[Anatomy and physiology] The cervical sympathetic ganglia are located posterior to the vascular sheaths of the neck, and there are generally three sympathetic ganglia on each side of the cervical transverse process called the superior cervical ganglion, the middle cervical ganglion, and the inferior cervical ganglion. The inferior cervical ganglion, also known as the stellate ganglion or cervicothoracic ganglion, is irregular in shape, larger than the middle cervical ganglion, and is located anteriorly between the base of the transverse process of the seventh cervical vertebra and the neck of the first rib, posterior to the vertebral artery, medial to the oblique muscle group, with the pulmonary apex below it. The stellate ganglion is oval in shape approximately 2 cm long and 1 cm wide. the inferior border of the stellate ganglion lies posterior to the pleura and is enveloped by loose cellular and adipose tissue. In addition, the stellate ganglion also gives off gray traffic branches, connecting the seventh and eighth cervical nerves and the first thoracic nerve, and also gives off branches that form a plexus around the subclavian artery and its branches and follow it to the first segment of the axillary artery. Other branches of this node form a vertebral artery plexus around the vertebral artery, respectively, and travel up the vertebral artery. It enters the cranial cavity, surrounds the vertebral artery and the basilar artery, and reaches the posterior cerebral artery, where it meets the plexus originating from the internal carotid artery. The subcardiac nerve from the stellate ganglion descends along the posterior aspect of the subclavian artery, anterior to the trachea, and joins the cardiac plexus to participate in cardiac activity.
Indications】 The blocking effect of the stellate ganglion is mainly in two aspects: central nerve action and peripheral nerve action. The central neurological effect is manifested in the maintenance of the stability of the internal environment by regulating the function of the thalamus to keep the body’s plant nervous function, endocrine function and immune function normal. This peripheral effect has been used to treat a number of diseases of the head and neck, upper limbs, shoulders, heart and lungs.
(1) Systemic diseases: phytodysfunction, primary hypertension, primary hypotension, hyperthyroidism, hypothyroidism, anorexia, anorexia nervosa, postural blood pressure abnormalities, insomnia, generalized hyperhidrosis, vertigo, generalized leukodystrophy, itchy skin, seborrheic dermatitis, post-stroke pain, multiple sclerosis, myasthenia gravis, herpes zoster, herpes simplex, infectious mononucleosis, chronic fatigue syndrome, reflex sympathetic dystrophy, phantom limb pain, amputation pain, diabetes mellitus.
(2) Head disorders: demodicosis, headache (including migraine, tension headache, cluster headache, temporal arteritis headache), cerebral thrombosis, cerebral vascular spasm, cerebral infarction, etc.
(3) Facial disorders: peripheral facial nerve palsy, atypical facial pain, masticatory muscle syndrome, mandibular joint syndrome.
(4) Eye diseases: retinal vascular occlusion, retinitis pigmentosa, uveitis, optic neuritis, cystoid macular swelling, corneal ulcer, cataract, pupillary strain, mosquito flying, visual fatigue, refractive abnormalities.
(5) ENT diseases: chronic paranasal sinusitis, acute paranasal sinusitis, allergic rhinitis, sudden hard of hearing, exudative otitis media, Meniere’s disease, benign episodic vertigo, nasal congestion, tonsillitis, tinnitus, pharyngeal sensory abnormalities, olfactory disorders.
(6) Oral disorders: post-extraction pain, tongue pain, endostomatitis, tongue inflammation, labyrinthitis, intraoral mucosal dryness.
(7) Neck and shoulder and upper limb disorders: upper limb blood circulation disorders (such as Raynaud’s disease, Raynaud’s syndrome, acute arterial occlusive disease, neck-shoulder-arm syndrome, traumatic neck syndrome, thoracic outlet syndrome, shoulder periarthritis, postoperative swelling, post-mastectomy syndrome) tennis elbow, tenosynovitis, cervical spondylosis, arthritis, palmar hyperhidrosis, frostbite, frostbite, perineuritis, longitudinal nail fracture, axillary odor.
(8) Circulatory system diseases: myocardial infarction, angina pectoris, sinus tachycardia, cardiac neurosis.
(9) Respiratory system diseases: chronic bronchitis, pulmonary embolism, pulmonary edema, hyperventilation syndrome, bronchial asthma.
(10) Digestive system diseases: allergic enteritis, ulcerative colitis, gastritis, gastric ulcer, Crohn’s disease, peptic ulcer, constipation, diarrhea, hemorrhoids, etc.
(11) Obstetrical and gynecological diseases: menstrual abnormalities, premenstrual tension, menstrual difficulties, menopausal syndrome, post-hysterectomy phytonadic disorders, female infertility.
(12) Urological disorders: neurogenic dysuria, nocturia, urinary incontinence, pyelonephritis, IgA nephropathy, wandering kidney, prostatitis, male infertility.
(13) Waist and lower limb disorders: lumbago, knee pain, tinea pedis, extremity erysipelas, corns, frostbite and frostbite.
(1) Anterolateral approach puncture method: The patient is placed on his back with a pillow under the shoulder. Routinely disinfect the skin, the operator is located on the left side and first uses the index and middle fingers of the left hand to push the common carotid artery and sternocleidomastoid muscle to the lateral side. In general, patients with the tip of the index finger can touch the transverse process of the seventh cervical vertebra, and the needle is guided to penetrate about 2-3 cm and touch the bone, indicating that the tip of the needle has reached the anterolateral aspect of the transverse process of the seventh cervical vertebra, and the needle is withdrawn a little (0.2-0.4 mm), and no blood is sucked back. It should be noted that there is no foreign sensation when puncturing the stellate ganglion, so it is not necessary to look for foreign sensation.
The concentration and dose of the injected drug should depend on the treatment needs. Generally, 0.5~1% lidocaine or 0.25~0.375% bupivacaine ~10ml can be injected. If you want to block the sympathetic nodes in the upper cervical and middle cervical nerves and the parasympathetic nerves in the 1st-4th thoracic vertebrae at the same time, you can inject 20% of 1% lidocaine or 30ml of 0.5% lidocaine.
The sign of successful block is the appearance of Horner’s syndrome on the side of the injected drug, which is manifested by pupil narrowing, eyelid drooping, sunken eyes, nasal congestion, conjunctival congestion, slightly red face, no sweating, and warm feeling.
(2) High lateral entry puncture method: The patient lies supine with the head turned to the opposite side and the skin is routinely disinfected. The puncture point on the left side is taken at the intersection of the posterior border of the sternocleidomastoid muscle and the external jugular vein, which is equivalent to the level of the cricoid cartilage or the transverse process of the sixth cervical vertebra. The cerebrospinal fluid can be injected with local anesthetic drugs.
Complications】 Complications of stellate ganglion block include those related to local anesthetic and those related to operation: (1) Complications related to local anesthetic: local anesthetic reaction will occur when the drug is injected into the blood vessel; a few reactions sensitive to local anesthetic; hormones or other drugs are still added to the local anesthetic. Injury to the stellate ganglion may be caused after multiple injections. Further research and evaluation are needed.
(2) Complications related to manipulation: the puncture needle damages the cervical vessels and causes local hematoma; the puncture needle should be withdrawn and pressure applied to stop the bleeding when there is re-blooding in the retraction. Puncture of the subarachnoid space by the puncture needle or even injection of drugs is an extremely serious complication. Inappropriate puncture angles or low puncture sites can lead to pneumothorax or hemopneumothorax. Inadequate aseptic operation can cause infection resulting in deep abscess.
[Caution] Stellate ganglion block should be used with caution in those with bleeding tendency. The tissue should be observed for 10-15 minutes after the block, and those without adverse reactions should be allowed to leave the hospital. Be careful not to block bilateral stellate ganglia at the same time to prevent cardiopulmonary accidents.