Development and Validation of a New Technique for Ultrasound-Guided Stellate Ganglion Block

Gofeld, Michael; Bhatia, Anuj; Abbas, Sherif; Ganapathy, Sugantha; Johnson, Marjorie

doi:10.1097/aap.0b013e3181b494de

Cited by 135 publications

(68 citation statements)

References 15 publications

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“…1). 8,10,13 In a recently published study, it was suggested that the ultrasound-guided anterior approach for SGB may avoid penetration of the esophagus and blood vessels 15 ; however, this study estimated the potential for vascular and esophageal puncture with conventional (non-image-guided) paratracheal approaches at the C6 and C7 levels, and risk with the lateral approach was not evaluated.…”

Section: Résumémentioning

confidence: 99%

“…5,6 These techniques are conventionally guided by the use of anatomic landmarks and/or fluoroscopy, 4,7 but both of these techniques can be associated with complications. There are many important soft-tissue structures that can be inadvertently pierced at these levels during needle placement for SGB, [8][9][10] including the trachea, thyroid gland, esophagus, arteries (carotid, vertebral, inferior thyroidal, deep and ascending cervical), cervical nerve roots, and external jugular vein. Puncture of the esophagus and blood vessels can result in serious complications, such as esophagitis, mediastinitis, and hematoma, and injection of local anesthetic into a vertebral artery can precipitate seizures.…”

Section: Résumémentioning

confidence: 99%

“…Another line, F, was drawn from the skin to the anterior surface of the LC to simulate the lateral inplane approach at the C6 level. 8,10 This line bisected the shortest distance between the medial surface of the carotid artery and the anterior tubercle of the C6 vertebra. The length of line F approximated the needle path for the lateral ultrasound-guided approach at the C6 level.…”

Section: Scanning Proceduresmentioning

confidence: 99%

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Evaluation of sonoanatomy relevant to performing stellate ganglion blocks using anterior and lateral simulated approaches: an observational study

Bhatia

Flamer

Peng

2012

Can J Anesth/J Can Anesth

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Purpose Stellate (cervicothoracic) ganglion block (SGB) can be associated with serious complications, such as esophageal and vascular injury. The objective of this study was to evaluate the potential for vascular and esophageal injury in healthy subjects by examining the sonoanatomy of the neck relevant to the SGB at the sixth (C6) and seventh (C7) cervical vertebral levels and determining the incidence of blood vessels and esophagi in the simulated path of needle insertion in the conventional and two different ultrasound-guided approaches used to perform a SGB. Methods Ultrasound scanning of the neck at the C6 and C7 cervical vertebral levels was performed in 100 adult subjects, and the following measurements were obtained: the degree of deviation of the esophagus relative to the larynx/trachea; the likelihood of encountering a vessel in the simulated path of needle insertion in the two different approaches to SGB; the incidence of the vertebral artery being situated outside the foramen transversarium at the C6 level; and the distance of the simulated path of needle insertion in the anterior and lateral approaches to SGB at the C6 level. Results The position of the esophagus was found to be variable but lateral to the airway in 50% and 74% of the subjects at C6 and C7, respectively. The esophagus covered more than half of the distance between the airway and the carotid artery in 14% and 44% of the subjects at the C6 and C7 levels, respectively. With the anterior approach, a major vessel was observed in up to 29% and 43% of patients at the C6 and C7 levels, respectively. The vertebral artery was outside the foramen transversarium in 7% of subjects at the C6 level. Conclusion Major blood vessels and the esophagus are in close proximity to needle pathways during the anterior approach to SGB performed with either anatomic landmarking or fluoroscopic guidance. An ultrasound-guided lateral approach at the C6 level may possibly confer a greater margin of safety for performing SGB. RésuméObjectif Le bloc du ganglion stellaire (cervicothoracique) (BGS) peut eˆtre associe´a`des complications graves, telles que des le´sions oesophagiennes et vasculaires. Les objectifs de l'e´tude e´taient les suivants : e´tudier l'e´cho-anatomie du cou pertinente pour le BGS au niveau des 6 e et 7 e verte`bres cervicales (C6 et C7) chez des patients en bonne sante´, e´valuer le risque de le´sion vasculaire et oesophagienne en enregistrant l'incidence des vaisseaux sanguins et de This study was conducted with written informed consent from the study subjects. This report describes an observational clinical study, and it adheres to the STROBE guidelines.

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Section: Résumémentioning

confidence: 99%

Section: Résumémentioning

confidence: 99%

Section: Scanning Proceduresmentioning

confidence: 99%

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Evaluation of sonoanatomy relevant to performing stellate ganglion blocks using anterior and lateral simulated approaches: an observational study

Bhatia

Flamer

Peng

2012

Can J Anesth/J Can Anesth

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“…Stellate ganglion blocks (SGB) have been performed for multiple indications including complex regional pain syndrome of the upper extremity, phantom limb pain, cancer pain, herpetic neuralgia and orofacial pain. Landmark-based and FS techniques have been limited by inefficacy as well as increased risk of soft tissue injury [60]. The stellate ganglion is classically described as located at the C7-T1 level of the neck.…”

Section: • Stellate Ganglion Blockmentioning

confidence: 99%

“…The stellate ganglion is classically described as located at the C7-T1 level of the neck. In blind or FS techniques, the needle is advanced to Chassaignac's tubercle (transverse process of C6), withdrawn and directed inferomedially to the body of C6; medication is injected after the needle is withdrawn 1-2 mm [60]. This allows relative safety from vertebral artery injury.…”

Section: • Stellate Ganglion Blockmentioning

confidence: 99%

Ultrasound-Guided Interventional Procedures for Chronic Pain Management

et al. 2015

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Ultrasonography has multiple advantages over traditional radiologic imaging modalities when used for interventional procedures. It allows improved visualization of the anatomy while avoiding ionizing radiation and risks associated with contrast use. It has proved superiority at accuracy of delivery and procedural effectiveness over blind procedures when used in association with interventional pain procedures. Although limited in its ability to see through bony structures, ultrasound has utility in visualizing soft tissues and vascular structures in anatomic regions of interest resulting in increased use for posterior neuraxial, periaxial, peripheral nerve and joint-related structures. Current evidence for use in these settings is presented here. In some cases, optimal utility may be improved by combining ultrasonography with other imaging modalities. KEYWORDS• chronic pain management Advantages of ultrasound imagingInterventional pain procedures were traditionally performed under fluoroscopic (FS), computed tomography (CT) or MRI guidance. The use of ultrasound (US) to perform injections for chronic pain has significantly increased in the past decade [1,2]. This increase is attributed to its multiple advantages over other imaging modalities including ease of performance, absence of ionizing radiation, better visualization of soft tissue (i.e., muscle, ligament) and blood vessels, real time visualization of needle advancement and, at times, the ability to observe the spread of injectate [3]. US Practice points• Use of ultrasound in medicine has grown with smaller size equipment, increased portability and decreased cost.• Ultrasound has multiple advantages over radiographic imaging when used for interventional pain procedures.• Sonography is useful for medial branch blocks and intra-articular facet blocks in the cervical and lumbar spine but there is little evidence to support its use in the thoracic spine.• Ultrasonography is limited in utility for many types of axial injections because of bony and acoustic shadowing artifact but it does show some promise with transforaminal epidurals or selective nerve root blocks.• Ultrasound guidance is effective in preventing soft tissue and vascular injury in stellate ganglion blocks compared with blind techniques. Soft tissue and vascular anomalies can be identified that fluoroscopic technique will miss.• Ultrasound improves accuracy and efficacy in ilioinguinal, iliohypogastric and genitofemoral blocks for inguinal and testicular pain.• Lateral femoral cutaneous nerve injections are more accurate under ultrasound guidance, especially given the anatomic variation the nerve exhibits in cadaver dissections.• Injections into the knee, shoulder and hip joints are more successful when performed using ultrasound.For reprint orders, please contact: reprints@futuremedicine.com

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Fetal anatomy of the lower cervical and upper thoracic fasciae with special reference to the prevertebral fascial structures including the suprapleural membrane

et al. 2011

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The aim of this study was to find basic rules governing the fetal anatomy of the deep cervical fasciae and their connections to the mediastinal fasciae. We examined the histology of paraffin-embedded preparations of 18 mid-term fetuses (5 between 9 and 12 weeks of gestation, 3 between 15 and 18 weeks, and 10 between 20 and 25 weeks). The prevertebral lamina of the deep cervical fasciae (PLDCF) developed as an intermediate aponeurosis for the bilateral bellies of the longus colli muscles. In contrast, the alar fascia developed as a connecting band between the bilateral adventitiae of the common carotid artery. The retropharyngeal fascia became evident much later than the latter two fasciae. The fascia covering the thymus was thicker than the fascia for the strap muscles (the pretracheal lamina of the cervical fascia). The primitive suprapleural membrane, or Sibson's fascia, contained veins and fatty tissues, and was composed of the alar fascia rather than the PLDCF, tranversalis fascia, or endothoracic fascia. The prevertebral two-laminar configuration was rather evident in the early stages of development because, in the later stages, the fasciae together provided a multilaminar structure, especially in the lateral area in front of the longus colli, which suspended the cupula pleurae. To consider a continuation from the base of the neck to the upper mediastinum, the alar fascia seems to be a key structure for connecting the vascular sheath to the parietal pleura.

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Development and Validation of a New Technique for Ultrasound-Guided Stellate Ganglion Block

Abstract: This study revealed that, at the C6 level, the cervical sympathetic trunk lies entirely subfascially. Subfascial injection via the lateral approach ensures reliable spread of a solution to the stellate ganglion.

Cited by 135 publications

References 15 publications

Evaluation of sonoanatomy relevant to performing stellate ganglion blocks using anterior and lateral simulated approaches: an observational study

Evaluation of sonoanatomy relevant to performing stellate ganglion blocks using anterior and lateral simulated approaches: an observational study

Ultrasound-Guided Interventional Procedures for Chronic Pain Management

Fetal anatomy of the lower cervical and upper thoracic fasciae with special reference to the prevertebral fascial structures including the suprapleural membrane

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