Scottsdale Pain Management Specialists
spinal cord graphic

Stellate Ganglion Blocks

The stellate ganglion is an oval-shaped structure that lies on each side of the neck at the level of C6-7. It is the fusion of the inferior cervical and first thoracic sympathetic ganglions that form the stellate ganglion. It is in close proximity to the internal jugular vein, the common carotid artery, the vertebral artery, and the phrenic nerve. Now that we have discussed the anatomy of the stellate ganglion, let’s discuss the indications for a block of the stellate ganglion. We will then discuss the approach to block the ganglion as well as potential risks and side effects.

man undergoing procedureThere are several indications for a block of the stellate ganglion. Some of them are very similar to what we have previously discussed with the lumbar sympathetic nerve blocks. The key difference is that the stellate ganglion block is for the arms, neck, and upper chest. Pain from neuropathy, CRPS, shingles, and phantom limb can be helped by block the stellate ganglion. There is additional anecdotal evidence, further research is occurring, that stellate ganglion block can be beneficial for the treatment of PTSD.

Performing the block can be done effectively and quickly with the appropriate equipment being used. First, we would have the patient lie on an OR bed that allows for X-ray use. The patient would lie face up but have a small pillow under the shoulder of the affected side, tilting them just a little bit. Then we would attach all the monitors to the patient, these include an EKG, blood pressure cuff, pulse oximeter, and a nasal cannula with oxygen and end-tidal CO2 monitoring if the patient is getting sedation. From here, we would use an antiseptic cleaning solution to sterilize the skin. A fluoroscopy camera would be used to visualize the cervical spine from an oblique view, as shown below. Once I have my target identified, I bring in an ultrasound to identify the blood vessels in the area as I want to leave them untouched. Now that I have my target and trajectory, I use a small spinal needle to enter the skin and eventually touch down on C6. Contrast dye is used to ensure that there is no vascular uptake and that the medication is deposited at the stellate ganglion, see the picture below (C shows needle placement and D shows dye at the stellate ganglion).

horner's syndrome graphicWhile the stellate ganglion is easy for me to perform (due to extensive experience with this block) there are still possible risks. These risks include bleeding, once again we are very close to large vessels but the use of the ultrasound limits the likelihood of this occurring. Infection is a possibility but also rare as we disinfect the skin prior to starting. Nerve damage is possible as well but the use of the fluoroscopy camera makes sure that our needle is in the proper location and not inside an unwanted area. There is a side effect of the procedure that is due to the blocking of this nerve. This is called Horner’s syndrome and consists of miosis (constricted pupil), drooping of the upper eyelid (ptosis), and lack of sweating (anhidrosis). These effects would be seen on the ipsilateral (same) side as the blocked nerve. It also goes away once the numbing medicine has worn off (usually an hour or two with Lidocaine).

Overall, the stellate ganglion block has been of great help for patients with nerve pain in the arm, neck, and upper chest. The use of imaging modalities results in a significant reduction in risks. Combining the block with physical therapy can prolong the beneficial effects of the block and can help the affected area become less sensitive to pain.