Current preclinical evidence suggests the involvement of the sympathetic nervous system in the pathophysiology of CRPS. However, there is growing debate regarding its contribution to the clinical syndrome.
A literature review on sympathetic blocks graded stellate ganglion block as 1C evidence strong recommendation, low-quality, or very low-quality evidence 3. The clinician needs to balance the benefits and risks in each individual case to justify its use. Stellate ganglion block continues to be used as a treatment modality in the management of CRPS but further randomized controlled trials would be required to more confidently validate its usefulness.
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About Recent Edits Go ad-free. Edit article. View revision history Report problem with Article. Citation, DOI and article data. Knipe, H. Stellate ganglion. Reference article, Radiopaedia. Cervicothoracic ganglion Cervicothoracic ganglia Stellate ganglia. URL of Article. Back to Pain Center. Expert Team. Facial Pain. Gasserian Blocks. Occipital Block. Sphenopalatine Blocks. Stellate Ganglion Blocks. Interventional Pain Management. Understanding the anatomy of the cervical-thoracic sympathetic chain and ganglion is key to determine whether the neural block was therapeutic and to avoid unnecessary nerve ablation procedures.
The cervical sympathetic trunk or the cervical sympathetic chain is a cephalic continuation of the thoracic sympathetic trunk located in a bundle space.
The middle cervical ganglion is occasionally absent, never exceeds 10 mm long and is placed below and in front of Chassaignac's tubercle at the level of the sixth cervical vertebra.
When present it is associated with C5—C6. The inferior cervical ganglion is constant, usually located in front of the 7th cervical vertebra and the 1st thoracic vertebra, fused with the first thoracic ganglion forming an irregular mass con el primer spider-like shape. The stellate ganglion is located medial to the scalene muscles, lateral to the longus colli muscle and the trachea, together with the laryngeal recurrent nerve, anterior to the transverse process; the inferior most section is located posteriorly to the superior margin of the first section of the subclavian artery and at the origin of the vertebral artery, posterior to the apex of the lung.
At the level of C6 it is in close relation with the anterior tubercle of Chassaignac and at the level of C7 is more medial at the level of the anterolateral aspect of the vertebral body 10 Fig. The stellate ganglion lateral longus Colli muscle and closely related to the brachial plexus, and the lower portion is situated back to the origin of the vertebral artery.
The stellate ganglion measures approximately 2. It is located in front of the neck of the first rib extending to the union of the seventh cervical vertebra and the first thoracic vertebra. However, its shape and location vary depending on the individual. It is localized lateral and posterior to the lateral border of the long muscle of the neck.
The most important vascular relationships are the carotid and vertebral arteries located at the level of C7. It should be noted that incomplete osteogenesis might be present at the level of C7 so a medial-most approach should be maintained to prevent puncturing of the vertebral artery.
The longus colli muscle is the muscular landmark usually lateral to the ganglion and varying in thickness from 5 to 10 mm in C6 and from 8 to 10 mm in C7. The total depth from the subcutaneous cell tissue to the transverse process at C6 usually does not exceed The sympathetic fibers of the head, neck and lower limbs cross the stellate or cervical-thoracic ganglion. The efferent postganglionic nerve fibers go cross the head, the neck, the upper limbs and the heart.
The sympathetic postganglionic nerve endings release noradrenaline as the transmitter substance. The stellate ganglion block causes a more complete denervation of the head and neck structures.
However, there are a considerable number of people in whom somatic intrathoracic branches of the second nerve come together with the first spinal thoracic nerve. These intrathoracic branches join the gray communicating vessels of the sympathetic fibers and arise from the second sympathetic thoracic ganglion and probably from the ganglion at T3.
These fibers join the lower section of the brachial plexus without crossing the stellate ganglion. This explains the incomplete block of the upper extremities when only the block of the stellate ganglion proper is done.
Herpes Zoster-associated pain. Ischemic neuropathies. Post-radiation neuritis. Atypical facial pan, orofacial pain syndrome, including neuropathic orofacial pain. Sympathetic nerve maintained pain. Quinine poisoning. Phantom limb. Hyperhidrosis of the upper limb. Cardiac arrhythmias: cardiac ischemic pain, long QT syndrome. Neuropathic pain syndromes due to cancer pain. Poor knowledge of the technique and of the anatomy. Acquired coagulopathy anticoagulant therapy without bridge treatment.
Congenital coagulopathy. Localized infection. Drug allergies local anesthetic or steroids. Unable to sign the informed consent. Bupivacaine has a longer life, lasting 2—3 times more that lidocaine. However, Bupovacaine has high cardiovascular risks but it has become increasingly popular for stellate ganglion and other nerve blocks because of its excellent differential block of various nerve fibers and relative long action. Other drugs : Local anesthetic 0. The patient is placed in decubitus supine position or in lateral decubitus, with the head slightly extended a small pillow may be used between the shoulders and it has to be neutral or slightly rotated toward the opposite side of the procedure.
Adequate asepsis of the neck is performed and sterile dressings are applied. An initial scan is performed to identify structures: thyroid, carotid artery and jugular vein. The transverse process at C6 has been identified because of its prominent anterior tubercle, different from C5 that is flat and C7 that does not have a tubercle 10 Fig. Is the ultrasound image where the carotid artery is observed at a higher level, this medial thyroid; below the carotid artery are the long Colli muscle and the lower part the transverse process of C6 which is recognized by its former tuber identified.
The long muscle of the neck or longus colli is found above the transverse process of C6.
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