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      Evaluation of new approach to ultrasound guided stellate ganglion block

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          Abstract

          Background:

          Ultrasound imaging is an ideal tool for stellate ganglion block (SGB) due to clarity, portability, lack of radiation, and low cost. Ultrasound guided anterior approach requires the application of pressure to the anterior neck and is associated with more risk of injury to inferior thyroid artery, vertebral artery, and esophagus. The lateral approach does not interfere with nerve or vascular structures. Blockade at the C 6 vertebral level results in more successful sympathetic blockade of the head and neck with less sympathetic blockade of the upper extremity compared to sympathetic blockade at C 7 vertebral level, which produces successful sympathetic blockade of upper extremity. This is helpful in patients of complex regional pain syndrome of the upper limb. Hence, we conducted a study using the lateral approach at C 7 level.

          Materials and Methods:

          Ultrasound guided SGBs using lateral in-plane technique at C 7 level were given in 20 patients suffering from chronic pain patients of upper extremity, head, and neck using 4 ml of 0.25% bupivacaine and 1 ml of 40 mg triamcinolone. The patients were assessed for a numeric pain intensity score (NPIS), the rise in axillary temperature, the range of motion of joints of upper extremity, and resolution of edema at various time intervals up to 3 months.

          Results:

          NPIS showed a statistically significant decrease from baseline at 30 min, which was sustained till 3 rd month. The rise in axillary temperature after the block was statistically significant, which was sustained till 2 nd week. The edema score decreased significantly at all-time intervals ( P ≤ 0.001). The restriction of motion in all joints of upper limb decreased from 13 to 3 patients.

          Conclusion:

          There is a significant variation in the anatomy of stellate ganglion at the level of C 6 and C 7. Ultrasound guided lateral approach increases the efficacy of SGB by deposition of drug subfascially with real-time imaging.

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          Cervical sympathetic and stellate ganglion blocks.

          Rosilene M Elias (2000)
          Sympathetic blocks in the cervical and upper thoracic region are commonly used techniques for a variety of diagnostic, therapeutic and prognostic purposes. Stellate ganglion block is the common nomenclature utilized, however, stellate ganglion is present in only 80% of the population, thus, either lower cervical sympathetic block or upper thoracic sympathetic block is an appropriate term. The cervical sympathetic ganglia are identified as the superior, middle, intermediate and the inferior cervical sympathetic ganglion. The superior cervical ganglia are approximately 3 to 5 cm in length and situated on the longus capitus muscle anterior to the transverse process of the second, third, and rarely the fourth cervical vertebrae; the middle cervical ganglia are the smallest of the cervical ganglia situated on the longus colli muscle, anterior to the base of the transverse process of the sixth vertebrae; and the intermediate cervical ganglia which are more consistent in position and are located on the medial side of the vertebral artery. The inferior cervical ganglia, when present, are located on the transverse process of the C7 vertebrae, whereas the first thoracic ganglia are situated in front of the neck of the first rib. In 70% to 80% of the population they are fused together forming the stellate ganglion. Stellate ganglion block or lower cervical sympathetic block has been advocated for both diagnostic, therapeutic, and prognostic purposes for a variety of conditions. Even though multiple techniques are advocated in performing this block, fluoroscopically guided sympathetic blocks are more appropriate. Complications of stellate ganglion block include complications related to the technique, infection, and pharmacological complications related to the drugs utilized. Cervical sympathetic or stellate ganglion block is a very commonly performed procedure. If performed correctly, this can provide good therapeutic, prognostic, and diagnostic values.
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            Ultrasound imaging for stellate ganglion block: direct visualization of puncture site and local anesthetic spread. A pilot study.

            S Kapral, Shane P Krafft, M Gosch … (2015)
            Stellate ganglion block (SGB) inhibits sympathetic innervation and is a common treatment for reflex sympathetic dystrophy. During the positioning of the needle, there is a risk of injury to the adjacent structures. The aim of the study was to develop an ultrasonographic imaging technique for the performance of SGB. Twelve patients (ASA I-II) underwent SGB first by using the blind standard technique (group A: 8 mL bupivacaine 0.25%) and a second time by using an ultrasonographic imaging technique (group B: 5 mL bupivacaine 0.25%). In group B a 10 MHz ultrasound scanning probe was used to identify the anatomic structures and to guide the needle toward the transverse process of C6. Stellate ganglion block was satisfactory in 11 of 12 attempts by the blind technique. Ultrasonographic guidance (group B) resulted in a complete block in all patients. Onset of block was observed within 10 minutes in only 10 of 12 group A patients, while all patients in group B exhibited an adequate block after 10 minutes. During the imaging technique, the needle was inserted to an average depth of 22 +/- 3 mm and the injection of 5 mL bupivacaine resulted in an anesthetic depot with a mean diameter of 14 +/- 3 mm. Distance from the depot to the vagal nerve was 5 +/- 3 mm and 5 +/- 4 mm to the root of C6. All patients (n = 4) with a distance of < 1 mm between anesthetic depot and the root of C6 developed paresthesia within the corresponding cutaneous segment. Blind technique resulted in hematoma formation in three study patients, with no hematoma occurring during imaging technique. Ultrasonographic guided SGB may improve safety and allows the visualization of the local anesthetic depot. Studying the local anesthetic spread might allow the avoidance of side effects as well as typical complications of SGB.
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              Development and validation of a new technique for ultrasound-guided stellate ganglion block.

              Michael Gofeld, Anuj Bhatia, Sherif Abbas … (2009)
              Although the stellate ganglion is located anteriorly to the first rib, anesthetic block is routinely performed at the C6 level. Ultrasonography allegedly improves accuracy of needle placement and spread of injectate. The technique is relatively new, and the optimal approach has not been determined. Moreover, the location of the cervical sympathetic trunk relative to the prevertebral fascia is debatable. Three-dimensional sonography was performed on 10 healthy volunteers, and image reconstruction was completed. On the basis of analysis of pertinent anatomy, a lateral trajectory for needle placement was simulated. Accuracy was tested by injection of methylene blue in cadavers. A clinical validation study was then conducted. A block needle was inserted according to the predetermined lateral path, and 5 mL of a mixture of bupivacaine and iohexol was injected. Spread of the contrast agent was verified fluoroscopically. Image reconstruction revealed that the cervical sympathetic trunk is located posterolaterally to the prevertebral fascia on the surface of the longus colli muscle. The mean anteroposterior width of the muscle at the C6 level was 11 mm. The lateral approach does not interfere with any visceral or nerve structures. Anatomic dissection in cadavers confirmed entirely subfascial spread of the dye and staining of the sympathetic trunk. The contrast agent spread was seen in all patients between the C4 and T1 levels in a typical prevertebral pattern. This study revealed that, at the C6 level, the cervical sympathetic trunk lies entirely subfascially. Subfascial injection via the lateral approach ensures reliable spread of a solution to the stellate ganglion.
              Article 0 comments Cited 23 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Saudi J Anaesth
                Journal ID (iso-abbrev): Saudi J Anaesth
                Journal ID (publisher-id): SJA
                Title: Saudi Journal of Anaesthesia
                Publisher: Medknow Publications & Media Pvt Ltd (India )
                ISSN (Print): 1658-354X
                ISSN (Electronic): 0975-3125
                Publication date (Print): Apr-Jun 2016
                Volume: 10
                Issue: 2
                Pages: 161-167
                Affiliations
                [1]Department of Anesthesia and Critical Care, PGIMS, Rohtak, Haryana, India
                [1 ]Department of Orthopedics, PGIMS, Rohtak, Haryana, India
                [2 ]MBBS student, PGIMS, Rohtak, Haryana, India
                [3 ]ENT, Pt. B.D. Sharma, PGIMS, Rohtak, Haryana, India
                Author notes
                Address for correspondence: Dr. Anju Ghai, Department of Anesthesia and Critical Care, Pt. B.D. Sharma, PGIMS, Rohtak, Haryana, India. E-mail: dr.wadhera@ 123456yahoo.com
                Article
                Publisher ID: SJA-10-161
                DOI: 10.4103/1658-354X.168815
                PMC ID: 4799607
                PubMed ID: 27051366
                SO-VID: 768892d0-1b55-410c-906c-03643c3a93eb
                Copyright © Copyright: © Saudi Journal of Anaesthesia
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

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                Subject: Original Article

                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: complex regional pain syndrome,lateral approach,stellate ganglion block,ultrasound guidance
                Data availability:
                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: complex regional pain syndrome, lateral approach, stellate ganglion block, ultrasound guidance

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