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Efficacy of the Stellate Ganglion Block Through the Lateral Approach Using Ultrasonogram and Fluoroscopy/Ultrason ve Floroskopi Kullanilarak Lateral Yaklasimla Uygulanan Stellat Ganglion Blogunun Etkinligi.

Introduction

Stellate ganglion (SG) is a sympathetic ganglion formed by the fusion of the inferior cervical ganglion and the first thoracic ganglion. It contains sympathetic preganglionic fibres supplying the head and neck and sympathetic postganglionic fibres supplying the upper limb and heart (1). Blockade of the SG may result in analgesia in sympathetically mediated painful conditions such as complex regional pain syndrome (CRPS), vasculopathies and post-herpetic neuralgia (PHN) (2). The SG extends from the neck of the first rib to the lower border of transverse process of the seventh cervical vertebra ([C.sub.7] ) and is in continuation with the middle cervical ganglion, which is located at the sixth cervical vertebra ([C.sub.6]) (1). Although the SG block has been practised for many years, there is no clarity about the safe technique for a successful block. The SG can be blocked at the [C.sub.6] level with the landmark technique and at the [C.sub.6] or [C.sub.7] level with the help of imaging tools like ultrasonogram (USG) and fluoroscopy. It can be accessed through anterior or oblique approach. Also, the site of injection can be intramuscular, subfascial or extrafascial. The landmark-guided technique is based on the location of the anterior tubercle of [C.sub.6] Variation in the size of anterior tubercle of [C.sub.6] and vicinity of the vertebral artery makes this technique vulnerable to complications and reduces the success rate (3). The SG can be blocked at [C.sub.7] under the fluoroscopic guidance but has the disadvantage of not visualising the surrounding structures such as vertebral artery, dome of pleura and oesophagus. These shortcomings can be overcome by USG as one can easily view the soft tissues, anatomic variations of cervical and vertebral arteries and other pathological conditions (4). The SG can be reached via the anterior-paratracheal or lateral approach under the USG guidance. The close proximity of major blood vessels and oesophagus in the needle pathway in the anterior approach makes it unsafe when compared to the lateral approach (5). Considering these facts approaching the SG laterally at the [C.sub.6] level under USG appears to be the safer technique. However, the blockade at [C.sub.6] may result in failure of pain relief for upper limb pathologies as there is a possibility of only blocking the middle cervical ganglion, which supplies the head and the neck (1, 6). A previous study of SG block performed at [C.sub.7] under USG guidance by the lateral approach in patients suffering from upper limb pathologies was found to provide analgesia with minimal adverse events (7).

Earlier, the location of the cervical sympathetic chain was considered to be superficial to prevertebral fascia, but now it is confirmed by the USG imaging and dissection that the sympathetic chain is located subfascially (8). Hence, when the drug was injected subfascially by the lateral approach under USG, it spreads from the fourth cervical vertebra to the first thoracic vertebra and blocks SG irrespective of the level of entry. This was proven by Gofeld et al. (8) in the study done in cadavers at the [C.sub.6] level under USG with its clinical validation in human beings under fluoroscopy. The spread of drug along the sympathetic chain was seen in healthy human volunteers, but the clinical benefits of the SG blockade in terms of pain relief and safety profile were not studied. Although the SG block at [C.sub.6] is safer than at [C.sub.7], the clinical efficacy of SG block performed at [C.sub.7] is proven to be better than at [C.sub.6] (1, 6). Hence, we decided to study the clinical efficacy of Gofeld's approach for the SG block at the [C.sub.6] level using USG and fluoroscopy (8). The objective of the study was to assess the success of block in terms of pain relief, post-block temperature change and safety profile.

Methods

This prospective study was conducted over a period of 1 year (June 2016-May 2017), after obtaining consent from the institutional ethics committee. The study has been registered in the clinical trials registry of India (CTRI/2017/04/008416). Ten patients suffering from sympathetically mediated painful conditions of the head, neck and upper limb such as complex regional pain syndrome (CRPS) I &II, post-herpetic neuralgia, phantom limb syndrome and vaso-occlusive disorder belonging to both the genders, aged between 18 and 60 years, and with the Numeric Pain Intensity Scale (NPIS) greater than 4 were included in the study. The patients with extremes of the body mass index (18<BMI>25), taking beta blockers, with a history of recent myocardial infarction, glaucoma, arrhythmias and deranged coagulation profile were excluded from the study.

The procedure was explained, and a pre-procedure informed consent was obtained from the patients. The block was performed in the operation theatre under minimal mandatory monitoring. All the patients were fasted for 6 hours prior to the procedure. The block was performed by an experienced anaesthesiologist, who had performed more than 100 USG-guided regional anaesthesia blocks and 10 SG block under fluoroscopy. The block was done under the USG guidance (Shenzhen Mindray Bio-Medical Electronics Co., Ltd) with a 10-15 MHz probe and fluoroscopy (C-arm, KMC 650). The pain intensity of the patients was assessed prior to the block by an anaesthesiologist on the day of procedure. The block was performed by the second anaesthesiologist. The post-procedure pain score was assessed by another anaesthesiologist in the recovery room, who was not aware of the pre-procedure pain score and intra-operative events. The axillary temperature was recorded on the side of the block.

The intravenous access was obtained with a 20 G cannula, and patients were sedated with 0.02 mg k[g.sup.-1] of midazolam and 2 [micro]g k[g.sup.-1] of fentanyl. The patients were placed in the supine position with the neck slightly extended by placing a pillow under the shoulder and neck turned to the side opposite to the block site. Oxygen was administered to the patient with nasal cannula at a flow rate of 3 L [min.sub.-1]. Under strict aseptic precaution, the fluoroscope was positioned so as to get a PA view of the cervical spine with [C.sub.6] and [C.sub.7] as the centre and stored as a reference image (Figure 1). The USG scanning was done with a 10-15 MHz probe in the transverse plane from medial to lateral at the level of [C.sub.6]. The trachea, thyroid gland, carotid artery, internal jugular vein, longismus colli muscle and the transverse process of [C.sub.6] were visualised. The probe was placed in such a position so as to visualise the carotid artery and internal jugular vein anteriorly and transverse process posteriorly with the longismus colli in the centre for an in-plane technique (Figure 2). After local infiltration with 2 mL of 2% lignocaine along the lateral end of the probe, a 22 G spinal needle attached to a 10 cm extension tube was advanced between the carotid artery and anterior tubercle under real-time USG guidance. The needle tip was placed subfascially between the longismus colli and prevertebral fascia (Figure 2). Once when the position was confirmed, 1 ml of non-ionic contrast agent (Iohexol, omnipaque 350 mgl m[L.sup.-1]) was injected, and a fluoroscopic image was obtained to assess the spread of the dye (Figure 3). Downward dye spread along the longismus colli was considered desirable (Figure 4). If the spread of the dye was not desirable, the needle was repositioned to obtain a preferred image. This was followed by injection of 4 mL 0.25% bupivacaine with 40 mg of depot methyl prednisolone. The patients were shifted to the post-operative recovery room and were assessed for pain relief, axillary temperature and safety profile after 30 minutes.

A primary outcome of the study was to compare the success of the block in terms of pain reduction and relief. The intensity of pain was assessed by the NPIS on the scale from 0 to 10, where 0 indicates no pain and 10 indicates the worst pain imaginable (9). The patients were graded as NPIS=0, excellent pain relief; NPIS=1&2, good pain relief; NPIS=3, average relief and NPIS>3, poor pain relief. The secondary outcome of the study was to assess temperature change in the upper limb, downward spread of dye on fluoroscopy, the incidence of Horner's syndrome and the safety profile. The safety profile was assessed by the incidence of the voice hoarseness, dysphagia, feeling of a lump in the throat, vascular injury, ipsilateral limb weakness and respiratory depression. The axillary temperature was noted 30 minutes after the block. Changes in voice from baseline to a more breathy and raspy voice was taken as hoarseness of voice. The muscle power less than 4/5 in the upper limb was taken as weakness. A reduction in the oxygen saturation to less than 92% on room air was taken as respiratory depression. Patients were asked for feeling of a lump in the throat and its presence was noted. During the procedure, if there was any accidental vascular injury, it was noted on USG and fluoroscopy. Other signs for the involvement of the sympathetic chain were assessed with the presence of ptosis, anhydrosis and myosis.

Statistical analysis

Sample size calculations were based on a previous study, in which pain relief was noted in 36% of patients (10). The sample size of 9 patients was required to detect 50% of pain relief for the power of 80% and significance of 5%. Ten patients were included in the study. The statistical analysis was done using the Statistical Package for Social Sciences for Windows (Microsoft USA, version 23, Armonk, NY: IBM corporation and its licensors 2015). The distribution of data was analysed with the Kolmogorov--Smirnov test. Patients characteristics were analysed with one sample Students t-test, and data were expressed as the mean[+ or -]standard deviation (SD). The NPIS and temperatures were analysed with the paired t-test and were expressed as the mean[+ or -]SD. Safety profile parameters were expressed as number and percent. A p-value <0.05 was taken as significant for two-sided test.

Results

The patients characteristics are shown in Table 1. The downward spread of dye up to T1 was observed in all the patients (Figure 4). The post-block NPIS scores (Table 2) were significantly reduced as compared to pre-block NPIS scores (p=0.000), and the CI was 5.95-8.24. Six patients had excellent pain relief with the NPIS of 0 at the end of 30 minutes. The pain relief was good in 2 patients, average in 1 patient and poor in 1 patient. An increase in the axillary temperature was statistically significant, p=0.000 (CI, 1.56-1.23). Ptosis was observed in all the patients. Post-procedure adverse events were purely restricted to hoarseness of voice (2 patients) and foreign body sensation in the throat in 1 patient (Table 3).

Discussion

In this study, we assessed the efficacy of the SG block performed by the lateral approach at [C.sub.6] under the USG and fluoroscopic guidance. We found a significant drop in the post-block NPIS scores, and an increase in axillary temperatures when compared to the baseline values were significantly less. Hoarseness of voice was seen in 20%, feeling of a lump in the throat in 10% and ptosis in 100% of patients.

The SGB is most commonly done at the [C.sub.6] level as this level provides well-defined landmarks and relative safety against an inadvertent intravascular injection. Most of the studies on the SGB are either based on the landmark technique or under fluoroscopy guidance. Very few studies have been done under the USG guidance, which are also at the [C.sub.6] level (5, 8, 11). Ghai et al. (7) have described the lateral approach to the SG at the [C.sub.7] level under USG. They found a statistically significant reduction in the post-block NPIS, which is similar to our results. However, the reduction in the post-block NPIS is greater in our study with a greater number of patients having an excellent pain relief. This could be due to a subjective assessment of pain by the NPIS and inclusion of a variety of painful conditions by Ghai et al. (7) Although the SG block is indicated in several conditions, the evidence scores based on several studies recommend it only for three conditions: namely, CRPS, vasculopathies and acute and chronic PHN (12-14).

In the study conducted by Ackerman et al. (10), the SG was blocked under fluoroscopic guidance in 25 patients suffering from CRPS. Forty percent of patients had an excellent pain relief, 36% had a partial pain relief and 24% had no pain relief. The post-block pain relief in our study was slightly better, which could be due the accuracy provided by the USG guidance. Rise in the axillary temperature is one of the signs of the sympathetic block. There was a statistically significant rise in temperature after the block in our study, which was comparable to the results of the study done by Ghai et al. (7). Shibata et al. (11) studied the SG block under USG at the [C.sub.6] level, and they found changes in temperature in the ipsilateral limb. Jadon studied the efficacy and safety of the SG block performed at the [C.sub.7] level by an oblique fluoroscopic approach with 1-2 mL of dye. They targeted the junction between the uncinate process and the vertebral body to avoid vascular injury in CRPS patients (15). They observed an increase in temperature on the ipsilateral side without vascular injury. The dye spread was seen from the [C.sub.6] to the [T.sub.1] level in their study. In our study, we used 1 mL of dye, and its spread from [C.sub.4] to [T.sub.1] was confirmed before injecting the drug in all patients. From the studies done by Matsumotos and Malmqvist et al., it is clear that the block carried out at the level of [C.sub.6] was producing a successful sympathetic block of the head/neck with sparing of the upper limb as compared to the block done at [C.sub.7] (6, 16). This may be due to the fact that the middle cervical ganglion supplying the head and the neck is located at [C.sub.6] and SG, which supplies the upper limb at [C.sub.7]/[T.sub.1]. We had six patients with CRPS involving the upper limb in our study, and all of them had an increase in the axillary temperature with pain relief, which indicates a successful stellate ganglion block at the [C.sub.6] level. Harano has proved that the spread of injectate to the SG was seen in 45% of patients when the block was performed at [C.sub.6] and in 63% of patients when it was performed at [C.sub.7] (17). The bony landmark of [C.sub.6] or [C.sub.7] is only a surrogate marker of the sympathetic chain. The ideal location for performing the SG block is in the subfascial plane, superficial to the longus colli muscle. This can be identified only under USG. Once the needle is placed in the correct location under the USG guidance, the injectate spreads to [C.sub.7] - [T.sub.1], even though the site of entry is [C.sub.6] (18). Gofeld et al. (8) have proved that the cervical sympathetic chain is superficial to prevertebral fascia, and when the drug is injected accurately under USG, it spreads from [C.sub.4] to [T.sub.1], there by blocking the SG irrespective of the level of entry (8). We studied a clinical validity of the SG block by a technique described by Gofeld et al. (8), in which the SG was accessed safely via the lateral approach at the [C.sub.6] level under USG, and the position of needle was confirmed by the spread of the dye under fluoroscopy. In our study, we injected the drug after confirming the dye spread to the [T.sub.1] level. We found that there was an increase in the axillary temperature on the ipsilateral side along with a statistically significant reduction in the post-block NPIS. Our results are similar to the results of a study done by Ghai et al. (7), in which the SG was accessed at the [C.sub.7] level under the USG guidance without the aid of fluoroscopy. Identifying the [C.sub.7] vertebra on USG and blocking the SG at that level can be technically demanding with a risk of a block failure (19).

The incidence of temporary hoarseness of voice in the present study was 20%, which was similar to a study by Jadon and Ghai et al. (7, 15). The cause of temporary hoarseness in our patients could be due to spillage of drug into the trachea-oesophageal groove. Shibata et al. approached SG ganglion paratracheally under USG at the [C.sub.6] level. They found that hoarseness of voice was not seen if the drug was injected correctly in the subfascial plane, but hoarseness was present if the drug was deposited suprafascially (11). Shibata et al. injected 1% of lignocaine without steroid, which could have spared the blockade of recurrent laryngeal nerve in subfacial injections. However, they used a large volume of local anaesthetic agent which could have spread to the trachea-oesophageal groove when given suprafascially. Hoarseness could be a presenting sign of retropharyngeal haematoma following the SG block; however, the incidence of haematoma following the USG-guided SG block was zero (20, 21).

One of our patients complained of the presence of a lump in the throat, which was transient and relieved after 2 hours. Two patients had similar complaints in the study by Gofeld et al. (8). In our study, none of the patients complained of a persistent foreign body sensation, which is usually due to the blockade of the external laryngeal or recurrent laryngeal nerve resulting from the local anaesthetic spread (22). Injury to the oesophagus can also present in a similar fashion. The oesophagus is located abnormally in 5% of population, and its lateral deviation increases from 50% at the [C.sub.6], level to 74% at the [C.sub.7] level (21). Although an exact incidence of the accidental oesophageal puncture is not known, the probability of injuring it is greater at [C.sub.7] (21). Respiratory distress following a SG block could be due to pneumothorax or spillage of drug resulting in the phrenic nerve block, which was not seen in any of the patients. In this study, blocks were performed at [C.sub.6] under the USG guidance, thus avoiding an injury to pleura. The amount of the local anaesthetic agent was less than 5 ml; hence, spreading of the drug to the phrenic nerve and brachial plexus was not seen (20, 23).

In our study, changes in temperature after the SG block were noted in all the patients. However, a change in temperature does not always indicate a successful sympathetic blockade, and hence, monitoring with laser Doppler flowmetry is needed (24). The limitation of our study was that we did not monitor the blood flow of the ipsilateral side with laser doppler. Another limitation of our study was that we could not compare the success of the SG block performed for the head and neck pathologies and upper limb pathologies. Further studies are needed to prove the efficacy of the [C.sub.6] level block under USG and fluoroscopy, while comparing between the upper limb and head/neck pathology.

Conclusion

We conclude that the SG ganglion can be blocked effectively and safely through the lateral approach at the C6 level under the USG and fluoroscopic guidance.

Ethics Committee Approval: Ethics committee approval was received for this study from the ethics committee of Shri Sathya Sai Medical College and Research Institute.

Informed Consent: Written informed consent was obtained from patients who participated in this study.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept - K.V.; Design - K.V., P.K.; Supervision - K.V., P.K.; Resources - K.V., M.S.R; Materials - P.K., K.V., M.S.R; Data Collection /or Processing - K.V., P.K., K.S.; Analysis and/or Interpretation - P.K., K.V., K.S.; Literature Search - K.V., P.K., M.S.R; Writing Manuscript - K.V., P.K., K.S.; Critical Review- K.V., P.K., M.S.R; Other- K.V., P.K., M.S.R.

Conflict of Interest: The authors have no conflicts of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.

Etik Komite Onayi: Bu calisma icin etik komite onayi Shri Sathya Sai Medical College And Research Enstitusu'nden ahnmistir.

Hasta Onami: Yazili hasta onami bu cahsmaya katilan hastalardan ahnmistir.

Hakem Degerlendirmesi: Dis bagimsiz.

Yazar Katkilari: Fikir - K.V.; Tasanm - K.V., P.K.; Denetleme -K.V., P.K.; Kaynaklar - K.V., M.S.R; Malzemeler - P.K., K.V., M.S.R; Veri Toplanmasi ve/veya Islemesi - K.V., P.K., K.S.; Analiz ve/veya Yorum - P.K., K.V., K.S.; Literatiir Taramasi - K.V., P.K., M.S.R; Yaziyi Yazan - K.V., P.K., K.S.; Elestirel Inceleme - K.V., P.K., M.S.R; Diger- K.V, P.K., M.S.R.

Cikar Catismasi: Yazarlar cikar catismasi bildirmemislerdir.

Finansal Destek: Yazarlar bu calisma icin finansal destek almadiklarini beyan etmislerdir.

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(4.) Narouze S, Vydyanathan A, Patel N. Ultrasound-guided stellate ganglion block successfully prevented esophageal puncture. Pain Physician 2007; 10: 747-52.

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(6.) Matsumoto S. Thermographic assessments of the sympathetic blockade by stellate ganglia block (1) Comparison between C6 SGB and C7 SGB in 40 patients. Masui 1991; 40: 562-9.

(7.) Ghai A, Kaushik T, Kundu Z S, Wadhera S, Wadhera R Evaluation of new approach to ultrasound guided stellate ganglion block. Saudi J Anaesth 2016; 10: 161-7. [CrossRef]

(8.) Gofeld M, Bhatia A, Abbas S, Ganapathy S, Johnson M. Development and validation of a new technique for ultrasound-guided stellate ganglion block. Reg Anesth Pain Med 2009; 34: 475-9. [CrossRef]

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(11.) Shibata Y, Fujiwara Y, Komatsu T A new approach of ultrasound guided stellate ganglion block. Anesth Analg 2007; 105: 550-1. [CrossRef]

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(13.) van Wijck AJM, Wallace M, Mekhail N, Kleef MV Herpes Zoster and Post Herpetic Neuralgia. In: Zundert JV editor. Evidence based interventional pain medicine according to clinical diagnosis, 1st ed. Oxford: John Wiley& sons, LTD; 2012.p.88-97.

(14.) Devulder J, Suijlekom HV, Dongen RV, Diwan S, Mekhail N, Kleef MV, et al. Ischemic Pain in the Extremities and Raynaud's Phenomenon. In: Zundert JV editor. Evidence based interventional pain medicine according to clinical diagnosis, 1st ed. Oxford: John Wiley& sons, LTD; 2012.p.70-87.

(15.) Jadon A. Revalidation of a modified and safe approach of stellate ganglion block. Indian J Anaesth 2011; 55: 52-6. [CrossRef]

(16.) Malmqvist EL, Bengtsson M, Sorenson J. Efficacy of stellate ganglion block: A clinical study with bupivacaine. Reg Anesth 1992; 17:340-7.

(17.) Harano K. Difference of spread of injectate solutions after stellate ganglion block to sixth and seventh vertebral levels. Anesthesiology 1998; 15:871-7.

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(19.) Choi DH, Jung HG, Lee JH, Park JH, Choi YS. Effectiveness of Doppler image of vertebral artery as an anatomical landmark for identification of ultrasound guided target level in cervical spine. Asian Spine J 2015; 9: 683-8. [CrossRef]

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Krishnagopal Vinod (1), Pranjali Kurhekar (1), Krishnakumar Sharanya (2), M. S. Raghuraman (1)

(1) Shri Sathya Sai Medical College and Research Institute, Sri Balaji Vidyapeeth (Deemed-to be-University) Ammapettai, Kancheepuram, Tamilnadu, India

(2) Shree Balaji Medical College and Hospital, Chennai, Tamilnadu, India

Corresponding Author / Sorumlu Yazar: Pranjali Kurhekar E-mail: pranjalrkurhekar@gmail.com

Received/Gelis Tarihi : 21.09.2017

Accepted / Kabul Tarihi: 02.04.2018

Available Online Date / Cevrimici Yayin Tarihi : 17.08.2018

DOI: 10.5152/TJAR.2018.45144
Table 1. Patient's characteristics

Parameter                Mean[+ or -]SD

Age (Years)              49.3[+ or -]6.70
BMI (kg [m.sub.-2])      22[+ or -]1.31
Sex M/F (Number)          7/3
Indications (Number)
CRPS I                    6
Post-herpetic neuralgia   4
Neck                      2
Face                      2

SD: standard deviation; M: male; F: female; BMI: body mass index; CRPS:
complex regional pain syndrome

Table 2. Pain scale

Parameter     Pre-block          Post-block         P

NPIS           8.1[+ or -]0.73    1[+ or -]1.4      0.000
Temperature   97.65[+ or -]0.35  99.05[+ or -]0.20  0.000
(Fahrenheit)

NPIS: Numeric Pain Intensity Scale

Table 3. Adverse events

Parameter                        Number (%)

Hoarseness                       2 (20)
Dysphagia                        0
Feeling of a lump in the throat  1 (10)
Vascular injury                  0
Respiratory depression           0
Ipsilateral upper limb weakness  0
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Title Annotation:Original Article / Ozgun Arastirma
Author:Vinod, Krishnagopal; Kurhekar, Pranjali; Sharanya, Krishnakumar; Raghuraman, M. S.
Publication:Turkish Journal of Anaesthesiology and Reanimation
Article Type:Report
Date:Oct 1, 2018
Words:4473
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