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:

Pain Syndromes

  • 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
  • Scleroderma

Miscellaneous

  • Hyperhidrosis (excessive perspiration) of the face and upper extremities
  • Hot flushes and sleep dysfunction related to hot flashes
  • Posttraumatic stress disorder (PTSD)

Anatomy

Stellate-Ganglion-Block-ExplainedThe 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.

Procedure

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.

Benefit

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.

Risk

Stellate Ganglion Block - DiagramThe 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.

Outcomes

After the block is preformed one of three things may occur:

  1. 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
  2. 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.
  3. Your pain is unchanged but there is no evidence of a sympathetic blockade. This indicates that the block was a technical failure.
Stellate-Ganglion-Block-EducationStellate ganglion blocks are a well-established treatment modality for providing relief from sympathetically-maintained pain syndromes; however, their utility does not end there. In conditions where there is decreased blood flow to the upper extremities, from causes such as arterial insufficiency, Raynaud’s phenomena and/or scleraderma, the stellate ganglion block has been documented to significantly increase blood flow, decrease the number of Raynaud attacks and ultimately provide symptom improvement.2,4,5Another therapeutic indication is intractable angina for patients where maximal medical and surgical intervention (including optimal revascularization) have failed to provide pain relief.1,10,13 The stellate ganglion block can provide these patients relief as they cope with their advanced cardiovascular disease. A recent study, Lipov et al. (2008) suggests that the stellate-ganglion block, with minimal if any side effects, can provide relief from hot flushes and associated sleep dysfunction in breast cancer survivors. This study highlights that the long-term relief of symptoms obtained from the stellate ganglion block has the potential to not only improve quality of life, but also compliance with the anti-estrogen medications.8 These same authors have also found that some success can be achieved with treatment of PTSD with the stellate ganglion block as well.6,7 The benefits of stellate ganglion block can be temporary for some people and the amount and duration of pain relief vary from person to person. Some tend to have relief for weeks where others can benefit from the block for years. Fortunately, the procedure is a low risk, nonsurgical treatment that if successful the first time, will most likely continue to provide pain relief with repeat treatments. If you are suffering with pain contact Arizona Pain Specialists today to see if you can benefit from a stellate ganglion block. We are happy to offer this exciting treatment option to patients in Scottsdale, Glendale, and the Phoenix metro area. Call today.

At Arizona Pain our goal is to relieve your pain and improve function to increase your quality of life.
Give us a call today at 480-563-6400.

Journal Articles

  1. Chester M, Hammond C, Leach A. Long-term benefits of stellate ganglion block in severe chronic refractory angina. Pain. 2000 Jul;87(1):103-5.
  2. Elias M. Continuous cervico-thoracic sympathetic ganglion block: therapeutic modality for arterial insufficiency of the arm of a neonate. Middle East J Anesthesiol. 2001 Oct;16(3):359-63.
  3. Gofeld M, Bhatia A, Abbas S, Ganapathy S, Johnson M. Development and validation of a new technique for ultrasound-guided stellate ganglion block. Reg Anesth Pain Med. 2009 Sep-Oct;34(5):475-9.
  4. Klyscz T, Jünger M, Meyer H, Rassner G. Improvement of acral circulation in a patient with systemic sclerosis with stellate blocks. Vasa. 1998 Feb;27(1):39-42.
  5. Lagade M, Poppers PJ: Stellate ganglion block: A therapeutic modality for arterial insufficiency of the arm in premature infants. Anesthesiology. 1984;61:203-204.
  6. Lipov EG, Joshi JR, Sanders S, Slavin KV. Lipov EG, Joshi JR, Sanders S, Slavin KV. A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD). Med Hypotheses. 2009 Jun;72(6):657-61. Epub 2009 Feb 23.
  7. Lipov EG, Joshi JR, Lipov S, Sanders SE, Siroko MK. Cervical sympathetic blockade in a patient with post-traumatic stress disorder: a case report. Ann Clin Psychiatry. 2008 Oct-Dec;20(4):227-8.
  8. Lipov EG, Joshi JR, Sanders S, Wilcox K, Lipov S, Xie H, Maganini R, Slavin K. Effectsof stellate-ganglion block on hot flushes and night awakenings in survivors of breast cancer: a pilot study. Lancet Oncol. 2008 Jun;9(6):523-32. Epub 2008 May 15.
  9. Marples, IL, Atkin RE. Stellate ganglion block. Pain Rev 2001; 8: 3-11.
  10. Moore R, Groves D, Hammond C, Leach A, Chester MR. Temporary sympathectomy in the treatment of chronic refractory angina. J Pain Symptom Manage. 2005 Aug;30(2):183-91.
  11. Narouze S, Vydyanathan A, Patel N. Pain Physician. Ultrasound-guided stellate ganglion block successfully prevented esophageal puncture. Pain Physician. 2007 Nov;10(6):747-52.
  12. Shibata Y, Fujiwara Y, Komatsu T. A new approach of ultrasound-guided stellate ganglion block. Anesth Analg. 2007 Aug;105(2):550-1.
  13. Stanik-Hutt JA. Management options for angina refractory to maximal medical and surgical interventions. AACN Clin Issues. 2005 Jul-Sep;16(3):320-32.