Stellate Blockade

Stellate blockade refers to targeted anesthesia of the so-called stellate ganglion, also known as the cervicothoracic ganglion. A ganglion is a collection of nerve cell bodies. The stellate ganglion is located at the level of the 6th cervical vertebra and is ventral (anterior) to the transverse processes of the 6th or 7th cervical vertebra. The procedure belongs to the nerve blocks and is used to interrupt pain-conducting impulses. Stellate blockade results in a temporary deactivation of the cervical sympathetic nervous system. In addition to the analgesic effect, vasodilation (vasodilatation) and anhidrosis (reduced sweat secretion) occur in the affected area. Stellate blockade is usually performed with local anesthetics. If the opiate buprenorphine is also administered, it is referred to as stellate GLOA (ganglionic local opioid application).

Indications (areas of application)

  • Chronic neuralgia of the 3rd trigeminal branch.
  • Complex regional pain syndrome (CRPS); synonyms: Algoneurodystrophy, Sudeck’s disease, Sudeck’s dystrophy, Sudeck-Leriche syndrome, sympathetic reflex dystrophy (SRD)) – neurological-orthopedic clinical picture, which is based on an inflammatory reaction after injury to an extremity and in addition, the central pain processing is involved in the event; represents a symptomatology in which there are severe circulatory disturbances, edema (fluid retention) and functional restrictions after the intervention, as well as hypersensitivity to touch or pain stimuli; Occur in up to five percent of patients after distal radius fractures, but also after fractures or minor trauma to the lower extremity; early functional treatment (physical and occupational therapy), with medications for neuropathic pain (“nerve pain) and with topical (“local”) therapies lead to better long-term results.
  • Local cervical syndrome with severe discomfort.
  • Migraine
  • Peripheral neuralgia after herpes zoster (shingles).
  • Root irritation syndromes of the cervical spine (segment C5-C8).

Contraindications

  • AV block – excitation conduction disorder of the heart resulting in a slowing of the heartbeat.
  • Existing recurrent or phrenic nerve palsy on the opposite side.
  • Coagulation disorders – e.g., taking anticoagulants (anticoagulants).
  • Ventilation disorder (ventilation disorder) of the contralateral (opposite) lung – e.g., pneumothorax or unilateral resection (removal) of the lung

Before stellate blockade

Before stellate blockade, a detailed medical history must be taken and the patient must be informed about possible complications. Radiographic examination of the spine, in addition to thorough clinical inspection, ensures planning for surgery. Platelet aggregation inhibitors (prevent aggregation of blood platelets (thrombocytes); blood-thinning medications) should be discontinued approximately 5 days prior to surgery. This must be checked with the help of a blood test. Venous access should be available in anticipation of possible complications.

The procedure

Stellate blockade is a procedure with many complications. Because of the risk of life-threatening vocal cord or respiratory paralysis (recurrent and phrenic nerve palsy), stellate blockade is performed exclusively on one side. 5 ml of a local anesthetic (e.g., 0.25% bupivacaine) is injected for a block in the area of the head. To achieve an effect in the area of the arm, up to 15 ml must be injected. The injection takes place under sterile conditions. The “ventral approach according to Herget” is most frequently used to perform stellate blockade. The patient is in a sitting position, while the head is slightly stretched dorsally (backwards) in the middle position. 3 cm lateral (sideways) and 3 cm cranial (towards the head) to the jugular fossa (jugular groove), and 2 cm lateral to the cricoid cartilage (part of the larynx) is where the puncture site is located. At this point, the anesthesiologist palpates the sternocleidomastoid muscle (muscle; head turner) and the internal carotid artery (semicarotid artery) and pushes them aside. He now palpates the transverse process of the 6th cervical vertebra and advances the cannula until contact is made with the bone.Subsequently, the cannula is slightly withdrawn and aspirated (suction is exerted over the cannula to check whether it is in a vessel; if this is the case, injection must not be performed under any circumstances), followed by injection.

After stellate blockade

After stellate blockade, close monitoring of the patient is necessary. Observation of the patient’s cardiovascular system is the main focus. Furthermore, the patient’s neurologic status must also be closely monitored to detect potential complications early.

Potential complications

Side effects

  • Horner’s syndrome – enophthalmos (inwardly-set eyes), miosis (narrow pupils), unilateral ptosis (drooping eyelid)
  • Unilateral redness of the facial skin with increased blood flow and increased skin temperature.
  • Unilateral anhidrosis (sweat production is blocked) – on the upper extremity and face (dry and warm skin).
  • Conjunctival injection (eye redness due to visible blood vessels in the conjunctiva).
  • Phrenic nerve palsy – diaphragmatic paralysis with respiratory and coughing disorders.
  • Recurrent paresis – paralysis of the recurrent nerve, which can lead to unilateral vocal cord paralysis with hoarseness and dysphagia.
  • Swelling of the nasal mucosa.
  • Increased lacrimation of the eye

Serious complications