Cardiac arrest following stellate ganglion block performed under ultrasound guidance

Ultrasound-Guided Blocks for Spine Surgery: Part 1-Cervix

Postoperative pain is common following spine surgery, particularly complex procedures. The main anesthetic efforts are focused on applying multimodal analgesia beforehand, and regional anesthesia is a critical component of it. The purpose of this study is to examine the existing techniques for regional anesthesia in cervical spine surgery and to determine their effect and safety on pain reduction and postoperative patient's recovery. The electronic databases were searched for all literature pertaining to cervical nerve block procedures. The following peripheral, cervical nerve blocks were selected and described: paravertebral block, cervical plexus clock, paraspinal interfascial plane blocks such as multifidus cervicis, retrolaminar, inter-semispinal and interfacial, as well as erector spinae plane block and stellate ganglion block. Clinicians should choose more superficial techniques in the cervical region, as they have been shown to be comparably effective and less hazardous compared to paravertebral blocks.

Tonic-clonic seizure during the ultrasound-guided stellate ganglion block because of an injection into an unrecognized variant vertebral artery: A case report

RATIONALE

Recent years have witnessed a marked improvement in the safety and accuracy of nerve blocks with the help of ultrasound and other visualization technologies. This study reports a challenging case of a severe complication during the ultrasound-guided stellate ganglion block.

PATIENT CONCERNS

A 28-year-old male patient with refractory migraine complained episodic pulsatile pain with photophobia, haphalgesia of the scalp for 3 years.

INTERVENTIONS

Ultrasound-guided stellate ganglion block with 4 ml of 1% lidocaine was administrated.

OUTCOMES

A sudden loss of consciousness and tonic-clonic seizure was occurred after negative aspiration and test dose. Further sonographic examination revealed a variation in the left vertebral artery, which remained unrecognized during the needle insertion because of its sliding ability under the differential pressure applied by the probe.

LESSONS

Inadvertent intra-arterial injection of a local anesthetic agent could be minimized under the ultrasound guidance with various protective strategies, including the determination of any prior variation, optimizing the block route, maintaining a constant probe pressure, and using saline for the test dosage. This case resulted in the implementation of new protocols of the ultrasound-guided stellate ganglion block in our department.

Complications associated with stellate ganglion nerve block: a systematic review

Stellate ganglion nerve blockade (SGNB) is a vital tool in our armamentarium for the treatment of various chronic pain syndromes. SGNB can be performed using the traditional landmark-based approach, or with image guidance using either fluoroscopy or ultrasound. In this review, we systematically analyzed reported SGNB-related complications between 1990 and 2018. Seven databases were queried for SGNB between January 1, 1990 and November 27, 2018. Search results of the complications associated with SGNB were reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Out of a total of 1909 articles, 67 articles met our inclusion criteria, yielding 260 cases with adverse events. In 134 of the 260 (51.5%) cases, SGNB was performed with image guidance. Sixty-four (24.6%) and 70 (26.9%) of the complication cases reported the use of ultrasound and fluoroscopy guidance, respectively. One hundred and seventy-eight (68.4%) patients had medication-related or systemic side effects, and 82 (31.5%) had procedure-related or local side effects. There was one report of death due to massive hematoma leading to airway obstruction. There was one case report of quadriplegia secondary to pyogenic cervical epidural abscess and discitis following an SGNB. Complications following SGNB have been reported with both landmark-based techniques and with imaging guidance using fluoroscopy or ultrasound. In our systematic review, most adverse events that were reported occurred during or shortly after SGNB. Vigilance, American Society of Anesthesiologists standard monitors for conscious sedation, and accessibility to resuscitation equipment are vital to the safe performance of SGNB.

The importance of perfusion index monitoring in evaluating the efficacy of stellate ganglion blockage treatment in Raynaud's disease

Stellate ganglion blockage (SGB) is a method used for treating Raynaud's phenomenon (RP). This study primarily aimed to determine whether the perfusion index (PI) can be used an alternative to Horner's signs in evaluating the efficacy of SGB in patients diagnosed with RP. In a total of 40 patients, aged 18-65 years and diagnosed with primary RP, SGB was applied for 5 days on the same side with the 2-finger method, using 6 mL of 5% levobupivacaine at the 7th cervical vertebra level. The PI values were recorded from the distal end of the 2nd finger of the upper extremity on the side applied with the block at baseline and at 5, 15, 30, 60 and 120 min. The onset time of Horner findings was recorded. The PI values and visual analogue scale (VAS) pain scores were recorded pre-treatment and after 2 weeks.When the PI values of the 40 patients were examined, a 62.7% increase was observed from baseline to the first session at 5 min (p < 0.05). When all sessions were evaluated, a statistically significant increase was determined in the PI values measured at 5, 15, 30, 60 and 120 min compared with the baseline PI values. There was a statistically significant decrease in the post-treatment VAS pain scores and a statistically significant increase in the post-treatment PI values (p < 0.05). By eliminating peripheral vasospasm with the application of SGB in patients with RP, the distal artery blood flow and PI are increased. PI measurement is a more objective method and therefore could be used as an alternative to Horner findings in evaluating the success of SGB. PI is a non-invasive and simple measurement and also an earlier indicator in evaluating the success of SGB than Horner's signs.

Evaluation of new approach to ultrasound guided stellate ganglion block

BACKGROUND

Ultrasound imaging is an ideal tool for stellate ganglion block (SGB) due to clarity, portability, lack of radiation, and low cost. Ultrasound guided anterior approach requires the application of pressure to the anterior neck and is associated with more risk of injury to inferior thyroid artery, vertebral artery, and esophagus. The lateral approach does not interfere with nerve or vascular structures. Blockade at the C6 vertebral level results in more successful sympathetic blockade of the head and neck with less sympathetic blockade of the upper extremity compared to sympathetic blockade at C7 vertebral level, which produces successful sympathetic blockade of upper extremity. This is helpful in patients of complex regional pain syndrome of the upper limb. Hence, we conducted a study using the lateral approach at C7 level.

MATERIALS AND METHODS

Ultrasound guided SGBs using lateral in-plane technique at C7 level were given in 20 patients suffering from chronic pain patients of upper extremity, head, and neck using 4 ml of 0.25% bupivacaine and 1 ml of 40 mg triamcinolone. The patients were assessed for a numeric pain intensity score (NPIS), the rise in axillary temperature, the range of motion of joints of upper extremity, and resolution of edema at various time intervals up to 3 months.

RESULTS

NPIS showed a statistically significant decrease from baseline at 30 min, which was sustained till 3(rd) month. The rise in axillary temperature after the block was statistically significant, which was sustained till 2(nd) week. The edema score decreased significantly at all-time intervals (P ≤ 0.001). The restriction of motion in all joints of upper limb decreased from 13 to 3 patients.

CONCLUSION

There is a significant variation in the anatomy of stellate ganglion at the level of C6 and C7. Ultrasound guided lateral approach increases the efficacy of SGB by deposition of drug subfascially with real-time imaging.

Successful use of stellate ganglion block and a new centrally acting analgesic with dual mode of action in a resistant temporomandibular joint pain

Stellate ganglion blocks have been shown to provide effective pain relief in a number of different conditions involving the upper body. This was demonstrated in a 65-year-old woman who had experienced severe debilitating pain in her left temporomandibular joint (TMJ) and the surrounding area of her face for over 10 years. The pain was unresponsive to indomethacin, carbamazepine, sodium valproate, gabapentin, lithium, melatonin and amitriptyline. She had also had four surgical procedures to the TMJ without success. The pain was partially responsive to Syndol tablets and pregabalin, although the use of pregabalin was limited by its adverse effects. The patient underwent 13 ultrasound guided stellate ganglion blocks over a 24-month period which demonstrated 90% pain relief for up to 10 weeks. Pulsed radio frequency lesioning showed no benefit over stellate ganglion block. More recently, tapentadol was found to be effective and this replaced the stellate ganglion blocks.

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

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.

Transient neuronal injury followed by intravascular injection during an ultrasound guided stellate ganglion block

Ultrasound guidance for pain interventions is becoming increasing recognized as a useful imaging tool. One of the common interventions where it is gaining wider acceptance is during the performance of a stellate ganglion block. The following is a unique report where intravascular and neuronal injury occurred during the performance of an ultrasound guided stellate ganglion block followed by dysphagia. 41 year old male, with a diagnosis of complex regional pain syndrome, was referred to our clinic for further management. He underwent a diagnostic ultrasound guided stellate ganglion block after having tried conservative therapies. The stellate ganglion block provided him with complete pain relief for over five weeks. During a subsequent therapeutic stellate ganglion block, performed by an experienced pain medicine fellow with more than 50 ultrasound guided proceduresclinician, the patient developed a transient injury to the brachial plexus upon needle entry. Subsequent redirection and injection of an ml of injectate resulted in an intravascular injection producing tinnitus. After the tinnitus decreased, he underwent another stellate block using an out of plane approach without any further complications. Two days later, he reported chest and throat discomfort which resolved over the next few days possibly due to a retropharyngeal hematoma. He declined further interventions and was subsequently managed with 3 tablets of oxycodone a day. This report highlights the importance of vigilance and meticulous planning during the performance of ultrasound guided pain interventions.