Download Stellate ganglion blockade-techniques and modalities

(Acta Anaesth. Belg., 2016, 67, 1-5)
Stellate ganglion blockade-techniques and modalities
A. Ghai (*), T. Kaushik (*), R. Wadhera (**) and S. Wadhera
Abstract : Stellate ganglion block (SGB) is utilized in
the diagnosis and management of various vascular
disorders and sympathetically mediated pain in upper
extremity, head and neck. The stellate ganglion lies
medial to the scalene muscles, lateral to longus coli
muscle, esophagus, trachea and recurrent laryngeal
nerve, anterior to C7 transverse process and prevertebral
fascia, superior to the subclavian artery and posterior to
vertebral vessels. Consequently, inadvertent placement
of the needle tip into these soft tissues and vessels occur
with blind technique. Henceforth, various interventional
modalities are being used for SGB, these have been
reviewed in this paper. Various techniques of SGB have
been described, and vary from the use of standard blind
technique to the use of fluoroscopy, computerized
tomography, magnetic resonance imaging, and radio
nucleotide tracers. However, these techniques may not be
practical in a clinical setting, insofar as they are time
consuming, costly, and may involve radiation exposure.
The use of fluoroscopy does not visualize the blood
vessels close to the stellate ganglion. Ultrasounds are the
alternative. They help in visualization of soft tissues to
prevent complications and help in deposition of drug
subfascially, under direct visual control.
Key words : Stellate ganglion ; Stellate ganglion block ;
blind technique ; fluoroscopy ; sonographic guidance.
Introduction
The stellate ganglion block (SGB) has been
used to treat vascular insufficiency, va­sospasm,
hyper­
hidrosis, and a variety of pain syndromes,
­including complex re­gional pain syndrome, type I
and II, phan­tom limb pain, postherpetic neuralgia,
herpes zoster, pain from cen­
tral nervous system
­lesions, atypical facial pain, and intractable angina
pectoris. First implemented by Leriche and further
refined by Findley and Patzer (1), the most common technique is blind paratracheal approach.
However, various complications like subarachnoid
or epidural injection, recurrent laryngeal nerve
­palsy, seizures, and blindness have led to the emergence of interventional radiology, including fluoroscopy, computerized tomography (CT scan),
magnetic resonance imaging (MRI) and ultrasound
guided techniques (2-4).
The stellate ganglion is located immediately
below the prevertebral fascia covering the longus
coli muscle, separated by loose areolar tissue from
posterior osseous structures. The vertebral artery is
located anterior to the stellate ganglion, usually runs
ventrally to the seventh cervical transverse process,
and usually enters the foramen transversum of the
C6 vertebra (Fig. 1). In 10% of individuals, it enters
the foramen transversum at the C5 level or higher,
and is more tortuous on the left side. This can lead
to vertebral artery injury during SGB. The inferior
thyroid artery runs ventrally to C6 and C7, lying
­anterior to the vertebral artery. The close proximity
of stellate ganglion may lead to retropharyngeal
­hematoma, and accidental intravascular injections,
eventually leading to cardiac arrest (5).
The preganglionic fibers of the head and neck
continue to travel cephalic to the superior and
middle cervical ganglion through the cervical
­
­sympathetic trunk, which is located anterior to the
prevertebral fascia (6). Hence, all sympathetic ­fibers
to the head and neck either synapse at the level of
the sympathetic ganglion, or pass through it to the
more cephalic ganglion. SGB provides complete
blockade of head and neck sympathetic structures (7-10).
Approaches and imaging modalities
Classic blind approach
Technique
The patient is placed in the supine position,
with head extended. The landmark is the anterior
Anju Ghai ; Teshi Kaushik ; Raman Wadhera ; Sarthak
Wadhera.
(*) Departments of Anesthesia and Critical Care, (**) Dept. of
ENT Pt. BD Sharma, PGIMS, Rohtak, Haryana, India.
Correspondence address : R. Wadhera, House no. 6/8 FM,
Medical campus, PGIMS, Rohtak, Haryana, India.
Tel. : 09416974794, 01262- 212860.
E-mail : [email protected]
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et al.
recurrent laryngeal nerve is also possible (2), as
well as esophageal injury (12).
Fluoroscopy-guided stellate ganglion block
This technique aims at guiding the needle towards the Chassaignac’s tubercle. However, there is
a large variability in size and location of it (13).
Epidural and intrathecal injections can be ruled out
using the spread of contrast in fluoroscopy. The
needle can be accurately directed to the landmark,
using oblique approach (14).
Technique
Fig. 1. — Anatomy of stellate ganglion
tubercle of C6, which lies against the cricoid cartilage. The sternocleidomastoid muscle is retracted
laterally, pulling the internal carotid artery away.
The needle is then inserted perpendicularly between
the cricoid cartilage and the operator fingers, and
passed until contact is made with the C6 tubercle.
The needle is withdrawn a few millimeters away
from the periosteum of C6 transverse process and,
after a negative aspiration test for blood and cerebrospinal fluid (CSF) detection, 1 ml of the local
anesthetic solution is injected.
Disadvantages
The C6 landmark is in close proximity to the
middle cervical ganglion instead of the stellate ganglion, and the cervical sympathetic ganglion is primarily blocked when the injected solution spreads
to the T1 level (2).
The width of the C6 tubercle can be as small as
6 mm, and can be missed during blind needle advancement. A small deviation of the needle may
puncture the vertebral artery. If the needle is directed to the posterior tubercle, the drug can spread
around the spinal nerve roots. The final position of
the needle and the spread of local anesthetic (LA)
agents is unpredictable (10, 11). There is also a risk
of thyroid gland hematoma. Intravascular injections
and vascular injury have been reported despite a
negative aspiration test, leading to life threatening
complications like retropharyngeal hematoma, cardiac arrest, and convulsions (5). A paralysis of the
The patient is positioned in a similar way as
for the blind technique. The fluoroscopy beam is
­directed in anteroposterior direction, with caudo­
cranial angulations of the C arm. The needle is
directed towards the C6 anterior tubercle, and
­
­advanced under real time imaging to contact the
bony target. The stylet is then removed, and the
needle is connected to a three-way extension set to
allow a 1-2 ml radio opaque contrast injection. ­After
a negative aspiration test, a test dose of local anesthetic agent is given, followed by the injection of
the therapeutic dose. Flow of contrast to the head of
first rib can be observed by increasing the amount of
contrast injection, which pushes the contrast up and
down.
A modified fluoroscopy-guided technique is
performed with the patient in the supine position,
with the neck slight­ly extended and the head rotated
slightly to the opposite side. The skin temperatures
are recorded at the distal portion of both upper
­extremities, in mirror-image locations.
The fluoroscopy beam is directed in an anteroposterior direction, until the C5-C6 disc is well
­visualized. This usually requires caudocra­nial angulations of the C-arm. The C-arm is then rotated
obliquely, on the side of the block. The rota­tion
must occur to allow adequate visu­alization of the
neural foramina. A skin wheal is raised at the surface point of the junction of the uncinate process
and the vertebral body, as seen on the fluoroscope.
Under real-time imaging, a single pass is made with
a 25-gauge spinal needle to contact bone at this
point. The stylet is removed, and 2 ml of radioopaque contrast is injected to vi­sualize the longus
coli muscle. A 0.5 mL test dose is injected.. This
approach provides better upper extremity blockade
and less chances of vertebral artery puncture due to
oblique rather than perpendicular view (13).
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stellate ganglion blockade3
Advantages
With this technique, the intravascular injection
is prevented by the prior administration of dye,
identification of bony anatomy is possible, and the
spread of drug is visualized.
Disadvantages
The anterior tubercle is only a surrogate ­marker
of the location of the stellate ganglion. This location
is defined by the fascia plane of the pre-­vertebral
fascia, which can’t be visualized using fluoroscopy.
Soft tissue structures surrounding the stellate ganglion are poorly visualized, including the longus
coli muscle, the thyroid gland, and the esophagus,
leading to increased risk of injury (15). The precise
needle placement into the subfascial plane of the
longus coli is not possible (16). The contrast agent
may show aberrant and inconsistent spread (16).
The fluoroscopic technique helps to avoid inadvertent intravascular injection of local anesthetic agent,
but the injection can be identified only after artery
is punctured. Therefore, vascular injury is possible (15).
CT/ MRI guided block
The spread of local anesthetic agent after C6
stellate ganglion block has been defined using computerized axial tomography (CAT) in 10 patients.
Radiocontrast and local anesthetic mixture were
given in 5 ml increments up to a 20 ml total volume
for C6 stellate ganglion nerve blocks in eight patients and C7 in two patients. CAT scanning was
performed at baseline and after 5, 10, 15, and 20 ml
administration. Cervical level and pattern of spread
was recorded after each increment. One half of the
injections were beneath the pre-vertebral fascia. Injections on top of the fascia spread more diffusely
around C6. All injections of high volume reached
the medial aspect of T1 around the head, not neck,
of the first rib (16).
Advantages
Although fluoroscopic guidance has helped reducing the complication rate of stellate ganglion
blocks, some complications such as lesions to the
lung or pleura may occur, particularly when a C7
approach is performed. Moreover, the accuracy of
needle placement allowed by the use of CT guidance, which is highly superior to that of fluoro­scopic
guidance, explains the low complication rate (1.7%)
with that technique (17).
Disadvantages
The use of MRI and CT can be expensive,
time-con­suming, and impractical for most pain physicians. Another point to consider is that different
blocks in the same patient can produce variable
spread and may consequently explain the inconsistent outcomes seen with a “blind” technique (18).
Studies using MRI (8) or CT (16) have failed
demonstrating any evi­dence of spread to the stellate
ganglion itself, although in the CT study, the stellate
ganglion could not actually be visualized. However,
an ultrasound imaging study showed spread from
C4 to C7 while us­ing 5 ml of local anesthetic mixture. In that study, the authors considered to be an
effective clinical stellate ganglion block in 23 out of
24 cases (19).
Ultrasound guided stellate ganglion block
The success or failure of either blind or fluoroscopic-guided injection depends on the thickness of
the longus coli muscle, and on the anatomic location of the cervical sympathetic trunk. The endpoint
for injection in the ultrasound-guided technique is
the pre-vertebral fascia, and not a contact with bone
as with the fluoroscopy and blind techniques.
Technique
The patient is positioned in the supine or lateral position. A high frequency linear transducer (613 MHz) is placed at the level of C6 or C7 to enable
cross sectional visualization of anatomic structures
– the transverse process and anterior tubercle of C6,
the longus coli muscle, the pre-vertebral fascia covering the muscle, the carotid artery, and the thyroid
gland. The transducer is gently pressed between the
carotid artery and the trachea, in a para-tracheal approach, to retract the carotid artery laterally and to
position the transducer close to the longus coli. A
1.0 inch, 25 G needle is inserted para-tracheally,
with the needle staying out-of -plane to the ultrasound beam towards the middle of the longus coli.
A pre-scan is important to determine the path
of needle insertion, as the esophagus, the inferior
thyroid artery, and, in some cases, the vertebral
­artery may obviate the needle insertion path ­between
the carotid artery and the trachea. In this situation,
the needle is inserted lateral to the carotid artery
(Fig. 2). When advancing the needle from the lateral
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Fig. 2. — Colour doppler mode used before needling to identify
major vessels. [A] Thyroid gland. [B] Carotid artery [C] Internal Jugular vein. [D] Vertebral artery [E] Transverse process of
C7.
aspect, the best interval is between the carotid artery
and the tip of the anterior tubercle, with needle staying in plane of the ultrasound beam. This needle
path avoids hitting the cervical nerve root. This
pathway is intramuscular, with needle passing
through the sternocleidomastoid and anterior scalene muscle. With this approach, the internal jugular
vein can be visualized by decreasing the probe pressure. Avoiding jugular vein puncture is obtained by
pushing it away with the needle (Fig. 3).
The tip of the needle is directed to the pre-­
vertebral fascia, superficial to the longus coli. A
­total of 5 ml of local anesthetic mixture is injected.
The visualization of the spread under real time scanning is important, insofar as the absence of spread
indicates intravascular injection (20).
et al.
Fig. 3. — Needle path in real time imaging [A] carotid artery
[B] Internal jugular vein [C] Needle piercing the fascia covering longus colli. [D] Transverse process of C7 [E] longus colli.
blockade to the head and neck as compared to sympathetic blockade at the C7 level (2, 14). This is because of the presence of Kuntz’s nerves. The caudal
spread of the solution to the T2 to T3 level is required
to block the sympathetic outflow to the upper extremity.
Methylene blue dye has been visualized at the
stellate ganglion level in only 46% of cases when
the C6 level is targeted, while at C7 the dye was seen
in 63% of cases (22). Therefore, the C7 level may be
more appropriate for upper limb sympathetic blockade.
Advantages
Conclusion
This technique improves the safety of the procedure through the direct visualization of the related
soft tissue structures that are not visualized with
fluoroscopy. It minimizes the risk of thyroid gland,
vessels, including vertebral artery, or esophageal injury (21). A minimal amount of drug is also needed (22). It provides real time needle advancement so
that the clinician may visualize the needle entry to
the soft tissue target ? and its final placement in the
subfascial plane. Ultrasound guidance allows a direct monitoring of the spread of the local anesthetic
solution. It results in more caudal spread due to subfascial injection than cephalic spread due to suprafascial injection with fluoroscopy.
Studies using MRI or CT have failed to demonstrate any evi­dence of spread to the stellate ganglion itself, However, the use of ultrasound imaging
has shown spread from C4 to C7. The bedside availability of ultrasound, the visualization of soft tissues, and the subfascial drug deposition with realtime imaging place the ultrasound above other
imaging modalities.
Level of sympathetic blockade
Studies have shown that blockade at the C6
level have resulted in more successful sympathetic
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