Indications

Indications for stellate ganglion block include circulatory insufficiency in the arm resulting from traumatic or embolic occlusion of the arterial supply of the arm, postembolectomy vasospasm, postreimplantation of a traumatic amputation, or arteriopathy from whatever cause; pain caused by complex regional pain syndrome, herpes zoster, neoplasm, phantom limb pain, Paget disease, or lesions in the central nervous system; and other problems, such as hyperhidrosis, Sudeck atrophy, tinnitus, and sympathetically maintained pain in the upper extremity, head, or neck. It has even been suggested as a treatment for cerebral vasospasm due to embolus or thrombosis and for upper extremity tourniquet-induced hypertension.

Anatomy

The peripheral sympathetic nervous system arises from the intermediolateral column of the spinal cord. The efferent preganglionic fibers pass out of the spinal cord via the ventral roots from T1 to L2. The fibers then enter the sympathetic chain through the white rami communicantes. The preganglionic fibers may travel for a variable distance within the sympathetic chain before synapsing in ganglia or exiting the chain to synapse in peripheral ganglia.

The sympathetic chain lies along the anterolateral aspect of the vertebral bodies in a fascial space bounded posteriorly by the prevertebral muscles and in the cervical region anteriorly by the carotid sheath. The nerve fibers in the cervicothoracic chain originate from preganglionic sympathetic fibers from T1 to T6 and visceral afferent fibers from the head, neck, and upper extremity (see Chapter 40). These fibers are distributed to the brain, meninges, eye, ear, glands, skin, and vessels of the head, neck, upper extremity, and some thoracic viscera. The efferent and afferent fibers form several ganglia; the first thoracic and inferior cervical ganglia lie in close proximity and are often fused to form the stellate ganglion, which is oval and about 1 inch long by 0.5 inch wide. It lies within the fascial space described earlier. It is bounded posteriorly by the neck of the first rib and the transverse process of C7 and anteriorly by the dome of the pleura, the carotid sheath, and the vertebral artery. The medial boundary is the vertebral column. It is important to note that some thoracic preganglionic sympathetic fibers may bypass the stellate ganglion.

Technique