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Therapeutic stellate ganglion block using local anesthetics
THERAPEUTIC
STELLATE GANGLION BLOCK USING LOCAL ANESTHETICS*
BLISSB. CLARK, M.D. AND SAMUEL Chief of Surgery, New Britain General HospitaI New Britain,
T
HE increasingIy extensive use of stelIate ganglion bIocks in modern military and civihan practice has stimuIated interest in the technic and results of this procedure. We wish to com-
FIG. I. Forefinger palpation.
on first
rib after
Attending
WOLFSON, Anesthetist,
M.D.
New Britain General Hospital
Connecticut
IateraI approach is described by VoIpitto and Risteen.; Posterior approaches are due to Peterson6 and White.’ A superoIatera1 approach has been contributed by ArnuIf.8 Goinardg used the IateraI approach.
preliminary
mend one technic, IittIe known and IittIe used in this country, describe our modification of it and present our resuhs with procaine stelIate bIock in a genera1 hospita1 overseas prior to V-E day. The gangIion has been approached from anterior, anteroIatera1, posterior, superoIateraI and IateraI directions. Anterior approaches are associated with the names of Leriche and Fontaine,l Ochsner and Debakey,2 Murphey3 and Pereira.4 An antero-
FIG. 2. The needle sIid off first rib, was advanced I .o cm. and is now in pIace for injection.
After some experience with other methods we eIected the method of Goinard modified as foIIows: The patient lies on the contraIatera1 side with the eIbow fIexed to 90 degrees and the arm held by an assistant in a 90 degree abduction. The muscIes of the shouIder girdIe are thereby relaxed. The left forefinger paIpates first, the anterior border of the trapezius muscIe and
* From The Surgical Service, New Britain General HospitaI, New Britain, Conn. 66
VOL. LXXVI,
No.
I
CIark,
Wolfson-SteIIate
then, deep to this and sIightIy anterior and media1 the Aat upper surface of the posterior portion of the first rib is feIt. (Fig. I,) The paIpating finger moves as far mediaIIy as possibIe along the rib. (This step insures that the fina position of the needle will
Ganghon
American Journnl of Surgery
67
plane wiI1 be directed sIightIy posterior, rendering a puncture of the pIeural cupoIa less likely.) Primary contact is then made with the rib immediateIy beneath the palpating finger. The point of the needIe is caused to advance mediahy by short
TABLE
I
Condition
- Blocks
‘i
Neuromaofstump ...................................... PhantomIimbwith pain ................................. ‘Burning’ of end of open stump; no neuroma ............... Causalgia. ............................................. Lesions of periphera1 nerves with burning pain in anesthetized areaofskin .......................................... Traumatic aneurysm; brachia1 artery with circulatory embarrassment ............................................ MuItiple wounds of arm associated with circulatory embarrassment............................................ Hysterical anesthesia of finger tips., ...................... Painful hand following old trauma., ...................... Painful wrist following old trauma. ....................... Kienbock’s disease of the wrist ......................... Old wound of hand with pain, coldness cyanosis and sweating Cold, bIue hand foIIowing severe cell&s. ................ Frost bite from high altitude. ............................ Raynaud’s syndrome. ................................. Phlebitis of the arm .......................... ......... Venous obstruction cause undetcrmincd ................... Hysterical cIaw hand .................................... PuImonary emboIus (diagnosis proven incorrect at autopsy) Tinnitus aurium folIowing explosion. ...................... Painful wrist, cause undetermined; all investigations negative MuItipIe wounds of arm associated with pain and circulatory embarassment ...................................... Totals ..............................................
BIock
- -
C
B
A
4 23 8 4
6
JO
2
7
z
3
2
I 3 2 3 7
: 5 9 II
D
-
15 3 4
-
7
E
-
0
J
J 0
3 2
0
0
3
0
I2
:
J
I
0
I
5 I
2
0
I
7
2
0
0
6
I
0
0
0
I
2
0
2
0
0
0
0
0
2
3
J
0
0
2
0
0
0
0
0
3 4 3
i
J
J
0
0
I
0
0
0
I
3 9
0
0
0
0
0
J
2
0
0
i
I 1 18
2
3
0
9 0
J
2
0
I
0
0
J
J
J
0
J
0
0
0 0
I
J
2
2
0
0
0
I
2
I
0
0
0
J
J
J
0
J
0
0
0
2
4
0
0
3
J
0
69
130
6
- -
68
33
- -
-
4
‘9 -
-
-
A.-No relief of symptom B.-ResuIt lasting less than four hours C.-Effect lasting one to three days D.-Effect lasting three to ten days E.-Effect lasting Ionger than ten days
form a more acute angIe with the Iong axis of the body in the fronta pIane, thus Iessening the IikeIihood of subdura1 puncture.) The needIe, preferabIy a 2 or 3 inch, short bevehed, AexibIe 22 gage, carried in the right hand with beve1 facing posteriorIy, punctures the skin -5 to I cm. anterior to the deeply paIpating forefinger of the left hand. (Fig. 2.) (The sIightIy anterior skin puncture heIps insure that the needIe in its fina position in the sagitta1
steps until it is just feIt to shde off the anterior surface of the rib at the region of the neck where the rib narrows. The needIe is then advanced I cm. further and 13 cc. of 2 per cent procaine are injected. Before the injection is made aspiration is practiced to avoid the possibiIity of a subdura1 or intravascular injection. A drop of procaine soIution is pIaced on the hub of the needIe and the patient is told to take a few deep breaths. Marked respira-
68
American ~~~~~~~ or
surgery CIark, WoIfson-SteIIate
tory ffuctuation and sucking in of the drop wil1 be seen if the point of the needIe Iies in the pIeura1 cavity. The method offers two technica advantages: (I) Its reIative safety. No vital or potentiaIly dangerous structures can be traversed by the needIe before bony contact is made. (2) Ease in changing the direction of the needle. Changes in direction can be made easiIy because no large amount of soft tissue is penetrated before contact with the rib is made (I to 3 cm.). This contrasts with other methods in which contact is made at depths of 5 to 6 cm.,5 6 to 7 cm.,2 and 3.5 to 6 cm.3 The cases Iisted in TabIe I were treated with I 5 cc. of 2 per cent procaine or I $5 per cent metycaine. In a11 cases Horner’s syndrome was obtained. Two cases of pneumothorax occurred. These cleared in a few days with no treatment. The therapeutic resuIts obtained were on the whoIe not encouraging. The therapeutic scope of this bIock when procaine or a similar agent is employed is not yet deIineated. Of 130 blocks empIoyed onIy four gave results which Iasted more than ten days. Most encouraging resuIts were obtained in the group with phantom limb with pain. In this group, a11 earIy amputees, symptoms when they returned were to variabIe
GangIion
BIock
extents ameliorated cotics and sedatives
JULY,1948
and the use of narconsiderabIy curtailed.
SUMMARY I. A usefu1 and littIe used method of steIIate gangIion bIock, somewhat modified from the original, is described, 2. The resuIts of 130 blocks in sixtynine patients using procaine and metycaine are summarized. REFERENCES I. LERICHE, R. and FONTAINE, R. L’anestesie isol& du Ganglion Etoile. Presse n&d., 42: 849-50, 1934. 2. OCHSNER, A. and DEBAKEY, M. Treatment of thrombophlebitis by novocain bIock of sympathetics. Technique of injection. Surgery, 5: 491-7, 1939. 3. MURPHEY, D. R., .JH. Stellate ganglion block: a new anterior approach. Ann. Surg., IZO: 759-763, 1944. 4. PEREIKA, A. DESOUSA. Blocking of the middle cervical and stellate ganglion with descending infiltration anesthesia. Arch. Surg., 50: 152-165, 1945. 5. VOLPITTO, P. P. and RISTEEN, W. A. Stellate gangIion block: a definite antero-lateral approach. Anesthesiology, 5: 491-4, 1944. 6. PETERSON, M. C. ParavertebraI alcohol injection for cardiac pain. Anesth. CY Analg., 17: 35-37, 1938. 7. WHITE and SMITHWICK. The Autonomic Nervous System. Pp. 445-451, New York, 1941. The Macmillan Co. 8. ARNULF, G. Infiltration du Ganglion Stellairc et dc la Chaine Thoracique Supkrciure par voie SuperoExterne. Presse mkd., 46: 1726-8, 1938. 9. GOINARD, ht. P. Novocainization de la Chaine Sympathique. M&n. Acad. de cbir., 62: 258-9, 1936.
STELLATE GANGLION BLOCK USING LOCAL ANESTHETICS*
BLISSB. CLARK, M.D. AND SAMUEL Chief of Surgery, New Britain General HospitaI New Britain,
T
HE increasingIy extensive use of stelIate ganglion bIocks in modern military and civihan practice has stimuIated interest in the technic and results of this procedure. We wish to com-
FIG. I. Forefinger palpation.
on first
rib after
Attending
WOLFSON, Anesthetist,
M.D.
New Britain General Hospital
Connecticut
IateraI approach is described by VoIpitto and Risteen.; Posterior approaches are due to Peterson6 and White.’ A superoIatera1 approach has been contributed by ArnuIf.8 Goinardg used the IateraI approach.
preliminary
mend one technic, IittIe known and IittIe used in this country, describe our modification of it and present our resuhs with procaine stelIate bIock in a genera1 hospita1 overseas prior to V-E day. The gangIion has been approached from anterior, anteroIatera1, posterior, superoIateraI and IateraI directions. Anterior approaches are associated with the names of Leriche and Fontaine,l Ochsner and Debakey,2 Murphey3 and Pereira.4 An antero-
FIG. 2. The needle sIid off first rib, was advanced I .o cm. and is now in pIace for injection.
After some experience with other methods we eIected the method of Goinard modified as foIIows: The patient lies on the contraIatera1 side with the eIbow fIexed to 90 degrees and the arm held by an assistant in a 90 degree abduction. The muscIes of the shouIder girdIe are thereby relaxed. The left forefinger paIpates first, the anterior border of the trapezius muscIe and
* From The Surgical Service, New Britain General HospitaI, New Britain, Conn. 66
VOL. LXXVI,
No.
I
CIark,
Wolfson-SteIIate
then, deep to this and sIightIy anterior and media1 the Aat upper surface of the posterior portion of the first rib is feIt. (Fig. I,) The paIpating finger moves as far mediaIIy as possibIe along the rib. (This step insures that the fina position of the needle will
Ganghon
American Journnl of Surgery
67
plane wiI1 be directed sIightIy posterior, rendering a puncture of the pIeural cupoIa less likely.) Primary contact is then made with the rib immediateIy beneath the palpating finger. The point of the needIe is caused to advance mediahy by short
TABLE
I
Condition
- Blocks
‘i
Neuromaofstump ...................................... PhantomIimbwith pain ................................. ‘Burning’ of end of open stump; no neuroma ............... Causalgia. ............................................. Lesions of periphera1 nerves with burning pain in anesthetized areaofskin .......................................... Traumatic aneurysm; brachia1 artery with circulatory embarrassment ............................................ MuItiple wounds of arm associated with circulatory embarrassment............................................ Hysterical anesthesia of finger tips., ...................... Painful hand following old trauma., ...................... Painful wrist following old trauma. ....................... Kienbock’s disease of the wrist ......................... Old wound of hand with pain, coldness cyanosis and sweating Cold, bIue hand foIIowing severe cell&s. ................ Frost bite from high altitude. ............................ Raynaud’s syndrome. ................................. Phlebitis of the arm .......................... ......... Venous obstruction cause undetcrmincd ................... Hysterical cIaw hand .................................... PuImonary emboIus (diagnosis proven incorrect at autopsy) Tinnitus aurium folIowing explosion. ...................... Painful wrist, cause undetermined; all investigations negative MuItipIe wounds of arm associated with pain and circulatory embarassment ...................................... Totals ..............................................
BIock
- -
C
B
A
4 23 8 4
6
JO
2
7
z
3
2
I 3 2 3 7
: 5 9 II
D
-
15 3 4
-
7
E
-
0
J
J 0
3 2
0
0
3
0
I2
:
J
I
0
I
5 I
2
0
I
7
2
0
0
6
I
0
0
0
I
2
0
2
0
0
0
0
0
2
3
J
0
0
2
0
0
0
0
0
3 4 3
i
J
J
0
0
I
0
0
0
I
3 9
0
0
0
0
0
J
2
0
0
i
I 1 18
2
3
0
9 0
J
2
0
I
0
0
J
J
J
0
J
0
0
0 0
I
J
2
2
0
0
0
I
2
I
0
0
0
J
J
J
0
J
0
0
0
2
4
0
0
3
J
0
69
130
6
- -
68
33
- -
-
4
‘9 -
-
-
A.-No relief of symptom B.-ResuIt lasting less than four hours C.-Effect lasting one to three days D.-Effect lasting three to ten days E.-Effect lasting Ionger than ten days
form a more acute angIe with the Iong axis of the body in the fronta pIane, thus Iessening the IikeIihood of subdura1 puncture.) The needIe, preferabIy a 2 or 3 inch, short bevehed, AexibIe 22 gage, carried in the right hand with beve1 facing posteriorIy, punctures the skin -5 to I cm. anterior to the deeply paIpating forefinger of the left hand. (Fig. 2.) (The sIightIy anterior skin puncture heIps insure that the needIe in its fina position in the sagitta1
steps until it is just feIt to shde off the anterior surface of the rib at the region of the neck where the rib narrows. The needIe is then advanced I cm. further and 13 cc. of 2 per cent procaine are injected. Before the injection is made aspiration is practiced to avoid the possibiIity of a subdura1 or intravascular injection. A drop of procaine soIution is pIaced on the hub of the needIe and the patient is told to take a few deep breaths. Marked respira-
68
American ~~~~~~~ or
surgery CIark, WoIfson-SteIIate
tory ffuctuation and sucking in of the drop wil1 be seen if the point of the needIe Iies in the pIeura1 cavity. The method offers two technica advantages: (I) Its reIative safety. No vital or potentiaIly dangerous structures can be traversed by the needIe before bony contact is made. (2) Ease in changing the direction of the needle. Changes in direction can be made easiIy because no large amount of soft tissue is penetrated before contact with the rib is made (I to 3 cm.). This contrasts with other methods in which contact is made at depths of 5 to 6 cm.,5 6 to 7 cm.,2 and 3.5 to 6 cm.3 The cases Iisted in TabIe I were treated with I 5 cc. of 2 per cent procaine or I $5 per cent metycaine. In a11 cases Horner’s syndrome was obtained. Two cases of pneumothorax occurred. These cleared in a few days with no treatment. The therapeutic resuIts obtained were on the whoIe not encouraging. The therapeutic scope of this bIock when procaine or a similar agent is employed is not yet deIineated. Of 130 blocks empIoyed onIy four gave results which Iasted more than ten days. Most encouraging resuIts were obtained in the group with phantom limb with pain. In this group, a11 earIy amputees, symptoms when they returned were to variabIe
GangIion
BIock
extents ameliorated cotics and sedatives
JULY,1948
and the use of narconsiderabIy curtailed.
SUMMARY I. A usefu1 and littIe used method of steIIate gangIion bIock, somewhat modified from the original, is described, 2. The resuIts of 130 blocks in sixtynine patients using procaine and metycaine are summarized. REFERENCES I. LERICHE, R. and FONTAINE, R. L’anestesie isol& du Ganglion Etoile. Presse n&d., 42: 849-50, 1934. 2. OCHSNER, A. and DEBAKEY, M. Treatment of thrombophlebitis by novocain bIock of sympathetics. Technique of injection. Surgery, 5: 491-7, 1939. 3. MURPHEY, D. R., .JH. Stellate ganglion block: a new anterior approach. Ann. Surg., IZO: 759-763, 1944. 4. PEREIKA, A. DESOUSA. Blocking of the middle cervical and stellate ganglion with descending infiltration anesthesia. Arch. Surg., 50: 152-165, 1945. 5. VOLPITTO, P. P. and RISTEEN, W. A. Stellate gangIion block: a definite antero-lateral approach. Anesthesiology, 5: 491-4, 1944. 6. PETERSON, M. C. ParavertebraI alcohol injection for cardiac pain. Anesth. CY Analg., 17: 35-37, 1938. 7. WHITE and SMITHWICK. The Autonomic Nervous System. Pp. 445-451, New York, 1941. The Macmillan Co. 8. ARNULF, G. Infiltration du Ganglion Stellairc et dc la Chaine Thoracique Supkrciure par voie SuperoExterne. Presse mkd., 46: 1726-8, 1938. 9. GOINARD, ht. P. Novocainization de la Chaine Sympathique. M&n. Acad. de cbir., 62: 258-9, 1936.