Stellate Ganglion Block

Performed by Top Pain Management Doctors in San Antonio, Texas


A nerve block is used to treat chronic pain that is unresponsive to pain medications. Nerve blocks are administered by injecting anesthetic medicine into a group of nerves, called a ganglion, to inhibit pain messages en route to the brain. The stellate ganglion is a group of sympathetic nerves in the neck traveling to the arms and face. A stellate ganglion block may be effective in reducing chronic pain to these body parts.

Stellate Ganglion Block is indicated in the treatment of pain syndromes such as:

  • Complex Regional Pain Syndromes Type 1 and 2
  • Pain syndromes that are maintained by the sympathetic nervous system
  • Shoulder/hand syndrome
  • Reflex sympathetic dystrophy
  • Phantom limb pain
  • Injury to the nerves, known as causalgia
  • Intractable angina
  • Herpetic neuralgia as a result of herpes zoster (shingles)

Conditions involving decreased blood flow and poor circulation of the upper extremities may be treated with stellate ganglion block:

  • Raynaud’s phenomenon
  • Scleroderma
  • Arterial insufficiency

Other conditions involving pain that may be effectively treated with stellate ganglion block include:

  • Hot flashes and disturbed sleep as a result of hot flashes
  • Post-traumatic stress disorder (PTSD)
  • Hyperhidrosis (excessive perspiration) found in the upper extremities and face

Anatomy

The stellate ganglion is formed at the place where the inferior cervical and first thoracic ganglion come together just in front of the C7 vertebral body in the neck. The alar fascial plane may transmit signals to the vertebral artery and brachial plexus. The longus colli muscle and anterior scalene muscle are located behind the stellate ganglion, close to where the carotid sheath, recurrent laryngeal nerve, and phrenic nerve can be found.

Procedure

A stellate ganglion block may be administered in several different routes. The most common route for the physician to take is to inject relatively large volumes (5-20ml) 2mm above the C6 tubercle. This approach is effective in spreading the solution down towards the upper thoracic and stellate ganglia. Alternately, the stellate ganglion block may be administered at the C7 level with a lesser volume of medication, but this approach carries a higher risk of vertebral artery injection resulting in a collapsed lung (pneumothorax). Lastly, the posterior paravertebral approach may be employed. This involves walking the needle off the upper thoracic lamina until proper placement is verified with fluoroscopy. Ultrasound may also be used to help the physician avoid injury to vascular and soft tissues close to the stellate ganglion.

During the procedure, the patient assumes a supine position with the neck slightly extended and the head rotated away from the block, mouth open. After prepping the neck with sterile cleaning supplies and draping the area to maintain a sterile field, the physician injects a local anesthetic into the skin to minimize discomfort during the procedure. Then the physician pushes the sternocleidomastoid muscle and carotid artery aside to palpate the Chassignac’s tubercle with his or her index and middle fingers. Once the area is located, the skin and subcutaneous tissue is firmly pressed aside to minimize the distance between the skin surface and bone. The purpose of this action is to make it easier for the physician to maneuver the needle, avoiding accidental injection of the vertebral artery resulting in a collapsed lung (pneumothorax).

Once the physician has felt the anatomical landmarks, the needle is inserted and fluoroscopy guidance is used to obtain correct position. Fluoroscopy employs X-ray visualization of contrast dye injected into the space to confirm placement of the needle. After verification of correct needle placement, the nerve block is administered by injecting local anesthetic to the stellate ganglion. The evidence of a successful nerve block is profound relief of pain and improvement of blood flow to the ipsilateral upper extremity. Pain relief from a local anesthetic nerve block is temporary, used for diagnostic purposes and to document if a nerve block is effective in treating the patient’s condition. Those patients who produce documented response to the stellate ganglion block are candidates for the same nerve block procedure using a neurolytic agent, such as phenol, for more long-term relief. Another long-term treatment available is radio ablation of the stellate ganglion.

Horner’s Syndrome, which involves pupil constriction, decreased sweating, and drooping of the upper eyelid on the side the block was administered, are normal side effects of the stellate ganglion block procedure. Horner’s Syndrome resolves when the anesthetic wears off, about four to six hours after the block. Though the entire procedure lasts only 15 minutes, the physician may order intravenous sedation to allow the patient to relax and remain comfortable during the administration of the nerve block. After the procedure, vital signs are monitored and the patient is asked to assume a sitting position in order to allow for the spread of the anesthetic medication.

Benefits

This procedure takes only minutes to perform and is minimally invasive, yet effective in treating many conditions where other interventions have failed. Stellate ganglion block has been shown to provide relief of sympathetic-related facial, chest, and upper extremity pain. It may also affect the upper extremities and face by reducing hot flashes and perspiration, allowing patients to resume normal sleeping habits. This treatment is showing promise in helping patients with Post Traumatic Stress Disorder (PTSD).

Risks

Though the procedure for administering a stellate ganglion block is low risk, complications may occur. Improper placement of the needle may cause:

  • Nerve injury
  • Bleeding
  • Esophageal perforation
  • Pneumothorax (collapsed lung)

If the anesthetic is injected to the wrong area and spreads, the patient may experience:

  • Seizure, from injection of medication into a blood vessel
  • Hoarseness, caused by accidentally anesthetizing the recurrent laryngeal nerve
  • Shortness of breath, a result of anesthetizing the phrenic nerve
  • Spinal or epidural block, manifesting as transient weakness or numbness occurring from the neck down during the injection

Infection is always a possibility when a needle is inserted into the skin.

Outcomes

Three possible outcomes may occur after the stellate ganglion block is administered:

  1. Immediate relief of pain, either complete or greatly reduced, which informs the physician that a nerve block is effective and helps with the formation of a more long-term treatment plan.
  2. Evidence of a sympathetic blockade occurs without relief of pain. This result is a diagnostic tool alerting the physician that the pain is unresponsive to a block of the sympathetic nerves, and other treatment options should be considered.
  3. There is no evidence of a sympathetic blockade, which means that the physician was unsuccessful in performing the procedure.

Stellate ganglion blocks are well documented as an effective treatment for pain syndromes related to the sympathetic nervous system. However, conditions involving decreased blood flow to the upper extremities resulting in arterial insufficiency may also be effectively treated by stellate ganglion block. This includes Raynaud’s phenomena and scleraderma, in which stellate ganglion block is able to increase blood flow significantly while decreasing the number of episodes of Raynaud’s. Also, patients with intractable angina for whom medical and surgical intervention has failed may experience relief of pain during advanced cardiovascular disease. According to Lipov et al. (2008), studies suggest that the minimally invasive stellate ganglion block is capable of giving patients relief of hot flushes and the associated sleep dysfunction in breast cancer survivors. The records show that patients achieved long-term relief of symptoms with stellate ganglion block, a treatment in compliance with anti-estrogen medications. The same study reveals that patients with PTSD may also experience relief of symptoms with administration of stellate ganglion block.

However, it is important to note that the benefits of stellate ganglion block may vary in terms of duration and amount of symptom relief. Some patients will notice a return of symptoms in a few weeks, while others may benefit from the treatment for several years. The benefits outweigh these factors, because the stellate ganglion block is low risk, minimally invasive, and can be performed repeatedly with good results.

Journal Articles/Resources

  1. Stellate Ganglion Block – PainDoctor.com
  2. Elizabeth Cudilo M.D, Paul Lynch M.D, and Tory McJunkin M.D. Stellate Ganglion Block. Retrieved from http://arizonapain.com/pain-center/pain-treatments/stellate-ganglion-block/
  3. MD Medicine. (May 18, 2011). Stellate Ganglion Block (cervicothoracic sympathetic block). Retrieved from http://mdmedicine.wordpress.com/2011/05/18/stellate-ganglion-block-cervicothoracic-sympathetic-block/