Stellate Ganglion Block (Cervicothoracic Sympathetic Ganglion Block)

Published on 06/02/2015 by admin

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Last modified 06/02/2015

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61 Stellate Ganglion Block (Cervicothoracic Sympathetic Ganglion Block)

Stellate ganglion blocks can be performed to treat sympathetically maintained pain (reflex sympathetic dystrophy, causalgia, complex regional pain syndrome type I). The stellate ganglion is the fusion of the inferior cervical and first thoracic sympathetic ganglia. Almost all of the sympathetic innervation of the head, neck, and upper extremity travels via pathways through the stellate ganglion. The stellate ganglion is approximately 0.5 to 2.5 cm in size.¹ Despite its name, the stellate ganglion is fusiform, triangular, or globular in shape on magnetic resonance scans.² Stellate ganglion block is used to diagnose and treat chronic pain syndromes of the upper extremity and head and neck.

At the level of the first thoracic vertebral level, the stellate ganglion lies lateral and posterior to the lateral edge of the longus colli muscle. As the cervical sympathetic chain travels cephalad, it comes to lie anterior to the longus colli muscle.^3,⁴ This muscle lies over the anterior surface of the cervical transverse processes.

Anatomic Structures to Be Identified for Stellate Ganglion Block

Esophagus

The esophagus is usually a midline structure that can be deviated, most often to the left side. Tilting the chin up straightens the esophagus to move it toward the midline. The esophagus is relatively easy to identify because it has muscular walls. Any question regarding identity can be resolved by asking the patient to swallow while imaging is performed. This forces intraluminal bubbles to move and enhance their conspicuity. The esophagus is important to recognize on ultrasound scans because of the risk of mediastinitus if it is punctured.

Inferior Thyroid Artery

The inferior thyroid artery has a tortuous course (hence its alternate name, the “serpentine” artery).⁵ This artery travels over the surface of the longus colli muscle from lateral to medial.

Vertebral Artery and Vein

As it ascends, the vertebral artery travels over the surface of the longus colli muscle from medial to lateral before it enters the vertebral canal. The level of entry is usually at the sixth cervical vertebra. The vertebral vein lies on the superficial aspect of the vertebral artery.

Anterior and Posterior Tubercles

The anterior and posterior tubercles of the transverse processes of the C6 and C7 vertebrae can be identified by their morphology. The anterior tubercle of C6 is prominent (Chassaignac’s tubercle) whereas the anterior tubercle of C7 is rudimentary. This helps establish the level for the block.

Phrenic Nerve

The phrenic nerve crosses over the anterior surface of the anterior scalene muscle from lateral to medial. On ultrasound scans the phrenic nerve appears as a small (<1 mm in diameter) monofascicular structure.⁶ The phrenic nerve lies adjacent to the C5 ventral ramus at the level of the cricoid cartilage (C6). Performing stellate block caudal to this level helps avoid the phrenic nerve within the lateral to medial needle path. Similarly, the superficial cervical artery (transverse cervical artery) that also lies over the anterior scalene muscle can be avoided in this fashion.

Longus Colli Muscle

This muscle is very hypoechoic (relatively dark) on ultrasound scans.

Approach and Suggested Technique

Confirm nothing per mouth (NPO) status and place a peripheral IV prior to the procedure. Some patients may require EMLA (eutectic mixture of local anesthetics) cream over the needle insertion site and sedation for the procedure.

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