Stellate Ganglion Blockade

The stellate ganglion is composed of the fusion between the most inferior cervical ganglion and the most superior thoracic ganglion. It is located posterior to the junction of the subclavian and vertebral arteries at the C7-T1 level, anterior to the junction point of the C7 vertebral body and its transverse process (Figure 12.1A). The stellate ganglion represents a key relay station for sympathetic nerves from the head and neck as well as from the upper extremity.

Figure 12.1. (A) The sympathetic chain in the region of the stellate ganglion, which lies behind the adjacent arteries and in front of the longus colli muscles at the C7-T1 level on each side. (B) Stellate ganglion blockade in a supine patient: anterior-posterior view of the lower neck, with a fluoroscopically guided 25-gauge needle at the junction point of the transverse process and vertebral body of C7. Radiographic contrast material spreads along the muscle plane, but there is no evidence of a vascular spread.

Ansa Subclavia
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Stellate Ganglion Block

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Thoracic and Splanchnic Sympathetic Blockades 221

Following are indications for stellate ganglion blockade:

Pain from upper face and neck (e.g., herpes zoster, Meniere's disease) Pain from upper extremities (e.g., chronic arterial embolic disease, Raynaud's disease, reflex sympathetic dystrophy) Hyperhydrosis and posttraumatic shock syndromes of the upper extremity

Technique

Anterior-to-posterior image guidance is used in placing the tip of a thin, 25-gauge, 3.5 in. spinal needle at the junction of the C7 vertebral body and the proximal transverse process.1,2 Confirmation that the needle tip is not in a vascular structure such as the vertebral artery can be obtained by aspirating and injecting under real-time fluoroscopy 3 to 4 mL of radiographic contrast (Omnipaque 240 or equivalent). The operator should see local pooling of contrast material, never any vascular runoff (Figure 12.1B).

A slow injection of 5 to 10 mL of 0.25% bupivacaine is used for temporary relief. For permanent neurolysis, 5 to 10 mL of absolute alcohol is injected slowly under general anesthetia or heavy conscious sedation (3-6% phenol can also be used in similar volumes). Permanent neurolysis should always follow a temporary test with anesthetic. Treatment with the smaller volumes should be tried, increasing as needed for effect.

An effective stellate ganglion blockade will typically produce an ip-silateral Horner's syndrome along with ipsilateral venous engorgement of the ipsilateral upper extremity. There may also be ipsilateral pares-thesia of the face and upper extremity.

The risk of stellate ganglion blockade includes intravascular injection, particularly into the vertebral artery. This could lead to vertebral dissection or occlusion, seizure, and stroke. In addition, the phrenic nerve and recurrent laryngeal nerve are in close proximity to the stellate ganglion, so that either could be temporarily or permanently paralyzed. Bilateral stellate ganglionic block is not advised because it can result in respiratory compromise and loss of laryngeal reflexes. Hypotension and brachycardia may also occur.

Contraindications to stellate ganglion blockade include contralateral pneumothorax, recent myocardial infarction (as the accelerator nerves to the heart pass through the stellate ganglion and will be affected such that any compensatory increase in cardiac output will be prevented), untreated heart block, glaucoma, and uncorrected coagulopathy.

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