Stellate Ganglion Block Use for Ocular Conditions
A stellate ganglion block is the injection of local anesthetic into or around the stellate ganglion to block the sympathetic nerves located on either side of the voice box in the neck. It is used for the treatment of various pain-related medical conditions involving the nerves and blood circulation.
Mechanism of Action
The sympathetic fibers that innervate the head, neck, heart, and upper limbs arise from the first thoracic segments, ascend through the sympathetic chain, and then synapse in superior, middle, and inferior cervical ganglions. The stellate ganglion is made up of the inferior cervical ganglion and the first thoracic ganglion fusion. As its name suggests, the stellate ganglion is star-shaped and is located anterior to the neck of the first rib and is present in up to 80% of the population. In the remaining population, the inferior cervical and first thoracic ganglion do not fuse normally, and the inferior cervical ganglion is designated as the stellate ganglion.
Stellate ganglion blocks mainly work by blocking neural connections in the region of innervation where they are administered. These blocks relieve sympathetically mediated pain which is due to abnormal connections between sympathetic and sensory nervous systems. However, they can also improve the blood supply of the region and reduce the concentration of adrenal hormones. Local anesthetic is injected at the level of the C6 transverse process and travels inferiorly towards the stellate ganglion where it anesthetizes sympathetic nerve fibers. It exerts its effect on both preganglionic and postganglionic fibers.
Indications and Contraindications
Stellate ganglion blocks can be used for diagnostic or therapeutic purposes to confirm or treat sympathetically mediated pain. Medical indications include complex regional pain syndrome of the head and upper limbs, peripheral vascular disease, chronic post-surgical pain, hyperhidrosis, Raynaud syndrome, scleroderma, phantom limb pain, upper extremity embolism, Meniere syndrome, orofacial pain, atypical angina, refractory angina, and refractory cardiac arrythmias. Recently, they have also been used in treatment of post-traumatic stress disorder. Ophthalmic indications include post-herpetic neuralgia, trigeminal neuralgia, migraine headache, cluster headache, painful blind eye, post-surgical eye pain, and photooculodynia syndrome. Contraindications include glaucoma, recent myocardial infarction, coagulopathy, severe emphysema, and cardiac conduction block.
Multiple approaches can be used to for stellate ganglion blocks and can use ultrasound, fluoroscopic or MRI guidance.
In the surface landmark technique, the cricoid cartilage is palpated to locate the C6 level where palpation for the C6 transverse process, or the Chassaignac tubercle, occurs. The needle is advanced anteroposteriorly until it hits the tubercle. In the fluoroscopy-guided technique, contrast is administered to provide better bony delineation and assure the needle tip is in the correct plane. In the ultrasound-guided technique, the ultrasound transducer is used to visualize relevant anatomy such as the carotid artery, internal jugular vein, thyroid gland, trachea, Longus colli, and Longus capitis muscle, prevertebral fascia, the root of C6 spinal nerve, and transverse process of C6.
Successful stellate ganglion blocks show specific clinical signs including miosis, anhidrosis, ptosis, and flushing of the extremities. These symptoms usually disappear in 4 to 6 hours after the blockade. Pain relief may not be immediate, and a pain diary can be used to track response. Some patients have pain that returns after the local anesthetic wears off while some patients have longer term relief. Usually, a series of injections may be needed, and relief tends to last longer with each treatment.
A study that included 35 patients with prolonged ocular pain after ocular surgery showed stellate ganglion block was 96.6% effective after being performed an average of 5.9 times in patients with nociceptive pain and 66.7% effective after being performed an average of 52.6 times in patients with neuropathic pain. Thus, stellate ganglion block may be more useful for treatment of nociceptive pain.
Six patients with painful blind eyes secondary to glaucoma underwent a course of 6 weekly injections of stellate ganglion blocks. After one year, 2 patients were completely asymptomatic, 2 had significantly decreased pain, 1 patient abandoned the clinic, and 1 patient presented with major depressive disorder concomitant to eye pain that greatly compromised treatment.
In a controlled trial in treatment of photo-oculodynia syndrome, 4 patients were given a randomized double-masked series of three cervical sympathetic ganglion blocks of saline, bupivacaine, and lidocaine. Cervical sympathetic ganglion block with lidocaine and bupivacaine reduced spontaneous pain and light sensitivity while increasing production of tears. Symptom reduction lasted from hours to days.
Complications include puncture of neighboring vasculature or nerves such as the carotid artery, internal jugular vein, inferior thyroid artery, vertebral artery, vagus nerve, recurrent nerve, or brachial plexus roots, intravascular injection, neuraxial spread of anesthetic, pneumothorax, infection, thyroid injury, esophageal puncture, tracheal puncture, total spinal anesthesia, generalized seizures, or severe hypertension.
Stellate ganglion blocks can be useful in diagnosis and treatment of various medical conditions. Ophthalmologists should be aware of its use and efficacy in cases of post-operative ocular pain, painful blind eye, photo-oculodynia syndrome, post-herpetic neuralgia, trigeminal neuralgia, migraines, and cluster headaches.
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