RSD - Padda Institute Center for Interventional Pain Management

Stellate Ganglion Block

 

 

 

 

Stellate Ganglion Block

Your body has special nerves known as sympathetic nerves in your neck which ,control blood supply and sweating to your arms and hands . These nerves can be anesthetized to change the blood flow to a limb and to decrease the pain which is mediated by these sympathetic nerves:

 

 

 

 

Reflex sympathetic dystrophy (RSD), also called Complex Regional Pain Syndrome (CRPS) typically involves a nerve injury involving the sympathetic nervous system.

 

 

  • Reflex sympathetic dystrophy  (RSD), also called Complex Regional Pain Syndrome (CRPS) typically involves a nerve injury involving the sympathetic nervous system.  Patients who suffer crushing or partial nerve injury develop excruciating burning pain accompanied by changes in blood supply to the area of the injury.   People with CRPS may exhibit abnormal sensation throughout all or part of the affected area. This often includes increased sensitivity to stimuli such as touch, pressure, or temperature.
  • Patients with severe ischemic limb pain have sharp, aching pain as a result of circulatory insufficiency.  Patients in end-stage PVD (peripheral vascular disease) will complain of rest pain with or without ulcers.
    1. Severe pain (claudication and rest pain)
    2. Decreased pulse in the limb
    3. Abnormal skin temperature
    4. Abnormal skin color
    5. Nonhealing ulcers
    6. Other trophic changes

Common types of PVD

  • Arteriosclerosis
  • Diabetic arteriosclerosis
  • Raynaud’s disease
  • Buerger’s disease

What is the purpose of Stellate Ganglion Block?

The Stellate Ganglion Block is an injection procedure used to block or decrease pain located in the head, neck, chest, or arm. It also helps increase circulation.

The Stellate Ganglion is a group of nerves located in the upper neck and is part of the sympathetic nervous system. After an injury or illness, the sympathetic nervous system may not function properly, causing pain. Some of the more common conditions are: complex regional pain syndrome (CRPS) also known as reflex sympathetic dystrophy (RSD), causalgia (nerve injury), and herpes zoster (shingles) of the head and face. The Stellate ganglion block is also used to treat intractable angina (severe pain caused by heart disease) or severe peripheral vascular disease (PVD).

 

If this treatment relieves your pain, the doctor will perform a series of blocks at another time in an attempt to break the pain cycle and provide long lasting pain relief. The number of blocks you will need depends on how long the pain relief lasted between injections. Usually you will get more and longer pain relief after each injection.

 

Some patient’s get short-term relief with Stellate blockade, but the series of blocks fails to provide long-term relief.  These individuals are usually considered candidates for Dorsal Column Stimulation (DCS).

 

What does the procedure involve?

The nerves going to the arm can be anesthetized in one of two place; the low neck which is known as a stellate block, or the upper chest area known as a T2 sympathetic block.

 

The Stellate Ganglion Block is an outpatient procedure, usually done in the Operating Room or a Procedure Room. For your safety and comfort, you will be connected to monitoring equipment (EKG monitor, blood pressure cuff, and a blood-oxygen monitoring device). The doctor or nurse may start an intravenous line and give some medicine to help you relax. You will also have skin temperature monitors placed on your hands.

 

The procedure is performed with you lying on your back. A rolled-up sheet or other support is placed between your shoulder blades, which may be a little uncomfortable.

 

After cleansing your neck with an antiseptic solution, the doctor will inject numbing medicine into the skin and tissue. This may cause a burning sensation for a few seconds. The doctor will also apply some pressure on your neck to determine exactly where to place the needle. It is very important that you do not talk, swallow, or cough. If you have to swallow or cough, raise your hand to let someone know.

 

After the numbing medicine takes effect the doctor will insert another needle, and with the assistance of a special X-ray machine called a fluoroscope, inject a radiopaque dye (contrast solution) to confirm correct needle position. When satisfied with the needle position, the doctor will inject a small mixture of numbing medicine (anesthetic) and anti-inflammatory medicine (cortisone/steroid).

 

Although it takes about 10 to 20 minutes for the medication to take effect, you will remain at the Clinic until the doctor feels you are ready to leave.

 

If the block works, then your hand will warm up and (depending upon the source of your pain) your pain may improve.  When utilized for CRPS (RSD), stellate blocks are used as a way of getting you to work with physical \ occupational therapy to desensitize your arm or hand.

 

Can I go to sleep for the procedure?

It is not necessary for you to go to sleep for this procedure; you must be awake and communicate with the physician during the procedure.

 

 

How long will the procedure take?

Normally, a Stellate ganglion block procedure takes no more than 30 minutes.

 

 

What should I do before the procedure?

• Since you will be receiving medication, it is recommended that you do not eat within four or five hours before the procedure. If you are a diabetic, be sure to discuss your eating and medication schedule with the doctor.

• You may need to stop taking certain medications several days before the procedure. Please remind the doctor of all prescription and over-the-counter medications you take, including herbal and vitamin supplements. The doctor will tell you if and when you need to discontinue the medications.

• It is very important to tell the doctor if you have asthma, had an allergic reaction (i.e. hives, itchiness, difficulty breathing, any treatment which required hospitalization) to the injected dye for a previous radiology exam (CT scan, angiogram, etc) or if you have had an allergic reaction to shellfish (shrimp, scallops, lobster, crab). The doctor may prescribe some medications for you to take before having the procedure.

• Tell the doctor if you develop a cold, fever, or flu symptoms before your scheduled appointment.

 

 

Is there anything special that I need do after the procedure?

You need to be aware of several potential side effects. These side effects, which usually disappear four to eight hours after the block may include: • A droopy eyelid on the side of the block; Redness and blurred vision in the eye on the side of the block; A feeling like a lump in your throat; Difficulty swallowing; Hoarseness of your voice; Warmth and weakness of the arm on the side of the block.

•          Drink plenty of clear liquids after the procedure to help remove the dye from the kidneys and do not eat solid food until you are comfortable swallowing.

•          Do not drive for the remainder of the day. Please have an adult drive you home or accompany you in a taxi or other public transportation.

•          Depending on how you feel, you may resume normal activities and return to work the following day.

•          If the doctor prescribes physical therapy, it is very important that you continue with the physical therapy program.

•          Although you may feel much better immediately after the injection (due to the numbing medicine), there is a possibility your pain may return within a few hours. It may take a few days for the steroid medication to start working.

•          You must participate in physical therapy, in order to get long-term control of symptoms.  Desensitization physical therapy can be an effective way to treat hypersensitivity, especially when used in combination with other medical and/or therapeutic interventions.

 

The stellate blockade is both diagnostic (helps diagnose the cause of your pain) and therapeutic (treats the cause of your pain).  You may need a series of injections in order to achieve long-term pain control.  Please keep track of your symptoms after the block.

 

What are the risks of a Stellate Ganglion Block?

The risks, although infrequent, include:

  • Collapsed lung
  • Numbness of an arm that may last for hours
  • Temporary weakness or numbness from the neck down
  • Allergic reaction to the medication
  • Nerve damage
  • Bruising at the injection site
  • Infection at the injection site
  • Injection of medication into a blood vessel with possibility of stroke or seizure
  • Post-injection flare (nerve root irritation with pain several hours after treatment, which may last days or weeks)
  • Depigmentation (a whitening of the skin)
  • Local fat atrophy (thinning of the skin)
  • Destruction of a motor or sensory nerve in the path of the needle
  • Bleeding, nerve injury, organ injury and death are rare but possible

Note: If you experience new shortness of breath 24 – 48 hours after the injection or any signs of infection in the area of the injection you should go to your nearest emergency room immediately.

 

 

 

 

 

 

Lumbar Sympathetic Nerve Block (including Celiac Plexus Block and Ganglion Impar Block)

 

 

Lumbar Sympathetic Nerve Block (including Celiac Plexus Block and Ganglion Impar Block)

Your body has special nerves known as sympathetic nerves in your back which ,control blood supply and sweating to your legs and feet . These nerves can be anesthetized to change the blood flow to a limb and to decrease the pain which is mediated by these sympathetic nerves:

 

 

 

 

Your body has special nerves known as sympathetic nerves in your back which ,control blood supply and sweating to your legs and feet .

 

 

  • Reflex sympathetic dystrophy  (RSD), also called Complex Regional Pain Syndrome (CRPS) typically involves a nerve injury involving the sympathetic nervous system.  Patients who suffer crushing or partial nerve injury develop excruciating burning pain accompanied by changes in blood supply to the area of the injury.   People with CRPS may exhibit abnormal sensation throughout all or part of the affected area. This often includes increased sensitivity to stimuli such as touch, pressure, or temperature.
  • Patients with severe ischemic limb pain have sharp, aching pain as a result of circulatory insufficiency.  Patients in end-stage PVD (peripheral vascular disease) will complain of rest pain with or without ulcers.
      • Severe pain (claudication and rest pain)
      • Decreased pulse in the limb
      • Abnormal skin temperature
      • Abnormal skin color
      • Non healing ulcers
      • Other trophic changes

 

  • Common types of PVD
      • Arteriosclerosis
      • Diabetic arteriosclerosis
      • Raynaud’s disease
      • Buerger’s disease

What is the purpose of a Lumbar Sympathetic Nerve Block?

The Lumbar Sympathetic Nerve Block is a procedure used to block or decrease pain in the lower extremities caused by injury or disease of the sympathetic nervous system. The lumbar sympathetic nerves are located on either side of the lumbar spine (lower back).

After an injury or illness, the sympathetic nervous system may not function properly, causing pain. Some of the more common conditions include Complex Regional Pain Syndrome (CRPS) also known as Reflex Sympathetic Dystrophy, Sympathetic Maintained Pain and Herpes Zoster (shingles) involving the lower part of the body.

If the block relieves your pain, the doctor will then perform a series of blocks at a another time, in an attempt to break the pain cycle and provide long lasting pain relief. The number of blocks you will need depends on how long the pain relief lasted between injections. Usually you will get more and longer pain relief after each injection.  If the series of blocks do not relieve your pain, a radiofrequency lesion may be done, or consideration of stimulator implant may be necessary.

The Celiac Plexus Block is a type of Lumbar Sympathetic Block used to diagnose and treat pain from abdominal sympathetic mediated set of nerves such as chronic pancreatitis.

The Ganglion Impar Block is a type of Lumbar Sympathetic Block used to diagnose and treat pain from a pelvic sympathetic mediated set of nerves such as interstitial cystitis or coccyxodinia.

 

What does the procedure involve?

The Lumbar Sympathetic Block is an outpatient procedure, usually done in the Operating Room or a Special Procedure Room. For your safety and comfort, you will be connected to monitoring equipment (EKG monitor, blood pressure cuff, and a blood-oxygen monitoring device), and positioned on your stomach. The doctor or nurse may start an intravenous line and give some medicine to help you relax. Your back is cleansed with an antiseptic soap after which the doctor injects numbing medicine deep into your skin and tissue. This will cause a burning sensation for a few seconds. After the numbing medicine takes effect, the doctor will insert a another needle and, with the assistance of a special X-ray machine called a fluoroscope, inject a radiopaque dye (contrast solution) to ensure the needle is in proper position.  With the needle in position, a small mixture of numbing medicine (anesthetic) and anti-inflammatory medicine (steroid) is injected.

After the procedure, we ask that you remain at the Clinic until the doctor feels you are ready to leave.

 

Can I go to sleep for the procedure?

It is not necessary for you to go to sleep for this procedure; however, you will receive enough medication to keep you comfortable.

 

How long will the procedure take?

Normally, a lumbar sympathetic block  procedure takes no more than 10 or 15 minutes.

 

What should I do before the procedure?

  • Since you will be receiving medication, it is recommended that you do not eat within four or five hours before the procedure. If you are a diabetic, be sure to discuss your eating and medication schedule with your doctor.
  • You may need to stop taking certain medications several days before the procedure. Please remind the doctor of all prescription and over-the-counter medications you take, including herbal and vitamin supplements. The doctor will tell you if and when you need to discontinue the medications.
  • It is very important to tell the doctor if you have asthma, had an allergic reaction (i.e. hives, itchiness, difficulty breathing, any treatment which required hospitalization) to the injected dye for a previous radiology exam (CT scan, angiogram, etc) or if you have had an allergic reaction to shellfish (shrimp, scallops, lobster, crab). The doctor may prescribe some medications for you to take before having the procedure.
  • Tell the doctor if you develop a cold, fever, or flu symptoms before your scheduled appointment.

 

Is there anything special that I need do after the procedure?

  • You may experience some weakness and/or numbness in your legs a few hours after the procedure. If so, do not engage in any activities that require lifting, balance and coordination.
  • Drink plenty of clear liquids after the procedure to help remove the dye from the kidneys.
  • Do not drive for the remainder of the day. Please have an adult drive you home or accompany you in a taxi or other public transportation.
  • Depending on how you feel, you may resume normal activities and return to work the following day.
  • If the doctor prescribes physical therapy, it is very important that you continue with the physical therapy program.
  • Although you may feel much better immediately after the injection (due to the numbing medicine), there is a possibility your pain may return within a few hours. It may take a few days for the steroid medication to start working.
  • You must participate in physical therapy, in order to get long-term control of symptoms.

 

What are the risks of a Lumbar Sympathetic Nerve Block?

The risks, although infrequent, include:

  • Puncture of the abdominal organs or the lungs
  • Numbness of an legs that may last for hours
  • Temporary weakness or numbness from the neck down
  • Allergic reaction to the medication
  • Nerve damage
  • Bruising at the injection site
  • Infection at the injection site
  • Injection of medication into a blood vessel with possibility of stroke or seizure or sudden cardiac arrest
  • Post-injection flare (nerve root irritation with pain several hours after treatment, which may last days or weeks)
  • Depigmentation (a whitening of the skin)
  • Local fat atrophy (thinning of the skin)
  • Destruction of a motor or sensory nerve in the path of the needle
  • Bleeding, nerve injury, organ injury and death are rare but possible

 

 

 

 

Complex Regional Pain Syndrome (CRPS) or Reflex Sympathetic Dystrophy (RSD)

The hallmark of CRPS is pain and mobility problems out of proportion to those expected from the initial injury.

“Of all the chronic neuropathic pain syndromes, none has perplexed patient, clinician, and scientist more than the complex regional pain syndromes (CRPS), heretofore known as reflex sympathetic dystrophy (RSD) and causalgia.”

  • Galer BS CRPS In Loeser J (ed) Bonica’s Management of Pain 3rd Ed. Lippincott Williams & Wilkins 2001 p 388

 

 

Complex Regional Pain Syndrome is the new term for what we used to call RSD or causalgia. Symptoms can develop into CRPS from a major nerve injury (CRPS Type II) or from minimal or no trauma (CRPS Type I).

 

Healthy nerve structure

 

 

Variety of methods by which nerves can suffer partial damage leading to CRPS.

 

 

 

Complex Regional Pain Syndrome is the new term for what we used to call RSD or causalgia.  Symptoms can develop into CRPS from a major nerve injury (CRPS Type II) or from minimal or no trauma (CRPS Type I).

 

Stage 1

The first stage typically lasts about 3 months and starts with severe, burning localized pain, hyperesthesia, localized edema, stiffness and vasospasm (warm, red and dry at first, then changes to cyanotic, cold and sweaty).

 

Stage 2

The second stage (which lasts 3-6 months), pain becomes more severe and diffuse.  Edema spreads, hair becomes scant, and nails become brittle, cracked and grooved.  Osteoporosis appears and spreads while muscles waste.

 

Stage 3

The third stage Pain may spread to the entire limb in stage 3, with marked muscle atrophy, extreme joint weakness and limited mobility.  Bone deossification becomes diffuse.  Contractures are often seen, with near mummification of the extremities.

 

 

 

RSD involves both pain and skin changes.

 

 

Pain from CRPS:

The hallmark of CRPS is pain and mobility problems out of proportion to those expected from the initial injury. The first and primary complaint occurring in one or more extremities is described as severe, constant, burning and/or deep aching pain. All tactile stimulation of the skin (e.g. wearing clothing, a light breeze) may be perceived as painful (allodynia). Repetitive tactile stimulation (e.g. tapping on the skin) may cause increasing pain with each tap and when the repetitive stimulation stops, there may be a prolonged after-sensation of pain (hyperpathia). There may be diffuse tenderness or point-tender spots in the muscles of the affected region due to small muscle spasms called muscle trigger points (myofascial pain syndrome). There may be spontaneous sharp jabs of pain in the affected region that seem to come from nowhere (paroxysmal dysesthesias and lancinating pains).

 

Skin changes in CRPS:

The skin may appear shiny (dystrophy-atrophy), dry or scaly. Hair may initially grow coarse and then thin. Nails in the affected extremity may be more brittle, grow faster and then slower. Faster growing nails is almost proof that the patient has CRPS.

 

CRPS is associated with a variety of skin disorders including rashes, ulcers and pustules.  Although extremely rare, some patients have required amputation of an extremity due to life-threatening recurring infections of the skin. Abnormal sympathetic (vasomotor changes) activity may be associated with skin that is either warm or cold to touch. The patient may perceive sensations of warmth or coolness in the affected limb without even touching it (vasomotor changes). The skin may show increased sweating (sudomotor changes) or increased chilling of the skin with goose flesh (pilomotor changes). Changes in skin color can range from a white mottled appearance to a red or blue appearance. Changes in skin color (and pain) can be triggered by changes in the room temperature, especially cold environments. However, many of these changes occur without any apparent provocation.

 

Reflex sympathetic dystrophy (RSD) or Complex Regional Pain Syndrome (CRPS) is a malignant pain syndrome most often seen in the distal upper or lower extremities, but in variant forms also affects more proximal structures.  It is characterized by:

 

  • extremity pain, often severe (often seen in a stocking or glove pattern)
  • most commonly, involvement of the hand or foot, following injury to that structure or to a proximal limb structure;
  • allodynia (pain to non-painful touch) and hyperpathia;
  • peripheral thermal abnormalities;
  • other symptoms and signs of local autonomic nervous system dysfunction may be present, including locally increased or decreased sweating and edema;
  • local trophic changes;
  • progressive osteoporosis of the affected extremity
  • flexion contracture with significant atrophy

 

CRPS usually remains restricted to one limb, but it can spread to other body parts. Processes in the spinal cord as well as supraspinal changes are responsible for spontaneous spread in CRPS to other extremities.

 

Diagnosis:

Diagnosis is made largely on the basis of history and clinical examination.  A dynamic phase bone scan may help to document perfusion abnormality and is the most sensitive and specific study applicable in diagnosis.  Local sympathetic anesthetic block, performed for treatment, typically results in pain relief outlasting the transient anesthetic effect, which is supportive of the diagnosis.

Evaporative skin testing with loss of temperature discrimination and development of allodynia upon evaporation is a useful screening tool.

Electrodiagnostic testing to exclude nerve entrapment as well as Neurodiagnostic imaging may be necessary to exclude a neuraxial pathology, such as a bulging disc.

 

Patients with ischemic rest pain (pain from insufficient blood supply due to advanced CRPS):

  • Frequently are sleep deprived
  • Are limited in mobility and activities of daily living
  • Often will consent to amputation for pain relief
  • Often are unable to obtain adequate pain relief from narcotic medication
  • Rarely improve spontaneously, unless the blood perfusion to the affected area can be improved
  • Have a high incidence of major depression disorder and are high risk of suicide

 

Treatment options:

Early diagnosis in the first six months to maximal two years is the key to successful treatment. Surgical sympathectomy procedures (removal of a part of the chain of sympathetic ganglia on the side of the spine) have limited application for the treatment of RSD.

 

Management options include sympathetic blocks utilizing regional anesthetic techniques and radiofrequency thermoneurolysis or neuromodulation with spinal cord stimulation or peripheral nerve stimulation.  Radiofrequency neurolysis is an extension of a continuous regional sympathetic block or neurolytic block providing long-term relief with added safety.

Consideration of sympathetic blocks is to facilitate management of CRPS with analgesia commensurate with a program of functional restoration and sympatholysis to provide unequivocal evidence of sympathetically maintained pain. Once it is established that sympatholysis is effective in relieving not only the burning dysesthesia but also allodynia or hyperalgesia, it is important to repeat the procedure to determine whether an increasing duration of effect can be expected in any particular patient. If this is the case, these individual blocks may be all that are necessary to enable a patient to regain function. When sympatholysis completely relieves the symptoms and facilitates exercise therapy but is limited to its duration of effect, it is appropriate to consider a prolonged block using radiofrequency neurolysis.

Radiofrequency has been described for lesioning of the cervical sympathetic chain, thoracic sympathetic chain, and lumbar sympathetic chain, in cases of CRPS I and II, as well as for neuropathic pain.