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Year : 2011  |  Volume : 55  |  Issue : 1  |  Page : 52-56  

Revalidation of a modified and safe approach of stellate ganglion block

Senior Consultant and HOD, Anaesthesia, Tata Motors Hospital, Jamshedpur, Jharkhand, India

Date of Web Publication9-Feb-2011

Correspondence Address:
Ashok Jadon
Duplex - 63, Vijaya Heritage, Phase-6, Uliyan, Kadma, Jamshedpur
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5049.76601

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Stellate ganglion block (SGB) is very effective in management of chronic regional pain syndrome (CRPS-1). However, serious complication may occur due to accidental intravascular (intra-arterial) injection of local anaesthetic agents. Abdi and others, has suggested a modified technique in which fluoroscopy-guided block is given at the junction of uncinate process and body of vertebra at C7 level. In this approach vascular structures remain away from the trajectory of needle and thus avoid accidental vascular injection. We have used this technique of SGB in nine patients who were treated for CRPS-I. The blocks were effective in all the patients all the time without any vascular or other serious complication.

Keywords: CRPS-I, modified technique, stellate ganglion block

How to cite this article:
Jadon A. Revalidation of a modified and safe approach of stellate ganglion block. Indian J Anaesth 2011;55:52-6

How to cite this URL:
Jadon A. Revalidation of a modified and safe approach of stellate ganglion block. Indian J Anaesth [serial online] 2011 [cited 2020 Dec 2];55:52-6. Available from: https://www.ijaweb.org/text.asp?2011/55/1/52/76601

   Introduction Top

Stellate ganglion block (SGB) is an effective technique to manage patients of chronic regional pain syndromes type 1 (CRPS-1). [1],[2] Previously anterior paratracheal technique [3] was the standard technique to block stellate ganglion (SG). But this technique may result in number of serious, some time life-threatening complications for e.g., subarachnoid or epidural injection, recurrent laryngeal nerve block, seizures, blindness, locked-in syndrome. [4],[5] Although various new techniques like computerized tomography, magnetic resonance imaging and radionuclide tracers have been suggested to facilitate SGB, it is difficult to use these techniques in routine clinical practice. Fluoroscopic-guided block which is easy to use and also provide safety is now the practical and appropriate choice for SGB. [6]

The SGB is most commonly done at C6 level as this level provides well defined landmarks and relative safety against inadvertent intravascular injection. However, blockade of SG at C6 may result in failure or unsuccessful block as there is always a possibility that sympathetic supply of upper limb may not be completely blocked. Studies have suggested that for complete block of sympathetic supply of upper limb it is necessary to give injection at C7. Moreover thermographical assessments of the sympathetic blockade by SG have shown that C7-SGB is more effective than C6-SGB. [6],[7] But as the C7 vertebra has no anterior tubercle and palpation is difficult, injury to the pleura and to the vertebral artery is common especially with the blind technique. Therefore newer and safer techniques have been suggested. [8]

Abdi and others [8] described an oblique fluoroscopic approach targeting the junction between the uncinate process and the vertebral body at the C7 level to block SG effectively and avoiding vascular injury. To revalidate the safety and efficacy of this fluoroscopic-guided technique of SGB we used this technique in 19 blocks given in nine patients who were treated for upper limb CRPS-1.

   Methods Top

Nine patients (male=2, female=7) of age 43.3±13.6 yrs (22-62yrs) were given SGB to manage symptoms of CRPS-1 [Table 1]. All the patients after confirmed diagnosis were initially managed by orthopaedic departments and received treatment with analgesics, anti-inflammatory medicine and physiotherapy for 2-4 months. After clinical physical examination and review of investigation informed consent was obtained. All the procedures were done in afternoon and patients were allowed to have breakfast in morning and water till 2 hrs before procedure.
Table 1: Patient's age, sex, parts affected, duration of symptoms, number of blocks and complications during individual block

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We used the similar technique as advised by Abdi and others. [8] Intravenous line with 20-G IV canulae was secured. SGB was performed with the patient in the supine position with the neck slight­ly extended (a pillow may be placed be­neath the shoulders), and the head rotated slightly to the opposite side to be blocked [Figure 1]a. Patients were monitored (pulse-oximeter and blood pres­sure) by multipara monitor (Infinity Vista XL, USA). The skin temperatures were recorded in the distal portion of both the upper extremities in mirror-image locations [Table 2]. The fluoroscopy beam was directed in an anteroposterior direction with caudocra­nial angulations of the C-arm. The C-arm is then rotated obliquely, to the side where blockade is desired [Figure 1]b. The rota­tion must occur to allow adequate visu­alization of the neural foramina [Figure 1]c. A skin wheal was raised at the surface point where the junction of the uncinate process and the vertebral body is seen on the fluoroscope [Figure 1]c. Under real-time imaging, a single pass is made with a 25-G spinal needle to contact bone at this point. In its final position, the nee­dle tip comes to rest at the junction be­tween the uncinate process and the verte­bral body [Figure 2]a. The stylet is removed, the extension set is attached and 1-2 ml of radio-opaque contrast is injected to vi­sualize the longus colli muscle [Figure 2]b. After nega­tive aspiration is performed, a 0.5-mL test dose of 1% xylocaine is injected to rule out intravascu­lar injection into the vertebral artery and then mixture of 1% Xylocaine (10 ml)+ 40 mg Depomedrol ® was injected. Flow of contrast extending to the head of the first rib can be observed by increasing the amount of contrast or injection of drug mixture which pushes the contrast up and down [Figure 2]c.
Figure 1: a: Neck extended and rotated to opposite side
b: C-arm is rotated in opposite direction of head turn
c: X-ray image shows uncinate process of C7 and intervertebral foramina

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Figure 2: a: spinal needle at uncinate process of C7 left
b: Contrast spreading up and down
c: Contrast spreading up to head of 1st rib

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Table 2: Changes in temperature of affected and contralateral limb; before and after stellate ganglion block

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Patients were observed in recovery area for 1 hr and then discharged. Review was done once weekly to evaluate pain intensity (VAS 0-10) and range of movements (ROM). [9] Blocks were repeated 1-3 weekly interval depending upon relief of symptoms and patients willingness.

   Results Top

Seven out of nine patients (2 males and 5 females) showed marked improvement in symptoms during follow-up. One young girl (case 2) although responded to treatment (objective improvement in colour and swelling) but did not get full ROM. She was seeking an outside referral and thus referred for corrective surgery of hand. Case 9 refused to treatment after first injection where she developed dyspnoea.

Few minor and short-lived side effects such as temporary hoarseness of voice, difficulty in swallowing and Horner's syndrome were noticed [Table 1]. One patient (case 9) developed dyspnoea. There was no evident cause of dyspnoea except nasal congestion and a patient has to breathe through mouth. Vitals and SpO 2 remained normal. Pneumothorax was ruled out by chest auscultation and fluoroscopy. Patient responded to reassurance and oxygen by mask for 10 minutes.No patient had any vascular injury or developed any other serious complication during or after procedure.

   Discussion Top

Although SGB is an important tool to manage sympathetically mediated pain in the upper extremity. There are two concerns regarding its success.

Firstly, to block the SG effectively for CRPS-1 of upper extremity it is essential to inject the drug near ganglion. There are a significant number of individuals in whom the intrathoracic somatic branches from the second thoracic spinal nerve join the first thoracic spinal nerve. These fibers (Kuntz's nerves) join the lower part of the brachial plexus without passing through the SG. This explains the incomplete sympathetic blockade of the upper extremities in SGB. [10] This happens because if drug is injected higher up (at C6) it may not reach up to target area. [6] It has been shown in one study that methylene blue injection with the classical blind ap­proach at C6 was thoracoscopically visu­alized at the SG in only 46%, while with the same blind technique at C7 the dye was seen at the SG in 63% of cases. [11]

Secondly, there is always a possibility of serious consequences of intravascular (intra-arterial injection) due to anatomy at C7specialy when blind technique is used. Other fluoroscopic-guided techniques [12],[13] also enhance safety. However, manual retraction of vascular sheath always poses practical difficulty of needle displacement while taking hands off for attaching the extension tube or syringe for contrast injection. This new modified technique has better (hands free) approach. The advantages of this new technique are as follows: [8]

  • Eliminates pressing or pushing the vascular system out of the way
  • Eliminates pressing on the Chassaignac tubercle, which can be uncomfortable and even painful for patients
  • Minimizes the chance of intravascular injection
  • Minimizes the chance of oesophageal perforation
  • Reduces the volume of local anaesthetics needed to cover lower cervical through upper thoracic areas
  • There are many case reports of intravascular injection and related complications with classical techniques. [14],[15] However; actual incidence of intravascular injection during classical approach of SGB is not given in literature. The incidence of vascular injury during SGB between 0 and 30% has been reported by various authors. [16],[17]

We noticed in our study that once C-arm is positioned correctly the localization of target point (the junction between uncinate process and body of vertebra) was achieved in all the patients in single attempt except to correct final angle in few patients.

   Conclusions Top

Our results of nine patients simply revalidate that this new technique of SGB is safe and effective technique of SGB to manage CRPS-1 of upper limb. However, studies with large number of patients and randomized control trials can only substantiate the claim of its superiority over other similar technique.

   References Top

1.Schürmann M, Gradl G, Wizgal I, Tutic M, Moser C, Azad S, et al. Clinical and physiologic evaluation of stellate ganglion blockade for complex regional pain syndrome type I. Clin J Pain 2001;17:94-100.   Back to cited text no. 1
2.Ackerman WE, Zhang JM. Efficacy of stellate ganglion blockade for the management of type 1 complex regional pain syndrome. South Med J 2006;99:1084-8.   Back to cited text no. 2
3.Carron H, Litwiller R. Stellate ganglion block. Anesth Analg 1975;54:567-70.  Back to cited text no. 3
4.Chaturvedi A, Dash H. Locked-in syndrome during stellate ganglion block. Indian J Anaesth 2010;54:324-6.  Back to cited text no. 4
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5.Higa K, Hirata K, Hirota K, Nitahara K, Shono S. Retropharyngeal hematoma after stellate ganglion block: Analysis of 27 patients reported in the literature. Anesthesiology 2006;105:1238-45.  Back to cited text no. 5
6.Elias M. Cervical sympathetic and stellate ganglion blocks. Pain Physician 2000;3:294-304.  Back to cited text no. 6
7.Matsumoto S. Thermographic assessments of the sympathetic blockade by stellate ganglion block (1) Comparison between C7-SGB and C6-SGB in 40 patients. Masui 1991;40:562-9.  Back to cited text no. 7
8.Abdi S, Zhou Y, Patel N, Saini B, Nelson J. A new and easy technique to block the stellate ganglion. Pain Physician 2004;7:327-31.  Back to cited text no. 8
9.Yucel I, Demiraran Y, Ozturan K, Degirmenci E. Complex regional pain syndrome type I: efficacy of stellate ganglion blockade. J Orthop Traumatol 2009;10:179-83.   Back to cited text no. 9
10.Kuntz A. Distribution of the sympathetic rami to the brachial plexus: its relation to sympathectomy affecting the upper extremity. Arch Surg 1927;15:871-7.  Back to cited text no. 10
11.Harano K. Difference of spread of injected solutions after stellate ganglion block to the sixth and seventh vertebral levels. Anesthesiology 1998; 89:1159.  Back to cited text no. 11
12.Elias M. The anterior approach for thoracic symphatetic ganglion block using a curved needle. Pain Clinic 2000;12:17-24.  Back to cited text no. 12
13.Moore DC, Bridenbaugh LD Jr. The anterior approach to the stellate ganglion use without a serious complication in two thousand blocks. J Am Med Assoc 1956;160:158-62.  Back to cited text no. 13
14.Dukes RR, Alexander LA. Transient locked-in syndrome after vascular injection during stellate ganglion block. Reg Anesth 1993;18:378-80.  Back to cited text no. 14
15.Mahli A, Coskun D, Akcali DT. Aetiology of convulsions due to stellate ganglion block: a review and report of two cases. Eur J Anaesthesiol 2002;19:376-80.  Back to cited text no. 15
16.Wulf H, Maier C, Schele HA, Wabbel W. Plasma concentration of bupivacaine after stellate ganglion blockade. Anesth Analg 1991;72:546-8.  Back to cited text no. 16
17.Warrick JW. Stellate ganglion block in the treatment of Ménière's disease and in the symptomatic relief of tinnitus. Br J Anaesth 1969;41:699-702.  Back to cited text no. 17


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]

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