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Ultrasound-guided stellate ganglion block
Bloqueo ganglio estrellado guiado por ultrasonografia
Juliana Serna-Gutiérrez
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Anaesthetist, Universidad Pontificia Bolivariana, Fellow Pain and Palliative Care, Universidad CES, Medellín, Colombia
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It was originally described in the 1930s by Leriche in the US and by Fontaine in Europe,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> to relieve causalgic pain and the reflex sympathetic dystrophy of the upper limbs.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Whilst fluoroscopy is a reliable method for identifying the nerve structures, ultrasound allows for the identification of the vertebral vessels, the thyroid gland and vessels, the <span class="elsevierStyleItalic">longus colli</span> muscle, the nerve roots and the esophagus. Therefore, ultrasound may prevent the inadvertent puncture of these structures, a risk that may arise with the blind technique or via fluoroscopy.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Several techniques have been used to block the lower sympathetic cervical chain. The 2 most frequent ones are the transverse process of C6 and the anterior or paratracheal approach at the level of C7, with or without fluoroscopy.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Ultrasound is a tool to view the structures, guide the needle advancing in real time, and confirm the injection and distribution of the medication, avoiding both the health practitioner and the patient's exposure to radiation.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The purpose of this article is to describe the most salient aspects of the stellate ganglion ultrasound-guided block, its indications, and contraindications.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Anatomy</span><p id="par0030" class="elsevierStylePara elsevierViewall">Understanding the anatomy of the cervical-thoracic sympathetic chain and ganglion is key to determine whether the neural block was therapeutic and to avoid unnecessary nerve ablation procedures.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The cervical sympathetic trunk or the cervical sympathetic chain is a cephalic continuation of the thoracic sympathetic trunk located in a bundle space.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">It is made up by three ganglia:<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">•</span><p id="par0045" class="elsevierStylePara elsevierViewall">The superior cervical ganglion, the largest of the three ganglia, is spindle shaped, measures 2–5<span class="elsevierStyleHsp" style=""></span>cm long and is usually located across the first vertebra and is associated with the 4 superior cervical vertebrae.</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">•</span><p id="par0050" class="elsevierStylePara elsevierViewall">The middle cervical ganglion is occasionally absent, never exceeds 10<span class="elsevierStyleHsp" style=""></span>mm long and is placed below and in front of Chassaignac's tubercle at the level of the sixth cervical vertebra. When present it is associated with C5–C6.</p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">•</span><p id="par0055" class="elsevierStylePara elsevierViewall">The inferior cervical ganglion is constant, usually located in front of the 7th cervical vertebra and the 1st thoracic vertebra, fused with the first thoracic ganglion forming an irregular mass con el primer (spider-like shape).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">In about 80% of the population this inferior cervical ganglion fuses with the first thoracic ganglion to form a single structure, the <span class="elsevierStyleItalic">cervical-thoracic ganglion or stellate ganglion</span>.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The stellate ganglion is located medial to the scalene muscles, lateral to the <span class="elsevierStyleItalic">longus colli</span> muscle and the trachea, together with the laryngeal recurrent nerve, anterior to the transverse process; the inferior most section is located posteriorly to the superior margin of the first section of the subclavian artery and at the origin of the vertebral artery, posterior to the apex of the lung. At the level of C6 it is in close relation with the anterior tubercle of Chassaignac and at the level of C7 is more medial at the level of the anterolateral aspect of the vertebral body <a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The stellate ganglion measures approximately 2.5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>0.5<span class="elsevierStyleHsp" style=""></span>cm. It is located in front of the neck of the first rib extending to the union of the seventh cervical vertebra and the first thoracic vertebra. However, its shape and location vary depending on the individual. It is localized lateral and posterior to the lateral border of the long muscle of the neck.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The ganglion may have a spindle, triangular of globular shape.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The most important vascular relationships are the carotid and vertebral arteries located at the level of C7. However, there can be a 10% anatomical variation when the vertebral artery enters above C7. It should be noted that incomplete osteogenesis might be present at the level of C7 so a medial-most approach should be maintained to prevent puncturing of the vertebral artery.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">longus colli</span> muscle is the muscular landmark usually lateral to the ganglion and varying in thickness from 5 to 10<span class="elsevierStyleHsp" style=""></span>mm in C6 and from 8 to 10<span class="elsevierStyleHsp" style=""></span>mm in C7. The total depth from the subcutaneous cell tissue to the transverse process at C6 usually does not exceed 16.6<span class="elsevierStyleHsp" style=""></span>mm.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The sympathetic fibers of the head, neck and lower limbs cross the stellate or cervical-thoracic ganglion.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,12</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The efferent postganglionic nerve fibers go cross the head, the neck, the upper limbs and the heart. The sympathetic postganglionic nerve endings release noradrenaline as the transmitter substance.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The stellate ganglion block causes a more complete denervation of the head and neck structures. However, there are a considerable number of people in whom somatic intrathoracic branches of the second nerve come together with the first spinal thoracic nerve. These intrathoracic branches join the gray communicating vessels of the sympathetic fibers and arise from the second sympathetic thoracic ganglion and probably from the ganglion at T3. These fibers join the lower section of the brachial plexus without crossing the stellate ganglion. This explains the incomplete block of the upper extremities when only the block of the stellate ganglion proper is done.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Indications</span><p id="par0100" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0105" class="elsevierStylePara elsevierViewall">Complex regional pain syndrome type 1 and type 2 of the upper extremities.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11,13,15,16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0110" class="elsevierStylePara elsevierViewall">Herpes Zoster-associated pain.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,17,18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0115" class="elsevierStylePara elsevierViewall">Ischemic neuropathies.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0120" class="elsevierStylePara elsevierViewall">Post-radiation neuritis.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0125" class="elsevierStylePara elsevierViewall">Atypical facial pan, orofacial pain syndrome, including neuropathic orofacial pain.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11,13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0130" class="elsevierStylePara elsevierViewall">Sympathetic nerve maintained pain.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0135" class="elsevierStylePara elsevierViewall">Vascular failure/occlusive vascular disorder, both acute and chronic of the upper extremities, Raynaud's disease.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,19</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0140" class="elsevierStylePara elsevierViewall">Quinine poisoning.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,13,20</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0145" class="elsevierStylePara elsevierViewall">Phantom limb.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0150" class="elsevierStylePara elsevierViewall">Hyperhidrosis of the upper limb.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,19</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0155" class="elsevierStylePara elsevierViewall">Cardiac arrhythmias: cardiac ischemic pain, long QT syndrome.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11,13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">•</span><p id="par0160" class="elsevierStylePara elsevierViewall">Neuropathic pain syndromes due to cancer pain.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,18</span></a></p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Contraindications</span><p id="par0165" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">•</span><p id="par0170" class="elsevierStylePara elsevierViewall">The patient refuses to undergo the procedure.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">•</span><p id="par0175" class="elsevierStylePara elsevierViewall">Poor knowledge of the technique and of the anatomy.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">•</span><p id="par0180" class="elsevierStylePara elsevierViewall">Acquired coagulopathy (anticoagulant therapy without bridge treatment).<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">•</span><p id="par0185" class="elsevierStylePara elsevierViewall">Congenital coagulopathy.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">•</span><p id="par0190" class="elsevierStylePara elsevierViewall">Localized infection.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">•</span><p id="par0195" class="elsevierStylePara elsevierViewall">Drug allergies (local anesthetic or steroids).<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">•</span><p id="par0200" class="elsevierStylePara elsevierViewall">Unable to sign the informed consent.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Materials</span><p id="par0205" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">•</span><p id="par0210" class="elsevierStylePara elsevierViewall">Lineal transducer (high frequency 8–12<span class="elsevierStyleHsp" style=""></span>MHz)</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">•</span><p id="par0215" class="elsevierStylePara elsevierViewall">4–5<span class="elsevierStyleHsp" style=""></span>cm long short bevel 22, 23 or 25<span class="elsevierStyleHsp" style=""></span>G gauge needle<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,13</span></a>; 22 gauge spinal needle may also be used.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">•</span><p id="par0220" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Selection of medicines</span>: Lidocaine (1–2%) and bupivacaine (0.25%) have been used for the stellate ganglion block. <a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Lidocaine is a fast-acting short-duration anesthetic (1–3<span class="elsevierStyleHsp" style=""></span>h), usually with less cardiovascular side effects. Bupivacaine has a longer life, lasting 2–3 times more that lidocaine. However, Bupovacaine has high cardiovascular risks but it has become increasingly popular for stellate ganglion and other nerve blocks because of its excellent differential block of various nerve fibers and relative long action.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The systemic effects of lidocaine or bupivacaine over the central nervous system and the cardiovascular system are not increased at a 10<span class="elsevierStyleHsp" style=""></span>ml dose, unless there is intravascular spread. <a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">•</span><p id="par0230" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Other drugs</span>: Local anesthetic (0.5% – bupivacaine, 0.5% ropivacaine, 0.25–0.75% levobupivacaine)<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,10,21,24–26</span></a> and steroid (methylprednisolone)<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>; however, some authors do not recommend the use of steroids.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Description of the technique</span><p id="par0235" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">1.</span><p id="par0240" class="elsevierStylePara elsevierViewall">The patient is placed in decubitus supine position or in lateral decubitus, with the head slightly extended (a small pillow may be used between the shoulders) and it has to be neutral or slightly rotated toward the opposite side of the procedure.</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">2.</span><p id="par0245" class="elsevierStylePara elsevierViewall">Adequate asepsis of the neck is performed and sterile dressings are applied.</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">3.</span><p id="par0250" class="elsevierStylePara elsevierViewall">An initial scan is performed to identify structures: thyroid, carotid artery and jugular vein.</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">4.</span><p id="par0255" class="elsevierStylePara elsevierViewall">The transverse process at C6 has been identified because of its prominent anterior tubercle, different from C5 that is flat and C7 that does not have a tubercle<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">5.</span><p id="par0260" class="elsevierStylePara elsevierViewall">The long muscle of the neck or <span class="elsevierStyleItalic">longus colli</span> is found above the transverse process of C6.</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">6.</span><p id="par0265" class="elsevierStylePara elsevierViewall">Plain approximation is used to observe the needle path; or, in some cases, outside the plane such as in the case of patients with a high body mass index (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">7.</span><p id="par0270" class="elsevierStylePara elsevierViewall">Ideally the puncture should be on the plane to see the tip of the needle at all times; the needle is directed medially until it passes through the deep cervical fascia, above the <span class="elsevierStyleItalic">longus colli</span> muscle.</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">8.</span><p id="par0275" class="elsevierStylePara elsevierViewall">Approximately 5<span class="elsevierStyleHsp" style=""></span>ml of drug are injected, observing the dissection between the carotid artery and the <span class="elsevierStyleItalic">longus colli</span> muscle.</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">9.</span><p id="par0280" class="elsevierStylePara elsevierViewall">The patient is transferred to the recovery room for 30–60<span class="elsevierStyleHsp" style=""></span>min to assess any potential complications.</p></li></ul></p><p id="par0285" class="elsevierStylePara elsevierViewall">The stellate ganglion block may be performed several times, according to the pathology and the patient's response. When the response is adequate but the effect is short lasting, radiofrequency may be considered.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Signs of a successful block</span><p id="par0290" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">1.</span><p id="par0295" class="elsevierStylePara elsevierViewall">Horner's syndrome: Ptosis, Miosis, and Enophthalmos.</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">2.</span><p id="par0300" class="elsevierStylePara elsevierViewall">Anhidrosis.</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">3.</span><p id="par0305" class="elsevierStylePara elsevierViewall">Nasal congestion, Guttman's sign and conjuntival.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29,30</span></a></p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">4.</span><p id="par0310" class="elsevierStylePara elsevierViewall">Venodilatation.</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">5.</span><p id="par0315" class="elsevierStylePara elsevierViewall">Increase in temperature by at least 1° centigrade.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Complications</span><p id="par0320" class="elsevierStylePara elsevierViewall">Injury to the surrounding nerves and viscera: brachial plexus injury, trachea and esophagus trauma, injury to the pleura or lung and bleeding or local hematomas.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">•</span><p id="par0410" class="elsevierStylePara elsevierViewall">The presence of Horner's syndrome is a sign of block success but should also be seen as a side effect.</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">•</span><p id="par0325" class="elsevierStylePara elsevierViewall">Dysphonia and a feeling of dysphagia may occur as a result of the recurrent laryngeal nerve. This is the main reason why a bilateral block should not be performed since it may result in a loss of the pharyngeal reflexes and subsequent respiratory involvement.</p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">•</span><p id="par0330" class="elsevierStylePara elsevierViewall">Brachial plexus block leads to somatic block. If this occurs, the patient shall be instructed to avoid inadvertent trauma.</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">•</span><p id="par0335" class="elsevierStylePara elsevierViewall">The intravascular injection of the local anesthetic agent is associated to toxicity; the epidural injection usually enters the foramen with anterolateral angulation, intrathecal injection with neuroaxial block.</p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Summary of complications<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Frequent</span><p id="par0340" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">1.</span><p id="par0345" class="elsevierStylePara elsevierViewall">Transient hoarseness and a foreign body sensation in the throat (recurrent laryngeal nerve block).</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">2.</span><p id="par0350" class="elsevierStylePara elsevierViewall">Horner's syndrome unpleasant effects (miosis, ptosis, enophthalmos).</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">3.</span><p id="par0355" class="elsevierStylePara elsevierViewall">Hematomas.</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Infrequent</span><p id="par0360" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">1.</span><p id="par0365" class="elsevierStylePara elsevierViewall">Brachial plexus effects.</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">2.</span><p id="par0370" class="elsevierStylePara elsevierViewall">Phrenic nerve block.</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">3.</span><p id="par0375" class="elsevierStylePara elsevierViewall">Pneumothorax.</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">4.</span><p id="par0380" class="elsevierStylePara elsevierViewall">Osteitis of the transverse process.</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Severe</span><p id="par0385" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">1.</span><p id="par0390" class="elsevierStylePara elsevierViewall">Intra-arterial injection: immediate neurological effects, loss of consciousness, seizures.</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">2.</span><p id="par0395" class="elsevierStylePara elsevierViewall">Epidural/intratecal injection slow presentation of symptoms.</p></li></ul></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0400" class="elsevierStylePara elsevierViewall">The stellate ganglion block is a procedure frequently used for pain management. Though there are multiple complications associated with the technique, currently the procedure can be safer using ultrasonography.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0405" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding</span><p id="par0415" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:17 [ 0 => array:3 [ "identificador" => "xres573625" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec590561" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres573626" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec590562" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Anatomy" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Indications" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Contraindications" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Materials" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Description of the technique" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Signs of a successful block" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Complications" ] 12 => array:3 [ "identificador" => "sec0065" "titulo" => "Summary of complications" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Frequent" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Infrequent" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Severe" ] ] ] 13 => array:2 [ "identificador" => "sec0060" "titulo" => "Conclusions" ] 14 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of interest" ] 15 => array:2 [ "identificador" => "sec0075" "titulo" => "Funding" ] 16 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-07-04" "fechaAceptado" => "2014-09-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec590561" "palabras" => array:5 [ 0 => "Stellate ganglion" 1 => "Chronic pain" 2 => "Complex regional pain syndromes" 3 => "Ultrasonography, Interventional" 4 => "Nerve block" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec590562" "palabras" => array:5 [ 0 => "Ganglio estrellado" 1 => "Dolor crónico" 2 => "Síndromes de dolor regional complejos" 3 => "Ultrasonografía intervencional" 4 => "Bloqueo nervioso" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The stellate ganglion block has multiple indications for pain management. The technique has evolved from using anatomical landmarks to image-guided puncture with fluoroscopy and ultrasound.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ultrasonography is a very useful tool that allows for real time visualization of the vascular structures (carotid, vertebral artery), the visceral structures (esophagus) and thus helps in preventing puncture injuries. This article offers a description of the indications, the ultrasound-guided technique and complications under the author's point of view.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El bloqueo del ganglio estrellado tiene múltiples indicaciones para el manejo del dolor, para este fin la técnica ha evolucionado desde la realización por medio de referencias anatómicas, hasta la punción guiada por imágenes como son el fluoroscopio y la ecografía.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La ultrasonografía es una herramienta muy útil ya que se puede ver en tiempo real las estructuras vasculares (carótida, arteria vertebral), las estructuras viscerales (esófago) y así evitar puncionarlas. En el presente artículo se hará una descripción de las indicaciones, la técnica guiada por ultrasonografía y las complicaciones, bajo la perspectiva del autor.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Serna-Gutiérrez J, Bloqueo ganglio estrellado guiado por ultrasonografia. Rev Colomb Anestesiol. 2015;43:278–282.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Author" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1292 "Ancho" => 1655 "Tamanyo" => 232529 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The stellate ganglion lateral longus Colli muscle and closely related to the brachial plexus, and the lower portion is situated back to the origin of the vertebral artery.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Author" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 783 "Ancho" => 993 "Tamanyo" => 106052 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Is the ultrasound image where the carotid artery is observed at a higher level, this medial thyroid; below the carotid artery are the long Colli muscle and the lower part the transverse process of C6 which is recognized by its former tuber identified.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Author" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 814 "Ancho" => 995 "Tamanyo" => 87180 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Is an ultrasound image, the approximation plane where the needle path heading medially over the longus colli muscle.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bloqueo del ganglio estrellado" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. 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| Year/Month | Html | Total | |
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| 2024 April | 197 | 20 | 217 |
| 2024 March | 262 | 10 | 272 |
| 2024 February | 268 | 10 | 278 |
| 2024 January | 319 | 15 | 334 |
| 2023 December | 253 | 20 | 273 |
| 2023 November | 350 | 29 | 379 |
| 2023 October | 293 | 38 | 331 |
| 2023 September | 225 | 7 | 232 |
| 2023 August | 197 | 22 | 219 |
| 2023 July | 190 | 12 | 202 |
| 2023 June | 199 | 11 | 210 |
| 2023 May | 200 | 12 | 212 |
| 2023 April | 218 | 24 | 242 |
| 2023 March | 150 | 14 | 164 |
| 2023 February | 123 | 5 | 128 |
| 2023 January | 95 | 10 | 105 |
| 2022 December | 93 | 18 | 111 |
| 2022 November | 106 | 21 | 127 |
| 2022 October | 121 | 12 | 133 |
| 2022 September | 94 | 20 | 114 |
| 2022 August | 111 | 15 | 126 |
| 2022 July | 87 | 8 | 95 |
| 2022 June | 86 | 13 | 99 |
| 2022 May | 79 | 11 | 90 |
| 2022 April | 104 | 26 | 130 |
| 2022 March | 89 | 22 | 111 |
| 2022 February | 79 | 19 | 98 |
| 2022 January | 118 | 21 | 139 |
| 2021 December | 84 | 11 | 95 |
| 2021 November | 138 | 27 | 165 |
| 2021 October | 114 | 7 | 121 |
| 2021 September | 110 | 18 | 128 |
| 2021 August | 96 | 10 | 106 |
| 2021 July | 93 | 9 | 102 |
| 2021 June | 61 | 9 | 70 |
| 2021 May | 85 | 9 | 94 |
| 2021 April | 168 | 25 | 193 |
| 2021 March | 61 | 7 | 68 |
| 2021 February | 24 | 5 | 29 |
| 2021 January | 44 | 12 | 56 |
| 2020 December | 38 | 8 | 46 |
| 2020 November | 41 | 10 | 51 |
| 2020 October | 27 | 10 | 37 |
| 2020 September | 52 | 8 | 60 |
| 2020 August | 44 | 16 | 60 |
| 2020 July | 32 | 11 | 43 |
| 2020 June | 16 | 3 | 19 |
| 2020 May | 64 | 4 | 68 |
| 2020 April | 17 | 5 | 22 |
| 2020 March | 20 | 4 | 24 |
| 2020 February | 16 | 2 | 18 |
| 2020 January | 11 | 7 | 18 |
| 2019 December | 8 | 8 | 16 |
| 2019 November | 4 | 7 | 11 |
| 2019 October | 4 | 2 | 6 |
| 2019 September | 5 | 3 | 8 |
| 2019 August | 1 | 1 | 2 |
| 2019 July | 6 | 11 | 17 |
| 2019 June | 1 | 1 | 2 |
| 2019 May | 5 | 8 | 13 |
| 2018 September | 1 | 0 | 1 |
| 2018 June | 7 | 3 | 10 |
| 2018 May | 85 | 7 | 92 |
| 2018 April | 54 | 10 | 64 |
| 2018 March | 80 | 12 | 92 |
| 2018 February | 68 | 15 | 83 |
| 2018 January | 69 | 8 | 77 |
| 2017 December | 62 | 5 | 67 |
| 2017 November | 69 | 10 | 79 |
| 2017 October | 77 | 11 | 88 |
| 2017 September | 79 | 10 | 89 |
| 2017 August | 75 | 8 | 83 |
| 2017 July | 71 | 5 | 76 |
| 2017 June | 97 | 14 | 111 |
| 2017 May | 97 | 10 | 107 |
| 2017 April | 109 | 14 | 123 |
| 2017 March | 80 | 10 | 90 |
| 2017 February | 62 | 14 | 76 |
| 2017 January | 72 | 9 | 81 |
| 2016 December | 116 | 10 | 126 |
| 2016 November | 151 | 11 | 162 |
| 2016 October | 139 | 18 | 157 |
| 2016 September | 201 | 16 | 217 |
| 2016 August | 211 | 23 | 234 |
| 2016 July | 68 | 8 | 76 |
| 2016 June | 3 | 9 | 12 |
| 2016 May | 4 | 20 | 24 |
| 2016 April | 0 | 22 | 22 |
| 2016 March | 3 | 25 | 28 |
| 2016 February | 10 | 21 | 31 |
| 2016 January | 3 | 0 | 3 |
| 2015 December | 17 | 8 | 25 |
| 2015 November | 58 | 19 | 77 |
| 2015 October | 4 | 3 | 7 |
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