Chapter 43: Thoracic (T2-3) Ganglion Block

INTRODUCTION

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

INDICATIONS

• 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.

INDICATIONS

Pain Syndromes

Common indications are as follows:

• Complex regional pain syndrome 1 and 2

• Herpes zoster (shingles)

• Postherpetic neuralgia (early)

• Postradiation arteritis

• Neuropathic pain associated with CNS pathology

• Paget disease

• Phantom limb pain

• Angina pectoris

The general indications for sympathetic block are shown in Table 43-1.

Vascular Insufficiency

Therapeutic applications for sympathetic block include:

• Raynaud disease

• Facial spasm

• Frost bite

• Microvascular pathology

• Embolic vascular disease

• Spasm of the ophthalmic artery

• Hyperhidrosis

• Buerger disease

• Stroke

• Vascular headaches

RELEVANT ANATOMY

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 ...