Stellate ganglion blockade is useful for diagnosing and treating pain of sympathetic origin. This includes pain involving the face, head, neck, and upper extremities secondary to complex regional pain syndrome, acute herpes zoster, and phantom limb pain.
After informed consent is obtained, the patient is placed in the supine position with a pillow under the shoulders and the neck extended. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. The transverse process of the C6 vertebral body is palpated between the cricoid cartilage and the carotid artery. A 1½-in. (4-cm), 22-gauge needle is inserted vertically and advanced to touch the periosteum of the C6 transverse process. The needle is withdrawn slightly, and after negative aspiration, a 1-mL test dose of local anesthetic is injected. After unremarkable test dose and repeated aspiration, 9 mL of local anesthetic is injected, in divided doses with continuous monitoring, to block the stellate ganglion (Fig. 67-4).
FIGURE 67-4. Stellate ganglion block. Approach for stellate ganglion injection and neural blockade. Cross-section at C6.
This technique is commonly used for differential diagnosis and is the preferred treatment of sympathetic mediated pain involving the upper extremity. The stellate ganglion is located between the anterolateral surface of the seventh cervical vertebral body and neck of the first rib. It is formed by the inferior cervical ganglion and first thoracic sympathetic ganglion. Autonomic mediated pain does not usually correspond to segmental or peripheral nerve distribution.
This procedure requires full monitoring capability to include blood pressure, EKG, heart rate, level of consciousness, and pulse oximeter. Temperature should be monitored and recorded for each hand before, during, and after the procedure. The patient is continuously monitored for change and level of consciousness or for adverse reaction. Successful stellate ganglion blockade is suggested by rising temperature on the block side as well as evidence of a Horner’s syndrome (miosis, ptosis, anhydrosis, and enophthalmos). Nasal congestion and hoarseness may occur with this injection. It is recommended that intravenous access be available before the block in the event of intravascular injection resulting in seizure activity or cardiovascular instability (34). Rarely are ablative nerve procedures (neurolysis) recommended in the management of sympathetic mediated pain of the upper extremity.
Performance of this procedure outside of a fully monitored environment is not recommended. Resuscitation equipment and personnel must be readily available. Although appearing technically simple, this block has multiple potential hazards, owing to the proximity of the common carotid artery, vagus and recurrent laryngeal nerves, jugular vein, vertebral artery, trachea, esophagus, lung, and dura. Intraarterial and intradural injection of local anesthetic may result in death, seizure, respiratory arrest, cardiac arrest, cerebral damage with multiple sequelae, and other lesser complications. The risk for intervascular injection may be reduced if a test dose is given, the total dose is injected incrementally, and aspiration is performed before each injection.