Peripheral and Visceral
Sympathetic Blocks
Michael Gofeld | Hariharan Shankar
CERVICAL SYMPATHETIC
(STELLATE GANGLION) BLOCK
Stellate ganglion block (SGB) was originally introduced by
René Leriche for the treatment of angina pectoris. Findley
and Patzer eventually modified the technique, which has
remained largely unchanged since then and was named
the anterior approach.1 This method is the most popular
technique in North America. In addition, lateral, superolat-
eral, and posterior approaches were introduced in the first
half of the 20th century.1 All techniques are based on bony
landmarks, such as the transverse process of C6, the spinous
process of C7, and the first rib. Eventually, these techniques
were empirically validated with fluoroscopy and computed
tomography (CT) and later with ultrasonography.
CLINICALLY RELEVANT ANATOMY
The stellate ganglion, also known as the cervicothoracic gan-
glion, represents a fusion of the inferior cervical and first
thoracic ganglia of the sympathetic trunk. It can be found
in about 80% of the population. The anatomy and position
of the stellate ganglion have been investigated by dissection,
magnetic resonance imaging (MRI), and CT.2-6 It is usu-
ally situated at the lateral border of the longus colli muscle
(LCM) anterior to the neck of the first rib (Fig. 56.1). It lies
posterior to the vertebral vessels and is separated from the
cervical pleura by the suprapleural membrane inferiorly.
The stellate ganglion measures 1 to 2.5 cm in length, is about
1 cm wide and 0.5 cm thick, and may be fusiform, triangular,
or globular in shape.5
INDICATIONS
SGB is commonly used for the diagnosis and management of
sympathetically mediated pain and vascular insufficiency of
the upper extremity. In addition, more esoteric indications
that have been advocated include the treatment of a variety
of medical conditions, such as phantom pain, post-herpetic
neuralgia, cancer pain, cardiac arrhythmias, orofacial pain,
and vascular headache.7 Recently, cervical sympathetic
blockade has been suggested as an effective method for
prevention and treatment of cerebral vasospasm, hot facial
flushes, and post-traumatic stress disorder.8-10
EVIDENCE FOR STELLATE GANGLION BLOCK
Clinical effectiveness of SGB can be defined as undeter-
mined. The majority of publications are case reports and
56
case series. Neurolytic SGB is currently rarely practiced
because the evidence is anecdotal. Malmqvist and colleagues
assessed 54 SGBs performed blindly with bupivacaine. Their
criteria for effective sympathetic blockade included Horner's
syndrome in combination with increased skin temperature,
increased skin blood flow, and a completely abolished skin
resistance response on both the radial and ulnar sides of
the blocked hand. Only 15 of 54 blocks met four of the five
criteria for an effective block.11 Another study examined
the efficacy of SGB in patients with complex regional pain
syndrome (CRPS) type 1. Pain relief and improved skin per-
fusion were observed in 40% of patients who had CRPS symp-
toms for 12 or fewer weeks, but no improvement occurred in
the group with more protracted disease (35.8 ± 27 weeks).12
Two small pilot studies suggested that SGB can provide relief
from hot flushes and sleep dysfunction with few or no side
effects in survivors of breast cancer and post-traumatic stress
disorder.9,10
No clinical studies have compared a “blind” with fluoros-
copy-guided SGB or fluoroscopy-guided with ultrasound-
guided SGB. According to a study that evaluated the oblique
and anterior paratracheal fluoroscopic approaches, both
techniques were equally effective. However, improved
safety and better satisfaction were reported with the former
approach.13 Comparison of an ultrasound-guided with a
surface landmark–based technique showed that less volume
of local anesthetic was used with ultrasound-guided injection
(5 vs. 8 mL). Hematoma did not develop in the ultrasound
group, but it did develop after the procedure in three
patients in the blind injection group. Ultrasound guidance
resulted in more rapid onset of Horner’s syndrome.14
AVAILABLE TECHNIQUES
Although a C7 approach to the stellate ganglion has been
described,13 SGB is still routinely performed at the C6 level
by using the following anatomic landmarks: prominent
anterior tubercle of the transverse process (Chassaignac’s
tubercle) and cricoid cartilage, both of which facilitate iden-
tification of the level and finally the location of the carotid
artery.2 Given that only traversing sympathetic fibers or
middle cervical ganglia can be found at the C6 level,15 the
procedure should more accurately be called a cervical sym-
pathetic block. The middle cervical ganglion or traversing
sympathetic fibers are located anterolateral to the belly of
the LCM.15 Conceivably, such a “convenient” location makes
it easy to access the sympathetic chain for either diagnostic
or therapeutic blockade.
Cervical sympathetic block is traditionally performed as a
“blind” injection via the anterior approach. It is accomplished
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