Chapter 67 Ultrasound-Guided Sympathetic Blocks: Stellate Ganglion and Celiac Plexus Block Flashcards
KEY POINTS 1. Celiac plexus is supplied by the greater, lesser, and least splanchnic nerves originating from the T5–T12. 2. Celiac plexus is made up of a few ganglia and interconnecting nerves and is located adjacent to the junction of the celiac artery and the aorta. 3. Ultrasound guidance for the performance of neurolytic celiac plexus block permits an anterior approach with relative safety and without radiation. 4. Ultrasound guidance is real time and may avoid accidental neurolytic in
Cervical sympathetic analgesic and neurolytic blockade commonly used in the diagnosis and management of
sympathetically mediated pain and vascular insufficiency of the upper extremities.
stellate ganglion block has been advocated for treatment of
phantom pain, postherpetic
neuralgia, cancer pain, cardiac arrhythmias, orofacial
pain, and vascular headache
stellate ganglion, also known as the cervicothoracic ganglion, represents a fusion of
the inferior cervical and
first thoracic ganglions of the sympathetic trunk.
stellate ganglion location
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.
Size of stellate ganglion
It measures 1 to 2.5 cm long, about 1 cm wide, and
0.5 cm thick, and may be fusiform, triangular, or globular
stellate ganglion blockade
C7 approach to stellate ganglion has been described, the blockade is routinely performed at the C6 level
stellate ganglion blockade landmarks
anatomic landmarks: prominent anterior tubercle of the transverse process
(Chassaignac’s tubercle), cricoid cartilage, and carotid
artery.
stellate ganglion blockade “blind” injection
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 The needle is then withdrawn by 1 to 5 mm, and a solution injected.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.
variety of side effects and complications of stellate ganglion blockade “blind” injection
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
Advantages of Flouroscopic guidance stellate ganglion blockade
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.
The cervical prevertebral
fascia
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.
There are two ultrasound-guided approaches to the cervical sympathetic trunk:
the modified “anterior” paratracheal
out-of-plane approach, and the newer “lateral” in-plane
method.
Both techniques can be performed using either
low-frequency curvilinear or high-frequency linear ultrasound transducers.
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
US stellate ganglion blockade
ANTERIOR APPROACH
Patient’s position
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.
US stellate ganglion blockade
ANTERIOR APPROACH Technique
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.
US stellate ganglion blockade
ANTERIOR APPROACH
Anatomy
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;
US stellate ganglion blockade
LATERAL APPROACH
Patient’s position
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
US stellate ganglion blockade
The advantage of
the lateral approach
avoiding the trespass
through the thyroid, is in the totally controllable visible progression of the needle from the skin entry point to the target.
Major causes for visceral
pain include
functional gastrointestinal disorders,
visceral malignancies, and chronic pancreatitis
amenable to celiac plexus
block (CPB)
Chronic visceral pain secondary to cancers of the pancreas, stomach, duodenum,
proximal small bowel, besides metastatic tumors in the lymph nodes in this area
Celiac Plexus
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.
The presynaptic sympathetic
fibers to the Celiac plexus are provided by
the greater, lesser, and least splanchnic nerves which originate from the paravertebral sympathetic ganglia T5 to T12.
The celiac plexus in turn supplies the
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.
The parasympathetic
fibers to the Celiac plexus are from
the vagus.
Neurolytic Celiac Plexus Block may provide relief of pain originating from tumors of the
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
The various techniques for Celiac Plexus Block include
endoscopic
transduodenal ultrasonography-guided CPB, intraoperative
CPB, and percutaneous CPB
Anterior approach for Celiac Plexus Block
used intraoperatively, during percutaneous
and endoscopic ultrasound-guided CPB.
Posterior approach for Celiac Plexus Block
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.
Advantages of Fluroscopy, CT
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.
Ultrasound-guided percutaneous CPB several advantages.
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.
Ultrasound-guided percutaneous CPB disadvantages.
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.
Neurolytic CPB is usually performed with either
phenol 6% to 10% or alcohol 50% to 100% following a diagnostic local anesthetic injection despite low negative predictive value of the diagnostic block
Complications of Celiac Plexus Block
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
Complications of Celiac Plexus Block injectant
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.
TECHNIQUE OF PERCUTANEOUS ULTRASOUNDGUIDED
CELIAC PLEXUS BLOCK
Ultrasound scanning
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.
TECHNIQUE OF PERCUTANEOUS ULTRASOUNDGUIDED
CELIAC PLEXUS BLOCK
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.
alternative two-needle technique
for CPB
the celiac trunk is visualized in a transverse view, and the needles are introduced from the lateral sides of the transducer.
