Chapter 42: Stellate Ganglion Block

INTRODUCTION

Stellate ganglion blockade has been utilized since the 1920s to treat a variety of medical conditions. Although blind stellate ganglion blockade had been the norm for decades, the use of fluoroscopy has allowed increased accuracy with the use of less medication and decreased complications.

INDICATIONS

The indications for stellate ganglion blockade include:

• Differentiation of sympathetically maintained (SMP) versus sympathetically independent (SIP) pain syndromes of the head or upper extremity

• Upper extremity/facial complex regional pain syndrome: type I (reflex sympathetic dystrophy [RSD]), type II (causalgia)

• To increase upper extremity perfusion

  • Raynaud disease

  • Upper extremity arterial embolism

  • Intra-arterial drug injection

• Phantom limb pain

• Cluster or atypical vascular headache

• Glaucoma

• Optic nerve neuritis

• Head and face sympathetically mediated cancer pain

• Head/neck/thoracic acute herpes zoster or postherpetic neuralgia

• Hyperhidrosis of the head/neck/axilla/thorax

• Refractory atypical chest pain

• Pulmonary embolism

• Intractable angina pectoris

• Ventricular arrhythmia secondary to sympathetic imbalance

• Post mastectomy pain

• Meniere syndrome

• Scleroderma

CONTRAINDICATIONS

• Systemic or local infection in the area of injection

• Primary or secondary coagulopathy

• Untreated allergy to any of the procedure medications

• Previous anterior lower cervical surgery

• Patient refusal

RELEVANT ANATOMY

The stellate ganglion is usually formed by the fusion of the inferior cervical and first thoracic sympathetic ganglia (Figure 42-1). The stellate ganglion lies just anterolateral to the seventh cervical vertebral body at the base of the C7 transverse process, lateral to the first thoracic vertebral body and over the neck of the first rib, in the groove between the vertebral body and the transverse process. It lies anterior or immediately lateral to the longus colli muscle (Figure 42-2) and is posterior to the vertebral and carotid arteries. The ganglion also lies just anterior to the C8 and T1 spinal roots.

Under fluoroscopy, the ganglion lies just lateral to the vertical line joining the uncovertebral joints in an anteroposterior view.

PREOPERATIVE CONSIDERATIONS

• Appropriate indications have been determined

• Evaluation and treatment of bleeding diathesis, contrast, or medication allergy

• Physical examination should identify previous neck or thyroid surgery, infection at the site of needle insertion, or decreased range of neck extension

• A detailed informed consent including the potential benefits and risks as well as realistic expectations of sympathetic blockade

• Possible postprocedural effects should be explained to the patient including ptosis; miosis; blurred vision; enophthalmos; ...