stellate ganglion block

1. SYMPATHETIC BLOCK FOR HEAD & NECK
AND UPPER EXTREMITIES
ANATOMY, LANDMARK BASED AND USG GUIDED TECHNIQUE
DR. RIYA SHARMA
MODERATOR : DR. POOJA MONGIA

2. Cervical sympatheticblock:Stellateganglionblock
Interruption of the sympathetic efferent fibres to the upper extremity,
head, and neck.
Diagnostic Prognostic Therapeutic

3. Cervical sympathetic block
Diagnostic :
◦ To determine if the pain is sympathetically mediated or not.
Prognostic:
◦ To determine if neurolysis or surgical sympathectomy could be beneficial

4. ANATOMY
The cervical sympathetic chain
comprises of superior, middle, &
inferior cervical ganglia
In 80% population, the inferior
cervical ganglion is fused with the
first thoracic ganglion, forming the
CERVICOTHORACIC or the STELLATE
ganglion

5. ANATOMY
Chassaignac tubercle refers to the paired
anterior tubercles of the transverse processes
of 6th
cervical vertebrae

6. ANATOMY
Oval shaped 2.5 x 1 x 0.5 cm
At the level of C7-T1, anterior to the
transverse process of C7 & 1st
rib &
longus coli muscle
Nearby structures
 the brachial plexus,
 spinal nerve roots,
 the prevertebral portion of the vertebral
artery
 Subclavian artery
 Cervical pleura

7. Sympathetically mediated pain occurs when the sympathetic component of the autonomic nervous
system is dysfunctional
The sympathetic block appears to interrupt and reset the dysfunctional autonomic nervous system,
while the resulting analgesia also permits more aggressive rehabilitation

8. INDICATIONS
Most common indication - sympathetically mediated pain
Less common indications
◦ VT and electrical storm
◦ Hyperhidrosis
◦ Postherpetic neuralgia
◦ Ménière disease
◦ Accidental intra arterial injection of intravenous medications,
◦ Frost bite
◦ Angina pectoris
◦ Hot flashes and
◦ Posttraumatic stress disorders.
◦ Raynauds syndrome

9. ELECTRICAL STORM :
3 or more sustained episodes of
Ventricular tachycardia or
ventricular fibrillation or
appropriate ICD shocks
Within 24 hours
INDICATIONS

10. Upper extremity
CRPS
INDICATIONS

11. Sympathetic pain of head
and neck/Phantom limb pain
INDICATIONS

12. Acute herpes zoster pain /
Post herpetic neuralgia
INDICATIONS

13. Pain secondary to
neoplastic infiltration,
Paget's disease.
INDICATIONS

14. Arterial embolism/
Venous insufficiency
INDICATIONS

15. Frostbite
INDICATIONS

16. CONTRAINDICATIONS
◦ Coagulopathy,
◦ Pneumothorax,
◦ Glaucoma
◦ Atrioventricular block

17. STELLATE GANGLION BLOCK
TECHNIQUES
Surface
Landmark
Technique
Fluoroscopic
Technique
Ultrasound
guided
CT guided

18. SURFACE LANDMARK TECHNIQUE
C6 Anterior Approach
A successful block is seen by the onset of Horner syndrome with
affected extremity temperature increase greater than 3°F (typically
seen within 3 min)

19. SURFACE LANDMARK TECHNIQUE
Supine position with slight extension of
the neck.
Head turned to the opposite side.
Cricoid cartilage is palpated to find the C6
level
Or more specifically, the C6 transverse
process (chassaignac’s tubercle)
Most individuals , tubercle ~ 3-4 cm
cephalad to the sternoclavicular joint at
the medial border of the SCM

21. SURFACE LANDMARK
TECHNIQUE
The skin and subcutaneous tissue are pressed firmly
onto the tubercle
Needle advanced in AP direction retracting
Carotid to hit the tubercle
Needle withdrawn 2 mm to to come out of longus
colli muscle
Bupivacaine (0.125-0.5%) or Ropivacaine, 0.2%
1 mL test dose after negative suction 8-10 ml LA
injected with repeated negative aspiration
Monitored for 30 mins for evidence of blockade

22. FLOUROSCOPY GUIDED
Landmarks and patient positioning similar to blind technique
Bony delineation better – fluoroscopy
Soft tissues including vascular structures -ultrasound
Both the C6 transverse process approach and the C7 anterior
paratracheal approach can be done
Contrast to confirm appropriate needle placement
◦ Proper facial plane- local spread of contrast between the tissue planes both
cephalad and caudad.
◦ Striated appearance – Intramuscular
◦ Intravascular injection -immediate dissipation of dye

23. Flouroscopy guided

24. USG GUIDED
C6 transverse process approach
Position & Needle insersion site Similar
Carotid sheath and SCM muscle retracted laterally with
transducer
Pressure is applied with the transducer
 reduce the distance between the skin and tubercle
 depresses dome of lung to reduce risk of pneumothorax

25. USG GUIDED
The needle is inserted towards to the
Chassaignac tubercle,
The needle is then withdrawn 1-2 mm to bring it out
of the longus colli muscle while still staying within the
prevertebral fascia.
After negative aspiration, 1-2 mL of local anesthetic
can be injected, and spread can be visualized with
ultrasound.
Once confirming that the injection was subfascial, the
remaining local anesthetic can be given.

26. ULTRASOUND IMAGE OF THE LEFT NECK AT THE
LEVEL OF C6 BEFORE STELLATE GANGLION
BLOCK.
CA, CAROTID ARTERY; C6, ROOT OF C6;
LC, LONGUS COLLI MUSCLE;
TP, TRANSVERSE PROCESS OF C6;
TH, THYROID GLAND;
ES, ESOPHAGUS

27. C7 Anterior Approach
Nearly identical to the C6 approach.
Performed with USG or fluoroscopy - anatomical landmarks are more difficult to identify
because the C7 vertebra has only a vestigial tubercle that is not readily palpable.
Risk of pneumothorax and vertebral artery injury is higher.
Advantages
◦ Needle is closer in proximity to ganglion
◦ A smaller volume of LA agent with more reliable and consistent blockade.
◦ Particularily usefull - failed blockade at the c6 level.
An oblique C7 fluoroscopic approach targeting the junction between the uncinate process
and the vertebral body is described in an effort to decrease those risks.
Lateral approach (USG Guided) also described

28. CT guided technique
By using CT scanning or CT fluoroscopy, the head of the first rib is identified, as well as the
adjacent vertebral artery and vein. Under sterile conditions, the skin and needle track are
anesthetized, and a 25-gauge spinal needle is maneuvered onto the head of the first rib,
as close to the vertebral body as possible. The physician should take care to avoid the
vertebral vessels (see image below).

29. The needle tip should be placed on the cortex to minimize the likelihood of intravascular placement, and after
negative aspiration a small amount of iodinated contrast material is injected to confirm an extravascular
location of the needle tip (see image below).
Once the needle is in place, a small amount of blocking agent is injected.The needle is withdrawn, and
pressure is held for 5-10 minutes.
CT guided technique

30. Expected result
Patients usually develop Horner’s syndrome,stuffynose and increased
temperature(1.5`C) on the ipsilateral side of the block (face and upper
extremity) within 5 minutes after the procedure.

31. COMPLICATIONS
Misplaced needle
Haematoma from vascular trauma
Carotid trauma
Internal jugular vein trauma
Neural injury (recurrent laryngeal nerve)
Vagus injury
Brachial plexus roots injury
Pulmonary injury
Pneumothorax
Haemothorax
Chylothorax (thoracic duct injury)
Oesophageal perforation
Infection
Soft tissue (abscess)
Neuraxial (meningitis)
Osteitis
Spread of local anaesthetic
Intravascular injection:
Carotid artery
Vertebral artery
Internal jugular vein
Neuraxial/brachial plexus spread:
Epidural block
Intrathecal
Brachial plexus anaesthesia or injury
(intraneural injection)
Local spread:
Horseness (recurrent laryngeal nerve)
Elevated hemidiaphragm (phrenic nerve)

32. SUMMARY
Stellate ganglion block is useful to denervate sympathetic component involved in upper
limb,head and neck disease conditions.
Careful evaluation of sympathetic involvement in disease process should be done before
deciding to perform block.
Blocking agent type, dose and subsequent blocks should be decided on the basis of
response to primary block.
After even successful stellate ganglion block patient should be monitored for side
effects.

33. THANK YOU