Background and indications: Ultrasound-guided stellate ganglion block was first introduced in 1995 with promising results.¹ The main advantages of ultrasound over the traditional technique are direct visualization of the stellate ganglion, adjacent structures, and visualization of the spread of the local anesthetic. Although more clinical reports are needed, the use of ultrasound in stellate ganglion block is reported to reduce the risk of vascular puncture, reduce the amount of the injected anesthetic solution, and provide a faster onset time.¹ An imporTant prerequisite is good clinical experience of the anesthesiologist in the practice of ultrasound.

Stellate ganglion block is usually used for the diagnosis and treatment of complex regional pain syndrome of the upper extremity.^2,3 Other uses include treatment of acute or postherpetic neuralgia of the face^{4, 5and 6} and neck and poor perfusion of the upper extremity, as seen with Raynaud and other vascular diseases.^7,8

Anatomy: The cervical sympathetic ganglia consist of the superior, middle, and inferior ganglia. The inferior cervical ganglion is located at the level of C7 and C8. It joins with the first thoracic ganglion to form the stellate ganglion. The cervical ganglia lie deep to the prevertebral fascia. The prevertebral fascia overlies the vertebral body, the longus colli muscle, and the anterior scalene muscle (Figs. 44.1 and 44.2). The three cervical ganglia give off grey rami communicantes that travel through and around the longus colli to join with spinal nerves C1-C8 and T1. The carotid artery lies anterior and lateral to the cervical ganglia. The recurrent laryngeal nerve is sandwiched between the thyroid and trachea. At the level of C6, the transverse process has a bony process (Chassaignac tubercle), which may be palpated with deep pressure by retracting the carotic artery laterally. This has traditionally been the landmark used to perform stellate block before ultrasound was available.