Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Image-Guided Stellate Ganglion Blocks

  • Author: Hassan H Amhaz, MD, MS; Chief Editor: Meda Raghavendra (Raghu), MD  more...
 
Updated: Mar 19, 2014
 

Overview

The stellate ganglion is part of the sympathetic network formed by the inferior cervical and first thoracic ganglia.[1, 2] It receives input from the paravertebral sympathetic chain and provides sympathetic efferents to the upper extremities, head, neck, and heart. The infiltration of local anesthetic has been used to treat a variety of disorders, but it is primarily performed in the setting of reflex sympathetic dystrophy. Although primarily performed by pain management physicians, ultrasound, fluoroscopic, and computed tomography (CT)–guided techniques have been described in the radiology literature.

Stellate ganglion blocks have traditionally been performed blindly by palpating the anterior tubercle of the transverse process of C6 (Chassaignac tubercle) and infiltrating a large volume (as much as 20 mL) of local anesthetic followed by the patient sitting up immediately afterwards so that the gravitational effect allows enough volume to reach the stellate ganglion to result in an effective block.[3, 4] This method has a relatively high failure rate, with numerous significant and even potentially fatal adverse effects.

Image-guided stellate ganglion blocks have the advantages of increased safety and accuracy compared with blind injections. The needle can be accurately placed near the stellate ganglion, and, as a result, a safer and smaller amount of local anesthetic can be used, reducing the risk of adverse effects.[5]

Anatomy

The cervical sympathetic chain is composed of the superior, middle, and inferior cervical ganglia. In approximately 80% of the population, the inferior cervical ganglion fuses with the first thoracic ganglion, forming the cervicothoracic ganglion also known as the stellate ganglion.[6, 7]

Understanding the surrounding anatomy of the stellate ganglion is critical for an effective block and to avoid serious and even life-threatening complications. The stellate ganglion lies anterolateral to the C7 vertebral body.[6] Structures lying anterior to the ganglion include skin, subcutaneous tissue, platysma, investing cervical fascia, sternocleidomastoid muscle, and the carotid sheath (containing the internal jugular vein laterally, carotid artery medially, and vagus nerve posteriorly). The lung apex lies anterior and inferior to the ganglion. Medial structures include the C7 vertebral body, esophagus, trachea, thoracic duct, recurrent laryngeal nerve, and thyroid gland. Posterolateral structures include the anterior scalene muscle with the phrenic nerve, brachial plexus and its branches, vertebral artery, and longus colli muscles.

The prevertebral fascia must be entered before these posterolateral structures become accessible. The inferior (serpentine) thyroid artery lies anterior to the vertebral artery at the seventh cervical level.[8] More commonly, however, is its location as it traverses the carotid artery posterior at C6, going laterally to medially into the thyroid gland. An important landmark located superior to the stellate ganglion is the anterior tubercle of the C6 vertebral body, Chassaignac tubercle (carotid tubercle). This is a commonly used landmark because it is easily palpated. Injection at this location allows for tracking of the local anesthetic down the prevertebral fascia to the stellate ganglion below.

Next

Indications

Indications for stellate ganglion blocks typically fall into 1 of 2 categories, as follows:

  • Pain syndromes: These conditions include complex regional pain syndromes (CRPSs) type I (reflex sympathetic dystrophy [RDS]) and type II (causalgia), hyperhidrosis, refractory angina, phantom limb pain, herpes zoster, and pain of the head and neck.
  • Arterial vascular insufficiency: These conditions include Raynaud syndrome, scleroderma, obliterative vascular diseases, vasospasm, trauma, and emboli. No benefit is seen in patients with venous insufficiency. [6, 7, 8, 9]
Previous
Next

Contraindications

Contraindications are as follows:

  • Current coagulopathy
  • Recent myocardial infarction
  • Pathological bradycardia
  • Glaucoma [6]
Previous
Next

Anesthesia

Image guidance allows for more precise needle placement and less local anesthetic use for an adequate block. Severe and possibly fatal consequences of intra-arterial injection and even local effects are not uncommon and have been reported in the literature.[9] Korevaar et al reported that the minimal toxic dose of local anesthetic injected intravascularly is approximately 4% of the minimum toxic intravenous dose.[10] Bupivacaine is associated with more adverse cardiovascular events than lidocaine. Although bupivacaine’s action may be more prolonged, the diagnostic value of the stellate ganglion block is the same with lidocaine. Finally, the epinephrine used with lidocaine can result in tachycardia if injected intravascularly and its vasoconstrictive effects confine the anesthetic locally and reduce its distribution. Note the following:

  • Omnipaque, 3 mL
  • Lidocaine 1% with epinephrine, 10 mL
  • Bupivacaine 0.25%, 10 mL [6, 9]
Previous
Next

Equipment

Equipment needs are as follows:

  • 3-mL syringe – For contrast agent
  • 10-mL syringe – For local anesthetic
  • 22- or 25-gauge, 1.5-inch short-bevel needle
  • Skin temperature monitor, typically placed on the finger
  • Ultrasound probe, fluoroscopy, C-arm
  • Appropriate equipment and medications for medical resuscitation [6, 9]
Previous
Next

Positioning

Ultrasound and fluoroscopic technique positioning is as follows:

  • Position the patient supine
  • Thin pillow under head to slightly extend the neck
  • Head rotated slightly to the side contralateral to the block
  • Mouth slightly opened [6, 9]

CT-guided technique positioning is as follows:

  • Position the patient supine with his or her chin turned away slightly from the injection site. [6, 9]
Previous
Next

Technique

Multiple imaging modalities, including ultrasound, fluoroscopy, and CT, have all been used to reduce adverse complications compared with the blind technique. Fluoroscopy and ultrasound are readily available and either is typically used instead of CT. Ultrasound provides greater delineation of soft tissue anatomy and uses the prevertebral fascia as its endpoint for injection.[8] Ultrasound guidance can reduce the amount of local anesthetic required to achieve blockade and can help reduce unintentional puncture of critical vascular and nerve structures.[11] Kapral was the first to describe ultrasound-guided nerve blockade in 1995.[12] Fluoroscopy is beneficial for visualizing bony anatomy; however, soft tissue structures are much more challenging to appreciate and there is additional radiation exposure to the patient’s thyroid.

Ultrasound guidance

Two main approaches have been described for stellate ganglion block: the C6 transverse process approach and the C7 anterior paratracheal approach.[6, 7]

C6 transverse process approach

The patient is first positioned as described above. The needle insertion site is located between the trachea and the carotid sheath. The C6 level is identified at the level of the cricoid cartilage. The Chassaignac tubercle is then identified. Placement of the ultrasound transducer helps retract the carotid sheath and sternocleidomastoid muscle laterally. Pressure is applied with the ultrasound transducer to reduce the distance between the skin and tubercle and to depress the dome of the lung to reduce risk of pneumothorax.

The needle is inserted towards to the Chassaignac tubercle, and, after contact, it is redirected inferomedially towards the body of C6. The needle is then withdrawn 1-2 mm to bring it out of the longus colli muscle while still staying within the prevertebral fascia. After negative aspiration, 1-2 mL of local anesthetic can be injected, and spread can be visualized with ultrasound. Once confirming that the injection was subfascial, the remaining local anesthetic can be given.[6, 7, 8, 9, 10]

C7 anterior paratracheal approach

The patient is first positioned as described above. The sternoclavicular junction is palpated, and the needle insertion site lies about 3 cm rostral. This landmark can help identify the C7 transverse process under ultrasound guidance. The needle is then inserted perpendicularly towards to the transverse process of C7. Once reached, the needle is withdrawn 1-2 mm. After negative aspiration, 1-2 mL of local anesthetic can be injected, and spread can be visualized with ultrasound. The remainder of the local anesthetic may be given. This approach is associated with a higher incidence of pneumothorax, so special attention must be made to avoid this complication.[6, 7, 8, 9, 10]

A successful block is seen by the onset of Horner syndrome with affected extremity temperature increase greater than 3°F (typically seen within 3 min). After the procedure, the patient should be allowed to recover in the department for approximately 1 hour.[13]

Fluoroscopic technique

Using the fluoroscopic technique for stellate ganglion blockade encompasses many of the landmarks and patient positioning used for the ultrasound-guided technique. Fluoroscopy provides exceptional bony delineation compared with that of ultrasound. Both the C6 transverse process approach and the C7 anterior paratracheal approach can be done under fluoroscopic guidance. An additional procedural step seen with fluoroscopy is the use of Omnipaque contrast to confirm appropriate needle placement on the Chassaignac tubercle or the transverse process of C7 and to rule out intravascular injection. As discussed earlier, if the needle is located subfascially, one will see local spread of contrast between the tissue planes both cephalad and caudad. Additionally, if intravascular injection occurs, immediate dissipation of contrast dye will be seen.[6] Note the image below:

Anteroposterior (AP) image demonstrates correct ne 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. Image courtesy of Wade Wong, DO.

CT-guided technique

The patient is placed supine with his or her chin turned away slightly from the injection site. Using CT scanning or CT fluoroscopy identifies the head of the first rib, as well as the adjacent vertebral artery. 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.[1, 2, 14] The physician should take care to avoid the vertebral artery (see image below).

Computed tomography fluoroscopic image shows the c 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 a small amount of Omnipaque is injected to confirm an extravascular location of the needle tip (see image below).

Contrast material has been injected to confirm the 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 local anesthetic is injected; additional amounts are slowly added until a sympathetic block is elicited. The needle is withdrawn, and pressure is held for 5-10 minutes. The patient should be observed for at least 1 hour.

Previous
Next

Complications

Complications of image-guided stellate ganglion blocks result from either direct injury from the needle, effect from the local anesthetic agent, or infection.

Injury to adjacent vascular structures, including the vertebral artery, carotid artery, and internal jugular vein, can result in hematoma formation, especially in patients with preexisting coagulopathy.

Intravascular/intrathecal injection of local anesthetic can result in arrhythmia, seizure, and cardiovascular collapse.

Local anesthetic can produce hoarseness and an elevated hemidiaphragm accompanied by dyspnea as a result of direct spread to the recurrent laryngeal and phrenic nerve, respectively. For this reason, bilateral stellate ganglion blockade not advised.

Pneumothorax, esophageal perforation, and chylothorax from thoracic duct injury can be seen owing to the close proximity of these structures to the stellate ganglion. These are uncommon when the block is done under image guidance.

Anesthetizing the stellate ganglion can also result in profound bradycardia, hypotension, and even heart block, owing to inhibition of sympathetic fibers

Additionally, soft tissue infection, osteitis, and neuraxial infection (meningitis) may be seen.

Neuraxial injection of local anesthetic into the epidural space, intrathecally and even the brachial plexus, can occur.[6, 9]

Previous
 
Contributor Information and Disclosures
Author

Hassan H Amhaz, MD, MS Resident Physician, Department of Anesthesiology, Detroit Medical Center, Wayne State University School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Marc S Orlewicz, MD Clinical Assistant Professor of Anesthesiology, Director of Clinical Simulator and Residency Site-Director for WSU/DMC Anesthesiology Residency Program, Wayne State University and Detroit Medical Center (WSU/DMC); Clinical Assistant Professor of Osteopathic Anesthesiology Residency Program, Michigan State University; Co-Director of Anesthesia Critical Care Services, Department of Anesthesiology, Surgical Intensivist, Harper Hospital and Sinai-Grace Hospital through WSU/DMC

Marc S Orlewicz, MD is a member of the following medical societies: American Society of Anesthesiologists, Society of Cardiovascular Anesthesiologists, Society of Critical Care Medicine, Society of Critical Care Anesthesiologists

Disclosure: Nothing to disclose.

Specialty Editor Board

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

C Douglas Phillips, MD, FACR Director of Head and Neck Imaging, Division of Neuroradiology, New York-Presbyterian Hospital; Professor of Radiology, Weill Cornell Medical College

C Douglas Phillips, MD, FACR is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Head and Neck Radiology, American Society of Neuroradiology, Association of University Radiologists, Radiological Society of North America

Disclosure: Nothing to disclose.

Chief Editor

Meda Raghavendra (Raghu), MD Associate Professor, Interventional Pain Management, Department of Anesthesiology, Chicago Stritch School of Medicine, Loyola University Medical Center

Meda Raghavendra (Raghu), MD is a member of the following medical societies: American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Additional Contributors

David S Levey, MD Orthopedic and Neurospinal MRI, Forensic Diagnostic Radiologist; President, David S Levey, MD, PA, San Antonio, Texas

David S Levey, MD is a member of the following medical societies: International Society of Forensic Radiology and Imaging, Forensic Expert Witness Association, Technical Advisory Service for Attorneys, Bexar County Medical Society, Texas Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Andrew L Wagner, MD, to the writing and development of this article.

References
  1. Wong W. Spinal nerve blocks. Williams AL, Murtagh FR, eds. Handbook of Diagnostic and Therapeutic Spine Procedures. St Louis, Mo: Mosby; 2002. 20-40.

  2. Erickson SJ, Hogan QH. CT-guided injection of the stellate ganglion: description of technique and efficacy of sympathetic blockade. Radiology. 1993 Sep. 188(3):707-9. [Medline].

  3. Feigl GC, Rosmarin W, Stelzl A, Weninger B, Likar R. Comparison of different injectate volumes for stellate ganglion block: an anatomic and radiologic study. Reg Anesth Pain Med. 2007 May-Jun. 32(3):203-8. [Medline].

  4. Christie JM, Martinez CR. Computerized axial tomography to define the distribution of solution after stellate ganglion nerve block. J Clin Anesth. 1995 Jun. 7(4):306-11. [Medline].

  5. Jung G, Kim BS, Shin KB, Park KB, Kim SY, Song SO. The optimal volume of 0.2% ropivacaine required for an ultrasound-guided stellate ganglion block. Korean J Anesthesiol. 2011 Mar. 60(3):179-84. [Medline]. [Full Text].

  6. Jadon A. Revalidation of a modified and safe approach of stellate ganglion block. Indian J Anaesth. 2011 Jan. 55(1):52-6. [Medline]. [Full Text].

  7. Hogan QH, Erickson SJ, Abram SE. Computerized tomography-guided stellate ganglion blockade. Anesthesiology. 1992 Sep. 77(3):596-9. [Medline].

  8. Malmqvist EL, Bengtsson M, Sorensen J. Efficacy of stellate ganglion block: a clinical study with bupivacaine. Reg Anesth. 1992 Nov-Dec. 17(6):340-7. [Medline].

  9. Feigl GC, Rosmarin W, Stelzl A, Weninger B, Likar R. Comparison of different injectate volumes for stellate ganglion block: an anatomic and radiologic study. Reg Anesth Pain Med. 2007 May-Jun. 32(3):203-8. [Medline].

  10. Hogan QH, Erickson SJ. MR imaging of the stellate ganglion: normal appearance. AJR Am J Roentgenol. 1992 Mar. 158(3):655-9. [Medline].

  11. Moore DC. Therapeutic stellate ganglion block: 5 versus 10 ml of a local anesthetic. Reg Anesth Pain Med. 2008 Mar-Apr. 33(2):191-2. [Medline].

  12. Narouze S, Vydyanathan A, Patel N. Ultrasound-guided stellate ganglion block successfully prevented esophageal puncture. Pain Physician. 2007 Nov. 10(6):747-52. [Medline].

  13. Price DD, Long S, Wilsey B, Rafii A. Analysis of peak magnitude and duration of analgesia produced by local anesthetics injected into sympathetic ganglia of complex regional pain syndrome patients. Clin J Pain. 1998 Sep. 14(3):216-26. [Medline].

  14. Shibata Y, Fujiwara Y, Komatsu T. A new approach of ultrasound-guided stellate ganglion block. Anesth Analg. 2007 Aug. 105(2):550-1. [Medline].

 
Previous
Next
 
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. Image courtesy of Wade Wong, DO.
Computed tomography fluoroscopic image shows the correct placement of a 25-gauge needle on the head of the first rib.
Contrast material has been injected to confirm the extravascular location of the needle tip (same patient as in image above).
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.