stellate block technique

[nvrsumr]

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Does anyone have an article/description/fluoro images of a "lateral" SGB? Was reading a SGB procedure report on a patient of mine performed by another pain doc. Described as needle placed at lateral boarder of C7 VB and thats it. Any thoughts? Pros and Cons? Thanks

 

[Ligament]

Does anyone have an article/description/fluoro images of a "lateral" SGB? Was reading a SGB procedure report on a patient of mine performed by another pain doc. Described as needle placed at lateral boarder of C7 VB and thats it. Any thoughts? Pros and Cons? Thanks

I have a write up of this somewhere.

 

[knoxdoc]

There was an article by Abdi in 2004 where he describes an oblique approach that I now use. It is super easy and very effective. I'm not sure if this is what you mean, but I highly recommend it.

 

[Jcm800]

There was an article by Abdi in 2004 where he describes an oblique approach that I now use. It is super easy and very effective. I'm not sure if this is what you mean, but I highly recommend it.

i used to use this technique. At the border of the uncinate process...but i tell you i had worse results then just at the tubercle at C6 or even C7. maybe i ll try it again. i dont do that many stellates these day...

 

[lobelsteve]

i used to use this technique. At the border of the uncinate process...but i tell you i had worse results then just at the tubercle at C6 or even C7. maybe i ll try it again. i dont do that many stellates these day...

I have not seen a patient needing a stellate in 2 years.

 

[nvrsumr]

There was an article by Abdi in 2004 where he describes an oblique approach that I now use. It is super easy and very effective. I'm not sure if this is what you mean, but I highly recommend it.

Perfect! Thank you. Do you get a good temperature change?

 

[Ligament]

I have not seen a patient needing a stellate in 2 years.

Yeah they've been very rare for me too. U just going straight to stim?

 

[Aether2000]

The risk to the vertebral artery increases as one performs this block with a more lateral approach. The oblique approach (70 deg or less from the coronal plane) spares the carotid, but as obliquity approaches 30-45 deg from the coronal plane, the risk to the vertebral a. increases.

 

[SleepIsGood]

The risk to the vertebral artery increases as one performs this block with a more lateral approach. The oblique approach (70 deg or less from the coronal plane) spares the carotid, but as obliquity approaches 30-45 deg from the coronal plane, the risk to the vertebral a. increases.

avoid the risk altogether for injecting into the vertebral artery.

Brachial Plexus blocks. Better sympathectomy for upper extremity. Strain gauge plethysmogrphy demonstrated 132% increased blood flow in the upper extremity with a SGB. With Brachial Plexus block 296% increase (see Raj's Textbook, Benzon's textbook, also study by Zenz, 1986).

Especially if using ultrasound...less risk and you dont have to use an 'anesthetic' dose that causes motor paralysis.

 

[specepic]

avoid the risk altogether for injecting into the vertebral artery.

Brachial Plexus blocks. Better sympathectomy for upper extremity. Strain gauge plethysmogrphy demonstrated 132% increased blood flow in the upper extremity with a SGB. With Brachial Plexus block 296% increase (see Raj's Textbook, Benzon's textbook, also study by Zenz, 1986).

Especially if using ultrasound...less risk and you dont have to use an 'anesthetic' dose that causes motor paralysis.

Please explain from an anatomic perspective why blocking the plexus blocks the sympathetics. I can see why a block in that area may get the sympathetics but it has nothing to do with the plexus.

 

[drf]

I switched from blind to fluoro to US. I tried a variety of US techniques but have ended up with the Gofeld technique.

Pt lateral decub. scan the neck laterally using the anterior/posterior tubercles versus the C7 transverse proces to decide level. Needle entry in-line with US beam from posterior to anterior, with the needle path immediately anterior to the C6 tubercle, going under the vessels, avoiding thyroid and associated vessels, and entering the anterior portion of the longus colli and prevertebral fascia. Horner is immediate.



Development and Validation of a New Technique for
Ultrasound-Guided Stellate Ganglion Block
Michael Gofeld, MD,* Anuj Bhatia, MD,Þ Sherif Abbas, MD,þ
(Reg Anesth Pain Med 2009;34: 475Y479)

 

[Aether2000]

What transducer are you using (curved or linear) and what frequency? How are you assuring lack of vascular uptake during injection?

 

[drf]

Linear probe. Doppler finds all the vessels for you if not sure. With the needle tip in view when injecting you will see where the local goes.

 

[Aether2000]

Thanks!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

 

[clubdeac]

I switched from blind to fluoro to US. I tried a variety of US techniques but have ended up with the Gofeld technique.

Pt lateral decub. scan the neck laterally using the anterior/posterior tubercles versus the C7 transverse proces to decide level. Needle entry in-line with US beam from posterior to anterior, with the needle path immediately anterior to the C6 tubercle, going under the vessels, avoiding thyroid and associated vessels, and entering the anterior portion of the longus colli and prevertebral fascia. Horner is immediate.



Development and Validation of a New Technique for
Ultrasound-Guided Stellate Ganglion Block
Michael Gofeld, MD,* Anuj Bhatia, MD,Þ Sherif Abbas, MD,þ
(Reg Anesth Pain Med 2009;34: 475Y479)

That's great! Now I just need to get an US machine. I always hated doing stellates. Basically taught myself and i probably actually suck at it....

 

[Ligament]

There is no way to rule out vascular uptake doing this procedure with U/S. That said, it is certainly better than doing it blindly. Have been doing a lot of U/S procedures lately, but inability to r/o vascular uptake is a big issue for our specialty.

 

[bedrock]

There is no way to rule out vascular uptake doing this procedure with U/S. That said, it is certainly better than doing it blindly. Have been doing a lot of U/S procedures lately, but inability to r/o vascular uptake is a big issue for our specialty.

Exactly, That's why I'd still rather do this under fluoro and run DSA to check for vascular uptake.

 

[PMR 4 MSK]

With US, if you put on doppler ("CF" button on my GE) you can see the flow of your injectate as well as any blood vessels in the area. While I don't do stellates, I do joints, nerves and tendons under US in the clinic. You should be able to see if you were intravascular with doppler on.

 

[DOctorJay]

Epi test?

 

[Ligament]

My unit has conventional doppler as well as power doppler. Keep in mind that both of these imaging modalities show fluid flow within a VERY narrow window of imaging at best. One cannot visualize collateral vascular flow whatsoever, which is what we need to see in our specialty.

We can only use doppler/powerdoppler to identify fluid flow in primarily cross sectional vessels. This DOES help to identify and avoid the carotid for stellate blocks, for example. But does nothing to r/o collateral uptake or even uptake into the carotid itself (in small amounts).

Now, where doppler/power doppler is VERY useful is to help identify small and deep nerves by first identifying their accompanying blood supply.

 

[Pain Applicant1]

avoid the risk altogether for injecting into the vertebral artery.

Brachial Plexus blocks. Better sympathectomy for upper extremity. Strain gauge plethysmogrphy demonstrated 132% increased blood flow in the upper extremity with a SGB. With Brachial Plexus block 296% increase (see Raj's Textbook, Benzon's textbook, also study by Zenz, 1986).

Especially if using ultrasound...less risk and you dont have to use an 'anesthetic' dose that causes motor paralysis.

That's a good point, plus you don't have to worry about missing the nerves of Kuntz.

Please explain from an anatomic perspective why blocking the plexus blocks the sympathetics. I can see why a block in that area may get the sympathetics but it has nothing to do with the plexus.

Sympathetic fibers run in close proximity with plexus fibers.

 

[Pain Applicant1]

I have not seen a patient needing a stellate in 2 years.

Do you do any lumbar sympathetic blocks?

 

[lobelsteve]

Do you do any lumbar sympathetic blocks?

I do more GRC than true LSB.
Probably 5 in the last year. I see a very limited role for sympathetic blocks outside of acute CRPS in the hospital patient or day rehab patient. I think they are useful to allow more aggressive therapy and desensitization.

These are easy blocks with highly limited utility. And I have the stellate needles with a side port 2mm off the tip. Longus my colli.

 

[nvrsumr]

And I have the stellate needles with a side port 2mm off the tip. Longus my colli.

nice. Who makes em?

 

[Ligament]

nice. Who makes em?

Kimberly Clark, nice needles.

 

[epidural man]

I switched from blind to fluoro to US. I tried a variety of US techniques but have ended up with the Gofeld technique.

Pt lateral decub. scan the neck laterally using the anterior/posterior tubercles versus the C7 transverse proces to decide level. Needle entry in-line with US beam from posterior to anterior, with the needle path immediately anterior to the C6 tubercle, going under the vessels, avoiding thyroid and associated vessels, and entering the anterior portion of the longus colli and prevertebral fascia. Horner is immediate.



Development and Validation of a New Technique for
Ultrasound-Guided Stellate Ganglion Block
Michael Gofeld, MD,* Anuj Bhatia, MD,Þ Sherif Abbas, MD,þ
(Reg Anesth Pain Med 2009;34: 475Y479)

I use the same approach, using a linear probe, in-plane approach from posterior to anterior (going through the anterior scalene, under the carotid and IJ, just over the anterior tubercle of C6). You can usually identify the vertebral artery, thyroidal arteries, deep cervical sometimes. Maybe you can't identify other smaller vessels, or vessels running parallel to the beam, but at least you can see where the needle tip is and watch the local spread. With ultrasound, you can complete the block in 3-5 ccs.

I have also done them with a small curvilinear probe out of plane, using the same approach as with anterior approach with fluoro. This is also a great technique to help avoid structures (that you have no idea with using a fluoro guided shot).

 

[drf]

I've expanded my cervical US to other random indications as well. Blocks I would likely not be able to do blind (not EMG trained).

I had one patient with omohyoid syndrome s/p 4-5 MD evals with no help. His neck was obviously asymmetrical, and he had difficulty swallowing. I put 2 ccs of bupi with a touch of kenalog in both bellies and all the symptoms resolved. Afterward he noticed that although the anterior neck symptoms were much improved he had some stiffness and pain at the ventral border of the scapula. I traced the omohyoid all the way there and injected at the scapular insertion and those sx resolved as well. Botox is next.

Just random stuff like that. It's fun.