What Are Stellate Ganglion Blocks?

Stellate ganglion blocks are a procedure that utilizes the injection of local anesthetic into the sympathetic nerves that are found within the neck area. The stellate ganglion is a network of nerves that is comprised of the cervical sympathetic trunk fused with the first thoracic ganglion. This network of nerves is also known as the cervicothoracic ganglion and provides the information transfer between the seventh and eighth cervical nerves, the spinal cord, and brain. In other words, the stellate ganglion is responsible for governing blood flow, as well as sensory processing, for the head, neck, chest, and upper limbs.

Damage sustained to the neural tissue that comprises the stellate ganglion can lead to symptoms of pain and discomfort within the head, face, neck, upper chest, arms, hands, and fingers. In many instances, these symptoms are not effectively managed with conventional oral medications, such as non-steroidal anti-inflammatory drugs (NSAIDs) or oral opioids.

For cases of neuropathic pain owing to damage to the neural tissue of the stellate ganglia, a stellate ganglion block injection may be warranted for symptom management. Stellate ganglion blocks can be used to treat symptoms that fall into two primary categories: conditions of arterial vascular insufficiency and pain conditions.

Contraindications of stellate ganglion blocks include:

  • Infection
  • Patient refusal
  • Allergy to anesthetic medication
  • Coagulopathy, either primary or secondary

Further, stellate ganglion blocks should be avoided if the patient has recently recovered from a cardiac infarction or has had a severe cardiac conduction block. Some evidence suggests that repeat stellate ganglion blocks can cause complications with regards to glaucoma.

As with most medical procedures, there is some risk associated with stellate ganglion blocks. These risks tend to be relatively rare and include:

  • Allergic reaction to the medication
  • Bleeding at the site of the injection
  • Slight bruising at the site of the injection
  • Collapsed lung
  • Seizure
  • Brachial plexus block
  • Epidural or spinal block
  • Nerve damage

How Is A Stellate Ganglion Block Performed?

Stellate ganglion blocks are generally performed with the patient lying in the supine position (i.e., lying face up). The patient will be asked to slightly extend their neck by pointing their chin upward. The performing physician may tilt the head slightly away from the site of the injection. Further, a pillow can be placed under the patient’s shoulders in order to allow them to be more comfortable during the procedure. The skin on the neck is thoroughly cleansed and sterilized. Typically, only a topical local anesthetic is required; however, some patients request to be sedated during the procedure for comfort purposes. Patients receiving only topical anesthetic are asked to refrain from talking, coughing, or swallowing during the injection.

There are a number of methods by which the physician can ensure that the injection needle has been properly placed. These include ultrasound, fluoroscopy, and computerized tomography (CT). Ultrasound and fluoroscopy are among the most popular. Ultrasounds are generally preferred, as they provide a more detailed depiction of the anatomy of the underlying soft tissue. Moreover, ultrasounds reduce the amount of anesthetic required and decrease the risk for incidental punctures to underlying vascular or neural structures.

Fluoroscopy provides strong visualization of bony structures; however, it does not provide detailed feedback in terms of the internal soft tissue. In many cases, once the injection needle is guided into the appropriate area with the assistance of imaging, the proper location is verified by injecting a contrast dye. Once the correct placement of the injection needle has been verified, the final step of stellate ganglion blocks is to inject the anesthetic solution.

The procedure for a stellate ganglion block typically takes about 30 minutes. Patients can expect to be monitored in the doctor’s office for several minutes following the procedure. During this time, your doctor will watch for any adverse side effects from the procedure or the medication used. In many cases, patients report feeling relief almost immediately; however, it is not uncommon for their symptoms of pain and discomfort to return after several hours. Patients are asked to refrain from operating a motor vehicle for 24 hours following the procedure. It may take several days for the long-term effects of the steroids to be noticed.

Side effects from the procedure are rare and may include:

  • Red or bloodshot eyes
  • Drooping eyelids
  • Tearing
  • Nasal congestion
  • Sensation of a lump in the throat
  • Hoarse voice
  • Trouble swallowing
  • Sensations of warmth or tingling in the arm or hand

There is no precise formula to calculate how long patients can expect to feel relief. A portion of stellate ganglion patients will be pain-free for a number of days or even several weeks. It is not uncommon for patients to require multiple injections to achieve full symptom relief, however.

Conditions Related To Stellate Ganglion Blocks

Conditions that have been effectively managed with stellate ganglion blocks generally fall into two different categories: pain conditions and arterial vascular insufficiency.

Pain conditions include:

  • Severe headaches
  • Complex regional pain in the upper extremities (e.g., reflex sympathetic dystrophy or causalgia)
  • Refractory angina
  • Hyperhydrosis
  • Phantom limb pain or discomfort
  • Herpes zoster outbreak (i.e., shingles) within the upper chest, head, neck, or arm regions
  • Postherpetic neuralgia
  • Paget’s disease
  • Postradiation neuritis

Arterial vascular insufficiency disorders treated with stellate ganglion blocks include:

  • Raynaud’s disease
  • Intra-arterial embolism
  • Vasospasm
  • Scleroderma
  • Insufficient lymphatic drainage and localized edema following mastectomy
  • Neoplasm

Conclusion

Stellate ganglion blocks are a minimally invasive procedure used to treat many conditions of pain or vascular insufficiency. The procedure for stellate ganglion blocks is non-surgical and requires only a topical local anesthetic. Patients receiving stellate ganglion block injections can expect to feel full relief from pain within several days of the procedure. Repeat injections are not uncommon in order to achieve full, long-term symptom relief.

Patients who have recently suffered a cardiac infarction should not receive stellate ganglion injections. Moreover, repeat injections may cause complications in patients with glaucoma. Patients considering stellate ganglion injections are encouraged to talk to their doctor to see if the procedure is right for them.

References

  1. Toshniwal G, Sunder R, Thomas R, Dureja GP. Management of complex regional pain syndrome type I in upper extremity-evaluation of continuous stellate ganglion block and continuous infraclavicular brachial plexus block: a pilot study. Pain medicine (Malden, Mass.). 2012;13(1):96-106.
  2. Gadhinglajkar S, Sreedhar R, Unnikrishnan M, Namboodiri N. Electrical storm: Role of stellate ganglion blockade and anesthetic implications of left cardiac sympathetic denervation. Indian journal of anaesthesia. 2013;57(4):397-400.
  3. Shanthanna H. Utility of stellate ganglion block in atypical facial pain: a case report and consideration of its possible mechanisms. Case reports in medicine. 2013;2013:293826.
  4. Lipov EG, Navaie M, Brown PR, Hickey AH, Stedje-Larsen ET, McLay RN. Stellate ganglion block improves refractory post-traumatic stress disorder and associated memory dysfunction: a case report and systematic literature review. Military medicine. 2013;178(2):e260-264.
  5. Noma N, Kamo H, Nakaya Y, et al. Stellate ganglion block as an early intervention in sympathetically maintained headache and orofacial pain caused by temporal arteritis. Pain medicine (Malden, Mass.). 2013;14(3):392-397.
  6. Bhatia A, Flamer D, Peng PW. Evaluation of sonoanatomy relevant to performing stellate ganglion blocks using anterior and lateral simulated approaches: an observational study. Canadian journal of anaesthesia = Journal canadien d’anesthesie. 2012;59(11):1040-1047.
  7. Narouze S, Vydyanathan A, Patel N. Ultrasound-guided stellate ganglion block successfully prevented esophageal puncture. Pain physician. 2007;10(6):747-752.
  8. Siegenthaler A, Mlekusch S, Schliessbach J, Curatolo M, Eichenberger U. Ultrasound imaging to estimate risk of esophageal and vascular puncture after conventional stellate ganglion block. Regional anesthesia and pain medicine. 2012;37(2):224-227.