The stellate ganglion refers to the ganglion formed by the fusion of the inferior cervical and the first thoracic ganglion as they meet anterior to the vertebral body of C7. The structures anterior to the ganglion include the skin and subcutaneous tissue, the sternocleidomastoid, and the carotid sheath. The dome of the lung lies anterior and inferior to the ganglion. The prevertebral fascia, vertebral body of C7, esophagus, and thoracic duct lie medially. Structures posterior to the ganglion include the longus colli muscle, anterior scalene muscle, vertebral artery, brachial plexus sheath, and neck of the first rib.
Complex Regional Pain Syndrome Type I and II
Phantom Limb Pain
Obliterative vascular disease
S/P vascular reconstruction, limb reimplatation
local edema s/p surgery
The patient is placed in the supine position with the neck slightly extended, the head rotated slightly to the side opposite the block, and the jaw open. The point of needle puncture is located between the trachea and the carotid sheath at the level of the cricoid cartilage and Chassignac’s tubercle. Although the ganglion lies at the level of the C7 vertebral body, the needle is inserted at the level of C6 to avoid the piercing the pleura.
The neck is prepped and draped. Cutaneous anesthesia is obtained with a skin wheal of local anesthetic.
The sternocleidomastoid and carotid artery are retracted laterally as the index and middle fingers palpate Chassignac’s tubercle. The skin and subcutaneous tissue are pressed firmly onto the tubercle to reduce the distance between the skin surface and bone, and in an attempt to push the dome of the lung out of the path of the needle. When properly performed, this maneuver is uncomfortable for the patient.
The needle is directed onto the tubercle, then redirected medially and inferiorly toward the body of C6. After the body is contacted, the needle is withdrawn 1-2 mm. This brings the needle out of the belly of the longus colli muscle which sits posterior to the ganglion and runs along the anterolateral surface of the cervical vertebral bodies. The needle is then held immobile.
Needle position is confirmed by fluoroscopy. Spread of radiocontrast is confirmed by both anteroposterior and lateral views. Failure of the solution to spread cephalad and caudad between tissue planes suggests intramuscular injection into the longus colli muscle. Immediate dissipation of the solution indicates intravascular placement of the needle orafice.
A 10 cc control syringe charged with local anesthetic is attached to the needle and aspiration is performed to rule-out intravascular placement . A 0.5 cc test dose is performed to rule out intravascular injection into the vertebral artery. The usefulness of this test dose to provide early warning of intraarterial injection is questionable, however, since seizures can occur immediately even with very small volumes of local anesthetic. This test dose is followed by a 3 ml epinephrine-containing test dose to rule-out intravenous placement. The remainder of the anesthetic (10 – 15 ml) is injected in divided doses of 3 ml with intermittent aspiration . The patient is placed in the sitting position to facilitate the spread of anesthesia inferiorly to the stellate ganglion.
The onset of Horner’s syndrome indicates a successful block.
NEEDLE IN THE WRONG PLACE
Hematoma from vascular trauma -Carotid trauma ,Internal jugular vein trauma
Neural injury -vagus ,brachial plexus roots
Pulmonary injury –Pneumothorax ,Hemothorax ,Chylothorax (thoracic duct injury)
Other –Esophageal perforation
SPREAD OF LOCAL ANESTHETIC
Intravascular injection -Carotid artery ,Vertebral artery ,Internal jugular vein
Neuraxial/brachial plexus spread –Epidural block ,Intrathecal ,Brachial plexus anesthesia or injury (intraneural injection)
Local spread -horseness (recurrent laryngeal nerve) ,elevated hemidiaphragm (phrenic nerve)
INFECTION (esophageal perforation is a predisposing factor)
soft tissue (abscess)