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Stellate Ganglion Block (SGB): Procedure, Indications, and Evidence

The stellate ganglion (cervicothoracic ganglion) is a fusion of the inferior cervical and first thoracic sympathetic ganglia, located at the C7-T1 vertebral level, anterior to the longus colli muscle and posterior to the carotid sheath. A stellate ganglion block (SGB) injects local anesthetic (± steroid) near this ganglion to temporarily block sympathetic outflow to the head, neck, upper extremity, and upper thorax.

Indications

Pain Conditions (Sympathetically-Mediated)

  • Complex Regional Pain Syndrome (CRPS) Type I/II — Upper Extremity: Most established indication. SGB reduces pain, edema, allodynia, improves ROM. Series of blocks often needed.
  • Post-herpetic neuralgia (trigeminal/cervical): Early intervention may reduce chronicity.
  • Phantom limb pain (upper limb).
  • Cervical sympathetically-mediated pain: Cervicogenic headache, facet-mediated pain with sympathetic component.

Vascular/Circulatory

  • Raynaud's phenomenon/disease: Improves digital perfusion, reduces ulceration.
  • Frostbite (acute): Vasodilation may salvage tissue.
  • Refractory upper extremity ischemia.

Other

  • PTSD (emerging): Right SGB modulates amygdala hyperactivity via sympathetic afferents. RCTs show rapid symptom reduction; protocol typically 2 injections 2 weeks apart.
  • Hot flashes (breast cancer survivors): Modest benefit.
  • Hyperhidrosis (face/scalp).
  • Diagnostic: Confirms sympathetically-maintained pain (SMP) if pain relieves with block.

Procedure (Ultrasound-Guided — Preferred)

  1. Supine, neck slightly extended, head turned contralateral.
  2. High-frequency linear probe at C6-C7 level, transverse. Identify: carotid artery, jugular vein, longus colli muscle, prevertebral fascia. Stellate ganglion lies on longus colli, medial to vertebral artery, at C7-T1.
  3. In-plane needle approach (lateral-to-medial or anterior). Hydrodissection with 1-2 mL saline to confirm plane.
  4. Inject 5-10 mL local anesthetic (0.25% bupivacaine or 1-2% lidocaine) ± 20-40 mg triamcinolone/dexamethasone.
  5. Confirm spread: Anterior to longus colli, around vertebral artery.

Expected Effects (Horner's Syndrome = Technical Success)

  • Ipsilateral ptosis, miosis, anhidrosis (face/neck).
  • Nasal congestion, conjunctival injection.
  • Hoarseness (recurrent laryngeal nerve block) — transient.
  • Arm warmth, erythema (sympathetic block).
  • Duration: Hours (lidocaine) to days-weeks (bupivacaine + steroid).

Risks & Complications

  • Vascular puncture (carotid, vertebral, jugular) — US guidance minimizes.
  • Pneumothorax (rare with US).
  • Epidural/Intrathecal spread (high volume) → high spinal.
  • Recurrent laryngeal nerve injury (hoarseness).
  • Phrenic nerve block (dyspnea if bilateral).
  • Seizure (intravascular injection).
  • Infection, bleeding.

Contraindications

  • Coagulopathy/anticoagulation (per ASRA guidelines).
  • Infection at site.
  • Severe cardiopulmonary disease (bilateral blocks risk).
  • Allergy to local anesthetic.

SGB is a valuable, minimally invasive tool for upper extremity sympathetically-mediated pain and emerging neuropsychiatric applications. Ultrasound guidance and strict adherence to safety protocols are essential.

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