Download Persistent ptosis following stellate ganglion block with local anesthetic

￭증례보고￭
Anesth Pain Med 2009; 4: 87～90
Persistent ptosis following stellate ganglion block with local
anesthetic
−A case report−
Departments of Anesthesiology and Pain Medicine, *Ophthalmology, College of Medicine, The Catholic University of Korea, Seoul, Korea
Seung Yong Kim, M.D., Young Hoon Kim, M.D., Suk Woo Yang, M.D.*, and Dong Eon Moon, M.D.
A 45-year-old woman underwent stellate ganglion block (SGB) for
treatment of anosmia. She was treated with standardized SGB two
to three times a week for two months. Although her anosmia
improved slightly, she complained of discomfort and persistent
ptosis in her left eye after the fourteenth block. After a five-month
observation period, she was evaluated in the department of
ophthalmology for persistent ptosis. A phenylephrine test suggested
a neurogenic origin for the ptosis. Surgical repair was performed.
Clinicians should be careful when performing SGB with local
anesthetics to avoid microtrauma, ischemic injury, and neurotoxic
injury of the sympathetic nerve fibers. (Anesth Pain Med 2009;
4: 87∼90)
CASE REPORT
A 45-year-old woman complained of anosmia lasting for one
year. Her anosmia developed shortly after a mild upper respiratory tract infection. She was evaluated in the department of
neurosurgery with brain magnetic resonance imaging (MRI),
but the probable cause of sensorineural anosmia was not determined. Although she underwent treatment with acupuncture,
herbal medicine, and medication from the department of otolaryngology, her symptom did not subside.
Key Words: anosmia, complication, Horner’s syndrome, phenylephrine, ptosis, stellate ganglion.
After failing all other treatments, she visited the pain clinic.
We performed a series of SGB’s on each side alternately two
to three times a week for two months using the paratracheal
Stellate ganglion block (SGB) is a procedure for blocking
technique with a 25-gauge needle inserted at Chassaignac’s
the lower cervical and upper thoracic sympathetic chain, and it
tubercle on the sixth cervical vertebra. We injected 6 ml of
is capable of increasing the cerebral blood flow and modifying
1.0% lidocaine for each block. After the eleventh block, the
the immunologic reaction.1,2) It is applicable in the treatment of
patient’s anosmia improved slightly.
olfactory dysfunction caused by sensorineural impairment in the
However, after the fourteenth block on her left side, she
olfactory nerves.3)
complained of discomfort and persistent ptosis in the ipsilateral
Successful block induces a typical Horner’s syndrome on the
eye. Anhidrosis was not demonstrated. Signs of miosis and
treated side that usually disappears spontaneously after a short
conjunctival hyperemia were transient. SGB was stopped since
period of time.
unexpected complication happened. After observation for five
We report a case of persistent Horner’s syndrome, an
months, she was evaluated in the department of ophthalmology.
uncommon complication, which we corrected through surgical
Before phenylephrine testing, the marginal reflex distance
repair.
(MRD1) and interpalpebral fissure height (IPF) of her left eye
were noted to be 0.5 mm and 5.5 mm, respectively, suggestive
of significant ptosis (Fig. 1). After two drops of 2.5% phenylephrine HCl and a 5-minute wait, the MRD1 and IPF of her
affected eye increased to 2.0 mm and 7.0 mm, respectively
논문접수일：2008년 11월 24일
책임저자：문동언, 서울시 서초구 반포동 505
가톨릭대학교 의과대학 마취통증의학교실
우편번호: 137-040
Tel: 02-590-1537, Fax: 02-537-1951
E-mail: [email protected]
(Fig. 2). She had persistent ptosis reversed by a phenylephrine
test, which indicated a neurogenic origin. She underwent
surgical repair of the ptosis, including ipsilateral levator advancement and bilateral upper blepharoplasty (Fig. 3). Six months
87
88 Anesth Pain Med Vol. 4, No. 1, 2009
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Fig. 1. Preoperative findings before phenylephrine test. Persistent ptosis
occurs in the left eye after stellate ganglion block with 1% lidocaine.
The left eye marginal reflex distance (MRD1) measures 0.5 mm, and the
interpalpebral fissure height (IPF) measures 5.5 mm. MRD1 indicates the
distance from the upper eyelid margin to the corneal reflex. IPF indicates
the vertical aperture height from the lower eyelid to the upper eyelid.
Fig. 3. Postoperative findings. The left eye marginal reflex distance
(MRD1) measures 2.5 mm, and the interpalpebral fissure height (IPF)
measures 7.5 mm after ipsilateral levator advancement and bilateral upper
blepharoplasty. MRD2 indicates the distance from the lower eyelid margin
to the corneal reflex.
syndrome consist of the central, preganglionic, and postganglionic neurons. The first-order (central) neuronal fibers begin
at the posterolateral hypothalamus. They descend via the brainstem and synapse at the ciliospinal center of Budge-Waller in
the intermediolateral column of the spinal cord at levels C8 to
T2. The second-order (preganglionic) neuronal fibers exit the
spinal cord through the ventral roots and ascend in the
cervical sympathetic chain to the superior cervical ganglion.
The
third-order
(postganglionic)
neuronal
fibers
exit
the
ganglion to ascend along the carotid artery. Nerve fibers to the
eyeball, eyelid, and orbit follow the internal carotid artery into
Fig. 2. Preoperative findings after phenylephrine test. After a phenylephrine test, the left eye marginal reflex distance (MRD1) measures 2
mm, and the interpalpebral fissure height (IPF) measures 7 mm.
the skull and pass into the cavernous sinus. They then run
along the sixth cranial nerve and merge with the ophthalmic
division of the trigeminal nerve (V1) to the orbit. Horner’s
syndrome can result from interruption of any level of these
later, ptosis correction was maintained without relapse, and she
components.4,5) Since SGB is related to the preganglionic
was satisfied with the result of the repair.
neuronal fibers, it is important to investigate a neurogenic
origin for persistent ptosis.
DISCUSSION
Although the diagnosis of Horner’s syndrome is established
by history and clinical observation, pharmacological testing can
Horner’s syndrome, also called oculosympathetic paralysis, is
be used to confirm the diagnosis and to localize the lesion.
caused by interruption of the sympathetic innervation to the
The foundation of the pharmacological tests is the ability of
eye and ocular adnexae. The relevant structures include the
the normal sympathetic postganglionic nerve to synthesize and
dilator pupillae muscle of the iris, Müller muscle of the upper
release norepinephrine at its terminals. The cocaine or pheny-
eyelid, sweat glands of the face, and smooth muscles of blood
lephrine test can be used to confirm the presence of sym-
vessels related to miosis, ptosis, anhidrosis, and conjunctival
pathetic denervation. After confirmation of the denervation,
4,5)
This patient presented with persistent ptosis after
hydroxyamphetamine (Paredrine) can be used to distinguish
SGB, but anhidrosis was not present, and miosis and con-
central and preganglionic lesions from postganglionic lesions.4,5)
hyperemia.
junctival hyperemia were transient phenomena. A diagnosis of
persistent Horner’s syndrome was made.
The sympathetic pathways to the targets related to Horner’s
Cocaine inhibits the reuptake of norepinephrine at the synaptic
junction between the postganglionic fibers and the dilator
pupillae muscle of the iris. A negative response to cocaine
Seung Yong Kim, et al：Persistent ptosis after stellate ganglion block 89
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instillation indicates the presence of sympathetic denervation.
needle injury can cause ischemic injury of the sympathetic
However, it does not confirm the location of the lesion.4,5)
fibers. Ekatodramis et al.10) reported prolonged Horner’s syn-
Phenylephrine, an alpha receptor agonist, acts on the sym-
drome due to neck hematoma-induced pressure injury after
pathetically innervated Müller muscle of the upper eyelid. We
continuous interscalene block. They recommended ultrasono-
used the phenylephrine test to evaluate the sympathetic dener-
graphic examination to exclude the presence of a hematoma in
vation. Normally, the upper eyelid margin overlaps the superior
case of persistent Horner’s syndrome. We noted no signs of
6)
When the upper eyelid
hematoma formation (i.e., swelling of the neck). However,
margin descends more than normal, ptosis can be quantified by
Kapral et al.11) showed that the blind technique resulted in
measuring the IPF and MRD1. IPF indicates the vertical height
asymptomatic hematoma formation in 3 out of 12 patients,
from the lower eyelid to the upper eyelid. MRD1 indicates the
with no hematoma occurring during ultrasonographic guided
distance from the light reflex on the cornea to the upper
SGB. Gold et al.12) demonstrated that lidocaine could cause
eyelid margin. Ptosis is graded according to the MRD1; mild
direct neurotoxic injury to neurons in an animal study, even in
when it is greater than 1.5 mm, moderate when it is between
clinical concentrations. Hodgson et al.13) reported that all local
corneal limbus by about 2 mm.
6)
0.5 and 1.5 mm, and severe when it is below 0.5 mm.
In
anesthetics have potential neurotoxic effects, especially in con-
our patient, the MRD1 before the phenylephrine test was 0.5
centrations higher than those used clinically. The mechanism of
mm, suggestive of moderate ptosis. It increased by 1.5 mm
local anesthetics-induced neurotoxicity includes an increase in
after the phenylephrine test. The IPF also increased from 5.5
intracellular Ca2＋, membrane disruption, altered perineural
mm to 7.0 mm, as much as the MRD1 did. This is paralleled
permeability, and edema.12,14,15) Moreover, we considered the
by the fact that the Müller muscle lifts the upper eyelid by
possibility of neurotoxic injury caused by the alcohol used for
about 2 mm as an adjunct elevator under normal conditions.6)
skin preparation, but SGB was performed after the skin dried.
Our findings indicated recovery of function of the Müller
One case of Horner’s syndrome lasting for one year
muscle. The findings of the phenylephrine test suggested a
following SGB has been reported.16) The investigators believed
neurogenic origin of the ptosis.
inflammation might have caused blepharospasm mimicking ptosis,
Hydroxyamphetamine causes pupillary mydriasis by releasing
because the signs and symptoms were resolved by treatment
norepinephrine from the postganglionic nerve endings. Pupillary
with a nonsteroidal anti-inflammatory agent for two weeks.
dilatation will not occur if a lesion exists in the postganglionic
Some cases of persistent Horner’s syndrome have been re-
Yet, we did not conduct the hydroxyamphetamine test
ported after interscalene block or epidural block.10,17,18) Most of
in this case. We believed that no central lesion was present
them have spontaneously recovered after one year. Sympa-
because there were no symptoms or signs suggestive of a
thetic preganglionic fibers have proven capable of regenerating
mass or vascular lesion, and there were no specific brain MRI
after denervation in animal studies. McLachlan19) resected the
findings. Moreover, hydroxyamphetamine is no longer commer-
cervical sympathetic trunk of guinea pigs and reported that
cially available.7) Although we were not sure if the origin of
reinnervation was nearly complete after three months. In
denervation was in the preganglionic or postganglionic fibers,
another experiment, Purves20) cut the cervical sympathetic trunk
we concluded that the persistent ptosis was due to sympathetic
below the caudal pole of the superior cervical ganglion of
denervation following SGB with local anesthetic.
guinea pigs and showed that most synaptic responses returned
fibers.
4,5)
Although the etiology of Horner’s syndrome in this case
to normal after six to seven months. However, if a patient has
was not determined, the authors discussed the possibilities of
trouble with ptosis, surgical repair is a treatment option in
microtrauma, ischemic injury, and neurotoxic injury of the
compliance with the patient’s request.17,18) We observed our
sympathetic fibers. Iannuzzi et al.8) suggested that bony contact
patient for five months and decided to perform surgical repair
of spinal needle can deform the needle tip (i.e., bending,
according to the patient’s needs. According to the literature,
splintering, or tearing) which may be the cause of microscopic
Müllectomy is the surgery of choice for the repair of ptosis
dural lacerations. The damaged needle tip may cause tears of
due to Horner’s syndrome.6) However, ipsilateral levator advan-
the sympathetic fibers, however carefully the SGB was
cement and bilateral upper blepharoplasty were performed in
performed. Hadzic et al.9) showed that high injection pressure
this case since the patient requested repair of her mild contra-
might indicate intraneural needle placement and lead to fasci-
lateral ptosis, as well.
cular injury and neurologic deficits in dogs. Microvascular
In conclusion, clinicians should be fully aware of the possi-
90 Anesth Pain Med Vol. 4, No. 1, 2009
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bility of persistent Horner’s syndrome after SGB with local
anesthetics, especially since a series of SGB’s is performed
frequently by a number of pain specialists. To minimize the
possibility of persistent Horner’s syndrome following SGB, we
suggest that clinicians avoid needle tip deformity due to bony
contact, dilute local anesthetics as much as possible, avoid
high injection pressure, administer the injection after the
alcohol preparation dries, and diminish the likelihood of
hematoma by means of ultrasonographic guided SGB or
adequate compression.
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