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Stellate Ganglion Block
Stellate Ganglion Block: Fluoroscopic Guidance Kermit W. Fox and Michael B. Furman Contrast injected at the C6 level has consistently reached the C7-T1 interspace, which is the commonly accepted location of the stellate ganglion. Ideal injectate spread should extend inferiorly to T2 for upper limb symptoms. The anterior (foraminal) oblique approach is advantageous over the traditional (i.e., paratracheal) approach because it provides an unobstructed trajectory view (i.e., it does not require pushing vascular structures out of the way and radiating the interventionalist’s hands).
Note: Please see pages ii and iii for a list of anatomic terms/abbreviations used throughout this book.
CHAPTER
28A
Chapter 28A Stellate Ganglion Block: Fluoroscopic Guidance
Trajectory View (Fig. 28A.1) The patient is placed in a supine position. Using the posteroanterior view, confirm the C6 level by counting cephalad from T1. n Tilt the C-arm image intensifier to line up the superior C6 vertebral end plate of the targeted vertebral body (see Chapter 3). n Oblique the C-arm image intensifier ipsilaterally to obtain a foraminal oblique view (see Chapter 3). With this trajectory view, count down from the most cephalad C3 neural foramen (NF) (AKA C2-C3 NF) to confirm the level of the C6 vertebral body. n The targeted structure, which is the junction of the vertebral body and the uncinate process (at or slightly medial to the uncinate line), can then be optimally visualized. n n
Trajectory view
Trajectory view
C3 NF
Clavicle
C7 VB 1st rib
VI
A
Safety view
B
Trajectory View Safety Considerations (Figure 28B.1E shows an axial view)
C3 NF Uncinate line VA C6 VB
Esophagus CCA
Remain directly over the vertebral body and at or slightly medial to the uncinate line to avoid the:
C7 SN Thyroid
Vertebral artery and spinal nerves dorsally. Trachea, thyroid, and esophagus, venro-medially. n CCA and internal jugular ventrally. n Subclavian artery caudally. n Intervertebral discs cephalad and caudally. n n
Trachea SCA
C
Fig. 28A.1. A, Fluoroscopic image of the trajectory view with the needle tip in position at or slightly medial to the uncinate line at the junction of the uncinate process and the vertebral body. Because this is the trajectory view, the needle entry position should be parallel to the C-arm beam. B, Radiopaque structures, trajectory view. C, Radiolucent structures, trajectory view.
430
Optimal Views in Multiplanar Imaging
Optimal Views in Multiplanar Imaging OPTIMAL NEEDLE POSITIONING IN THE POSTEROANTERIOR VIEW (FIG. 28A.2)
Multiplanar view
Multiplanar view
Uncinate joints ArP C7 VB 1st rib
C7 SP Clavicle
1st rib
A
VA Thyroid cartilage Thyroid Stellate ganglion SN
T1 VB Trachea
C
Anterior View Safety Considerations (Figure 28B.1E shows an axial view) The needle should ideally be against the periosteum with the posteroanterior view. n If the needle strays postero-lateral to the planned target, it can pierce the vertebral artery. n If the needle strays superior or inferior, it can inadvertently pierce the intervertebral disc. n If the needle strays ventro-medial, it can pierce the trachea, thyroid, or esophagus. n Avoid the superficial common carotid artery and juguar vein. n
VI
Common carotid Multiplanar artery view Jugular vein Sympathetic chain Subclavian artery and vein
B
Fig. 28A.2. A, Fluoroscopic posteroanterior view with the ideal needle position. Confirm the C6 level by counting cephalad from T1. B, Radiopaque structures, posteroanterior view. C, Radiolucent structures, posteroanterior view.
431
Chapter 28A Stellate Ganglion Block: Fluoroscopic Guidance
OPTIMAL NEEDLE POSITIONING IN THE LATERAL VIEW (FIG. 28A.3)
C2 VB Multiplanar view
Multiplanar view
C6 SP C6 VB
A
B
Lateral View Safety Considerations
Multiplanar view SC VA
C5-6 IVD
VI
C6 VB
If the needle is against the vertebral body periosteum, it is unlikely to get near any vital structures that are posteriorly located. n The lateral view should be used to confirm that the needle is not inadvertently transdiscal or in the spinal cord before injection. n
C Fig. 28A.3. A, Fluoroscopic lateral view with the ideal needle position. B, Radiopaque structures, lateral view. C, Radiolucent structures, lateral view.
432
Optimal Views
Optimal Views (Figs. 28A.4 and 28A.5) When optimal flow has been confirmed with contrast, a small (i.e., 0.5 cc) test dose of local anesthetic (e.g., 1% lidocaine) is injected, and the patient is observed for 60 to 90 seconds to further minimize the risk of intravascular injection. n Subsequently, if no abnormal symptoms are noted, 10 cc of anesthetic is injected. n Although larger volumes have traditionally been used for landmark-guided (aka “blind”) stellate ganglion blocks, adequate coverage of the stellate ganglion is obtained with this smaller volume of injectate. n A smaller injectate volume may also decrease the risk of anesthetic-related complications that were discussed in the chapter’s introduction. n For facial and neck issues, flow to C6 or C7 is adequate. For the upper limb, flow inferior to T2 is optimal. n
Optimal
Optimal
A
B
Optimal
Optimal
VI
C
D
Fig. 28A.4. A, Fluoroscopic image of a posteroanterior view after the injection of 2 cc of contrast. The contrast is tracking vertically along the longissimus colli muscle in the region where the sympathetic trunk is known to reside. B, Fluoroscopic image of a foraminal oblique view after the injection of 2 cc of contrast. C, Fluoroscopic image of a posteroanterior view of the same patient after slowly injecting 5 cc of anesthetic into the ganglion. Note the cephalad flow of contrast to the C4-C5 interspace and the caudad flow to the first thoracic segment. D, Fluoroscopic image of a lateral view of a different patient after slowly injecting 5 cc of anesthetic into the ganglion.
433
Chapter 28A Stellate Ganglion Block: Fluoroscopic Guidance
Optimal
VI
Fig. 28A.5. Horner’s syndrome in a patient after right stellate ganglion block. Note the ptosis and miosis on the patient’s right side.
434
Note: Please see pages ii and iii for a list of anatomic terms/abbreviations used throughout this book.
CHAPTER
28A
Chapter 28A Stellate Ganglion Block: Fluoroscopic Guidance
Trajectory View (Fig. 28A.1) The patient is placed in a supine position. Using the posteroanterior view, confirm the C6 level by counting cephalad from T1. n Tilt the C-arm image intensifier to line up the superior C6 vertebral end plate of the targeted vertebral body (see Chapter 3). n Oblique the C-arm image intensifier ipsilaterally to obtain a foraminal oblique view (see Chapter 3). With this trajectory view, count down from the most cephalad C3 neural foramen (NF) (AKA C2-C3 NF) to confirm the level of the C6 vertebral body. n The targeted structure, which is the junction of the vertebral body and the uncinate process (at or slightly medial to the uncinate line), can then be optimally visualized. n n
Trajectory view
Trajectory view
C3 NF
Clavicle
C7 VB 1st rib
VI
A
Safety view
B
Trajectory View Safety Considerations (Figure 28B.1E shows an axial view)
C3 NF Uncinate line VA C6 VB
Esophagus CCA
Remain directly over the vertebral body and at or slightly medial to the uncinate line to avoid the:
C7 SN Thyroid
Vertebral artery and spinal nerves dorsally. Trachea, thyroid, and esophagus, venro-medially. n CCA and internal jugular ventrally. n Subclavian artery caudally. n Intervertebral discs cephalad and caudally. n n
Trachea SCA
C
Fig. 28A.1. A, Fluoroscopic image of the trajectory view with the needle tip in position at or slightly medial to the uncinate line at the junction of the uncinate process and the vertebral body. Because this is the trajectory view, the needle entry position should be parallel to the C-arm beam. B, Radiopaque structures, trajectory view. C, Radiolucent structures, trajectory view.
430
Optimal Views in Multiplanar Imaging
Optimal Views in Multiplanar Imaging OPTIMAL NEEDLE POSITIONING IN THE POSTEROANTERIOR VIEW (FIG. 28A.2)
Multiplanar view
Multiplanar view
Uncinate joints ArP C7 VB 1st rib
C7 SP Clavicle
1st rib
A
VA Thyroid cartilage Thyroid Stellate ganglion SN
T1 VB Trachea
C
Anterior View Safety Considerations (Figure 28B.1E shows an axial view) The needle should ideally be against the periosteum with the posteroanterior view. n If the needle strays postero-lateral to the planned target, it can pierce the vertebral artery. n If the needle strays superior or inferior, it can inadvertently pierce the intervertebral disc. n If the needle strays ventro-medial, it can pierce the trachea, thyroid, or esophagus. n Avoid the superficial common carotid artery and juguar vein. n
VI
Common carotid Multiplanar artery view Jugular vein Sympathetic chain Subclavian artery and vein
B
Fig. 28A.2. A, Fluoroscopic posteroanterior view with the ideal needle position. Confirm the C6 level by counting cephalad from T1. B, Radiopaque structures, posteroanterior view. C, Radiolucent structures, posteroanterior view.
431
Chapter 28A Stellate Ganglion Block: Fluoroscopic Guidance
OPTIMAL NEEDLE POSITIONING IN THE LATERAL VIEW (FIG. 28A.3)
C2 VB Multiplanar view
Multiplanar view
C6 SP C6 VB
A
B
Lateral View Safety Considerations
Multiplanar view SC VA
C5-6 IVD
VI
C6 VB
If the needle is against the vertebral body periosteum, it is unlikely to get near any vital structures that are posteriorly located. n The lateral view should be used to confirm that the needle is not inadvertently transdiscal or in the spinal cord before injection. n
C Fig. 28A.3. A, Fluoroscopic lateral view with the ideal needle position. B, Radiopaque structures, lateral view. C, Radiolucent structures, lateral view.
432
Optimal Views
Optimal Views (Figs. 28A.4 and 28A.5) When optimal flow has been confirmed with contrast, a small (i.e., 0.5 cc) test dose of local anesthetic (e.g., 1% lidocaine) is injected, and the patient is observed for 60 to 90 seconds to further minimize the risk of intravascular injection. n Subsequently, if no abnormal symptoms are noted, 10 cc of anesthetic is injected. n Although larger volumes have traditionally been used for landmark-guided (aka “blind”) stellate ganglion blocks, adequate coverage of the stellate ganglion is obtained with this smaller volume of injectate. n A smaller injectate volume may also decrease the risk of anesthetic-related complications that were discussed in the chapter’s introduction. n For facial and neck issues, flow to C6 or C7 is adequate. For the upper limb, flow inferior to T2 is optimal. n
Optimal
Optimal
A
B
Optimal
Optimal
VI
C
D
Fig. 28A.4. A, Fluoroscopic image of a posteroanterior view after the injection of 2 cc of contrast. The contrast is tracking vertically along the longissimus colli muscle in the region where the sympathetic trunk is known to reside. B, Fluoroscopic image of a foraminal oblique view after the injection of 2 cc of contrast. C, Fluoroscopic image of a posteroanterior view of the same patient after slowly injecting 5 cc of anesthetic into the ganglion. Note the cephalad flow of contrast to the C4-C5 interspace and the caudad flow to the first thoracic segment. D, Fluoroscopic image of a lateral view of a different patient after slowly injecting 5 cc of anesthetic into the ganglion.
433
Chapter 28A Stellate Ganglion Block: Fluoroscopic Guidance
Optimal
VI
Fig. 28A.5. Horner’s syndrome in a patient after right stellate ganglion block. Note the ptosis and miosis on the patient’s right side.
434