Unusual case of contralateral Horner's syndrome following stellate-ganglion block: a case report and review of the literature

Abstract

Stellate-ganglion block (SGB) is a commonly performed procedure for the treatment of numerous conditions, including upper-extremity complex regional pain syndromes and arterial insufficiency. The appropriate response to SGB includes ipsilateral Horner’s syndrome and temperature elevation of affected extremity. Contralateral and bilateral Horner’s syndrome following SGB are rarely seen, with only six prior cases reported. We describe a case of a 47-year-old female with right-hand pain secondary to Raynaud’s phenomenon who underwent SGB with subsequent contralateral Horner’s syndrome and review the literature of this rare phenomenon.

A study of the efficacy of stellate ganglion blocks in complex regional pain syndromes of the upper body

“…These suggest that bilateral sympathetic blockade occurs commonly, ranging from functional changes (such as increased hand warming and facial skin blood flow) without gross anatomic changes (such as HS) to a full spectrum. [ 26 27 28 29 ] In our series, we injected 6 ml LA, with the needle apparently perpendicular to the plane, although slight medial angulation of the needle cannot be ruled out. It is theorized that in this patient, the contralateral HS developed due to blockade of contralateral cervical and bilateral thoracic sympathetic chain.…”

“…Pneumothorax, esophageal perforation, and chylothorax from thoracic duct injury have been reported due to the proximity of these structures to the stellate ganglion. [ 3 4 7 16 20 27 ] These are uncommon when the block is done under image guidance. There was only one case of pneumothorax which was small, not warranting intervention.…”

“…Three cases of bilateral and four cases of contralateral HS have been previously reported in the literature. [ 27 ] Postulated causes are LA migration to the contralateral side, cross-variations in stellate ganglion innervations or ipsilateral ciliospinal center inhibition. The LA can migrate to the opposite side if there is a medial angulation of the needle, injection given behind the longus colli muscle, or a large LA volume injected.…”

“…This results in an ipsilateral pupillary dilation, facial hyperhidrosis, and lid lift which may be confused as contralateral HS. [ 4 27 ] In addition, it is also postulated that the cervical sympathetic trunk can be blocked independent of upper limb thoracic sympathetic fibers, especially when the drug is injected at the level of C6 tubercle. [ 4 ] Similar findings can be seen in upper spinal cord lesions and Harlequin syndrome where hemifacial cutaneous sympathetic denervation is caused by the failure of the upper thoracic sympathetic chain with sparing of T1 segment.…”

Perspectives on the first randomized sham-controlled trial of stellate ganglion block for hot flashes

“…4,5,7,8,10,30 Financial disclosure/conflicts of interest: C.S.W. Thus, these studies and interventions should be performed by well-trained and experienced operators with vigilance for rare but serious complications.…”