Peripheral Nerve Blocks: A Color Atlas, 3rd Edition

63. Sympathetic Blocks

A. Stellate Ganglion Block

Nashaat N. Rizk

Cheryl D. Bernstein

Patient Position: Supine, with a roll placed under the shoulders to extend the neck.

Indications: Diagnosis and treatment of sympathetically mediated pain of the face, neck, and upper extremity; treatment of postherpetic neuralgia of the cervical dermatomes.

Needle Size: 25-gauge precision Glide needle.

Medication/Volume: 5 to 10 mL of 0.25% bupivacaine.

Anatomic Landmarks: Stellate ganglion, which is composed of the fusion of C7 and T1 sympathetic ganglia, which lies anterior to the transverse process of C7 and T1 on the anterior surface of the longus colli muscles, lateral to the trachea and esophagus, anteromedial to the vertebral artery, and medial to the common carotid artery. The block is performed lateral to the cricoid cartilage at the level of the C6 transverse process (Chassaignac tubercle) (Fig. 63-1A).

Approach and Technique: Prepare the skin with a sterile solution lateral to the cricoid cartilage. Insert the needle perpendicular to the skin plane approximately one fingerbreadth lateral to the cricoid cartilage to make contact with the C6 transverse process (Fig. 63-1B). After negative aspiration, inject 0.5 mL of 0.25% bupivacaine test dose. After the negative aspiration and the injection of a test dose, inject the remaining 5 to 10 mL of 0.25% bupivacaine. Under fluoroscopy, insert the needle at the junction of the transverse process and the C7 vertebral body (Fig. 63-2). Use 2 mL of Isovue-200 (Bracco Diagnostics, Princeton, NJ) for verification of needle position. Figure 63-3 presents an anteroposterior (A) and lateral view (B).

 

Figure 63-1. Stellate ganglion block anatomic landmarks.

Figure 63-2. Insert the needle at the junction of the transverse process and the C7 vertebral body.

Figure 63-3. A: Anteroposterior view. B: Lateral view.

 

Complications: Bleeding, infection, intravascular injection, pneumothorax, hoarseness and dysphagia, and epidural, subdural, or subarachnoid injection.

Tips

1.   Application of routine monitors, including blood pressure and pulse oxygen, is required.

2.   Having the patient's mouth slightly open decreases skin tension and facilitates palpation of the landmarks.

3.   To avoid the risk for aspiration, the patient should avoid oral intake for 4 to 6 hours after the block and then resume with clear liquids as tolerated.

B. Celiac Plexus Block (Anterocrural)

Nashaat N. Rizk

Patient Position: Prone.

Indications: Abdominal pain associated with malignancy. Nonmalignant abdominal pain (controversial).

Needle Size: 22-gauge Quincke type, 178-mm.

Medication/Volume: For diagnostic purposes: 15–20 cc of bupivacaine 0.5%, lidocaine 2%, or ropivacaine 0.5%. For neurolysis: 10–15 cc of alcohol 50–100% or phenol 6.5%.

Anatomic Landmarks: At T12-L1, the celiac plexus lies anterior to the aorta. Traditionally, a single-needle technique is used on the left side.

Approach and Technique: Fluoroscopy is used to take an anterior–posterior (AP) view and mark the T12-L1 junction (Fig. 63-4A). The beam is oblique to hide the ipsilateral transverse process (left side) behind the shadow of the upper third of the L1 vertebral body. A slight cephalad–caudad tilt of the beam may be necessary to square the endplates. This point should be marked and is approximately 6–8 cm from midline. After skin wheal and deep infiltration of local anesthetics, advance the needle parallel to the x-ray beam. Of great importance is taking frequent AP views to assess needle direction and lateral views (Fig. 63-4B) to assess depth. Once the anterior third of the vertebral body is reached, the stylet is removed from the needle and 0.1 cc–0.2 cc of PFNS is injected to occupy the needle and prevent air embolization. Once the aorta is pierced, very gentle aspiration is continuously applied until negative aspiration for blood. Advance 2–3 mm. Inject a small amount of the dye. Injection should be very slow and you should not feel any resistance. Resistance to injection may indicate injection in the wall of the aorta and may cause dissection. Injection of the local anesthetic should commence after desirable AP (Figs. 63-4D and E) and lateral (Figs. 63-4C and F) views are obtained with adequate propagation of the dye without intravascular runoff. Following the local anesthetic, absolute alcohol is injected slowly. Needle tip is about 1½ -2cm anterior to the vertebral body. The same is done on the right side, stopping just anterior to the vertebral body.

If splanchnic blocks are to be done, the needle tip should not be deeper than the anterior third of the vertebral body.

Complications: Bleeding, infection, seizures, pneumothorax, hypotension (mild and short-lived), and paraplegia.

Tips

1.   Alternatively, a right-sided needle can be placed at the same level to block the splanchnic nerves retrocrural in conjunction with the celiac plexus block or anterocrural as some fibers from the celiac plexus may be blocked as well.

2.   Before performing this blocks, it is essential to confirm that the patient's coagulation is normal.

 

Figure 63-4. A: Needle position at T12-L1 AP view. B: Lateral view. C and F: Lateral view with contrast. D and E: AP view with contrast.

3.   Frequent AP and lateral views assure certainty of needle position.

4.   After injecting the dye, monitor the spread and watch for backtracking through the foramina to the spinal cord. This is especially important if splanchnic nerves are blocked.

5.   Use a diagnostic block prior to neurolytic blocks, preferably on different days, to test for signs of sensory or motor deficits.

6.   Chiba type needle with a blocker may be used to secure the needle position.

7.   Obtain informed consent and explain possible complications to both the patient and the family.

8.   This block is not very useful or practical for the treatment of chronic nonmalignant pain.

9.   If the tumor is occupying the space adjacent to the celiac plexus, pain relief may not be obtained. In this case, a splanchnic block is indicated, or radiofrequency ablation after a successful diagnostic block.

C. Lumbar Sympathetic Block

Nashaat N. Rizk

Shashank Saxena

Patient Position: The patient is placed in a prone position. A pillow may be used to flex the lumbar spine to reduce the lumbar lordosis. We usually rest the head and chest of the patient on the pillow.

Indications: Evaluation and management of sympathetically mediated pain (reflex sympathetic dystrophy and causalgia) in the genitalia or lower extremity. In addition, phantom limb pain, peripheral neuropathies, lower extremity pain secondary to vascular insufficiency, and acute herpes zoster or postherpetic neuralgia involving lumbar and sacral dermatomes. It can also be used as a prognostic indicator for the degree of pain relief before a destructive block or radiofrequency.

Needle Size: A 22-gauge, 178-mm Quincke spinal needle is used for this procedure. The needle tip is bent about 1 cm from the tip at an angle of 20° to 30°, and care is taken so that the stylet can be removed after bending the needle (Fig. 63-5).

Medication/Volume: 5 mL of 0.5% bupivacaine. It may be mixed with 40 mg of Depo-Medrol (Pharmacia Canada, Inc., Hamilton, Ontario, Canada) during the first few blocks to give prolonged pain relief. For a diagnostic block, we use only bupivacaine.

Anatomic Landmarks: The lumbar sympathetic chain lies at the anterolateral border of the vertebral bodies. The lumbar sympathetic chain consists of preganglionic axons and postganglionic neurons. The cell bodies of the preganglionic nerves arise from the intermediolateral column of the spinal cord at T11, T12, L1, and L2 and occasionally from T10 and L3. The preganglionic fibers pass by way of the ventral root from T11 to L2 to a white rami communicants and then to a paravertebral sympathetic chain ganglion. The postganglionic fibers depart the chain either directly to form a diffuse plexus around the iliac and femoral arteries, or more commonly as gray rami communicants to combine with spinal nerves of the lumbosacral plexus. They join all the major nerves of the lower extremity and ultimately end with the corresponding vessels.

The preganglionic axons for visceral structures synapse with the inferior three thoracic and first lumbar ganglia. They join the hypogastric and aortic plexuses en route to the pelvic viscera. Afferent nociceptive fibers in this region accompany the sympathetic fibers and relay pain sensations from the kidney, ureter, bladder, and distal portions of the transverse colon, left descending colon, rectum, prostate, testicle, cervix, and uterus. There are four sets (one on each side) of lumbar sympathetic ganglia rather than five due to the fusion of the T12 and L1 ganglia. The position of the ganglia is variable and can be segmentally located or closely grouped between L2 and L4.

Figure 63-5. The needle tip is bent about 1 cm from the tip at an angle of 20° to 30°, and care is taken so that the stylet can be removed after bending the needle.

The lumbar sympathetic chain is located in the fascial plane immediately anterolateral to the lumbar vertebral bodies. The sympathetic chain is separated from the somatic nerves by the psoas muscle and fascia, the psoas muscle being situated posteriorly and laterally to the sympathetic chain. The aorta is positioned anteriorly and slightly medially to the chain on the left side. The inferior vena cava is in closer proximity to the chain on the right in an anterior plane.

Approach and Technique: The lumbar region is prepared and draped using sterile techniques. The block is performed at the L3 level. The fluoroscopy beam is rotated 25° to 30° lateral to the midline toward the side to be blocked, and a fluoroscopic view is obtained. The upper lateral edge of the L3 vertebra is then isolated by keeping a sterile clamp tip at that point on the skin, and local anesthesia is applied to the skin and underlying tissues (Fig. 63-6A). The bent 22-gauge spinal needle is then introduced under the skin with the tip pointing laterally. The needle is advanced gradually toward the upper lateral border of L3 with the bevel pointing laterally. The lateral (Fig. 63-6B) and anteroposterior (Fig. 63-6C) views are taken to confirm the depth of the needle and its distance from the midline. The needle is advanced until it approaches the anterolateral margin of the vertebral body in the lateral view, taking care that the needle does not cross the facet line in the anteroposterior view. The bevel is then directed medially to hug the vertebral body anterolaterally. After negative aspiration for blood and cerebrospinal fluid, 5 mL of Isovue-200 is injected. After confirming spread of the dye in anteroposterior and lateral views, 5 mL of 0.5% bupivacaine is injected. Temperature recordings are obtained 5 to 10 minutes after the block and compared with the temperatures before.

Figure 63-6. Lumbar sympathetic block.

Complications: Epidural or spinal block, intravascular injection of local anesthetic, puncture of the aorta and the inferior vena cava, backache (the most common complication) from placement of the needle through the paravertebral muscles, needle entry into a disc, and renal trauma. A block of the genitofemoral nerve or lumbar plexus within the psoas muscle can occur if the needle is placed too far laterally or posteriorly.

Tips

1.   Intravenous access is obtained for administering monitored anesthetic care.

2.   The anteroposterior view is taken to assess the direction of the needle, and the lateral view is taken to assess the depth of the needle.

D. Hypogastric Plexus Block

Nashaat N. Rizk

Patient Position: Prone.

Indications: Pelvic visceral pain, testicular pain not responding to ilioinguinal and genitofemoral nerve blocks, postradiation pelvic pain, prostatic pain, and rectal pain not responding to other blocks, such as ganglion impar.

Needle Size: 22-gauge, 178-mm Quincke spinal needle.

Medication/Volume: 10 mL of 0.5% bupivacaine with or without 40 mg of Depo-Medrol; 3 to 5 mL of Isovue-200 or 300; 1% lidocaine for skin wheal and deep infiltration.

Figure 63-7. Hypogastric plexus block.

 

Anatomic Landmarks: Ipsilateral transverse process of L5.

Approach and Technique: The lumbar region is prepared and draped using sterile techniques. Using fluoroscopy in a 10° to 20° cephalad caudad and ipsilateral 15° to 30° oblique view, identify the triangular shape formed by shadows of L5 transverse process and sacral and iliac crest. Using a gun-barrel technique (i.e., the needle parallel to x-ray beam), take frequent anteroposterior views (Fig. 63-7A with dye, Fig. 63-7C without dye) to assess direction and lateral views (Fig. 63-7B) to assess depth. The tip of the needle is placed at the anterolateral upper edge of the sacral promontory in the lateral view and medial to the facet line in the anteroposterior view. Confirm placement using Isovue-200, 3 to 5 mL, and take anteroposterior and lateral views.

Tips

1.   As always, monitoring, working intravenous lines, and sterile techniques are essential.

2.   If sedation is used, make sure the patient is able to communicate.

3.   The needle is usually bent 1 cm from the tip to facilitate steering.

4.   If the patient complains of pain in the L5 distribution, the needle needs to be withdrawn to the level of the skin and repositioned away from L5 in a more medial position.

5.   If the needle still cannot be passed, the procedure needs to be aborted.

6.   Alternatively, it is possible to use a blunt Racz-Finch Kit (Radionics, Burlington, MA) radiofrequency needle, which may minimize the risks for L5 root or vascular injuries.

7.   For optimal results, it is necessary to take the time to optimize the view of the lumbar triangle to allow adequate visualization of the needle, aiming anterior medial and caudad.

E. Ganglion Impar Block

Nashaat N. Rizk

Meera Appaswarny

Patient Position: Prone, with a pillow beneath the pubic symphysis.

Indications: Evaluation and management of sympathetically mediated pain of the perineum, rectum, and genitalia. Also can be used in cases of malignancy, endometriosis, reflex sympathetic dystrophy/causalgia, proctalgia fugax, and radiation enteritis.

Needle Size: 22-gauge, 88-mm spinal needle.

Medication/Volume: 2 to 3 mL of radiocontrast dye Isovue-M 200; 3 to 5 mL of 1% lidocaine or 0.25% bupivacaine, along with 80 mg of methylprednisolone, if an inflammatory component is present; and 4 to 6 mL of 10% phenol for neurolytic blockade.

Anatomic Landmarks: The ganglion impar is a solitary retroperitoneal structure situated at the level of the sacrococcygeal junction and in front of it. This structure marks the termination of the paired paravertebral sympathetic chains. It receives fibers from the lumbar and sacral portions of the sympathetic and parasympathetic systems.

Approach and Technique: The lumbosacral region is prepared and draped using sterile techniques. The sacrococcygeal junction and the tip of the coccyx are located using fluoroscopy. The midline is identified and a skin wheal using a 25-gauge needle with 1% lidocaine is performed. The spinal needle is advanced perpendicular to the skin at the sacrococcygeal junction, and its tip is placed anterior to the sacrococcygeal junction using fluoroscopy, confirming appropriate position using anteroposterior and lateral views. After careful aspirate for blood, air, or feces, and after negative aspiration, the radiocontrast dye is injected to confirm the spread of contrast medium just anterior to the sacrococcygeal junction. This is then followed with injection of the local anesthetic mixture/phenol. Figure 63-8 presents the anteroposterior (A) and lateral view (B).

Figure 63-8. Anteroposterior (A) and lateral (B) view of ganglion impar block.

Complications

1.   Rectal perforation with tracking of contaminants back to the rectum.

2.   Infection and fistula formation, especially in patients who are immunocompromised or who underwent prior radiation therapy to the perineum.

3.   Epidural spread within the caudal canal.

4.   Periosteal injection.

Suggested Readings

Breivik H, Cousins MJ, Löfström JB. Sympathetic neural blockade of upper and lower extremity. In: Cousins MJ, Bridenbaugh PO, eds. Neural blockade in clinical anesthesia and management of pain, 3rd ed. Philadelphia: Lippincott-Raven, 1998.

de Leon-Casasola OA. Sympathetic nerve block: pelvis. In: Raj PP, ed. Practical management of pain, 3rd ed. Philadelphia: Mosby, 2000.

Hogan, QH, Abram SE. Diagnostic and prognostic neural blockade. In: Cousins MJ, Bridenbaugh PO, eds. Neural blockade in clinical anesthesia and management of pain, 3rd ed. Philadelphia: Lippincott-Raven, 1998.

Rauck R. Sympathetic nerve block: head, neck and trunk. In: Raj PP, ed. Practical management of pain, 3rd ed. Philadelphia: Mosby, 2000.

Waldman SD. Lumbar sympathetic ganglion block. Atlas of interventional pain management. Philadelphia: WB Saunders Co, 1998.