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Effects of stellate ganglion block: A result of ganglion blockade or vertical spread of local anesthetic
Poster Discussion VII 65
Effects of Stellat¢ Ganglion Block: A Result of Ganglion Blockade or Vertical Spread of Local Anesthetic.
WE Ackerman, III, MD, FAADEP
I'3, and M Abroad, MD ~ 3.
1Associate Professor, 2Assistant Professor. 3Center for Pain Medicine, Dept of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR 72205. Introduction: This study was performed to ascertain if the vertical flow of a local anesthetic during stellate ganglion block affected the incidence of Hornets syndrome, and temperature change in the upper extremity of patients with complex regional pain syndrome type I. Methods: Fifty patients were studied after IRB approval. All patients had prC-lXoceduralphysical findings of aUedynia, hyperhydrosis, as well as a decreased temperature of at least 2°C in the extremity being studie& No patient had a pre-injection skin surface ten-q~eraturee~ceeding 33°C. Each block was performed by the same anesthesiologist at ambient temperatures of 20-22°C. S~face skin temperature was monitored bilaterally with liquid crystal tempo'ature strips (Crystalline, Sham, Inc., Tampa, FL). A galvanic skin reslxame was assessed pre- and post-block. An anterior lateral approach was used using fluoroscopic guidance (1). A 22-gauge 3½-inch spinal needle was advanced to the anterior lateral border of the C7 vertebral body at the level of the transverse process. After the vertebral body was contacted, the needle was withdrawn approximately 1 millimeter. A 5 ml solution of bupivacaine 0.5% (4 ml) with Iopamidol 300 (1 ml) was nse~ Under continuous fluoroscopy 5 ml of the solution was administered at a rate of 1 ml per 10 seconds. Post-injection vertical spread in a cephalad and caudal direction was noted. The vertebral body level obtained was defmed as the level of the transverse process above and below needle placement at C7. Incidence of Homer's syndrome and changes in skin tempcm~res were noted. Statisticalanalysiswas done using the complex Chi-square testwith Yates correctionfor continuitywhere applicable.A p value < 0.05 was considered significant. Results: The incidence of a Homer's syndrome increasedas the solutionapproached the superiorcervical ganglion (C3XTable 2). Skin temperature changes were more pronounced when the solutionspread distalto TI. Table 1 Demographic Data Male: 21 Sex Female: 29 Age 39.8 (+9.4) Hei~ht (cm) 168.3 (_+2.7) Weight (ks) 77.3 (_+5.8) Table 2 Results of Ccphalad Spread of Solution Vertebral body Presence of Hornets Post-procedure Galvanic Skin Temperature level Syndrome Response Increase c3 (n=4) 4/4+ (100%) 0 (0%) 1/5 (20%) 5/6+ (83.3%) 0 (0%) 2/7 (28.5%) C4 (n=6) 8/11+ (72.7%) 2/11 (18.3%) 11/21+ (52.3%) C5 (n=ll) 12/19 (63.1%) C6 (n=9) 3/9+ (33.3%) 10/16+ (62.5%) 5/lO (50%) 4/10+ (40%) 1/1 + (100%) c 7 (n=lO) <0.05 Table 3 Results of Caudal Spread of Solution Post-procedure Galvanic Skin Temperature Vertebral body Presence of Homc~s Increase Syndrome Response level 3/18 (16.6%) c7 (n=lS) ~18 + (33%) 2/18 (11.1%) 4/lO (40%) Wl0 + (2w~) 3/10 (30%) Tl (n=10) T2 (n=12) 10/12+ (83.3%) 10/12+ (83.3%) 0 (~) 8/8 + (100%) T3 (n=8) o (~) 8/8 + (10o%) 2/2+ (100%) 2/2+ (100%) T4 (n=2) 0 (~) ~_<0.05 Conclusion: The resultssuggest thatfailureto produce an increasein skin temlx:ratureof the upper extremity is due to lack of spread of local anestheticto T2 and T3 ganglia.The presence of a Homaes syndrome is hypothesized to be a resultof eithera cemplctc steUate,middle ganglion, or a superiorcervicalganglion block. References: 1. Ackerman WE, et al: Pain Digest; 8:80-84, 1998.
Effects of Stellat¢ Ganglion Block: A Result of Ganglion Blockade or Vertical Spread of Local Anesthetic.
WE Ackerman, III, MD, FAADEP
I'3, and M Abroad, MD ~ 3.
1Associate Professor, 2Assistant Professor. 3Center for Pain Medicine, Dept of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR 72205. Introduction: This study was performed to ascertain if the vertical flow of a local anesthetic during stellate ganglion block affected the incidence of Hornets syndrome, and temperature change in the upper extremity of patients with complex regional pain syndrome type I. Methods: Fifty patients were studied after IRB approval. All patients had prC-lXoceduralphysical findings of aUedynia, hyperhydrosis, as well as a decreased temperature of at least 2°C in the extremity being studie& No patient had a pre-injection skin surface ten-q~eraturee~ceeding 33°C. Each block was performed by the same anesthesiologist at ambient temperatures of 20-22°C. S~face skin temperature was monitored bilaterally with liquid crystal tempo'ature strips (Crystalline, Sham, Inc., Tampa, FL). A galvanic skin reslxame was assessed pre- and post-block. An anterior lateral approach was used using fluoroscopic guidance (1). A 22-gauge 3½-inch spinal needle was advanced to the anterior lateral border of the C7 vertebral body at the level of the transverse process. After the vertebral body was contacted, the needle was withdrawn approximately 1 millimeter. A 5 ml solution of bupivacaine 0.5% (4 ml) with Iopamidol 300 (1 ml) was nse~ Under continuous fluoroscopy 5 ml of the solution was administered at a rate of 1 ml per 10 seconds. Post-injection vertical spread in a cephalad and caudal direction was noted. The vertebral body level obtained was defmed as the level of the transverse process above and below needle placement at C7. Incidence of Homer's syndrome and changes in skin tempcm~res were noted. Statisticalanalysiswas done using the complex Chi-square testwith Yates correctionfor continuitywhere applicable.A p value < 0.05 was considered significant. Results: The incidence of a Homer's syndrome increasedas the solutionapproached the superiorcervical ganglion (C3XTable 2). Skin temperature changes were more pronounced when the solutionspread distalto TI. Table 1 Demographic Data Male: 21 Sex Female: 29 Age 39.8 (+9.4) Hei~ht (cm) 168.3 (_+2.7) Weight (ks) 77.3 (_+5.8) Table 2 Results of Ccphalad Spread of Solution Vertebral body Presence of Hornets Post-procedure Galvanic Skin Temperature level Syndrome Response Increase c3 (n=4) 4/4+ (100%) 0 (0%) 1/5 (20%) 5/6+ (83.3%) 0 (0%) 2/7 (28.5%) C4 (n=6) 8/11+ (72.7%) 2/11 (18.3%) 11/21+ (52.3%) C5 (n=ll) 12/19 (63.1%) C6 (n=9) 3/9+ (33.3%) 10/16+ (62.5%) 5/lO (50%) 4/10+ (40%) 1/1 + (100%) c 7 (n=lO) <0.05 Table 3 Results of Caudal Spread of Solution Post-procedure Galvanic Skin Temperature Vertebral body Presence of Homc~s Increase Syndrome Response level 3/18 (16.6%) c7 (n=lS) ~18 + (33%) 2/18 (11.1%) 4/lO (40%) Wl0 + (2w~) 3/10 (30%) Tl (n=10) T2 (n=12) 10/12+ (83.3%) 10/12+ (83.3%) 0 (~) 8/8 + (100%) T3 (n=8) o (~) 8/8 + (10o%) 2/2+ (100%) 2/2+ (100%) T4 (n=2) 0 (~) ~_<0.05 Conclusion: The resultssuggest thatfailureto produce an increasein skin temlx:ratureof the upper extremity is due to lack of spread of local anestheticto T2 and T3 ganglia.The presence of a Homaes syndrome is hypothesized to be a resultof eithera cemplctc steUate,middle ganglion, or a superiorcervicalganglion block. References: 1. Ackerman WE, et al: Pain Digest; 8:80-84, 1998.