Stellate Ganglion Block - Indications, Contraindications, and Technique

Introduction:

A stellate ganglion block is an injection of the local anesthetic drug into the neck to inhibit the sympathetic nerves on each side of the vocal cords that can help reduce pain in the head and neck region and also in the upper part of the body, including upper extremities, herpes zoster (shingles), refractory angina or intractable angina (patients of heart disease continue to suffer from recurrent restricting angina). In addition, it helps boost the vascular supply to the forearm. In addition, injection into these nerves may relieve pain, edema, color, and sweating alterations in the upper extremity and enhance movement. The anesthesia was administered at the C6 or C7 vertebral level, with the Chassignac's tubercle, cricoid cartilage, and carotid artery acting as anatomic references.

What Are the Anatomic Considerations of the Stellate Ganglion?

• From the first thoracic segments, sympathetic fibers for the head, neck, heart, and superior limbs ascend along the sympathetic chain and synapses in the upper, middle, and lower cervical ganglions.

• The stellate ganglion, formed of the inferior cervical ganglion and the first thoracic ganglion fusion, is found in 80 % of the general population.

• It is located anterior to the first rib in the neck and extends to the inferior border of the transverse process of the seventh cervical vertebrae. It is usually seen adjacent to the dome of the pleura, medially or posteriorly to the vertebral artery.

• Unless the inferior cervical ganglion and first thoracic ganglion are not united, the stellate ganglion refers to the inferior cervical ganglion positioned next to the anterior seventh cervical vertebra tubercle.

• The stellate ganglion preganglionic fibers travel along the cervical sympathetic chain, while the postganglionic fibers deliver sympathetic innervation to the upper limbs.

• SGB with local anesthetic has an impact on both preganglionic and postganglionic fibers.

What Are the Indications for the Stellate Ganglion Block?

• The pain eased by a sympathetic block is known as sympathetically mediated pain (SMP), which is caused by improper connections between the sympathetic and sensory nerve systems.

• The therapeutic benefits of SGB are attributable to the blockage of neuronal connections in its innervation area, the enhancement of blood flow to the region, and the lowering of adrenal hormone plasma concentration. SGB can be used to treat medical disorders such as post-traumatic stress disorder or cluster headaches. In addition, SGB could be employed to validate an SMP as a diagnostic instrument.

• Head and upper limb complex regional pain syndrome.

• Vascular disease of the peripheral blood vessels.

• Embolism of the upper limbs.

• Neuralgia due to post-herpetic pain in the skin areas where shingles are affected.

• Chronic postoperative pain.

• Hyperhidrosis (excessive sweating).

• Raynaud's syndrome.

• Scleroderma (a chronic hardening and shrinkage of the skin and connective tissue locally or throughout the body).

• Orofacial discomfort.

• The sensation of the amputation of a limb (Phantom limb).

• Unusual chest discomfort.

• A cluster headache or a vascular headache.

• Post-traumatic stress disorder (PTSD).

• Meniere's disease (a disease affecting the membranous labyrinth of the ear, leading to deafness, tinnitus, and vertigo).

• Patients with heart disease continue to suffer from recurrent restricting angina.

• Refractory arrhythmias of the heart.

What Are the Contraindications for the Stellate Ganglion Block?

• Recent heart attack.

• Patients under anticoagulated or coagulopathy therapy (risk/benefit analysis).

• Glaucoma (increased pressure within the eyeball, leading to loss of sight).

• Previously existent contralateral nerve palsy.

• Emphysema is severe.

• Blockage of cardiac conduction.

What Are The Equipment Used for Stellate Ganglion Block?

Fluoroscopic Technique:

• C-arm image intensifier.

• Contrast media.

• 22-gauge spinal needle (9 cm length).

• Local anesthetic solution.

• Non-particulate steroid (Betamethasone Sodium Phosphate, Dexamethasone Sodium Phosphate, and Dexamethasone Palmitate).

Ultrasound-Guided Technique:

• Linear transducer with a high-frequency range between 6 to 13 MHz.

• Using an echo-enhanced needle of 22 to 25 gauge.

• Anesthetic solution.

• Non-particulate steroid (Betamethasone Sodium Phosphate, Dexamethasone Sodium Phosphate, and Dexamethasone Palmitate).

How Is the Patient Prepared for Stellate Ganglion Block?

Should check the patient's vital signs both before and after the surgery. Every patient must have a peripheral venous catheter inserted. Before the technique, it is critical to gather a thorough medical history to rule out contraindications and assess the risk/benefit ratio.

What Is Fluoroscopic Technique?

• The patient is positioned horizontally with the face and torso facing up. An anteroposterior view is acquired with the C-arm to locate the sixth cervical vertebrae by counting up from T1.

• The C-arm is then rotated to align the superior aspect of the sixth cervical vertebral body and turned obliquely at about 25 to 30 degrees ipsilaterally to produce a foraminal view. The target is the intersection of the vertebral body and the uncinate process (of the sixth cervical vertebrae).

• Under an oblique aspect, the needle is placed laterally with a lateral to medial trajectory and remains above the vertebral body or slightly medial to prevent damage to arteries, spinal nerves, and the disc.

• Must verify the alignment from the anteroposterior and lateral aspects. A small quantity of contrast media (0.5 to 1 ml) might be initially administered to locate the needle.

• A small test dose of local anesthetic is then given to limit the possibility of intravascular injection further. The patient is then given 10 ml of a topical anesthetic, such as Lidocaine, one percent.

• If necessary, the same treatment can be performed at the seventh cervical vertebrae level. However, clinicians must be mindful of the increased risks of vascular puncture at the seventh cervical vertebrae level.

What Is the Ultrasound-Guided Technique?

• The patient is lying horizontally on his back with his neck somewhat stretched and his head slightly turned contralaterally to the approaching side.

• The area is cleansed and wrapped before placing the transducer perpendicular to the tracheal axis at the cricoid cartilage and moving inferiorly until the superior side of the thyroid gland is visible.

• Later, the transducer should be moved laterally to view the anterior portion of the Chassaignac's tubercle on the sixth cervical vertebrae transverse process and may find the spinal nerve.

• The location of the vessels should be determined using the color, Doppler. Next, the needle is positioned behind the trachea in a lateral to medial direction using an in-plane technique.

• The tip of the transducer must reach the fascia covering the vertebral muscles (longus colli muscle), which is placed between the carotid artery's posterior side and the tip of the sixth cervical vertebrae anterior tubercle.

• It should prevent any damage to the vascular and nerves. First, an aspiration test is performed to avoid blood or cerebrospinal fluid suction. Then, a local anesthetic is delivered, and the local anesthetic solution diffusion is monitored in real-time.

• The vertebral artery is unguarded at the seventh cervical vertebrae level due to its absence or rudimentary anterior protection, and the injection is not inferior to the C6 level.

• Two percent Lidocaine five-milliliter solution is administered until the fluid has diffused through the prevertebral fascia to the stellate ganglion.

What Are the Complications of Stellate Ganglion Block?

• Any vascular injury (carotid artery, internal jugular vein, inferior thyroid artery, vertebral artery).

• Any neural injury (vagus nerve, recurrent nerve, brachial plexus roots).

• Pneumothorax (a collapsed lung).

• Damage to the thyroid gland.

• Injury to the tracheal and esophageal.

• Horner syndrome (transient).

• The injection was administered into the vessel.

• Spread local anesthetic infections through the neuraxial, phrenic nerve, or brachial plexus.

• Any infection (around the injection site internally or externally).

• Bleeding (around the injection site internally or externally).

Conclusion:

This block is accomplished only by specialists who understand the anatomy and can control difficulties during the procedure. The surgery should be performed under fluoroscopic monitoring to reduce the challenges. A nurse should consistently monitor the patient's vital signs before and after the procedure.