Stellate C6 or C7

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schmee90

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DId about 5 stellates in Fellowship, only 2 using this technique outlines in this paper. "A New and Easy Technique to Block the Stellate Ganglion."Salahadin Abdi et al

While low risk for pneumothorax you are theorotically at higher risk for pneumothorax or intravacular injections at C7, seems like C6 is safer level to go at with this approach. There is some discussion on this in the paper as well as some of my reference books I use such as Furman who rec C6. I am thinking about changing to C6 junction of vert body uncinate process, any real downside that I am missing (paper I referenced mentioned possible inadaquate spread of medicine, but not really sure thats an issue if you get good contrast spread).
 
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I use fluoro and I always do C6. However, I had a patient with vascular uptake of contrast at C6 no matter where I placed it, so I went up to C5, got good spread to T1 and good benefit from the block. I would not do C7.
 
schmee90 said:
DId about 5 stellates in Fellowship, only 2 using this technique outlines in this paper. "A New and Easy Technique to Block the Stellate Ganglion."Salahadin Abdi et al

While low risk for pneumothorax you are theorotically at higher risk for pneumothorax or intravacular injections at C7, seems like C6 is safer level to go at with this approach. There is some discussion on this in the paper as well as some of my reference books I use such as Furman who rec C6. I am thinking about changing to C6 junction of vert body uncinate process, any real downside that I am missing (paper I referenced mentioned possible inadaquate spread of medicine, but not really sure thats an issue if you get good contrast spread).
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C6 if pain in hand make sure to get spread below T1
 
The anatomic target is at T1

Textbook, board tests, and lawyers will tell you C6
With ultrasound, I'll go as low as C7 or T1 depending on what I see and the reason for the block
- Cardiac indications lower
- PTSD/brain issues higher
- Arm issues are generally C6 unless they fail and I'm worried about Kuntz's nerve fiber shenanigans

The fibers you need for may be reached by spread from C6 if you increase your volume, so with fluoro if you get coverage to T1 from C5 or C6, I'd call it a day.
 
Orin said:
The anatomic target is at T1

Textbook, board tests, and lawyers will tell you C6
With ultrasound, I'll go as low as C7 or T1 depending on what I see and the reason for the block
- Cardiac indications lower
- PTSD/brain issues higher
- Arm issues are generally C6 unless they fail and I'm worried about Kuntz's nerve fiber shenanigans

The fibers you need for may be reached by spread from C6 if you increase your volume, so with fluoro if you get coverage to T1 from C5 or C6, I'd call it a day.
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Agree with this idea.

Optimal level of placement depends on reason for the injection.

However, having said that, I use ultrasound and where I place the needle ultimately is determined by what level gives me the safest pass.
 
painfree23 said:
What resuscitation equipment do you have? Start IVs? Anesthesia?
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That's a great question. We started putting Intralipid out and visible for the SGBs, or other larger volume injections with LA (like an LSB or splanchnic). We have a code cart somewhere in the clinic. We have ephedrine and robinol drawn up ready to go for every pain procedure.

I don't think we keep airway equipment in the procedure room except a mask and jackson-reese or BVM.

For SGB's or anything cervical, we place an IV (unless they ask us not to - or the tech begs me not to).

Rarely sedate, but will if the patient asks for it, or we decide it is safer. Often will give oral valium as the first line for requested sedation.
 
epidural man said:
That's a great question. We started putting Intralipid out and visible for the SGBs, or other larger volume injections with LA (like an LSB or splanchnic). We have a code cart somewhere in the clinic. We have ephedrine and robinol drawn up ready to go for every pain procedure.

I don't think we keep airway equipment in the procedure room except a mask and jackson-reese or BVM.

For SGB's or anything cervical, we place an IV (unless they ask us not to - or the tech begs me not to).

Rarely sedate, but will if the patient asks for it, or we decide it is safer. Often will give oral valium as the first line for requested sedation.
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IV's for every cervical, and ephedrine/robinol for every pain procedure seems very overkill.
 
SgtThunderfistMD said:
IV's for every cervical, and ephedrine/robinol for every pain procedure seems very overkill.
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IVs for every cervical is overkill. SGB yes, but unless you're doing local in your CESI, why for ESI? How much local do you use for facet procedures? I'm liberal and never get close to giving someone LAST.
 
Ducttape said:
here, IVs only for stellates.

drug of choice for seizures due to LAST is still benzos. do you stock?
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IV free here.

I'd agree that if you're getting LAST with a stellate, you're probably better off with a benzo than intralipid
 
Orin said:
IV free here.

I'd agree that if you're getting LAST with a stellate, you're probably better off with a benzo than intralipid
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Last protocol calls for both. Benzos to stop seizure (if present), but lipid is 99.9% necessary to save a life if it goes beyond seizure.
 
Ferrismonk said:
Last protocol calls for both. Benzos to stop seizure (if present), but lipid is 99.9% necessary to save a life if it goes beyond seizure.
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Sure, but the protocol isn't specific for a stellate. With that intra-arterial local, you're more likely to see seizures and less likely to see cardiac effects right? Bier block's or high volume LSBs, get the white stuff running first for sure, but a little Versed beats Intralipid for the seizures.

I keep waiting for someone to make an on-label rescue drug rather than all the off-label Intralipid usage for this
 
Orin said:
Sure, but the protocol isn't specific for a stellate. With that intra-arterial local, you're more likely to see seizures and less likely to see cardiac effects right? Bier block's or high volume LSBs, get the white stuff running first for sure, but a little Versed beats Intralipid for the seizures.

I keep waiting for someone to make an on-label rescue drug rather than all the off-label Intralipid usage for this
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I'd give them both....very little downside to lipids.
 
How much IV versed y’all give if patient starts seizing
 
epidural man said:
That's a great question. We started putting Intralipid out and visible for the SGBs, or other larger volume injections with LA (like an LSB or splanchnic). We have a code cart somewhere in the clinic. We have ephedrine and robinol drawn up ready to go for every pain procedure.

I don't think we keep airway equipment in the procedure room except a mask and jackson-reese or BVM.

For SGB's or anything cervical, we place an IV (unless they ask us not to - or the tech begs me not to).

Rarely sedate, but will if the patient asks for it, or we decide it is safer. Often will give oral valium as the first line for requested sedation.
Click to expand...

All injections get a neck line, art line, Swan-Ganz, and I keep a Belmont infuser primed and ready. The thoracotomy tray and sternal saw are out and available within arms reach for all but trigger points. I've had to crack a chest or two in my time. Fulminant fibromyalgia. Phew.. pain is a wild world. I broke ground on my own blood bank last week.
 
a while ago, my C arm broke down. there was no thought of buying a new one. admin and i asked multiple other services if we could use their C arms 1 day a week.

the Nurse Manager of Cardiac Surgery told us in person that my spine procedures were too dangerous to do in the cardiac fluoro suite.
 
Ducttape said:
a while ago, my C arm broke down. there was no thought of buying a new one. admin and i asked multiple other services if we could use their C arms 1 day a week.

the Nurse Manager of Cardiac Surgery told us in person that my spine procedures were too dangerous to do in the cardiac fluoro suite.
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1 in 6 pts ends up paralyzed. Terrifying.
 
After hearing about hundreds of patients paralyzed from spinal and epidurals I had a standing offer for patients. If they would bring one of these hundreds of people wandering around our community to meet me I’d give them $100. I still have the hundred.
 
My first assistant in this current practice in Portland had worked with tons of area pain docs over many years before coming to work for me. She was floored at how dull and boring my office was by comparison. No drama with patients. No medical emergencies. No "get the code box!". No ambulance calls. Just peace, quiet, and happy patients.

The guy I worked for out of fellowship used to do RFs with no local and "reassure" patients through the burning, searing pain in their backs and necks. F'kng horrifying. As soon as I took over those cases the staff remarked about how much quieter things were.
 
MitchLevi said:
BS
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I'll give you the benefit of the doubt that this is just ribbing and you're not actually calling me a liar.

Have you never heard of this? When I moved to Bangor there was a husband/wife neuro team doing pain at one of the local hospitals who did RFs this way. I would hear the stories from patients transferring to my clinic. They eventually left town.
 
powermd said:
I'll give you the benefit of the doubt that this is just ribbing and you're not actually calling me a liar.

Have you never heard of this? When I moved to Bangor there was a husband/wife neuro team doing pain at one of the local hospitals who did RFs this way. I would hear the stories from patients transferring to my clinic. They eventually left town.
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That’s horrifying. I did have one patient who told me that someone did their RF without numbing them up, so they were (understandably) afraid of having another RF done. I had assumed they meant that the other doctor didn’t numb them up enough and didn’t stop to rectify the situation.
 
powermd said:
I'll give you the benefit of the doubt that this is just ribbing and you're not actually calling me a liar.

Have you never heard of this? When I moved to Bangor there was a husband/wife neuro team doing pain at one of the local hospitals who did RFs this way. I would hear the stories from patients transferring to my clinic. They eventually left town.
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The reality is the amount of local was insufficient.

I’m just not going to believe any pain doctor did an RFA with no local.

Come on man, unless you directly stood at the bedside watching I don’t believe it.

What ppl in the room say is irrelevant, bc XRAY techs and MAs say all types of things that aren’t true.

Pts saying no local was used is also BS.
 
MitchLevi said:
The reality is the amount of local was insufficient.

I’m just not going to believe any pain doctor did an RFA with no local.

Come on man, unless you directly stood at the bedside watching I don’t believe it.

What ppl in the room say is irrelevant, bc XRAY techs and MAs say all types of things that aren’t true.

Pts saying no local was used is also BS.
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Well, I was there and saw it over and over. The doctor treated his patients like cattle, and they still loved him. Probably had something to do with his very loose script pad. This was back in 2010.
 
powermd said:
Well, I was there and saw it over and over. The doctor treated his patients like cattle, and they still loved him. Probably had something to do with his very loose script pad. This was back in 2010.
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So you stood in the procedure room and watched him do this without saying or doing anything about it?
 
MitchLevi said:
So you stood in the procedure room and watched him do this without saying or doing anything about it?
Click to expand...

Oh, I definitely spoke up. Didn't change his practice though. A lot of things were messed up about that practice. It was pills for injections and IV sedation. Plenty of oxy 30s being rx'd QID. Patients would drive up hours from all over just to get knocked out with propofol and have 'therapeutic' mbbs. That practice is the reason I went 100% non-narcotic. I was too conservative for them and my contract wasn't renewed (which was good, because that meant he had to pay tail, and I wanted to leave anyway).
 
In case anyone is wondering, Powermd’s stories are freaking insane. Hahahaha. WTF.
 
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