Stellate Ganglion Block
If you suffer from chronic pain in your shoulder, arms or hands that has failed to respond to conventional therapy, you may benefit from this truly amazing treatment.
What is a Stellate Ganglion Block?
A stellate ganglion block is highly advanced treatment option of precision and accuracy that is used to treat a multitude of chronic pain syndromes. This injection is a type of sympathetic block that is used to treat pain in the head, neck and upper extremities. The block is performed by injecting a small amount of anesthetic onto the stellate ganglion (also known as the cervicothoracic ganglion) in the neck, interrupting the signals of the sympathetic nervous system (SNS), leading to dramatic pain relief.
The stellate ganglion is a well-known target for transmitting chronic pain from the extremities, neck and even face. By placing a small amount of local anesthetic on it, Pain Management specialists can effectively stop pain at the source.
The first reports of pain relief from stellate ganglion blocks date back to the 1920’s.[1] A few years later, Brunn and Mandl described the technique and indications for its use.[2] Since that time number of indications for this block have grown substantially.[3]
Complex regional pain syndrome (CRPS), types I and II
Reflex Sympathetic Dystrophy (RSD)
Vascular insufficiency
Raynaud’s syndrome
Shoulder/hand syndrome
Postherpetic neuralgia and acute herpes zoster
Phantom limb pain
Neuropathic pain syndromes including central pain
Cancer pain
Facial pain—atypical and trigeminal neuralgia
A stellate ganglion block is a minimally invasive procedure that takes just minutes to perform and can be used to diagnose and treat a variety of types of pain that are non-responsive to conventional therapies.
| Pain Syndromes | Vascular and Autoimmune Syndromes | Miscellaneous Uses |
|---|---|---|
| Complex Regional Pain Syndrome (CRPS) | Scleroderma | Accidental intra-atrial injection of drug |
| Reflex Sympathetic Dystrophy (RSD) | Raynaud’s syndrome | Hyperhidrosis (excessive perspiration) of the upper extremity and/or face |
| Sympathetically-maintained pain | Vasospasm | Hot flashes |
| Shoulder/hand syndrome | Frostbite | Quinine poisoning |
| Neuropathy | Arterial Insufficiency | Post-Traumatic stress disorder (PTSD) |
| Facial pain | Cardiac arrhythmias | |
| Trigeminal Neuralgia | ||
| Post-Mastectomy pain | ||
| Phantom limb pain | ||
| Headaches | ||
| Intractable angina | ||
| Cancer pain | ||
| Post herpetic neuralgia |
One of the most important aspects of this procedure is the ability to witness immediate pain relief. In some cases the relief may be temporary. Regardless of the outcome of the procedure, your physician will be able to determine what part, if any, the Sympathetic Nervous System (SNS) plays in the perpetuation of certain pain processes. In cases were there is only temporary relief, radiofrequency ablation (RFA) can be applied to the stellate ganglion to extend the pain relief.
The SNS is known to play a significant role in neuropathic pain,[4] and the ability to block it has proven invaluable in treating certain types of pain that traditionally are non-responsive to conventional therapies. Stellate ganglion blocks can be used for diagnostic, prognostic and therapeutic purposes.[3]
- Diagnostic: To determine if the pain is sympathetically mediated or not.
- Prognostic: To determine if a neurolytic procedure (i.e. radiofrequency ablation or chemoneurolysis) would be beneficial.
- Therapeutic: To treat a variety of conditions.
This procedure could more accurately be named a cervical sympathetic block. Much like the lumbar sympathetic block, the target is the sympathetic chain and ganglion. This procedure, however, is performed in the cervical spine with the target being the stellate ganglion.
More Details - Stellate Ganglion Block
The stellate ganglion is part of the sympathetic nervous system and is formed by the fusion of the inferior cervical and first thoracic ganglion. It is a relatively a small structure located in the vicinity of C6-7, positioned immediately posterior to the vertebral artery and anterior to the longus colli muscle.
The goal of this injection is to deposit a small amount of anesthetic at the C6 vertebra within the vicinity of the longus colli muscle and a structure known as Chassaignac’s tubercle. The ganglion is generally located below these structures. The anesthetic will “drip” downward onto the stellate ganglion, thus blocking the sympathetic signals in the area, resulting in pain relief.
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The amount of treatments varies on the severity of the pain and the length of time it has been present.
After a successful blockade of the stellate ganglion, there will be an increase skin temperature that most describe as a sensation of warmth coming over the arm and face on the side of the procedure. This should happen within a few hours of the procedure and is an indication of a successfully performed sympathetic block.
After the procedure is completed there are several possible outcomes:
- Your pain is decreased or eliminated for several days, long after the effect of the anesthetic has worn off. This indicates an obvious therapeutic value as the procedure was a success. It also offers some insight as to the process causing the pain and guiding future treatment plans.
- There is the sensation of warmth in the arm and face (evidence of a successful sympathetic blockade), however there is no pain relief. The lack of pain relief is still of diagnostic value to your doctor as it will his/her decision making when coming up with future treatment plans.
- There is no sensation of warmth in the arm or face and there is no pain relief. This indicates the block was not performed correctly and may need to be repeated to properly assess whether or not the pain is driven by the sympathetic nervous system.
Is a Stellate Ganglion Block Right for Me?
If you suffer from chronic pain that has failed to resolve with medications, physical therapy and other conservative therapies, this treatment may be an option for you. This procedure should be performed under the strict supervision of a board-certified pain management specialist.
Contact the Ainsworth Institute to set up an initial evaluation to find out if you are a candidate for a stellate ganglion block.
Procedure - Patient Details
This treatment is an outpatient procedure in your doctor’s office. A stellate ganglion block is generally performed under local anesthetic, although IV sedation can be provided for additional comfort if needed.
You will be placed on your back, facing upward, with monitors in place to track your vital signs during the procedure. Before starting, your skin will be cleaned with sterile soap and draped in a manner to minimize the risk of infection. The skin and underlying tissue are then anesthetized for comfort. The target for this procedure will be C6 – more specifically Chassaignac’s tubercle which is located on the transverse process of C6 (the lateral aspect of the vertebra). Once the target has been identified and the area numb, a small, thin needle is advanced onto Chassaignac’s tubercle on C6. This portion of the procedure can be performed in 3 fashions:
- Blind – The physician will palpate for certain anatomical landmarks (Chassaignac’s tubercle, carotid arteries and the sternocleidomastoid muscle) and the needle is inserted without radiographic guidance. Based on location of these landmarks, the needle is guided to the appropriate endpoint.
- Fluoroscopic Guidance – A real time X-ray is used to visualize the C6 vertebra and guide the needle onto Chassaignac’s tubercle.
- Ultrasound Guidance – Under real time visualization, the needle and all of the underlying structures are apparent on a monitor, thus enabling the physician to precisely maneuver the needle around any blood vessels and into the correct position.
Once the needle tip is in the proper position directly adjacent to Chassaignac’s tubercle and the longus colli muscle, a small amount of local anesthetic (Lidocaine or Bupivacaine) is injected. On occasion, your physician may elect to add corticosteroid to the anesthetic to provide added potency.
The entire procedure takes less than 15 minutes. Once the injection is complete, a small dressing will be placed and you will be transferred to the recovery area and monitored to see what effects the procedure had. One or more of the following marks a successful block:
- Immediate, profound pain relief
- A warm sensation in the face and arm on the same side as the procedure due to improved blood flow
- Temporary Horner’s syndrome – drooping of the eye, constricted pupil and decreased sweating on the face, all on the same side of the procedure
The latter of the 2 will stop in 4-6 hours as the anesthetic used in the procedure wears off.
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Risk Factors
A stellate ganglion block is considered to be a safe and appropriate procedure for the treatment of a variety of types of pain. As with any medical procedure, there is always the risk of a potential complication. In the case of a stellate ganglion block, these risks are quite rare and the complication rate is considered low. Bleeding, nerve injury, pneumothorax (lung collapse), esophageal perforation and arterial injury are possibilities that may ensue from a misplaced needle. The potential for these, however, are dramatically decreased with the use of ultrasound to guide the needle and avoid surrounding structures. There are also risks associated with the spread of the anesthetic. These include drug allergy, seizure if the anesthetic is injected into a blood vessel, weakness, hoarseness from the spread of anesthetic on the recurrent laryngeal nerve, and shortness of breath. Infection is also a potential risk.
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Evidence of Performance
There is a multitude of evidence that supports the use of stellate ganglion blocks for treating sympathetically-mediated pain. This procedure is considered an established modality, not only for offering pain relief but also as a diagnostic method to determine the etiology of one’s pain.
In a 2008 literature review of the available data and published studies at the time, the authors concluded there was strong evidence to support the use of stellate ganglion blocks for the treatment of pain.[5]
The most studied application for procedures blocking the sympathetic nervous system like the stellate ganglion block is in the treatment of CRPS. Meier and colleagues published a study on the treatment of CRPS in children where he reported a clinically relevant improvement in pain as well as a statistically significant reduction in allodynia with stellate ganglion blocks.[6] In 2003, Dr. Stanton-Hicks offered a treatment algorithm for CRPS.[7] In his publication, he reported stellate ganglion blocks to be integral part of the treatment approach and suggested they be used early in the management.
The utility of this procedure extends beyond the treatment of pain. In certain conditions where arterial blood supply to the arms is compromised, such as in Raynaud’s syndrome, a stellate ganglion block has been shown to improve blood flow and reduce discomfort. There are a number of studies reporting that stellate ganglion blocks have been shown to decrease pain scores, improve temperature in the arms due to changes in blood flow and improve quality of life.[8][9]
In addition to Raynaud’s, stellate ganglion blocks have been used to treat hot flashes and night awakenings in breast cancer survivors. In a prospective study by Lipov and colleagues, 13 survivors of breast cancer were treated with stellate ganglion blocks and followed for 12 weeks.[10] The patients in this study reported a significant decrease in their hot flashes and waking in the night by 37.5% and 62.5%, respectively.
- Hydrodissection – Science or Science Fiction - March 23, 2021
- Facebook Live 2 – Full Video - April 2, 2020
- (Full Presentation) Top 5 Things Pain Patients Need To Know During The Coronavirus Pandemic - March 30, 2020
The Ainsworth Institute is Here to Help
If you are suffering from chronic pain that has failed to respond to treatment and would like to see if you may be a candidate for this exciting treatment option contact the Ainsworth Institute of Pain Management today. Schedule an appointment with one of our Board Certified Physicians to learn more about stellate ganglion blocks and see if you are a candidate for treatment.
References
[1] Hansen HC, Trescot AM, Manchikanti L: Stellate ganglion block. Manchikanti L Singh V Interventional techniques in chronic non-spinal pain. 2009 ASIPP Publishing Paducah, KY 115-140.
[2] Datta S, Pai UT, Manchikanti L: Lumbar sympathetic blocks. Manchikanti L Singh V Interventional techniques in chronic non-spinal pain. 2009 ASIPP Publishing Paducah, KY 141-167.
[3] Benzon, Honorio. Essentials of Pain Medicine. Philadelphia: Saunders Elsevier, 2011. Print
[4] Lanz S, Maihöfner C: Symptoms and pathophysiological mechanisms of neuropathic pain syndromes. Nervenarzt. 2009; 80:430-444
[5] Day M: Sympathetic blocks. the evidence Pain Pract. 2008; 8:98-109.
[6] Meier PM, Zurakowski D, Berde CB: Lumbar sympathetic blockade in children with complex regional pain syndromes. a double blind placebo-controlled crossover trial Anesthesiology. 2009; 111:372-380.
[7] Stanton-Hicks M: Complex regional pain syndrome. Anesthesiol Clin North Am. 2003; 21:733-744.
[8] Gabrhelik T, Michalek P, Adamus M, et al.: Percutaneous upper thoracic radiofrequency sympathectomy in Raynaud phenomenon. a comparison of T2/T3 procedure versus T2 lesion with phenol application Reg Anesth Pain Med. 2009; 34:425-429.
[9] Klyscz T, Jünger M, Meyer H, Rassner G. Improvement of acral circulation in a patient with systemic sclerosis with stellate blocks. Vasa. 1998; 27:39-42.
[10] Lipov EG, Joshi JR, Sanders S, et al.: Effects of stellate-ganglion block on hot flashes and night awakenings in survivors of breast cancer. a pilot study Lancet Oncol. 2008; 9:523-532.
- Hydrodissection – Science or Science Fiction - March 23, 2021
- Facebook Live 2 – Full Video - April 2, 2020
- (Full Presentation) Top 5 Things Pain Patients Need To Know During The Coronavirus Pandemic - March 30, 2020
