The functional separation of the vagi (vagal nerves) and sympathetic trunks can be attributed to Estienne (1544),1 but it was Winslow who, in 1732,2 described the sympathetic trunk as the paravertebral chain. Many anatomists, including Michener and Auerbach, explored the sympathetic fibers and trunk. But as a functional component of the autonomic nervous system, the association had to wait until Langley and Dickerson in 1899.3
During the 20th century, many physicians (including Mandal,4 Kapppis,5 Brunn,6 Adriani,7 Loeser,8 Arnulf,9 Seabelund10) introduced their own variations on the best approach to the sympathetic trunk.5 However, they all involve variations of paravertebral techniques, the most recent being that described by Butler and Charlton in 2001.11
The anterior approaches to the sympathetic trunk in the neck (stellate ganglion) are easily performed and are most commonly used; however, a posterior approach to the sympathetic trunk at the T2, T3 level provides the most reliable and consistent block of sympathetic activity to the upper extremity.12
20% of patients have sympathetic fibers that bypass the stellate ganglion called Kuntz fibers. These patients may not reliably achieve sympathetic blockade with a stellate ganglion block.
Neurolytic techniques of the stellate ganglion have a significant risk of prolonged or permanent Horner syndrome, as well as damage to the phrenic and recurrent laryngeal nerves.
The thoracic sympathetic block avoids these potential complications.
The thoracic sympathetic block is indicated for all the same conditions as a stellate ganglion block.
Common indications are as follows:
Complex regional pain syndrome 1 and 2
Herpes zoster (shingles)
Postherpetic neuralgia (early)
Neuropathic pain associated with CNS pathology
Phantom limb pain
The general indications for sympathetic block are shown in Table 43-1.
TABLE 43-1.Indications for Sympathetic Blocks |Favorite Table|Download (.pdf) TABLE 43-1.Indications for Sympathetic Blocks
|Vascular insufficiency ||Pain ||Other |
|Trauma, embolic ||CRPS I and II ||Hyperhidrosis (prognostic block) |
|Postoperative vascular enhancement (eg, hand surgery) ||Herpes zoster ||Tinnitus |
|Postembolectomy vasospasm ||Paget disease ||Stroke |
|Raynaud disease (ie, phenomenon) ||Neoplasm || |
|CREST ||Phantom limb || |
|Frostbite ||CNS lesion || |
|Occlusive vascular disease ||Pancreatitis || |
|Retinal artery spasm || || |
Therapeutic applications for sympathetic block include:
The autonomic nervous system:
The autonomic nervous system is divided into sympathetic and parasympathetic components, each made up of preganglionic and postganglionic neurons.
Their axons travel along the anterior roots of the spinal nerve as white rami communicantes that project to the paravertebral ...