Ultrasound guided stellate ganglion block; best technique?

[Ligament]

Can any of you point me in the direction of what is considered the best technique publication or video for ultrasound guided stellate ganglion block? Thanks!

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[deleted131481]

Ultrasound-guided stellate ganglion block: safety and efficacy - PubMed

Cervical sympathetic and stellate ganglion blocks (SGB) provide a valuable diagnostic and therapeutic benefit to sympathetically maintained pain syndromes in the head, neck, and upper extremity. With the ongoing efforts to improve the safety of the procedure, the techniques for SGB have evolved...

www.ncbi.nlm.nih.gov

 

[Ligament]

Ultrasound-guided stellate ganglion block: safety and efficacy - PubMed

Cervical sympathetic and stellate ganglion blocks (SGB) provide a valuable diagnostic and therapeutic benefit to sympathetically maintained pain syndromes in the head, neck, and upper extremity. With the ongoing efforts to improve the safety of the procedure, the techniques for SGB have evolved...

www.ncbi.nlm.nih.gov

I love Dr. Escolar's videos. Very well done and enjoy the music somehow.

 

[Ligament]

Ultrasound-guided stellate ganglion block: safety and efficacy - PubMed

Cervical sympathetic and stellate ganglion blocks (SGB) provide a valuable diagnostic and therapeutic benefit to sympathetically maintained pain syndromes in the head, neck, and upper extremity. With the ongoing efforts to improve the safety of the procedure, the techniques for SGB have evolved...

www.ncbi.nlm.nih.gov

 

[drusso]

Ultrasound-guided stellate ganglion block: safety and efficacy - PubMed

Cervical sympathetic and stellate ganglion blocks (SGB) provide a valuable diagnostic and therapeutic benefit to sympathetically maintained pain syndromes in the head, neck, and upper extremity. With the ongoing efforts to improve the safety of the procedure, the techniques for SGB have evolved...

www.ncbi.nlm.nih.gov

This is the technique that I've used. But, it is a little faster IMHO to do it with fluoroscopy.

 

[SommeRiver]

This is the technique that I've used. But, it is a little faster IMHO to do it with fluoroscopy.

Am I wrong thinking US is standard of care? I know a lot of ppl did fluoro guided but I've never seen one done that way.

One of my fav procedures bc it is cool to do an injxn and see direct results (Horner's). I think that's fun.

 

[Ligament]

I've done a ton with fluoro it is fast and easy, but the anatomy is very complex here, target small, and I can see a lot of advantages in u/s guided. I don't have an opinion either way what stadard of care is in this particular procedure; I also use DSA during fluoro, which is not available for u/s, so there are pros and cons to each

 

[lobelsteve]

I don’t see many folks with a real need for this. Weird how so many others do. But my practice is mostly elderly.

 

[Ligament]

I induced hypertensive emergency with a SGB once, local tracked up the carotid sheath, blocked baroreceptors, and patients BP skyrocketed. Young patient too. Resolved as local wore off.

 

[deleted131481]

I do this for only one patient currently about every 4 months.

I wouldn't call US standard of care yet for it. I definitely prefer it to fluoro given all the vasculature. It is a bit slower.

 

[DOctorJay]

I induced hypertensive emergency with a SGB once, local tracked up the carotid sheath, blocked baroreceptors, and patients BP skyrocketed. Young patient too. Resolved as local wore off.

I do these combined with fluoro and ultrasound. Place needle under ultrasound. Inject contrast to ensure appropriate spread under fluoro. Then local to complete injection.


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[Baron Samedi]

I do under fluoro. I do a bunch for PTSD.

Oblique 45 degrees ipsilateral, skin wheal, put 2in needle halfway down the posterior vertebral body along the unicinate line in that view, attach to tubing, contrast, inject. 10cc of 0.50 ropivicaine with an epi wash as another intravascular marker, 2-3mL at a time. If you go for C7(indicated more for pain as C6 can result in an incomplete block), the procedure is the same but you may need a 3.5in needle.

Very quick and satisfying procedure.

Before doing an oblique view I was doing them straight AP, but found the patients tolerate it less and the anatomy a little less clear to see sometimes. I've also done a bunch under ultrasound, but found that as I fatigue the image quality degrades and I dont like to feel a time constraint with my procedures.

 

[deleted993114]

I don’t see many folks with a real need for this. Weird how so many others do. But my practice is mostly elderly.

Nor do I. Sympathetic blocks really are not a part of the CRPS algorithms anymore, so I think I do a stellate about once every other year. With fluoro, it is fast, easy, and you see results. I guess I would be hard pressed to find an indication for one, but I'm sure there are still a few.

For the most part, US is a very interesting tool, but I rarely find any use for it and it takes too long. It is cool to see the images, however.

 

[paindoc007]

Nor do I. Sympathetic blocks really are not a part of the CRPS algorithms anymore, so I think I do a stellate about once every other year. With fluoro, it is fast, easy, and you see results. I guess I would be hard pressed to find an indication for one, but I'm sure there are still a few.

For the most part, US is a very interesting tool, but I rarely find any use for it and it takes too long. It is cool to see the images, however.

Sympathetic blocks not part of treatment algorithm for crps? Care to expand ?

 

[deleted993114]

Sympathetic blocks not part of treatment algorithm for crps? Care to expand ?

Woopsie! Brain freeze- I was thinking Bier block- my goof. That happens when you get older. The evidenced based guidelines, however, do not support the use of sympathetic blocks in the treatment of CRPS, as it is considered low level evidence:

Evidence based guidelines for complex regional pain syndrome type 1 - BMC Neurology

Background Treatment of complex regional pain syndrome type I (CRPS-I) is subject to discussion. The purpose of this study was to develop multidisciplinary guidelines for treatment of CRPS-I. Method A multidisciplinary task force graded literature evaluating treatment effects for CRPS-I...

bmcneurol.biomedcentral.com

Regarding "standard of care", this article suggests that using US is the standard of care relative to fluoro for stellate blocks:

A study of the efficacy of stellate ganglion blocks in complex regional pain syndromes of the upper body

The effect of stellate ganglion blocks (SGBs) was examined in complex regional pain syndromes (CRPS) of the upper body.A total of 287 SGB were given to patients with documented CRPS on medications. Spontaneous and provoked pain assessment was done with ...

www.ncbi.nlm.nih.gov

News to me.

 

[Baron Samedi]

For CRPS I'll do 1 or 2 sympathetic blocks and then it's off to stim. I do far many more stellates for PTSD than for CRPS. You guys will probably start getting requests for them, too.

 

[SommeRiver]

I've done 3 stellates in the last 18 months, all on the same patient.

Same patient recent IME in Atlanta by a very well known POS (IMO) recommended against SCS in favor of stellates several times per year indefinitely.

I met with the employer attorney and told him my thoughts about the IME. Same doctor 100% of the time denies CRPS in favor of "disuse atrophy."

But yeah, stellate under US simply has to be a safer procedure and I don't necessarily think a stellate is something I would try to do quickly bc you'll be doing them rarely to begin with, and you CAN hurt someone.

 

[deleted993114]

I've done 3 stellates in the last 18 months, all on the same patient.

Same patient recent IME in Atlanta by a very well known POS (IMO) recommended against SCS in favor of stellates several times per year indefinitely.

I met with the employer attorney and told him my thoughts about the IME. Same doctor 100% of the time denies CRPS in favor of "disuse atrophy."

But yeah, stellate under US simply has to be a safer procedure and I don't necessarily think a stellate is something I would try to do quickly bc you'll be doing them rarely to begin with, and you CAN hurt someone.

In review of "CRPS cases", well over 90% ARE actually disuse atrophy and do not meet Budapest criterion.

Despite stellates not being in the evidence based CRPS algorithm, I see nothing wrong with doing them. Most think (despite the algorithm stating otherwise) that "early" CRPS does respond to stellates. I think so as well, but just rarely see actual CRPS and if it is, it is chronic.

Keep in mind the guy who did the IME is just a guy, and sometimes those guys make incorrect evaluations. I do plenty of IMEs as well, and am just a normal, average chucklehead. IMEs SHOULD come up with the same impairment number (if the guidelines are used correctly). However, reccs are subjective.

 

[SommeRiver]

In review of "CRPS cases", well over 90% ARE actually disuse atrophy and do not meet Budapest criterion.

Despite stellates not being in the evidence based CRPS algorithm, I see nothing wrong with doing them. Most think (despite the algorithm stating otherwise) that "early" CRPS does respond to stellates. I think so as well, but just rarely see actual CRPS and if it is, it is chronic.

Keep in mind the guy who did the IME is just a guy, and sometimes those guys make incorrect evaluations. I do plenty of IMEs as well, and am just a normal, average chucklehead. IMEs SHOULD come up with the same impairment number (if the guidelines are used correctly). However, reccs are subjective.

If you have Budapest, you're diagnosed with CRPS no matter which law firm is paying you to for the IME.

If the Dx is disuse atrophy and not CRPS why do a stellate? Does it work for disuse atrophy or no (serious Q)?

 

[Bsb2015]

I do under fluoro. I do a bunch for PTSD.

Oblique 45 degrees ipsilateral, skin wheal, put 2in needle halfway down the posterior vertebral body along the unicinate line in that view, attach to tubing, contrast, inject. 10cc of 0.50 ropivicaine with an epi wash as another intravascular marker, 2-3mL at a time. If you go for C7(indicated more for pain as C6 can result in an incomplete block), the procedure is the same but you may need a 3.5in needle.

Very quick and satisfying procedure.

Before doing an oblique view I was doing them straight AP, but found the patients tolerate it less and the anatomy a little less clear to see sometimes. I've also done a bunch under ultrasound, but found that as I fatigue the image quality degrades and I dont like to feel a time constraint with my procedures.

What ICD 10 code are you using for it to get approved for PTSD? How are patients doing afterwards? Would be nice if this could be an option for my patients with PTSD

 

[drusso]

What ICD 10 code are you using for it to get approved for PTSD? How are patients doing afterwards? Would be nice if this could be an option for my patients with PTSD

It's still considered experimental. Just have them pay cash. Much easier. No insurance hassles.

 

[Baron Samedi]

What ICD 10 code are you using for it to get approved for PTSD? How are patients doing afterwards? Would be nice if this could be an option for my patients with PTSD

I work in a federal facility, so coding doesn't really apply.

 

[deleted993114]

If you have Budapest, you're diagnosed with CRPS no matter which law firm is paying you to for the IME.

If the Dx is disuse atrophy and not CRPS why do a stellate? Does it work for disuse atrophy or no (serious Q)?

Nope- However, a stellate block is not even a part of the CRPS upper extremity or facial algorithm. I think that most of us still do them for "acute" perceived CRPS. However, I do tell patients that they are no longer a part of the recommended treatment algorithm- most want to try it anyway. I guess when your next best procedure is a stim, I can understand why. There are very few, if any, meds that have good data to support their use in CRPS as well. I think that the paucity of data is due to the fact that it is hard to find a large group of patients who actually have legitimate CRPS. I think I have seen under twenty in my career, but I have had a ton sent with that diagnosis.

I would offer that most pain docs still do sympathetic blocks. We do a lot of things that have weak evidence or are not a part of a formal algorithm, so sympathetic blocks are not in an exclusive realm. Heck, epidural steroids, which we do all the time, has rather weak evidence to support its continued use, but we do them anyway.

 

[SommeRiver]

Nope- However, a stellate block is not even a part of the CRPS upper extremity or facial algorithm. I think that most of us still do them for "acute" perceived CRPS. However, I do tell patients that they are no longer a part of the recommended treatment algorithm- most want to try it anyway. I guess when your next best procedure is a stim, I can understand why. There are very few, if any, meds that have good data to support their use in CRPS as well. I think that the paucity of data is due to the fact that it is hard to find a large group of patients who actually have legitimate CRPS. I think I have seen under twenty in my career, but I have had a ton sent with that diagnosis.

I would offer that most pain docs still do sympathetic blocks. We do a lot of things that have weak evidence or are not a part of a formal algorithm, so sympathetic blocks are not in an exclusive realm. Heck, epidural steroids, which we do all the time, has rather weak evidence to support its continued use, but we do them anyway.

Thanks for the reply.

After you said the majority of CRPS Dx in Work Comp is disuse atrophy I've looked this up and can't find much on it to be honest. I never heard that Dx until I'd been out of fellowship for over a year, and I still have no clue what it really means other than atrophy from limited use...Not quite sure why that doesn't count as a change on Budapest and if it occurs in the setting of allodynia why it isn't 2/4, but I'd love to read an article about it.

I know you've been in practice many years at this point, but you're saying you've seen true CRPS less than 20x? Really?

I work in a large ortho group and we have a lot of foot/ankle pts and obviously hand/wrist and I see a few each year. Usually lower extremity...

This case is as follows:

1. Indisputable CRPS after shoulder arthroscopy. Not debatable. Bluish and mottled skin. Edema. Allodynia. Cool relative to contralateral hand (I don't do laser thermometer temp measurement bc I keep forgetting to buy one).

2. Stellate x 3 over 9 months.

3. Now just allodynia and atrophy. Color change is resolved. No puffy edema. No temperature issues.

4. Pt with severe psychological distress. Long standing problem. Decades of anxiety, MDD, PTSD, etc. This is not related to the shoulder injury, but obviously portends a negative prognosis overall, and obviously she can't get a stimulator trial any time soon and I wanted to work on psych first and foremost. Work Comp refused a pain psych referral bc it is a black hole of resource consumption and I get that completely.

I just saw her a few days ago and I'm caught in between multiple other doctors all going after multiple problems. Huge mess...This is the comp case that everyone dreads.

I actually think this pt could commit suicide.

 

[deleted993114]

Thanks for the reply.

After you said the majority of CRPS Dx in Work Comp is disuse atrophy I've looked this up and can't find much on it to be honest. I never heard that Dx until I'd been out of fellowship for over a year, and I still have no clue what it really means other than atrophy from limited use...Not quite sure why that doesn't count as a change on Budapest and if it occurs in the setting of allodynia why it isn't 2/4, but I'd love to read an article about it.

I know you've been in practice many years at this point, but you're saying you've seen true CRPS less than 20x? Really?

I work in a large ortho group and we have a lot of foot/ankle pts and obviously hand/wrist and I see a few each year. Usually lower extremity...

This case is as follows:

1. Indisputable CRPS after shoulder arthroscopy. Not debatable. Bluish and mottled skin. Edema. Allodynia. Cool relative to contralateral hand (I don't do laser thermometer temp measurement bc I keep forgetting to buy one).

2. Stellate x 3 over 9 months.

3. Now just allodynia and atrophy. Color change is resolved. No puffy edema. No temperature issues.

4. Pt with severe psychological distress. Long standing problem. Decades of anxiety, MDD, PTSD, etc. This is not related to the shoulder injury, but obviously portends a negative prognosis overall, and obviously she can't get a stimulator trial any time soon and I wanted to work on psych first and foremost. Work Comp refused a pain psych referral bc it is a black hole of resource consumption and I get that completely.

I just saw her a few days ago and I'm caught in between multiple other doctors all going after multiple problems. Huge mess...This is the comp case that everyone dreads.

I actually think this pt could commit suicide.

Yep- I've seen under twenty real cases of CRPS in my career. There is a nice article that applied Budapest Criteria to a bunch of "CRPS" patients and found that 95% of them didn't have CRPS by Budapest Criteria. I have had a zillion patients with that diagnosis, but rarely, if ever, is it real CRPS.

WORK COMP??!! NEVER put a stim in a comp patient. The efficacy of stim in the comp setting is only 5%, so don't even bother. The comp carriers know this as well, which is why they are very reluctant to pursue stim.

Sounds like you have done your bit with that patient and that is the best that can be done. Don't even talk to them about a stim, as you will be sorry later.

You can do an rf stellate- those are kind of fun and is an interesting procedure that is not nearly as "pricey" as a stim. Give that whirl if you are bored with the patient. Again, stellates are not even in the CRPS algorithm anymore (haven't been for a while), but we all do them anyway in "early CRPS".

Haven't been in practice long? Don't diminish the knowledge and skill sets you have. A more "experienced" practitioner like me is no better than you- we have just had our asses kicked more times, as we have been in the water longer. I learn MANY things from younger providers who have not been in practice nearly as long- EVERYONE has pearls to offer. I'll bet your training is better than mine, as pain was new then and essentially 100% of what I learned that was useful was from the Neurosurgery, Neurology and Radiology departments in my fellowship- the Anesthesia pain guys were useless. Keep in mind that in the past, very little, if any, innovation happened in the academic programs, so most were way behind the times. Have faith in your training and keep reading as much as you did in training. I'm sure you're pretty darn good- just remind yourself of that every once in a while.