What is a Stellate Ganglion Block?

A stellate ganglion block is a injection of medication into a nerve bundle in the neck. It is used to diagnose and treat pain disorders of the upper extremities that are sustained by the sympathetic nervous system (SNS).

The stellate ganglion (or cervicothoracic ganglion) is a nerve bundle belonging to the sympathetic nervous system (SNS) that provides sensation to the upper body. It is located at the level of C7 (the 7th cervical vertebrae) on either side of the trachea. The stellate ganglion has shown to have second and third order neurons that connect with central nervous system (CNS) nuclei that modulate body temperature, neuropathic pain, and other areas1.

Stellate ganglion blocks are used primarily to combat conditions that involve upper extremity pain, circulatory problems, and sensory changes that are maintained by the SNS. These conditions are associated with increased levels of nerve growth factor (NGF), which has been shown to cause increased levels of the brain transmitter norepinephrine (NR). The stellate ganglion block is believed to help reduce levels of NGF, which consequently leads to a decrease in NR. This, in turn, may cause reduction or elimination of many of the symptoms of SNS-maintained health conditions2.

Wake Spine & Pain Specialists are experts in the administration of the stellate ganglion block. Our doctors understand the burden of living with painful, complicated conditions and are proud to offer this safe, innovative, effective treatment.



Stellate Ganglion Block Related Conditions

One of the most common reasons patients are prescribed the stellate ganglion block is to help control SNS-maintained pain. Patients with painful SNS-facilitated conditions may experience pain that is characteristically different than non-SNS pain. For example, patients may report allodynia, which is pain provoked by stimuli that are not ordinarily painful (e.g., the touch of a feather on the skin). In addition, patients with pain conditions maintained by the SNS may find that a normally painful stimulus may cause disproportionately severe irritation and pain (hyperalgesia). Allodynia and hyperalgesia are signs of central sensitization, in which local tissue injury and inflammation activate the PNS, which sends signals to the central nervous system (CNS). The excitability of neurons within the CNS increases, causing normal inputs from the PNS to produce abnormal responses. Gradually, low-threshold sensory fibers activated by light touch begin to excite neurons in the spinal cord that would normally respond only to more painful stimuli. As a result, a gentle touch that would normally produce a harmless sensation now produces significant pain.

Patients with SNS-related conditions may find that allodynia, hyperalgesia, central sensitization, and other types of characteristic pain associated with their painful conditions may be eradicated in some cases if treated early. For this reason, these patients are encouraged to seek medical help for chronic upper body pain as soon as possible. If chronic SNS-related pain goes untreated, it may become irreversible. For example, a clinical study in patients with painful SNS conditions found untreated symptoms lasting greater than 16 weeks and/or a decrease in skin perfusion of 22% between normal and affected areas before initial treatment with stellate ganglion block adversely affects the efficacy of therapy3.

Watch This Patient Review of a Spinal Nerve Block For Shoulder Pain

The stellate ganglion block is used primarily to help diagnose and treat upper body pain that results from pain syndromes and other painful conditions maintained by the SNS. These symptoms occur in conditions including:

  • Complex Regional Pain Syndromes (CRPS) Type 1 and 2 – Complex Regional Pain Syndrome (CRPS), also known as Reflex Sympathetic Dystrophy (RSD), is a condition involving chronic, intense pain that usually occurs in the arms, hands, legs or feet. It is thought that CRPS is precipitated by trauma to nerves in the affected area or an immune reaction. In addition to allodynia, hyperalgesia, and central sensitization, CRPS patients may experience changes in skin texture, color and temperature, and reduced range of motion in affected extremities. There are two types of CRPS: CRPS 1 is a chronic nerve disorder that occurs in an extremity after a minor injury, and CRPS 2 is caused by direct injury to a nerve. The International Association for the Study of Pain supports the use of sympathetic blocks to reduce sympathetic nervous system over-activity and other symptoms in CRPS patients, and educational reviews promote stellate ganglion blockade as beneficial in such individuals4. One clinical study in 17 patients, aged between 33 and 72 years, suffering from CRPS type I of the hand who received two series of intravenous regional sympathetic block sessions with guanethidine and lidocaine found the treatment produced complete disappearance of pain and restored normal function and range of movement of the extremity in all patients treated5.
  • Sympathetically Maintained Pain (SMP) – This condition is similar to CRPS but may not involve all the signs and symptoms of full-blown CRPS6. Stellate ganglion blocks may help control the symptoms of SMP when it occurs in the upper extremities.
  • Causalgia – This condition involves burning pain and skin changes following peripheral nerve injury. A study found causalgic pain of the left hand was successfully treated in a nonsurgical candidate by a continuous stellate ganglion block; this technique was performed without significant complication and provided relief for extended periods of time7.
  • Shoulder-hand syndrome – Stellate ganglion block can be used to treat this chronic, incompletely understood condition of the shoulder and arm which involves intractable pain, limited joint motion, swelling of the upper extremities, muscle fibrosis and atrophy, and bone decalcification.
  • Post Herpetic Neuralgia (PHN) – PHN is a painful complication of shingles (herpes zoster). Shingles is a reactivation of dormant chickenpox virus (varicella zoster) residing in nervous tissue. Years after an individual has had the chickenpox infection, the dormant varicella virus may escape from nerve cell bodies and migrate down nerve axons where it causes viral infection of tissues around the nerve. The virus may spread to adjacent ganglia, infecting the local dermatome. The infection manifests as a painful rash that appears in a stripe or band around the torso, usually on one side of the body. In most cases, the rash clears within two to four weeks. However, in some people residual nerve pain may persist for months or even years. Clinical trials of stellate ganglion blocks in PHN patients have shown results such as reduction of pain and edema as well as improvement in mobility of the upper extremities8,9.
  • Facial pain – Pain felt in the face may be caused by a nerve disorder, an injury, or an infection. A study in 50 patients (divided into two randomized groups) with facial pain caused by traumas, iatrogenic issues, herpes zoster, or neurological pathologies found that before stellate ganglion block, the mean visual analog scale (VAS) pain score for the first group was 8.89; after the 10th block treatment it was just 0.2, and it remained at that reduced level for the 6th and 12th months10. In the second group, the mean VAS pain score before stellate ganglion block was 8.83; after the 20th day on medication it was reduced to 4.1, after 6 months it was 5.7 and after 12 months it was 4.9.
  • Phantom limb pain – Phantom limb pain is pain that is felt in the area where an extremity has been amputated. Fentanyl infiltration of the stellate ganglion has been shown to produce significant alleviation of pain and sensation of warmth at the stump and in the phantom upper extremity11.
  • Intractable angina – Angina is a type of chest pain caused by ischemia, or reduced blood flow, to the heart muscle. Unfortunately, angina that is refractory to optimal medication and revascularization is becoming an increasingly common clinical problem12. Intractable angina occurs when the pain of angina is chronic, severe, difficult to control, and may appear at rest or during simple activities of daily living13. Stellate ganglion block may be indicated in treatment of upper body pain caused by angina.
  • Arterial insufficiency – This condition is inadequate blood flow through the arteries. One of the most common causes of arterial insufficiency is atherosclerotic disease. Stellate ganglion block may help to treat upper body pain that arises from arterial insufficiency.
  • Raynaud’s phenomenon – This is a disorder that causes the tips of body parts (e.g., fingers, toes, tip of the nose, ears) to feel cool and numb in response to cold temperatures and stress. During an attack of Raynaud’s, affected areas of skin usually turn white, then blue. The skin feels cold and numb, and sensory perception is dulled. These reactions occur due to vasospasm, a sudden constriction of blood vessels that decreases blood supply to the respective regions. As circulation returns, the affected areas may turn red, throb, tingle and swell. Stellate ganglion blockade made help release vascular spasm and lower pain.
  • Scleroderma – Scleroderma is an autoimmune disease of the connective tissue that involves formation of scar tissue in skin and organs. Scleroderma results from an overproduction and accumulation of collagen in body tissues. Collagen is a fibrous type of protein that helps provide support and framework in tissues of the body. Stellate ganglion blocks have provided benefit to scleroderma patients. For example, a case study notes a 77-year-old male with systemic sclerosis and secondary Raynaud’s phenomenon who received stellate blocks over a period of several weeks received lasting therapeutic benefit14. Complaints and Raynaud’s attacks abated significantly in the patient, as documented by local cold exposure tests.
  • Hyperhidrosis – Stellate ganglion blocks may help control hyperhidrosis (excessive perspiration) of the face and upper extremities. A study of 28 patients with craniofacial hyperhidrosis who received sympathetic blocks of the stellate ganglion found all patients achieved improvement of their condition without recurrent symptoms after a mean of 25.3 months of follow-up15.
  • Hot flashes – Studies have shown that stellate ganglion blocks may help control the hot flashes caused by menopause and other reasons, as well as related sleep dysfunction. A study in 13 survivors of breast cancer (in remission) with severe hot flashes and night awakenings who were treated with stellate-ganglion block found the total number of hot flashes decreased from a mean of 79.4 per week before the procedure to a mean of 49.9 per week during the first 2 weeks after the procedure16. The total number of hot flashes continued to decrease over the remaining follow-up period (weeks 3-12), and the number of very severe hot flashes decreased to near zero by the end of the follow-up period (week 12). Night awakenings decreased from a mean of 19.5 per week before the procedure to a mean of 7.3 per week during the first 2 weeks after the procedure. The total number of night awakenings continued to decrease over the remaining follow-up period (weeks 3-12).

Stellate Ganglion Block Diagram

Stellate Ganglion Block Procedure

A sympathetic nerve block involves injection of a local numbing anesthetic (e.g., lidocaine, bupivacaine) and a corticosteroid into the region containing the target sympathetic nerve ganglion. The patient will be placed in a reclining (supine) position, with the head rotated slightly to the side. After the neck is prepared and draped to promote sterility, the medications will be administered through a needle into the stellate ganglion. A successful block generally produces profound pain relief and improved vascular flow.

Generally, the patient will be given intravenous (IV) sedation to promote comfort during the procedure. The physician uses painless fluoroscopy to help visualize the area being injected. Fluoroscopy is an x-ray imaging technique that provides real-time, live images of the internal structures of a patient through the use of an x-ray source and fluorescent screen.

Following the procedure, which ordinarily takes only 15 minutes, the patient will be monitored for changes in vital signs (pulse, blood pressure, temperature) and placed in a sitting position to facilitate the spread of the anesthetic. In addition, the physician will evaluate the effects of the nerve block upon the patient’s pain. If the nerve block alleviates the patient’s pain and remains in effect beyond the duration of the anesthetic, the physician may determine that the blockade has therapeutic value for the patient and prescribe a treatment plan involving subsequent injections. The physician may also recommend more permanent forms of pain relief such as administration of neurolytic agents or radiofrequency ablation (RFA)18. If the nerve block fails to alleviate the patient’s pain, the pain is likely unrelated to the SNS and a different treatment strategy may be required.

Individuals who experience pain relief during a nerve block may be invited to participate in physical therapy while blockade is in effect and wide dynamic range neurons are being rested19. The goal of such therapy is to rehabilitate joints and strengthen the muscles in affected areas.

Stellate ganglion block is a quick, minimally invasive procedure that can effectively treat a broad variety of conditions.

Stellate Ganglion Block Procedure

The most significant benefit of sympathetic nerve blockade is the rapid relief of symptoms afforded to many patients with chronic SNS-related pain. Other significant benefits include improvement of circulation and modulation of temperature fluctuations in patients with SNS-related conditions. Most patients who respond to nerve blocks regain the ability to resume their normal daily activities and report a higher quality of life.

Stellate ganglion blockade has been shown to be a low risk procedure. One reason for this is that stellate ganglion blockade is a minimally invasive treatment. Less invasive therapies carry lower rates of complications than more aggressive, riskier treatments such as open surgery, which carries a higher risk of infection and other serious complications.

As with any medical procedure, the lumbar sympathetic nerve block is associated with risks. However, the minimally invasive nature of this treatment makes it a safe and reasonable non-surgical approach to pain relief.

Reported complications of the stellate ganglion nerve block include infection, bleeding, pneumothorax (collapsed lung), nerve damage, and pharmacological complications related to the drugs utilized20. In addition, some patients experience soreness at the injection site, and infection is always a risk with any procedure that involves penetration of tissues. In addition, blockade of sympathetic nerves can occasionally cause a transient set of symptoms called Horner’s Syndrome, which involves drooping of the eyelid and nasal congestion; however, these effects typically resolve within hours.

The prognosis for SNS-driven pain syndromes is generally improved with early diagnosis and treatment. Sometimes, if the condition is caught during early stages, restored range of motion and even remission are possible. Without early diagnosis and treatment, changes to tissues and functionality will eventually become irreversible. Consequently, patients who live with CRPS and other painful conditions are encouraged to seek help as soon as possible to prevent long-term damage that cannot be reversed.

Wake Spine & Pain Specialists understands the burden of living with a painful condition and strives to help patients regain their quality of life. Our caring practitioners are dedicated to working closely with patients to create individualized pain management programs designed to restore good health and happiness. To investigate treatment options, call to schedule an appointment with us today.

At Wake Spine & Pain Specialists our goal is to relieve your pain and improve function to increase your quality of life.
Give us a call today at (919)-787-7246.

References

  1. Lipov EG, Joshi JR, Sanders S, & Slavin KV. (2009). A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD). Med Hypotheses., 72(6), 657-61.
  2. Lipov EG, Joshi JR, Sanders S, & Slavin KV. (2009). A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD). Med Hypotheses., 72(6), 657-61.
  3. Ackerman WE, & Zhang JM. (2006). Efficacy of stellate ganglion blockade for the management of type 1 complex regional pain syndrome. South Med J., 99(10), 1084-8.
  4. Hey M, Wilson I, & Johnson MI. (2011). Stellate ganglion blockade (SGB) for refractory index finger pain – a case report. Ann Phys Rehabil Med., [Epub ahead of print]. Retrieved fromwww.ncbi.nlm.nih.gov/pubmed/21493175
  5. Paraskevas KI, Michaloglou AA, Briana DD, & Samara M. Treatment of complex regional pain syndrome type I of the hand with a series of intravenous regional sympathetic blocks with guanethidine and lidocaine. Clin Rheumatol., 25(5), 687-93.
  6. Carden, E. (2011). Complex regional pain syndrome (CRPS). Informally published manuscript, School of Medicine, University of California, Santa Monica, CA. Retrieved from[PDF]www.forgrace.org/documents/carden-nonphysician.pdf
  7. Leipzig TJ, & Mullan SF. (1984). Causalgic pain relieved by prolonged procaine amide sympathetic blockade. Case report. J Neurosurg., 60(5), 1095-6.
  8. Mizuno J, Sugimoto S, Ikeda M, Kamakura T, Machida K, & Kusume S. (2001). [Treatment with stellate ganglion block, continuous epidural block and ulnar nerve block of a patient with postherpetic neuralgia who developed complex regional pain syndrome (CRPS)]. [Article in Japanese]. Masui., 50(5), 548-51.
  9. Fine PG, & Ashburn MA. (1988). Effect of stellate ganglion block with fentanyl on postherpetic neuralgia with a sympathetic component. Anesth Analg., 67(9), 97-9.
  10. Salvaggio I, Adducci E, Dell’Aquila L, Rinaldi S, Marini M, Zappia L, & Mascaro A. (2008). Facial pain: a possible therapy with stellate ganglion block. Pain Med., 9(7), 958-62.
  11. Wassef MR. (1997). Phantom pain with probable reflex sympathetic dystrophy: efficacy of fentanyl infiltration of the stellate ganglion. Reg Anesth., 22(3), 287-90.
  12. Chester M, Hammond C, & Leach A. (2000). Long-term benefits of stellate ganglion block in severe chronic refractory angina. Pain., 87(1), 103-5.
  13. Stanik-Hutt JA. (2005). Management options for angina refractory to maximal medical and surgical interventions. AACN Clin Issues., 16(3), 320-32.
  14. Klyscz T, Jünger M, Meyer H, & Rassner G. (1998). Improvement of acral circulation in a patient with systemic sclerosis with stellate blocks. Vasa., 27(1), 39-42.
  15. Lin TS, & Chou MC. (2002). Needlescopic thoracic sympathetic block by clipping for craniofacial hyperhidrosis: an analysis of 28 cases. Surg Endosc., 16(7), 1055-8.
  16. Lipov EG, Joshi JR, Sanders S, Wilcox K, Lipov S, Xie H, Maganini R, & Slavin K. (2008). Effects of stellate-ganglion block on hot flushes and night awakenings in survivors of breast cancer: a pilot study. Lancet Oncol., 9(6), 523-32.
  17. Mulvaney SW, McLean B, & de Leeuw J. (2010). The use of stellate ganglion block in the treatment of panic/anxiety symptoms with combat-related post-traumatic stress disorder; preliminary results of long-term follow-up: a case series. Pain Pract., 10(4), 359-65.
  18. Day M. (2008). Sympathetic blocks: the evidence. Pain Pract., 8(2), 98-109.
  19. Carden, E. (2011). Complex regional pain syndrome (CRPS). Informally published manuscript, School of Medicine, University of California, Santa Monica, CA. Retrieved from[PDF]www.forgrace.org/documents/carden-nonphysician.pdf
  20. Elias M. (2000). Cervical sympathetic and stellate ganglion blocks. Pain Physician., 3(3), 294-304.