Sympathetic Trunk

Fig. 3.1

Anatomy of cervical sympathetic chain. (Reprint with permission from Philip Peng Educational Series)

The preganglionic fibers of the head and neck region continue to travel cephalad to the superior and middle cervical ganglion through the cervical sympathetic trunk. Injection of local anesthetic around the stellate ganglion interrupts the sympathetic outflow to the head, neck, and upper limbs through inactivation of both preganglionic and postganglionic fibers (Fig. 3.2). The stellate ganglion is located in close proximity to the pleural and vertebral artery. As a result, the SGB is performed at a more cephalad location, in proximity to the middle cervical ganglion.

../images/457420_1_En_3_Chapter/457420_1_En_3_Fig2_HTML.jpg — Fig. 3.2

The cervical ganglion trunk: (1) superior cervical ganglion, (2) middle cervical ganglion, and (3) cervicothoracic ganglion. (Reprinted with permission from Danilo Jankovic)

Patient Selection

Stellate ganglion blocks are used for a variety of painful conditions, most notably for sympathetically mediated pain in the context of complex regional pain syndrome. However, the technique is not limited to painful conditions. There is growing evidence for its use in treating numerous non-painful medical conditions.

Indications
Painful medication conditions: Sympathetically mediated pain of the upper extremity, head, or neck Acute herpes zoster or postherpetic neuralgia of the head, neck, or upper thorax Phantom limb pain Cluster headache or atypical vascular headache Intractable angina pectoris Non-painful medication conditions: Raynaud disease Obliterative vascular disease Vasospasm Hyperhidrosis Lymphedema Refractory ventricular arrhythmia Post-traumatic stress disorders

Indications

Painful medication conditions:

Sympathetically mediated pain of the upper extremity, head, or neck

Acute herpes zoster or postherpetic neuralgia of the head, neck, or upper thorax

Phantom limb pain

Cluster headache or atypical vascular headache

Intractable angina pectoris

Non-painful medication conditions:

Raynaud disease

Obliterative vascular disease

Vasospasm

Hyperhidrosis

Lymphedema

Refractory ventricular arrhythmia

Post-traumatic stress disorders

Contraindications
Anticoagulated patient or coagulopathy Preexisting contralateral phrenic nerve palsy Recent myocardial infarction Cardiac conduction block Only unilateral blocks should be performed to avoid bilateral recurrent laryngeal nerve block and resulting stridor.

Contraindications

Anticoagulated patient or coagulopathy

Preexisting contralateral phrenic nerve palsy

Recent myocardial infarction

Cardiac conduction block

Only unilateral blocks should be performed to avoid bilateral recurrent laryngeal nerve block and resulting stridor.

Ultrasound Scanning

Position: Semi-lateral decubitus position, with the neck turned contralateral
Probe: Linear 6–13 MHz

Scan 1: Place the probe at the C6 level (Figs. 3.3 and 3.4). Identify the key landmarks, including the longus colli muscle (LC), longus capitis muscle (LCa), prevertebral fascia (arrows), cervical nerve root (N), carotid artery (C), and internal jugular vein (∗∗). At this level, the transverse process has a prominent anterior tubercle (AT).
Scan 2: To confirm the level, scan the probe caudally to the C7 level. The transverse process is the key landmark to identify at this level (Fig. 3.5). At this level, the transverse process has a prominent posterior tubercle and vestigial anterior tubercle. Use color Doppler to identify the vertebral artery.

Note that at the C6 level, the vertebral artery most commonly enters the foramen transversarium. In up to 10% of patients, the vertebral artery travels outside the foramen transversarium at the C6 or even C5 level. The figure showed the presence of vertebral artery anterior to the anterior tubercle at C5 level (Fig. 3.6).
Scan 3: At the C6 level, perform a pre-scan with and without color Doppler (Fig. 3.7). Identifying aberrant vessels and structures such as the esophagus will help plan for the safest approach, which may change in location on swallowing (Fig. 3.7). The location of the esophagus and the vessel may discourage a practitioner from performing a medial or lateral approach (see procedure below).