus colli muscle. The syringe containing the contrast is exchanged with the one that contains the local anesthetic. After ensuring that negative aspiration is performed, a 0.5-mL test dose is injected to rule out intravascular injection into the vertebral artery. The value of this test dose in providing early warning if intra-arterial injection is questionable, as seizures can occur immediately, even with very small volumes of local anesthetic. This is followed by slow injection 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 thoracic segment. Meaningful verbal contact should be maintained, and the patient should be urged to respond verbally without moving the head-neck so as to allow recognition of any adverse reaction should it occur. Concomitant

hemodynamic monitoring is crucial as well. If stable in the recovery area for 30 to 60 minutes and tolerating clear liquids 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 injection Minimizes 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 trainees The experience obtained in this technique suggests that in addition to efficacy, the technique is safe but also easily learned.

However, theoretically, in the individual with emphysematous

bullous pleura, an oblique C7 insertion to the base of the uncinate process can lead to a pneumothorax.

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.

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 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.

 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 Spread of local anaesthetic Intravascular injection: Carotid artery Vertebral artery Internal jugular vein Neuraxial/brachial plexus spread: Epidural block Intrathecal Brachial plexus anaesthesia or injury (intraneural injection) Local spread: Horseness (recurrent laryngeal nerve) Elevated hemidiaphragm (phrenic nerve)

Soft tissue (abscess) Neuraxial (meningitis) Osteitis

Summary
Stellate ganglion block is useful to denervate sympathetic component

involved in upper limb,head and neck disease conditions. should be done before deciding to perform block.

Careful evaluation of sympathetic involvement in disease process 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 . the basis of response to primary block.

Blocking agent type, dose and subsequent blocks should be decided on After even successful stellate ganglion block patient should be

monitored for side effects.