The thoracic sympathetics run vertically along the anterior lateral aspect of the vertebral bodies from T2 to T8 and supply the middle and upper deep mediastinal structures (Figure 12.2A). The splanchnic sym-
Figure 12.2. (A) The upper thoracic spine region, showing the sympathetic ganglia along the lateral aspect of the vertebral bodies. (B) Thoracic sympathetic blockade in a prone patient. Under computed tomography the needle is guided from posterior to anterior obliquely (small arrows) along the lateral aspect of the vertebral body. The needle tip (large arrow) should lie along the anterior-lateral aspect of the vertebral body: thoracic sympathetic block, T2-T3; splanchnic sympathetic block, T11-T12.
pathetics arise from T11-12 and give sympathetic supply to the lower mediastinum.
The indications for thoracic or splanchnic sympathetic blockade include pain from deep mediastinal structures (e.g., locally invasive esophageal cancer, lung cancer).
The technique for thoracic or splanchnic sympathetic blockade involves placing a needle (22 or 25 gauge) adjacent to the thoracic vertebral bodies just deep enough to the pleural surface so that the tip will lie along the lateral aspect of the vertebrae at the level to be treated.2-4 The actual location of the thoracic ganglion may vary from the anterolateral vertebral margin to 15 to 20 mm behind the anterior vertebral margin.4 Usually, needle positioning is accomplished from a posterior oblique approach by means of computed tomographic (CT) guidance. Injecting small amounts of saline while passing the needle along an extrapleural course may help to avoid pneumothorax by expanding the extrapleural space (Figure 12.2B).
An injection of 7 to 10 mL of 0.25% bupivacaine can be administered for temporary relief. After appropriate temporary testing, permanent neurolysis can be achieved by using 5 to 10 mL of absolute alcohol. Again, the dose should be the minimum one that will produce the desired effect.
The risk of thoracic sympathetic blockade includes pneumothorax, bleeding, and intravascular injection. The contraindications to thoracic sympathetic blockade are uncorrected coagulopathy and contralateral pneumothorax, and a relative contraindication is allergy to any of the medications that might be administered.
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