Stellate Ganglion Block
by Elizabeth Cudilo M.D, Paul Lynch M.D, and Tory McJunkin M.D
A stellate ganglion block has both diagnostic and therapeutic value. It has a wide array of therapeutic indications including:
- Sympathetically-maintained pain syndromes
- Complex Regional Pain Syndromes Type 1 and 2
- Reflex sympathetic dystrophy
- Shoulder/hand syndrome
- Causalgia (nerve injury)
- Phantom limb pain
- Intractable angina
- Herpetic neuralgia from herpes zoster (shingles)
Vascular Insufficiency in Upper Extremities
- Arterial insufficiency
- Raynaud’s phenomenon
- Hyperhidrosis (excessive perspiration) of the face and upper extremities
- Hot flushes and sleep dysfunction related to hot flashes
- Posttraumatic stress disorder (PTSD)
AnatomyThe stellate ganglion refers to the ganglion formed by the fusion of the inferior cervical and the first thoracic ganglion as they meet anterior to the vertebral body of C7. It lies anterior to the prevertebral fasci and anterolateral to the longus colli muscle. Its alar fascial plane may communicate with the brachial plexus and the vertebral artery and it is in close proximity to the carotid sheath, phrenic nerve, and recurrent laryngeal nerve.
The stellate ganglion block can be performed in many ways. One of the most common ways to perform the stellate ganglion block is to perform it at the C6 level. Relatively large volumes (5-20ml) are injected 2mm superficial to the C6 tubercle. This is done to spread the solution downward to reach the stellate and upper thoracic ganglia. The stellate ganglion block can also be approached from at C7 with administration of a smaller volume; however, this approach increases the risk of vertebral artery injection and collapsed lung (pneumothorax). Another possible approach to this block is the posterior paravertebral approach. With this method the needle is walked off the upper thoracic lamina until correct needle placement is confirmed with fluoroscopy and contrast dye. Some physicians may also use ultra-sound guidance to decrease the chance of injury to vascular and soft tissue structures that are adjacent to the stellate ganglion.3,11,13 You will be asked to lie down on your back with your neck slightly extended, your head rotated slightly to the side opposite of the block, with your mouth open. Your neck will be prepped and draped in a sterile manner before local anesthesia is administered at the point of entry of the needle into the skin. After your skin is anesthetized your physician will retract your sternocleidomastoid muscle and carotid artery as his or her index and middle fingers palpate your Chassignac’s tubercle. Your skin and subcutaneous tissue will be pressed firmly onto the tubercle to reduce the distance between the skin surface and bone. This is done to reduce the chance of pneumothorax (collapsed lung) occurring. This may be mildly comfortable. Upon palpating these anatomical landmarks the needle is then advanced under fluoroscopy guidance until correct needle placement is obtained. Correct placement is also confirmed by administration of contrast dye. Once position is confirmed local anesthetic is administered. A successful block is marked by profound pain relief and improved vascular flow to ipsilateral upper extremity. Local anesthetic is usually administered for diagnostic stellate ganglion block. For patients who have a documented response to administration of local anesthetic onto the stellate ganglion, a therapeutic block can be performed with administration of the neurolytic agent like phenol. Radioablation of the stellate ganglion is also another treatment modality for longer-lasting pain relief. Some patients may experience a constellation of symptoms known as Horner’s Syndrome (drooping of the upper eyelid, pupil constriction, and decreased sweating on the side that the block was preformed). This is normal and symptoms usually subside when the anesthetic wears of (usually ~4-6 hours after the block is preformed). The procedure usually takes less than 15 minutes. Sometimes your physician will recommend intravenous sedation to make the procedure more comfortable. Your physician will monitor your pain and vital signs (pulse, blood pressure, temperature) after the procedure and place you in a sitting position to facilitate the spread of the anesthetic.
Stellate ganglion block is a short, minimally invasive procedure that can effectively treat a wide array of conditions that have failed optimal medical management. These include providing relief for sympathetic-related pain in face, chest, and upper extremities, improving circulation in upper extremities and face, decreasing perspiration in upper extremities and face, decreasing hot flashes and associated sleep disturbances, and showing promise as a novel treatment for PTSD.
RiskThe risks for the procedure are typically low9, but can include misplacement of the needle resulting in: bleeding, nerve injury, pneumothorax (collapsed lung), or esophageal perforation. Risks secondary to the spread of the anesthetic include: drug allergy, seizure (if the medication is injected into a blood vessel), brachial plexus block (numb arm on side of block that lasts as long as the life of the anesthetic injected), spinal or epidural block (transient weakness and/or numbness from neck down as long as the life of the anesthetic injected), hoarseness (from anesthetizing recurrent laryngeal nerve), and shortness of breath (from anesthetizing phrenic nerve). Lastly with any penetration of skin and soft tissues the risk of infection always exists. The most common side-effects related to the procedure are drooping of the upper eyelid, pupil constriction, and decreased sweating on the side that the block as well as voice becoming more hoarse. These side effects usually subside after the anesthetic wears off.
After the block is preformed one of three things may occur:
- Your pain is gone or greatly improved and stays that way for longer than the life of the anesthetic. This shows your physician that the block has therapeutic value for you and he or she can come up with a treatment plan that maximizes your pain control
- Your pain is unchanged but, there is evidence of a sympathetic blockade. This is of diagnostic value to your physician and tells him or her that your pain is not responsive to a sympathetic block and he or she can try other treatment modalities to treat your pain.
- Your pain is unchanged but there is no evidence of a sympathetic blockade. This indicates that the block was a technical failure.
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