Chapter 67 Ultrasound-Guided Sympathetic Blocks: Stellate Ganglion and Celiac Plexus Block

Question 1

Cervical sympathetic analgesic and neurolytic blockade commonly used in the diagnosis and management of

Answer 1

sympathetically mediated pain and vascular insufficiency of the upper extremities.

Question 2

stellate ganglion block has been advocated for treatment of

Answer 2

phantom pain, postherpetic
neuralgia, cancer pain, cardiac arrhythmias, orofacial
pain, and vascular headache

Question 3

stellate ganglion, also known as the cervicothoracic ganglion, represents a fusion of

Answer 3

the inferior cervical and
first thoracic ganglions of the sympathetic trunk.

Question 4

stellate ganglion location

Answer 4

It is usually situated on the lateral border of the longus colli muscle anterior to the neck of first rib. It lies posterior to the vertebral vessels and is separated from the cervical pleura by the suprapleural membrane inferiorly.

Question 5

Size of stellate ganglion

Answer 5

It measures 1 to 2.5 cm long, about 1 cm wide, and
0.5 cm thick, and may be fusiform, triangular, or globular

Question 6

stellate ganglion blockade

Answer 6

C7 approach to stellate ganglion has been described, the blockade is routinely performed at the C6 level

Question 7

stellate ganglion blockade landmarks

Answer 7

anatomic landmarks: prominent anterior tubercle of the transverse process
(Chassaignac’s tubercle), cricoid cartilage, and carotid
artery.

Question 8

stellate ganglion blockade “blind” injection

Answer 8

Practitioners are typically taught to palpate Chassaignac’s tubercle, to gently retract the carotid artery, and then to insert the needle paratracheally until it contacts a bone, presumably the lateral part of the vertebral body. The needle is then withdrawn by 1 to 5 mm, and a solution injected. This maneuver was presumed to be sufficient to position the needle outside the longus colli muscle, where the stellate ganglion is thought to be situated.

Question 9

variety of side effects and complications of stellate ganglion blockade “blind” injection

Answer 9

as intravascular injection, formation of hematomas (is likely related to damage to the inferior thyroid artery),
temporary paralysis of the recurrent laryngeal nerve, discitis, and esophageal injury

Question 10

Advantages of Flouroscopic guidance stellate ganglion blockade

Answer 10

reduces overall risk associate associated with the “blind” technique. advantage of identifying bony anatomy, though the anatomic position of the cervical sympathetic trunk (CST) is confined to the soft tissues (longus colli muscle, thyroid, and esophagus) rather than the cervical vertebrae.

Question 11

The cervical prevertebral
fascia

Answer 11

attached to the base of the skull and extends over the prevertebral muscles (longus capitis, rectus capitis, and
longus colli muscles) to attach distally at the T4 vertebra,
just beyond the longus colli muscle. This positioning
of the fascia forms a plane along which the injected fluid can flow.

Question 12

There are two ultrasound-guided approaches to the cervical sympathetic trunk:

Answer 12

the modified “anterior” paratracheal
out-of-plane approach, and the newer “lateral” in-plane
method.

Question 13

Both techniques can be performed using either
low-frequency curvilinear or high-frequency linear ultrasound transducers.

Answer 13

Low-frequency sonography provides better visualization of the surrounding structures and
facilitates needle entry planning, while high frequency gives better resolution of pertinent anatomy and fascial planes

Question 14

US stellate ganglion blockade

ANTERIOR APPROACH

Patient’s position

Answer 14

The patient is placed in the supine position. A pillow can
be placed under the lower neck to achieve some extension.
The head may be slightly rotated contralaterally to the
injection side increasing distance between the carotid
artery and the trachea and improving sonographic view.

Question 15

US stellate ganglion blockade

ANTERIOR APPROACH Technique

Answer 15

After skin preparation and dressing, sterile ultrasonic gel is
applied. Ultrasonography of the anterior neck is performed with initial transducer placement at
the level of the cricoid cartilage, anterior to the SCM muscle. Short-axis ultrasonography reveals the typical appearance of the C6 transverse process—the prominent anterior tubercle, the short posterior tubercle, and the exiting C6 nerve root. The injection is performed as a short-axis out-off-plane
approach. The skin is anesthetized immediately
caudad to the transducer. The injection is performed using
a spinal needle (22–25 gauge and 2–3.5 inches long) with
a three-way stopcock and extension tubing connecting
two syringes, one with NaCl 0.9% and one with local
anesthetic. The needle is inserted under continuous ultrasound guidance, directed to the anterior surface of the
longus colli muscle using a short-axis out-of-plane
approach. When the needle tip is visualized, either directly
or indirectly (tissue movement) as approaching the target,
1 to 2 ml of saline is injected to confirm placement of the needle under the prevertebral fascia, facilitating clear separation of the tissue planes. If the spread is appropriate, 5 ml
of local anesthetic is injected, and the needle is withdrawn.

Question 16

US stellate ganglion blockade

ANTERIOR APPROACH
Anatomy

Answer 16

The C7 nerve root is situated just anterior to the posterior
tubercle. At the C6 level, the longus colli muscle is seen as an oval structure adjacent to the base of the transverse process and vertebral body.
Sometimes the caudal portion of the longus capitis muscle
could be seen as well. The CST is visualized as a spindle shaped structure (the midcervical ganglion), and typically situated on the posterolateral surface of the longus colli muscle;

Question 17

US stellate ganglion blockade

LATERAL APPROACH

Patient’s position

Answer 17

The patient is placed in the lateral decubitus position, with
the side to be treated uppermost. the transducer is centered at the C6 transverse process and not at the anterior neck. It is of utmost importance to localize the C6 nerve root and the anterior process. The needle tract should be entirely intramuscular, passing
through the SCM muscle, the anterior scalene muscle, or both. Skin anesthesia is performed immediately posterior to the US transducer. Injection of 5 ml of a local anesthetic typically results in
C3–T1 prevertebral spread and the complete blockade of
the cervical sympathetic trunk and the stellate ganglion

Question 18

US stellate ganglion blockade

The advantage of
the lateral approach

Answer 18

avoiding the trespass
through the thyroid, is in the totally controllable visible progression of the needle from the skin entry point to the target.

Question 19

Major causes for visceral
pain include

Answer 19

functional gastrointestinal disorders,
visceral malignancies, and chronic pancreatitis

Question 20

amenable to celiac plexus
block (CPB)

Answer 20

Chronic visceral pain secondary to cancers of the pancreas, stomach, duodenum,
proximal small bowel, besides metastatic tumors in the lymph nodes in this area

Question 21

Celiac Plexus

Answer 21

Located approximately at the level of the 12th thoracic and/or first lumbar vertebra, the celiac plexus is composed
of two to five celiac ganglia with its network of nerve
fibers. The plexus surrounds the celiac trunk and the superior mesenteric artery at its root). It is located in front
of the aorta and the crura of the diaphragm, and posterior
to the stomach and omental bursa.

Question 22

The presynaptic sympathetic
fibers to the Celiac plexus are provided by

Answer 22

the greater, lesser, and least splanchnic nerves which originate from the paravertebral sympathetic ganglia T5 to T12.

Question 23

The celiac plexus in turn supplies the

Answer 23

various abdominal viscera
through multiple smaller plexuses and nerve fibers accompanying the arteries. The various structures
supplied include the diaphragm, liver, stomach,
spleen, suprarenal glands, kidneys, the ovaries and testis,
the small intestine, and the colon up to the splenic flexure. The celiac plexus also sends branches to the superior and
inferior mesenteric plexuses.

Question 24

The parasympathetic
fibers to the Celiac plexus are from

Answer 24

the vagus.

Question 25

Neurolytic Celiac Plexus Block may provide relief of pain originating from tumors of the

Answer 25

the stomach, liver, pancreas, spleen, and proximal small bowel beside adrenals. CPB has also been attempted for relief from chronic pancreatitis pain and during biliary interventions

Question 26

The various techniques for Celiac Plexus Block include

Answer 26

endoscopic
transduodenal ultrasonography-guided CPB, intraoperative
CPB, and percutaneous CPB

Question 27

Anterior approach for Celiac Plexus Block

Answer 27

used intraoperatively, during percutaneous
and endoscopic ultrasound-guided CPB.

Question 28

Posterior approach for Celiac Plexus Block

Answer 28

Fluoroscopic,
MRI, and landmark-based injections approach the CPB
posteriorly. CT-guided CPB may be performed through
an anterior or posterior approach, although the posterior approach is commonly preferred.

Question 29

Advantages of Fluroscopy, CT

Answer 29

Fluoroscopy and CT
carry the risk of increased radiation exposure to the patient and personnel. CT may provide finer details about
the plexus, celiac artery, and neighboring structures for improved safety and better targeting. Fluoroscopy may
fail to visualize the soft tissues, posing the hazard of soft
tissue damage.

Question 30

Ultrasound-guided percutaneous CPB several advantages.

Answer 30

It is low cost, portable, may be
performed at the bedside, and lacks the risk of radiation.
In addition, the supine position is more comfortable to the
patient. It may also avoid entry into the kidney or spinal
cord, and the abdominal aorta, the celiac trunk, and the
superior mesenteric artery are clearly visualized. It permits real-time visualization of the injectate spread.

Question 31

Ultrasound-guided percutaneous CPB disadvantages.

Answer 31

The disadvantages
include poor visualization of deeper structures, including
the pancreas, and the interference of the air in the intestinal loops. Similar to CT guidance, it may cause perforation of the stomach, intestine, pancreas, or liver.

Question 32

Neurolytic CPB is usually performed with either

Answer 32

phenol 6% to 10% or alcohol 50% to 100% following a diagnostic local anesthetic injection despite low negative predictive value of the diagnostic block

Question 33

Complications of Celiac Plexus Block

Answer 33

Side effects such as orthostatic hypotension and transient diarrhea are known to occur after a CPB, pain at the injection site. Other rare complications are retroperitoneal hematoma, injury to the pleura and lung leading to pneumothorax, injury to kidneys and intestines, and paraplegia secondary to neurolytic injection into the epidural
or spinal canal or secondary to accidental injection of
neurolytic agent into the artery of Adamkiewicz, all of which are reported in less than 1% of cases

Question 34

Complications of Celiac Plexus Block injectant

Answer 34

Superior mesenteric vein thrombosis has been reported with alcohol CPB. An intravascular injection of neurolytic agent is a potential complication and can cause tremors and convulsions
with phenol.

Question 35

TECHNIQUE OF PERCUTANEOUS ULTRASOUNDGUIDED
CELIAC PLEXUS BLOCK

Ultrasound scanning

Answer 35

the patient supine, monitor guidelines are applied. A peripheral intravenous line is established. The patient may be instructed to control his/her respiration at certain times during the procedure. Typically, a low-frequency, curved-array, 3- to 5-MHz transducer is used. A scout scan is performed starting from the epigastrium
and moving caudad to visualize the aorta, vertebral
body, and the liver in a transverse view. Once
the celiac trunk is visualized, colorflow Doppler is turned
on to verify the vessels. Following this, the
transducer is turned longitudinally and the celiac trunk and the superior mesenteric artery are visualized. The target is the space between the celiac trunk and the superior mesenteric artery.

Question 36

TECHNIQUE OF PERCUTANEOUS ULTRASOUNDGUIDED
CELIAC PLEXUS BLOCK

Answer 36

Following the scout scan, the area is prepped and draped. A 22-gauge, 15-cm-long Chiba needle is advanced to the space. After negative aspiration, a test dose
of 3 ml of lidocaine with epinephrine is injected realtime to rule out any intravascular uptake. Subsequently, real-time injection of the neurolytic agent in 5-ml increments is done. The typical volume of injectate used varies from 10 to 50 ml. The concentrations of alcohol used vary from 50% to 100%. With phenol, the concentration ranges from 6% to 10%. The needle is flushed with 1 ml of local anesthetic at the end of the procedure to flush the needle track of remaining neurolytic agent.

Question 37

alternative two-needle technique
for CPB

Answer 37

the celiac trunk is visualized in a transverse view, and the needles are introduced from the lateral sides of the transducer.