stellate ganglion block

Stellate
ganglion block as an intervention in refractory eosinophilic granulomatosis with polyangiitis: a case report. Transducer position and corresponding ultrasound image of the stellate ganglion block (SGB). A Performance of the SGB using transverse scanning with needle in-plane approach. B Ultrasound images for the SGB. The internal jugular vein was compressed (blue circle); the yellow line represents the prevertebral fascia, and the red arrow indicates the in-plane needle path. LC longus colli, SCM sternocleidomastoid muscle, LA local anesthetic, Th thyroid gland, CA carotid arter, AT anterior tubercle of C6 transverse process, VB C6 vertebral body
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Effect of
early stellate ganglion block in cerebral vasospasm after aneurysmal subarachnoid hemorrhage (BLOCK-CVS): study protocol for a randomized controlled trial. Schematic diagram of stellate ganglion block under ultrasound guidance. After routine disinfection, 0.5% ropivacaine 8–10 mL will be injected into the surface of the longus colli muscle on the medial side of the prevertebral fascia at the level of the C6 anterior tubercle, and then the puncture point will be covered with sterile dressings. B The ultrasonic image of the cross-section of the sixth cervical segment: the blue arrow indicates the prevertebral fascia; the blue dotted line area is the longus colli muscle, and its lateral highlight area is the distribution of the stellate ganglion; and the green triangle indicates the drug injection site (the inner side of the prevertebral fascia), in which the stellate ganglion can be effectively blocked through the diffusion of the drug solution under the fascia and without nerve injury. C6, the sixth cervical segment; CA, carotid artery; CV, jugular vein; TH, thyroid; at, anterior tubercle; M, muscle; SCM, sternocleidomastoid muscle; LCol, longus colli muscle; LCap, longus capitis muscle; N, nerve from cervical plexus; pt, posterior tubercle. ASM, anterior scalene muscle; MSM, middle scalene muscle
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Real-time
ultrasound-guided stellate ganglion block for migraine: an observational study. Ultrasonic exploration of stellate ganglion. A: Patient’s position and placement of ultrasound probe. B: Ultrasound image of the cervical structure during stellate ganglion block.1, thyroid; 2, common carotid artery; 3, internal jugular vein; 4, brachial plexus; 5, vertebral artery; 6, longus colli muscle
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Real-time
ultrasound-guided stellate ganglion block for migraine: an observational study. Stellate ganglion block process. A: The tip of the needle reached the surface of the longus colli muscle and the 5 o’clock position of the carotid artery. B: After administration of ropivacaine, the carotid artery can be seen floating like a balloon in real time under ultrasound, which indicates that the ropivacaine diffuses in the paravertebral space and can effectively block the stellate ganglion. 1, common carotid artery; 2, longus colli muscle; The three arrows indicate the puncture needle, and the two-way arrows indicate that the distance between the common carotid artery and the longus colli muscle is larger than that in Fig. A
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The stellate ganglion block describes blockade of the cervicothoracic sympathetic chain which provides post-ganglionic sympathetic efferents to the head, neck and upper extremities. Neural blockade is typically acheived by deposition of local anesthetic between the prevertebral fascia and longus colli muscle.

Terminology

Clusters of nerve cell bodies within the cervical sympathetic chain can be anatomically subdivided into the superior, middle, intermediate and inferior cervical ganglia. The stellate ganglion refers to a structure comprised of a fused inferior cervical and first thoracic ganglion. While anatomically inexact, it is common practice to refer to blockade of the cervical sympathetic trunk as a stellate ganglion block.

Indications

Indications for stellate ganglion blocks include:

  • sympathetically mediated pain from the head, neck and upper extremities
    • reflex sympathetic dystrophy
    • herpes zoster
  • vasospasm
    • Raynaud's disease
    • temporal arterities
    • Buerger's disease
  • hyperhidrosis
  • electrical storm
    • three or more ventricular arrhythmias within 24 hours requiring defibrillation or overdrive pacing
    • a left-sided (or bilateral) stellate ganglion block is preferred in this context

Contraindications

Contraindications are current coagulopathy, recent myocardial infarction, pathologic bradycardia, and glaucoma.

Procedure

The procedure can be done by either palpating anatomical landmarks (done mainly by pain therapists) or under fluoroscopic, ultrasound or CT guidance. Using CT guidance the stellate ganglion; which comprises of lower cervical and T1 sympathetic ganglia overlying the C7 and T1 transverse process can be accurately targeted and hence a lower volume of drug needs to be delivered. Complications rates are also low as the ganglion is accurately targeted.

The choice of local anesthetic used during the procedure varies based on indicaiton and patient factors; overall bupivicaine (0.25 or 0.5%) is the most common agent.  Absolute alcohol is injected to induce permanent neurolysis. Recently RF ablation is also used to cause permanent neurolysis of Stellate ganglion.

Ultrasound

The patient may be positioned supine or in a lateral decubitus position. Sequential palpation of the laryngeal prominence, cricothyroid membrane, and cricoid cartilage are commonly identified external landmarks. The cricoid cartilage demarcates the level of C6, which has a prominent anterior tubercle on its transverse process, also known as Chassaignac's tubercle, forming a conspicuous sonographic landmark. Performing the procedure at this level is crucial to ensure the vertebral artery will be protected in the foramen transversarium; puncture below this level risks violation of this structure .

The ultrasound transducer is then placed slightly lateral to midline in a transverse orientation attempting to visualize the anterior tubercle of C6. The esophagus and regional vasculature should be identified to plan needle trajectory; color flow Doppler is useful for the latter. The needle should be inserted in a lateral to medial orientation, directed toward Chassaignac's tubercle. Slight redirection is then necessary to traverse the prevertebral fascia, targeting the potential space it forms with its apposition to the fascia overlying the longus colli muscle, which invests the anterior aspect of the transverse process of C6. Care should be taken to ensure injectate spreads anterior to, and circumfrentially around, the longus colli, dissecting the deep cervical fascia and carotid sheath anteriorly .

Complications

Complications include:

  • pneumothorax
  • bleeding
  • infection
  • allergic reaction
  • intravascular injection and its consequences
  • phrenic nerve or recurrent laryngeal nerve palsy
  • hypotension
  • injury to adjacent vascular structures (particularly the vertebral artery)
  • bradycardia 
Siehe auch:
und weiter:
Assoziationen und Differentialdiagnosen zu Blockade des Ganglion stellatum:
Pneumothorax
 
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Sympathikolyse
 
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