Situated
as the lowest cervical ganglion on the lateral borders of the C-7 Vertebral
Bodies bilaterally.Stellate Ganglion Blockade
Indications
Pain relief of dystrophies of the upper arms
Raynaud’s Phenomenon
Pain associated with Herpes Zoster, located in the head or neck
S/P thoracotomy pain management
Precursor to assess effectiveness preoperatively for surgical sympathectomy
Refractory angina and Quinine poisoning www.angina.org/source/pro/sgb.htm
Arterial vasoconstriction in upper limb due to:
Intra-arterial injection of Sodium Thiopental
Frostbite
Prevention of arterial vasoconstriction following microvascular surgery
Drugs
1% Lidocaine
0.25% Bupivacaine-some practitioners desire to use with 1:200,000 epinephrine
Usually 10ml is used which will often produce desired effect down to the T5 ganglia and upward to localize all three ganglia of the cervical chain.
Anatomy
Situated
as the lowest cervical ganglion on the lateral borders of the C-7 Vertebral
Bodies bilaterally.
Lies posterior to the vertebral artery branch of the subclavian artery.
Posteriomedial of the internal jugular veins.
Medial of the scalene muscle..
Just slightly superior to the apex of the pleura.
Right Stellate Ganglion- supplies SNS to epicardial surface and intraventricular septum.
Left Stellate Ganglion- supplies SNS to bi-ventricular posterior/lateral myocardial walls.
Sympathetic stimulation for the head, neck, and most of the upper extremities.
Technique
Place
the patient supine with a neck roll similar to Thyroidectomy procedures.
Mark the medial border of the SCM muscle of the involved side @ the level of the cricoid cartilage
Palpate 2cm lateral of the mark to locate the Anterior Tubercle (Chasaignac’s Tubercle) on the transverse process of the 6th cervical vertebra and place a circle is over this tubercle. An “X” is placed 1.5-2cm caudal the circle
If unable to locate this area, then 3-5cm superior to the clavicle and 2cm lateral to the cricoid, along the medial border of the SCM will yield the desired area.
Site preparation is performed and a skin wheel made.
The non-operative hand of the anesthetist retracts laterally the SCM muscle, to include the carotid sheath (common carotid artery, internal jugular vein, and the vagus nerve).
-carotid sheath visual (http://www.pitt.edu/~anat/Head/Neck/Neck.htm)
A 22-25g- 3.75 cm needle is introduced, in a paratracheal approach (see picture left), thru the “X” until it rests on the bone of the transverse process.
Paresthesia of the Brachial Plexus at this point indicates too lateral of an angle past the transverse process and needs realigned more medial, and possibly either caudle or cephalad as well.
After contact with the bone, retraction of the needle 1-2mm is done with careful aspiration to ascertain unwanted Vertebral/Carotid artery puncture, or for CSF of accidental injection into a subarachnoid dural sleeve
If no aspiration of blood is noted-a 2ml test dose of medication is injected to rule out any unappreciable vascular cannulation.
Mental status is continuously observed pre, peri and post injection to note changes of accidental injection.
Subsequent injections should be made in small increments only after aspiration each time; as only a small amt of local is needed to produce severe cerebral symptoms. This is done until 10-15ml of local is injected and then steady removal of the needle is advised.
Assessment of Efficacy
Almost immediately following injection an increase in temperature of the ipsilateral arm is noted
Subsequent onset of Horner’s Syndrome
Ipsilateral:
Ptosis
Miosis
Anhydrosis of the neck and face
Enophthalmos-posterior displacement of the globe of the eye
Nasal Congestion
Complications
Pneumothorax
Systemic injection – Most serious
Hematoma
Toxicity
Hoarseness secondary to recurrent laryngeal nerve injury/blockade
Phrenic nerve paralysis-paralyzed hemidiaphram
Subarachnoid blockade at the cervical level
Brachial plexus blockade
Rare Complications
Osteitis
Mediastinitis following esophageal puncture
Subsequent loss of cardioacceleratory fibers in rare uses of bilateral blockade