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Paravertebral Cevical Sympathetic Block


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Presented at Egyptian Anesthesia 2011 @ MEDICONEX 2011

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Paravertebral Cevical Sympathetic Block

  1. 1. Paravertebral cervical sympathetic block Dr. Ahmed Helmy Abouel Soud Board member of ESMP Professor of Pain Relief, N.C.I., Cairo University, Egypt
  2. 2. History <ul><li>Selective block of the sympathetic trunk was first reported by Sellheim and shortly thereafter, by Läwen, Kappis, and Finsterer between 1905 – 1910 </li></ul><ul><li>Reports were published by Brumm , Mandle and Swertlow in 1924 </li></ul><ul><li>After 1930 , the technique and indications were established by White in U.S.A. , and Leriche and Fontaine in Europe </li></ul>
  3. 3. Paravertebral sympathetic chain & ganglia <ul><li>Cell bodies (intermedio-lateral D1- L2) </li></ul><ul><li>Tow trunks along ventrolateral aspect of vertebral column </li></ul><ul><li>C2 to coccyx (internal carotid & ganglion impar) </li></ul><ul><li>Cervical : 4, thoracic : 10-12, lumbar : 3-5, sacral : 4-5 and 1 coccygeal </li></ul><ul><li>Cervical: superior, middle, intermediate and inferior </li></ul>
  4. 4. Patient selection <ul><li>Hyperactive sympathetic outflow: </li></ul><ul><li>CRPS </li></ul><ul><li>Phantom pain </li></ul><ul><li>Ischemic vascular diseases </li></ul><ul><ul><li>Hyperhidrosis </li></ul></ul>
  5. 5. Indications of Stellate block <ul><li>Reynaud's disease , arterial embolism in the area of the arm, accidental intra-arterial injection of drugs </li></ul><ul><li>Herpetic and post herpetic neuralgia </li></ul><ul><li>Post-traumatic syndrome (e.g. reflex dystrophy, causalgia, and Sudeck's disease, phantom pain) </li></ul><ul><li>Hyperhidrosis </li></ul><ul><li>N.B. simultaneous bilateral blocks are not advisable except in case of pulmonary embolism </li></ul>
  6. 6. Contraindications <ul><li>Absolute : coagulation defects, local infection, recent cardiac infarction, and contralateral pneumothorax and pneumonectomy </li></ul><ul><li>Relative : glaucoma, A-V heart block </li></ul>
  7. 7. Applied anatomy and important relations Preganglionic fibers <ul><li>Origin of fibers to head & neck is the 1 st and 2 nd thoracic segment </li></ul><ul><li>Origin of fibers to upper extremity is segments D2-D8 </li></ul>
  8. 8. Preganglionic axons <ul><li>Preganglionic axons to the head and neck exit with the ventral roots of D1-D2, travel as white communicating rami before joining the sympathetic chain, passing cephalad to synapse at superior, middle, intermediate or inferior cervical ganglion </li></ul>
  9. 10. Stellate ganglion <ul><li>In 80% of individuals the inferior cervical ganglion is fused to the 1 st thoracic ganglion, forming the Stellate ganglion. </li></ul><ul><li>It commonly measures 2.5 cm long, 1.0 cm wide, and 0.5 cm thick. </li></ul><ul><li>It lies anterior of the neck of the 1 st rib and extends to interspace between C7 & D1 </li></ul>
  10. 11. Stellate ganglion <ul><li>It may lie over the anterior tubercle of C7 </li></ul><ul><li>In individuals with unfused ganglia, the inferior cervical ganglion rests over C7, and the 1 st thoracic ganglion over the neck of the 1 st rib </li></ul>
  11. 12. Stellate ganglion <ul><li>It is limited medially by the longus colli muscle </li></ul><ul><li>Laterally by the scalene muscles </li></ul><ul><li>Anteriorly by the subclavian artery at the point of origin of vertebral artery </li></ul><ul><li>Posteriorly by the neck of 1 st rib, transverse process of C7 and prevertebral fascia </li></ul><ul><li>Inferiorly by posterior aspect of pleura </li></ul>
  12. 13. Stellate ganglion <ul><li>It is 5 mm anterolateral to the bony structures, being separated from them by loose areolar and adipose tissue and longus colli muscle. </li></ul><ul><li>The loose areolar and adipose tissue facilitate diffusion of solutions (L.A.) deposited near the ganglion </li></ul>
  13. 14. Stellate ganglion <ul><li>The lower part of the Stellate connects with the D2 sympathetic ganglion, which contains the largest number of the synaptic connections between the pre. and postganglionic sympathetic fibers that supply the upper limb </li></ul><ul><li>Usually all the sympathetic nerves that supply the head and neck, and most of those that supply the upper limb, traverse the Stellate ganglion , thus blocking the Stellate ganglion effects a temporary sympathetic denervation of these areas </li></ul>
  14. 15. Important anomaly <ul><li>Anomalous pathways bypass the Stellate ganglion ( Kuntz's nerves ): intrathoracic somatic branches arising from D2 and D3 spinal nerves joined by grey rami communicantes carrying postganglionic sympathetic fibers of D2 and D3 sympathetic ganglia </li></ul>
  15. 16. Clinical importance of Kuntz's nerves <ul><li>Sometimes blocks limited to the Stellate ganglion or a pure Stellectomy do not produce complete sympathetic denervation of the upper limb </li></ul><ul><li>Because all the fibers to the upper limb pass through D2 and occasionally D3 ganglia, it deemed necessary to block these (key) relay stations to achieve adequate sympathetic block </li></ul>
  16. 17. The other Cervical sympathetic ganglia <ul><li>Superior, middle, and intermediate </li></ul><ul><li>The superior is the largest, the middle is the smallest, and the intermediate is intermediate in size </li></ul><ul><li>They lie on the longus colli muscle and are thus in the same fascial plane as the stellate ganglion </li></ul>
  17. 18. Methods of block <ul><li>Short term (Stellate block, L.A.) </li></ul><ul><li>Long term (permanent), neurodestruction i.e. Stellate sympathectomy </li></ul>
  18. 19. Techniques <ul><li>Anterior paratracheal </li></ul><ul><li>Lateral </li></ul><ul><li>Anterolateral </li></ul><ul><li>Superior </li></ul><ul><li>Posterior </li></ul>
  19. 20. Anterior paratracheal technique <ul><li>Pre-operative visit </li></ul><ul><li>Placement of I.V. line & monitors (ready for resuscitation) </li></ul><ul><li>Supine position (head flat & thin pillow under the shoulders to facilitate extension of the neck and make palpation of bony landmarks easier, hyperextension helps to move the esophagus to the midline) </li></ul><ul><li>Head is in the midline position with the mouth slightly open to relax the muscles </li></ul>
  20. 21. Anterior paratracheal technique <ul><li>The site of needle entry is at C6 level (cricoid cartilage) , Chaussignac's tubercle , about 3.0 cm cephalad to the sternoclavicular joint, 1.5 cm lateral to the midline </li></ul><ul><li>Gentle but firm probing can easily define the borders of the tubercle by the index finger of the operator's nondominant hand or traps it between the index and middle fingers </li></ul>
  21. 22. Anterior paratracheal technique <ul><li>A 23-25 gauge 4-5 cm needle is used and pushed in a posterior direction and perpendicular to the table in all the planes, until it contacts bone (C6 tubercle, or the junction between C6 body and tubercle) </li></ul><ul><li>If the skin is being properly displaced posteriorly by the operator's fingers, the depth is rarely beyond 2.0-2.5 cm </li></ul>
  22. 23. Anterior paratracheal technique <ul><li>Once the bone is encountered, the palpating fingers maintain the pressure, the needle is withdrawn 2-5 mm, negative aspiration in four quadrants, then injection of the L.A. solution slowly in small increments and after an initial test dose </li></ul><ul><li>Talking is prohibited and instead pointing the hand or fingers for any reason </li></ul>
  23. 24. Anterior paratracheal technique <ul><li>Repositioning of the needle is essential (positive aspiration before injection or paresthesia of arm or hand is elicited during injection) </li></ul><ul><li>The level of the desired block (head & neck, upper limb or chest) can be achieved by the volume of L.A. solution used (5 ml, 10-12 ml & 15-20 ml), changing the patient's position following the block </li></ul>
  24. 25. Clinical evidence of the block <ul><li>Interruption of sympathetic innervations to the head and neck (Horner's syndrome) </li></ul><ul><li>To the upper limb (visible engorgement of the veins on the back of the hand and forearm & rise in skin temperature, provided that the pre-block temperature did not exceed 33-34 ˚C </li></ul>
  25. 26. Side effects & complications <ul><li>Horner's syndrome </li></ul><ul><li>Diffusion of injectable solution (L.A.) to nearby nerves: recurrent laryngeal nerve, phrenic nerve, brachial plexus </li></ul><ul><li>Intravascular (vertebral artery) and intraspinal injection </li></ul><ul><li>Cerebral air embolism and pneumothorax </li></ul>
  26. 27. Neurodestruction Methods <ul><li>Open surgery </li></ul><ul><li>Radio-active material </li></ul><ul><li>Cryo-surgery </li></ul><ul><li>Direct current </li></ul><ul><li>Focused ultrasound </li></ul><ul><li>Laser </li></ul><ul><li>Chemical </li></ul><ul><li>Radiofrequency </li></ul>
  27. 28. RF Principles <ul><li>Microprocessor based device </li></ul><ul><li>High frequency current 500 KHz/sec </li></ul><ul><li>Thermocouple electrode </li></ul><ul><li>Stimulation and lesion production </li></ul><ul><li>Monitor impedance, stimulation & temperature </li></ul>
  28. 29. Why Radiofrequency ? <ul><li>Percutaneous </li></ul><ul><li>Functional confirmation </li></ul><ul><li>Precise </li></ul><ul><li>Controllable </li></ul><ul><li>reproducable </li></ul>
  29. 30. Imaging <ul><li>Fluoroscopy: </li></ul><ul><li>No soft tissue </li></ul><ul><li>Simple </li></ul><ul><li>Fast </li></ul><ul><li>CT- guidance: </li></ul><ul><li>Soft tissue visualization </li></ul><ul><li>Safe </li></ul><ul><li>Time consuming </li></ul>
  30. 31. Technique <ul><li>Supine position, head extended & L.A. </li></ul><ul><li>C7 localization </li></ul>
  31. 32. RF Thermal Lesions <ul><li>Competent RF generator </li></ul><ul><li>Suitable Kits </li></ul>
  32. 33. RF Parameters <ul><li>Negative sensory stimulation at 50 Hz up to 1.0 V </li></ul><ul><li>No motor response to stimulation at 2 Hz up to 3.0 V </li></ul><ul><li>2-3 lesions at 70-80°C for 60-90 seconds </li></ul>
  33. 34. Results <ul><li>Immediate or rapid onset of symptom relief </li></ul><ul><li>Couple of months & up to years </li></ul><ul><li>75-95 % success </li></ul><ul><li>Temporary neck or back pain </li></ul>
  34. 35. Conclusion <ul><li>Simple, safe and reproducible interventional pain therapy </li></ul><ul><li>N.B. good selection of the patients and proper timing is the key for success </li></ul>
  35. 36. Alleviate pain, save fingers and stop sweating