Anatomic Structures to Be Identified for Stellate Ganglion Block

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.

Stellate block is performed in supine position with arms at the side. Performing the procedure on an operating room table is optimal because it allows the operator to be close to the patient and adjust elevation of the head of the bed. The patient’s head should be turned to the side opposite the block. A blue foam headrest helps stabilize the head in this position. Pre- and postprocedural pain scores should be recorded. Skin temperature probes should be applied to the dorsum of the hand on the ipsilateral and contralateral sides for monitoring. The patient should be instructed to not talk, swallow, cough, or move during the procedure (use hand signals if necessary).

For the lateral-to-medial in-plane approach the needle is placed through the anterior scalene muscle into the longus colli muscle. This is usually done between C6 and C7 or between C7 and T1. Gentle pressure is held on the injection syringe as the needle is slowly withdrawn until a rim of local anesthetic is seen to distribute around the lateral aspect of the longus colli muscle. There is debate regarding the correct layer for successful stellate block as being over, under, or within the fascia that invests the longus colli muscle.⁷ Regardless, a rim of local anesthetic that outlines the surface of the longus colli muscle is predictive of block success. Because the site of injection is distant from the stellate ganglion (which lies closer to the level of T1), 5 to 15 mL of local anesthetic is used for the block. The head of the bed is elevated after injection to promote caudal and posterior distribution toward the stellate ganglion.

Postprocedure neurologic examination is performed to rule out somatic brachial plexus block. A temperature increase of the ipsilateral upper extremity and Horner’s syndrome is expected with successful block. The sympathetic efferents to the arm are primarily found in the C8 and T1 roots.⁸ It is therefore important that local anesthetic distribute to the sympathetic chain at or below those levels. Bilateral stellate ganglion blocks should be avoided or at least temporally staggered because of the risk of bilateral pneumothorax, cardiac accelerator nerve fiber block, recurrent laryngeal nerve block, and phrenic nerve block.

FIGURE 61-1 External photograph showing lateral in-plane approach to stellate ganglion block between the transverse processes of the sixth and seventh cervical vertebrae.

FIGURE 61-2 Transverse view of the longus colli muscle adjacent to the transverse process of sixth cervical vertebra (A). For comparison, the transverse process of the sixth cervical vertebra with a prominent anterior tubercle is shown (Chassaignac’s tubercle) (B).

FIGURE 61-3 Transverse view of the longus colli muscle showing the position of the vertebral artery and vein. This scan was obtained adjacent to the seventh cervical vertebra.

FIGURE 61-4 Long-axis view of the inferior thyroid artery. Because the artery is tortuous (the “serpentine” artery), only a limited portion of the artery is contained within the field of view (a partial long-axis view).

FIGURE 61-5 The esophagus has a tubular appearance on ultrasound scans. High-frequency sonography is capable of resolving multiple layers of the muscular esophageal wall. The esophagus can often be seen posterior to the thyroid gland on the left side, and can be identified by the mucosal pattern characteristic of a hollow viscus. In this example a longitudinal view shows the esophageal lumen with hyperechoic bands.

FIGURE 61-6 Lateral to medial in-plane approach to stellate ganglion block. The block needle tip has been placed in the longus colli muscle. Injection occurs as the needle is slowly withdrawn to the surface of the muscle.