Stellate Ganglion Block

CRPS, RSD, Causalgia, Raynaud’s, Accidental intraarterial injections, acute herpes zoster of the face and lower cervical and upper thoracic dermatomes, pulmonary embolism
Supplies sympathetic innervation to the user extremity through the gray communicating rami of C7, C8 and T1 (occaisionally C5 and C6).
In some patients, T2 and T3 gray communicating rami innervate the distal upper extremity and do not pass through the ganglion (hence sympathetically mediated pain not relieved with satisfactory stellate ganglion block)
CPT 64510, 76942

Indications

Pain Syndromes
Complex Regional Pain Syndrome Type I and II
Refractory Angina
Phantom Limb Pain
Vascular Insufficiency
Raynaud's Syndrome
Scleroderma
Frostbite
Obliterative vascular disease
Vasospasm
Trauma
Emboli
S/P vascular reconstruction, limb reimplantation
Edema
local edema s/p surgery

Complications

WRONG NEEDLE PLACEMENT

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)
Neuraxial (meningitis)
(osteitis)

Ultrasound Guided Stellate Ganglion

Lateral Approach

Contraindications

Anticoagulation therapy
Pneumothorax (and pneumonectomy on contralateral side,
Recent cardiac infarction because the stellate ganglion cuts off the cardiac sympathetic fibers (accelerator nerves)
Glaucoma is a relative contraindication (provocation of glaucoma by repeated stellate ganglion block has been reported).
Caution with atrioventricular block and impairment of cardiac stimulus conduction as well.

Complications

Pneumothorax,
Neuraxial injection
Phrenic and brachial plexus block
Cervical nerve root puncture/ block
Cocal cord paralysis,
Vascular puncture (superior thyroid artery,vertebral artery, carotic artery etc.)
Hematoma
Esophageal perforation
Using the classic (blind or flouroscopic) approach, the superior thyroid artery may be punctured or transected. An ultrasound in the hands of a skilled physician may identify the structure so that it can be avoided.

References

and Interesting Articles

Piraccini E, Munakomi S, Chang KV. Stellate Ganglion Blocks. [Updated 2022 Aug 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507798/
McLean B. Safety and Patient Acceptability of Stellate Ganglion Blockade as a Treatment Adjunct for Combat-Related Post-Traumatic Stress Disorder: A Quality Assurance Initiative. Cureus. 2015 Sep 10;7(9):e320. doi: 10.7759/cureus.320. PMID: 26487996; PMCID: PMC4601906.
Wang D. Image Guidance Technologies for Interventional Pain Procedures: Ultrasound, Fluoroscopy, and CT. Curr Pain Headache Rep. 2018 Jan 26;22(1):6. doi: 10.1007/s11916-018-0660-1. PMID: 29374352.
Duong S, Bravo D, Todd KJ, Finlayson RJ, Tran Q. Treatment of complex regional pain syndrome: an updated systematic review and narrative synthesis. Can J Anaesth. 2018 Jun;65(6):658-684. English. doi: 10.1007/s12630-018-1091-5. Epub 2018 Feb 28. PMID: 29492826.
Datta R, Agrawal J, Sharma A, Rathore VS, Datta S. A study of the efficacy of stellate ganglion blocks in complex regional pain syndromes of the upper body. J Anaesthesiol Clin Pharmacol. 2017 Oct-Dec;33(4):534-540. doi: 10.4103/joacp.JOACP_326_16. PMID: 29416250; PMCID: PMC5791271.

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