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Stellate ganglion nerve blockade (SGNB) is a vital tool in our armamentarium for the treatment of various chronic pain syndromes. SGNB can be performed using the traditional landmark-based approach, or with image guidance using either fluoroscopy or ultrasound. In this review, we systematically analyzed reported SGNB-related complications between 1990 and 2018. Seven databases were queried for SGNB between January 1, 1990 and November 27, 2018. Search results of the complications associated with SGNB were reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Out of a total of 1909 articles, 67 articles met our inclusion criteria, yielding 260 cases with adverse events. In 134 of the 260 (51.5%) cases, SGNB was performed with image guidance. Sixty-four (24.6%) and 70 (26.9%) of the complication cases reported the use of ultrasound and fluoroscopy guidance, respectively. One hundred and seventy-eight (68.4%) patients had medication-related or systemic side effects, and 82 (31.5%) had procedure-related or local side effects. There was one report of death due to massive hematoma leading to airway obstruction. There was one case report of quadriplegia secondary to pyogenic cervical epidural abscess and discitis following an SGNB. Complications following SGNB have been reported with both landmark-based techniques and with imaging guidance using fluoroscopy or ultrasound. In our systematic review, most adverse events that were reported occurred during or shortly after SGNB. Vigilance, American Society of Anesthesiologists standard monitors for conscious sedation, and accessibility to resuscitation equipment are vital to the safe performance of SGNB.

Ventricular arrhythmias are a life-threatening factor in cardiac sarcoidosis (CS), posing a significant therapeutic challenge. Stellate ganglion phototherapy (SGP), a non-invasive procedure for modification of the sympathetic nervous system, is an effective treatment for refractory ventricular tachycardia (RVT). However, there are limited data on the efficacy of SGP for RVT in patients with CS. In our case report, we found that SGP was effective for treating RVT in a patient with CS.We present the case of a man in his 60s with multiple cardioversions of implantable cardioverter defibrillator for ventricular tachycardia. The patient was administered prednisolone for the management of CS, which subsequently led to an increase in anti-tachycardia pacing for ventricular tachycardias. We introduced SGP to suppress RVT and anti-tachycardia pacing decreased from 371 to 25 events. Thus, SGP could be a feasible option for the management of RVT in patients with CS.

Background and Objective Bleeding into the retropharyngeal space is a potential complication in stellate ganglion block (SGB). Retropharyngeal hematoma formation is considered to be due to damage of small arteries in the region, although only scanty details of the region are available. The aim of this study was to map the risk blood vessels in the retropharyngeal space to avoid accidental damage during SGB. Methods Contrast-enhanced 3-dimensional computed tomography images performed on 80 patients were reanalyzed retrospectively to construct detailed map of cervical blood vessels that are prone to damage and bleeding during SGB. Results Of the 160 bilateral necks, 6 (3.8%) and 82 (51.3%) small arteries were identified in the medial portions of the ventral surface of the transverse processes of the sixth and seventh cervical vertebrae, respectively. In particular, 5 of the 6 small arteries detected in the medial portion of the ventral surface of the transverse process of the sixth cervical vertebra were the inferior thyroid artery (ITA). Of the 160 vertebral arteries, 2 arteries were missing, 4 (2.5%) entered the transverse foramen of the fifth cervical vertebra, whereas 1 artery (0.6%) entered the transverse foramen of the fourth cervical vertebra. Conclusions Three-dimensional computed tomography identified the ITA in the medial portion of the ventral surface of the transverse process of the sixth cervical vertebra. The risk vessels of retropharyngeal hematoma during SGB could include the ITA.

BackgroundWe present a case report of a patient who developed severe reversible cerebral vasoconstriction syndrome, which was worsening despite typical interventional and supportive care. We administered a stellate ganglion block (SGB) and monitored the vasospasm with transcranial Doppler measurements.Case reportA 25-year-old woman was admitted with recurrent headaches and neurological symptoms, which angiography showed to be caused by diffuse, multifocal, segmental narrowing of the cerebral arteries leading to severe ischemia in multiple regions. Typical treatment was initiated with arterial verapamil followed by supportive critical care, including nimodipine, intravenous fluids, permissive hypertension, and analgesia. Vasospasm was monitored daily via transcranial Doppler ultrasound (TCD). After symptoms and monitoring suggested worsening vasospasm, an SGB was administered under ultrasound guidance. Block success was confirmed via pupillometry, and repeat TCD showed improved flow through the cerebral vasculature. Improvement in vascular flow was accompanied by a gradual reduction in acute neurological symptoms, with the patient reporting no headaches the following morning.ConclusionsFor patients with reversible cerebral vasoconstriction syndrome who develop severe signs or symptoms despite typical treatment, sympathetic blockade may be a possible rescue therapy. This may extend to other causes of severe vasospasm as well, and further study is needed to determine if the SGB should be included in routine or rescue therapy.

Background and Objectives The most common techniques to perform stellate ganglion blocks (SGBs) are the blind C6 approach and the fluoroscopic-controlled paratracheal C7 approach, both after manual dislocation of the large vessels. Complications due to vascular or esophageal puncture have been reported. The goal of this ultrasound imaging study was to determine how frequently hazardous structures are located along the needle path of conventional SGB and to determine the influence of the dislocation maneuver on their position. Methods Sixty volunteers were examined on both sides. The presence of the esophagus, vertebral artery, and other arteries located within the needle path of an SGB at the C6 and C7 levels was determined before and during the dislocation maneuver. Results On the left side, the esophagus was located along the needle path in 22 and 39 of 60 cases at the C6 and C7 levels, respectively, and remained there in 10 and 22 of 60 cases during dislocation. The esophagus appeared in the needle path during dislocation from a previously safe location in 5 and 8 of these cases at the C6 and C7 locations, respectively. The vertebral artery was located in the needle path in a range of 2 to 8 of 60 cases without impact of dislocation on its position. Other arteries were located in the needle path in the range of 10 to 17 of 60 cases with a slight decrease during dislocation. Conclusions The esophagus and relevant arteries were frequently located in the needle path of conventional SGBs. The dislocation maneuver had a partial impact on moving these structures away from the target and may increase left-sided esophageal puncture risk in certain individuals. Ultrasound (US) imaging is expected to improve the safety of SGB, but it will require clinical trials to confirm this expectation.

Background and Objectives: The goal of this study was to compare tissue blood flow at various sites before and after stellate ganglion block (SGB) and to discuss the redistribution of tissue blood flow after SGB. Methods: We studied 16 male Japanese white rabbits. For SGB, the tip of a 26-gauge needle was placed on the left transverse process of the cervical vertebra, 1 to 2 mm caudal to the cricoid cartilage. Either 0.2 mL of 1% lidocaine (lidocaine group) or normal saline solution (saline group) was injected. In the lidocaine group, data were recorded immediately before SGB and at the time when the maximal change in the common carotid arterial blood flow was observed after SGB. In the saline group, data were recorded immediately before SGB and 3 minutes after SGB. Observed variables were blood pressure, heart rate, common carotid arterial blood flow, tongue mucosal blood flow, mandibular bone marrow blood flow (BBF), masseter muscle blood flow (MBF), quadriceps muscle blood flow, liver blood flow, and renal blood flow. Results: Common carotid arterial blood flow, tongue mucosal blood flow, BBF, and MBF on the block side were increased, whereas BBF and MBF on the nonblock side and quadriceps muscle blood flow, liver blood flow, and renal blood flow were decreased after SGB in the lidocaine group. Conclusions: These results indicate that lower limb and visceral blood flow as well as blood flow on the nonblock side are redistributed to the block side after SGB. Redistribution from peripheral tissue may have a more important role than that of visceral blood flow redistribution after SGB.

Background and Objectives: Although the stellate ganglion is located anteriorly to the first rib, anesthetic block is routinely performed at the C6 level. Ultrasonography allegedly improves accuracy of needle placement and spread of injectate. The technique is relatively new, and the optimal approach has not been determined. Moreover, the location of the cervical sympathetic trunk relative to the prevertebral fascia is debatable. Methods: Three-dimensional sonography was performed on 10 healthy volunteers, and image reconstruction was completed. On the basis of analysis of pertinent anatomy, a lateral trajectory for needle placement was simulated. Accuracy was tested by injection of methylene blue in cadavers. A clinical validation study was then conducted. A block needle was inserted according to the predetermined lateral path, and 5 mL of a mixture of bupivacaine and iohexol was injected. Spread of the contrast agent was verified fluoroscopically. Results: Image reconstruction revealed that the cervical sympathetic trunk is located posterolaterally to the prevertebral fascia on the surface of the longus colli muscle. The mean anteroposterior width of the muscle at the C6 level was 11 mm. The lateral approach does not interfere with any visceral or nerve structures. Anatomic dissection in cadavers confirmed entirely subfascial spread of the dye and staining of the sympathetic trunk. The contrast agent spread was seen in all patients between the C4 and T1 levels in a typical prevertebral pattern. Conclusions: This study revealed that, at the C6 level, the cervical sympathetic trunk lies entirely subfascially. Subfascial injection via the lateral approach ensures reliable spread of a solution to the stellate ganglion.

Background and Objectives: The longus colli (LC) muscle is an important structure of the anterior cervical spine and has a critical role in stellate ganglion block. This technique involves withdrawing the needle to locate its port for injection above the anterior surface of the LC muscle; however, its exact thickness at the C5, C6, and C7 levels has not been measured. The aim of this anatomic and magnetic resonance-supported study was to evaluate the thickness of the LC muscle at these levels from the anterior tubercle of each vertebra toward the vertebral body at 5-, 10-, and 15-mm distances to provide precise anatomic data for stellate ganglion block. Methods: Ten cadavers, 60 vertebral body specimens, and cervical magnetic resonance imaging (MRI) scans of 40 adult patients were used for measurements. Results: The main findings of this study are that the thickness of the LC muscle varies between 5.0 and 10.0 mm at C6 and C7 in cadavers and between 8.0 and 10.0 mm in MRI scans. Sex has an important role; MRI scans revealed that male patients have a considerably thicker LC muscle at each vertebral level. Conclusion: We found a highly variable thickness of the LC muscle in anatomic and imaging studies, which may lead to negative block results.

Background and Objectives Stellate ganglion block is often carried out using palpation of surface landmarks to guide needle placement. However, anatomic variation of the surface landmarks used is common and block failure has been reported in as many as 30% of patients, even when the surface landmarks that guide needle placement can be easily identified. Methods Computed tomography (CT) images of the cervical spine of 70 adult patients were examined to measure the distances in the coronal and sagittal planes between various points on the cricoid cartilage, anterior tubercle, posterior tubercle, and nadir of the vertebral gutter. The width of the tubercle in the caudal and cephalad plane was determined through multiplanar reformatted CT images in 6 randomly chosen patients. Results The mean distance from the lateral margin of the cricoid cartilage laterally to the anterior tubercle was 13 ± 5 mm (range 3-22 mm) in men and 12 ± 3 mm (range 6-22 mm) in women. The mean depth of the anterior tubercle as measured posteriorly from the midpoint of the trachea was 20 ± 4 (range 10-33 mm) in men and 19 ± 4 mm (range 9-33 mm) in women. The maximal and minimal cephalad-caudad dimensions of the transverse process of C6 were 9.3 ± 0.3 mm, and 6.7 ± 0.3 mm, respectively. Conclusions Large variability was observed in the size and location of the landmarks used for needle placement during stellate ganglion block. Placement of the needle medially where the transverse process joins the lateral margin of the vertebral body provides a larger bony target that may potentially provide a safer, more reliable block.

Background and objectives The aim of this study is to examine the effects of head-up tilt (70°) 30 minutes after right or left stellate ganglion block (SGB) on RR interval, QT interval, the rate-corrected QT (QTc) interval, QT dispersion (QTD), and the rate-corrected QT dispersion (QTcD) using computerized measurement. Methods Ten healthy volunteers underwent both right and left SGBs using 7 mL 1% mepivacaine with a 7-day interval between the two blocks. A 12-lead electrocardiogram was monitored to measure parameters before SGB; 30 minutes after SGB (before head-up tilt); and immediately, 5, 10, and 15 minutes after head-up tilt. Results Right SGB induced significant increases in QT interval, QTc interval, QTD, and QTcD from 30 minutes after the block through 15 minutes after head-up tilt. There were significant increases of QT interval, QTc interval, and QTcD between before and immediately after head-up tilt in right SGB. Left SGB induced significant decreases of QT interval and QTc interval from 30 minutes after SGB through 15 minutes after head-up tilt. Left SGB also induced a significant decrease of QTD from immediately after through 10 minutes after head-up tilt. Conclusions Significant increases of QT interval, QTc interval, and QTcD, which are associated with an increased risk of ventricular arrhythmias and cardiac events, occur immediately after head-up tilt in right SGB. However, head-up tilt does not induce increases of QT interval, QTc interval, QTD, and QTcD in left SGB.

The liver is a major site for the synthesis and actions of platelet activating factor (PAF), a potent hepatic vasoconstrictor and systemic vasodilator. As PAF is implicated in portal hypertension and hyperdynamic circulation associated with liver cirrhosis, we characterised changes in the hepatic PAF system in experimental cirrhosis.In rats made cirrhotic by carbon tetrachloride (CCl(4)) administration for eight weeks, we determined hepatic levels of PAF and its cognate receptor, and the effects of PAF and PAF antagonist (BN52021) on portal and arterial pressure.Compared with control rats, cirrhotic rats had higher hepatic PAF levels, higher apparent hepatic efflux of PAF, and higher PAF levels in arterial blood (p0.01, p0.01, p0.05, respectively). Relative to controls, cirrhotic livers had elevated hepatic PAF receptors (by mRNA and protein levels and [(3)H]PAF binding), higher (p0.01) baseline hepatic portal pressure, and an augmented (p = 0.03) portal pressure response to PAF infusion (1 microg/kg). Portal infusion of BN52021 (5 mg/kg) showed that elevated endogenous PAF was responsible for 23% of the cirrhotic portal pressure increase but made no contribution to systemic hypotension. Finally, increased PAF receptor density was observed in the contractile perisinusoidal stellate cells isolated from cirrhotic livers relative to those from control livers.In cirrhosis, increased hepatic release of PAF elevates systemic PAF; in combination with upregulated hepatic PAF receptors in stellate cells, this contributes to portal hypertension.

Background and Objectives: Prolongation of QT interval and QT dispersion (QTD) may be associated with an increased risk of arrhythmias. This study was designed to investigate the effects of right or left stellate ganglion block (SGB) on RR interval, QT interval, the rate-corrected QT (QTc) interval, QTD and the rate-corrected QTD (QTcD) using computerized measurements. Methods: Ten healthy volunteers underwent both right and left SGBs using 7 mL 1% mepivacaine with a 7-day interval between the 2 blocks. The measurement from the 12-lead electrocardiogram was performed for 60 minutes after SGB. Results: Right SGB induced a significant decrease of RR interval immediately after the block, and significant increases of QT interval, QTc interval, QTD, and QTcD from immediately through 50 minutes after the block ( P [lt ] .01). Left SGB induced a significant decrease of RR interval, and significant increases of QTc interval and QTD immediately after the block ( P [lt ] .01). Left SGB also produced a significant decrease of QT interval from 20 through 50 minutes after the block, and a significant decrease of QTc interval from 30 through 50 minutes after the block ( P [lt ] .05). Conclusions: Right SGB induces increases of the QT interval, QTc interval, QTD, and QTcD, and left SGB induces decreases of the QT interval and QTc interval. Reg Anesth Pain Med 2001;26:539-544.

Background and Objectives: The aim of this study is to clarify the influence of acute cigarette smoking on vasodilation induced by sympathetic block. Methods: We measured mean arterial pressure, heart rate, left brachial artery blood flow (BABF), right femoral artery blood flow (FABF), and plasma catecholamines in dogs to examine the effect of acute cigarette smoking after stellate ganglion block (SGB). The experimental protocol was: (1) Left SGB using 1.0 mL 0.5% mepivacaine without smoking (sham smoking); and (2) left SGB using 1.0 mL 0.5% mepivacaine followed by a single cigarette smoking (nicotine 1 mg) 15 minutes after the block. Results: SGB induced a significant increase of BABF during the study (baseline, 100%; peak at 10 minutes after SGB, 176% ± 9%; P < .05) in sham smoking and a significant decrease of FABF from 10 minutes after the block to 20 minutes after sham smoking (baseline, 100%; bottom at 5 minutes after sham smoking, 82% ± 8%; P < .05). Smoking after SGB induced a significant decrease of BABF 60 minutes after smoking (baseline, 100%; 69% ± 11%; P < .05) and a significant decrease of FABF during the study (baseline, 100%; bottom at 20 minutes after smoking, 74% ± 20%; P < .05). Smoking significantly increased plasma norepinephrine and epinephrine through the study. Conclusions: Sympathetic block induces a significant increase of peripheral blood flow, but smoking produces a significant decrease in the blood flow in the SGB-induced dilated vessels. Reg Anesth Pain Med 2001;26:41-45.

Stellate ganglion block (SGB) leads to vasodilation of the head and neck, as a result of a regional sympathetic blockade. However, in such cases, controversy remains concerning changes in cerebral and extracerebral blood flow in the head. We estimated the effect of SGB on blood flow in the head by measuring the blood flow velocity in cervical vessels, using magnetic resonance imaging and the direct bolus tracking method. This noninvasive method is free from potential artifacts of bones and other connective tissues.Seven adult patients with acute or chronic pain in the head or neck underwent SGBs, using an anterior paratracheal approach with 6-8 mL of 1% mepivacaine (3 right and 4 left SGBs). Blood flow velocity in common carotid and vertebral arteries (CCA and VA) was measured simultaneously before and after SGB, using the direct bolus tracking method.On the side of SGB, blood flow velocity in CCA significantly increased (P.002), whereas velocity in VA was unchanged after SGB. On the side contralateral to the SGB, significant changes in blood flow velocity in CCA and VA were never observed.Blood from the VA flows primarily to cerebral vessels, whereas that from CCA goes to both cerebral and extracerebral vessels. Given the presumed differences in blood flow distribution through the VA and CCA, we assume that the observed CCA blood flow increases, ipsilateral to the SGB, primarily as a result of vasodilation of extracerebral vessels and independent of changes in brain blood flow.

Background and Objectives Delayed onset of airway obstruction following stellate ganglion block (SGB) may be life threatening. We treated a patient who developed a severe airway obstruction caused by a large hematoma several hours after an SGB. Methods A 62-year-old woman suffering from sudden deafness developed dyspnea 2 hours after undergoing her fourth SGB, and evidenced swelling and tenderness in her anterior neck and chest. Her pharyngolaryngeal tissues were edematous, and the glottis was markedly narrowed. Computed tomograms and magnetic resonance images revealed a large soft tissue mass extending from the first cervical vertebra to the diaphragm. Results Surgical tracheotomy was performed to maintain her airway. Swelling of the vocal cord disappeared on the eleventh day after the operation. Conclusions We believe that the SGB needle injured the vertebral artery and caused massive hemorrhage anterior to the cervical vertebra, subsequently inducing pharyngolaryngeal edema by obstructing the venous and lymphatic drainage of the cervical region.

Background and Objectives. Although an increase in skin temperature of the hand implies sympathetic block after stellate ganglion block (SGB), it does not indicate complete sympathetic block unless accompanied by an absence of sweating because skin temperature may increase even with a partial sympathetic block. This study examined the efficacy of the SGB to block sweating in the hand and to determine if the magnitude of temperature change in the hand is predictive of a negative sweat test. Methods. Fifty-nine SGBs were performed in 30 patients (15 women and 15 men) for diagnostic or therapeutic indications. Stellate ganglion block was performed via an anterior paratracheal approach at C6 using 15 mL 0.25% bupivacaine. Skin temperature was measured bilaterally on the index finger. A cobalt blue sweat test was performed bilaterally pre-and post-SGB on the middle finger. Successful sympathetic block after SGB was considered present when: (a) (change in ipsilateral temperature (postblock-preblock)] (Di)-[change in contralateral temperature] (Dc) ≥ 1.5°C; (b) Horner's syndrome present; and (c) sweat test changed from positive to negative. Logistical regression was applied to determine what value of Di − Dc could be used to predict a negative sweat test. Results. Thirty-six percent ( 21 59 ) of blocks met all three criteria. Of the blocks where Di − Dc ≥ 1.5°C, 72% ( 21 29 ) had a negative sweat test post-SGB. Of the blocks where Di − Dc 11 30 ) had a negative sweat test postblock. If Di − Dc ≥ 2.0°C, a negative sweat test could be predicted with 69 ± 12% sensitivity and 85 ± 10% specificity. Conclusions. Stellate ganglion block often fails to increase skin temperature in the ipsilateral more than the contralateral hand. A value of Di − Dc ≥ 2.0°C was a good predictor of a sympathetic block, but was not sufficient to guarantee a complete sympathetic block of the hand after SGB in all cases. An apparently successful SGB as measured by “usual” clinical criteria may not result in a complete sympathectomy of the hand as is often assumed. Therefore, if obtaining a sympathectomy is important for diagnostic or therapeutic purposes, performing a sweat test provides important confirmatory evidence of the genuine success of the sympathetic block.

Background and Objectives Stellate ganglion block can promptly relieve acute herpetic pain (AHP) involving the trigeminal and cervical regions. However, repeated blocks are needed to maintain pain relief in most patients with severe AHP. Because continuous epidural block is easily performed using an indwelling catheter, we compared the effect of high thoracic epidural block with that of stellate ganglion block to relieve moderate-to-severe AHP involving these regions. Methods Six patients received stellate ganglion blocks and seven patients received high thoracic epidural blocks. Six milliliters 1% of mepivacaine was given to each patient. Acute herpetic pain was evaluated before and up to 60 minutes after the blocks, using a visual analog scale (VAS) of pain. Results There was no significant difference in VAS pain scores before the blocks between the groups, but there were significant (P Conclusions High thoracic epidural block was as effective as stellate ganglion block in relieving moderate-to-severe AHP involving the trigeminal and cervical regions.

Objective: This report describes the effects of ganglionic local opioid application (GLOA) in patients with chronic headache and persistent idiopathic facial pain. Case Report: We present 2 patients with chronic headaches and 1 patient with persistent idiopathic facial pain who were refractory to medical treatment. These patients responded well to a series of ganglionic local opioid applications (GLOAs) by administration of buprenorphine. The beneficial effect of GLOA was manifested by a decrease in pain intensity, reduction of pain medications, and improvement in quality of life. Conclusions: These results support the theory of sympathetically mediated pain in the head and face, the presence of opioid receptors on the sympathetic ganglia, and a possible beneficial role of opioids in modulation of this process. To our knowledge, this case series is the first case series in the English literature of the use of GLOA at the stellate ganglion for head-and-face pain.

Background and Objectives. The stellate ganglion can alleviate phantom pain of the upper extremity, possibly because of the presence in it of enkephalin receptors, as has been suggested by experimental and clinical reports. A case is reported in which fentanyl, instead of local anesthetic, was used for stellate ganglion block. Methods. A 49-year-old man with a left below-elbow amputation, presented with probable symptoms of reflex sympathetic dystrophy, pain and temperature changes at the stump, and phantom hand symptoms the English-language literature revealed no reports of the use of fentanyl infiltration of the stellate ganglion was performed for management of this condition. Results. Significant alleviation of pain and sensation of warmth at the stump and in the phantom hand was achieved. Conclusions. Fentanyl infiltration of the stellate ganglion proved to be successful in the management of the pain and temperature sensation changes in the stump and phantom upper extremity.

A 74-year-old man presents to the Emergency Department with acute decompensated heart failure. During the examination, drooping of the right eyelid was noted. Further examination revealed a near-right pinpoint pupil and dryness of the skin on the right face and neck area. In 1970 he had undergone an open bilateral sympathectomy for craniofacial hyperhidrosis. Physical examination revealed a right-sided ptosis, miosis and anhydrosis (figure 1). Examination of his back …

Background and Objectives The chronic intestinal pseudo-obstruction due to visceral myopathy is a disorder resembling bowel obstruction but without mechanical occlusion. Frequently, parenteral nutrition becomes the final palliative treatment. A patient affected with this syndrome for 16 years was suffering causalgic pain provoked by intraveneous perfusion. Stellate ganglion block was requested in the hope of maintaining the perfusion. Methods Stellate ganglion block not only stopped the pain but unexpectedly, it temporarily relieved the pseudo-obstruction symptoms. Two radiofrequency coagulations in the stellate ganglion prolonged the beneficial effects on gastrointestinal transit for more than 3 weeks, after which the symptoms returned. Multidisciplinary and multicenter advice was that further destructive treatments not be attempted. Results Repetitive stellate ganglion blocks with 2 mL of bupivacaine 0.75% restored gastrointestinal function for more than 3 weeks. However, after performance of radiofrequency coagulation, infiltration with bupivacaine was followed by hypermetropia on the right eye of 2 weeks duration. Conclusions The relationship between stellate ganglion block and gastrointestinal function has not been described. This case report does not provide sufficient information to recommend this technique for pseudo-obstruction symptoms. Moreover, the result in this case is a fortuitous observation, lacking a clear scientific explanation. Further study may be warranted.

Stellate ganglion blocks have been shown to provide effective pain relief in a number of different conditions involving the upper body. This was demonstrated in a 65-year-old woman who had experienced severe debilitating pain in her left temporomandibular joint (TMJ) and the surrounding area of her face for over 10 years. The pain was unresponsive to indomethacin, carbamazepine, sodium valproate, gabapentin, lithium, melatonin and amitriptyline. She had also had four surgical procedures to the TMJ without success. The pain was partially responsive to Syndol tablets and pregabalin, although the use of pregabalin was limited by its adverse effects. The patient underwent 13 ultrasound guided stellate ganglion blocks over a 24-month period which demonstrated 90% pain relief for up to 10 weeks. Pulsed radio frequency lesioning showed no benefit over stellate ganglion block. More recently, tapentadol was found to be effective and this replaced the stellate ganglion blocks.

Objectives To explore the mechanism of electrical remodelling and autonomic neural remodelling in acute atrial fibrillation induced by stellate ganglion. Methods Twelve adult mongrel dogs weighing 18 to 25 kg were randomly divided into 2 groups. Control group (n = 6) underwent 6-hour rapid atial pacing only. SG group (n = 6) underwent 6-hour stellate ganglion (SG) stimulation puls rapid atial pacing. AF induction rate, AF duration, ERP, dERP and ERP rate-adaption in left atrium (LA), right atrium (RA), left superior pulmonary vein (LSPV) and left inferior pulmonary vein (LIPV) sites were measured. The density of TH, ChAT, GAP-43 positive nerve in RA and LA were detectd by immunohistochemistry staining. Results (1) The induction rate of AF was significantly increased in SG group (P Conclusions Stellate ganglion stimulation promote AF induction and prolong AF maintenance in atrial and pulmonary sites. The inhibition sympathetic nerve activation by unilateral stellate ganglionectomy can reduce the AF initiating and sustaining. Acute atrial electrical remodelling and acute autonomic neural remodeling may form a vicious cycle in which each perpetuates the other, thereby initiating and sustaining AF. This vicious cycle may help to explain how AF maintains itself in its very early stage.

brachial plexus block. Reg Anesth Pain Med.2012;37:473Y477.4. Gonzalez AP, Bernucci F, Pham K, CorreaJA, Finlayson RJ, Tran DQH. Minimumeffective volume of lidocaine fordouble-injection ultrasound-guided axillaryblock. Reg Anesth Pain Med. 2013;38:16Y20.5. Alakkad H, Chin KJ. The importance ofgood needling technique inultrasound-guided axillary block.Reg Anesth Pain Med. 2013;38:165.6. Chin KJ. How I do it: ultrasound-guidedaxillary block. ASRA News. Nov 2011;4Y7.7. Sites BD, Neal JM. Keep it simple.Reg Anesth Pain Med. 2012;37:465Y466.8. Wong MH, George A, Varma M.Ultrasound-guided perivascular axillarybrachial plexus block: not so simple.Reg Anesth Pain Med. 2013;38:165Y166.9. Sites BD, Taenzer AH, Herrick MD, et al.Incidence of local anesthetic systemictoxicity and postoperative neurologicsymptoms associated with 12,668ultrasound-guided nerve blocks. RegAnesth Pain Med. 2012;37:478Y482.

Background and Aim Long QT syndrome (LQTS) is a relatively common disease, however, it is rarely described in Black African patients. We would like to present a west African patient with sickle cell disease and LQTS who was treated with thoracoscopic left sympathectomy and 1/3 lower stellectomy. Methods An 11-year old boy with sickle cell anemia (Hb=7.2g/dl) was also found to have LQTS. He has had >15 defibrillations in 5 years. He was on high dose beta-blockers but required a number of shocks despite it. Implantable defibrillator was rule out due to his home country lack of cardiac surgical expertise in case of complications. He was considered to be a suitable candidate for sympathectomy. This was done through a 3 trocar approach to the left upper chest. Sympathetic chain including stellate gangion was exposed. 20mls of 0.5% lignoaine was sprayed over the ganglions. Prior to excision of sympathetic chain, all visible nerves traveling medially (to the heart) was excised with hook diathermy. Lower 1/3 of stellate ganglion as well as T2–T4 ganglia was resected en-bloc and submitted for histology. Results There were no per- or post-operative complications and no evidence of Horner’s syndrome post surgery. The patient was discharged 72 hours later. QTc interval before surgery was 532ms and reduced to 448ms prior to discharge. Conclusion Sympathectomy including lower portion of stellate ganglion is a viable alternative for patient with LQTS.

Objectives To build the methodology of acute animal model of atrial fibrillation (AF) induced by increased sympathetic nerve activity. Methods Sixteen adult mongrel dogs weighing 18 to 25 kg were randomly divided into 3 groups. Control group (n=4) underwent 6-h rapid atrial pacing only. RSG group (n=6) underwent 6-h right stellate ganglion (RSG) stimulation plus rapid atrial pacing. LSG group (n=6) underwent 6-h left stellate ganglion (LSG) electrical stimulation plus rapid atrial pacing. AF induction rate, and AF duration in left atrium (LA), right atrium (RA), left superior pulmonary vein (LSPV) and left inferior pulmonary vein (LIPV) sites were measured. Results (1) We successfully established canine models of acute AF induced by increased sympathetic nerve activity. The methods were relatively simple and repeatable. The AF duration was relatively long. (2) The effect on AF inducibility: In RSG group, the induction rate of AF was significantly increased in RA sites (73.30% vs 25.00%, p Conclusions Unilateral stellate ganglion electrical stimulation plus rapid atrial pacing for 6 h can successfully establish canine model of acute AF mediated by sympathetic nerve. Stellate ganglion stimulation promote AF induction and prolong AF maintenance in atrial and pulmonary sites. The inhibition sympathetic nerve activation by unilateral stellate ganglionectomy can reduce the AF initiating and sustaining. RSG is mainly associated with AF originating from RA, LSG is mainly associated with AF originating from LA and PV.

Introduction/purpose Aim of this education exhibit is to offer an overview on image guided sympathetic blocks, focusing on specific indications and techniques, through the use of Fluoroscopy and/or CT imaging guidance, at each level of blockade. Materials and Methods Sympathetic blocks are used for diagnostic, prognostic and therapeutic purposes for painful and other conditions associated with sympathetic system dysfunctions. Main indications for sympathetic blockade are: Complex regional pain syndrome (CRPS), phantom limb pain, central pain, hyperhydrosis, acute pancreatitis, and abdominal viscera cancer pain. Stellate ganglion blocks are utilized for painful and non-painful conditions related to sympathetic dysfunctions of head, neck and upper extremities. Thoracic sympathetic blocks are utilized for CRPS, postoperative analgesia, pain from fractured ribs, therapeutic control of hyperhydrosis of the upper limbs and torso, liver capsule pain after blunt trauma, acute postherpetic neuralgia, and premature ventricular contractions. Coeliac plexus blocks are utilized in pain due to intra-abdominal cancer, stemming from organs innervated by coeliac plexus. Lumbar sympathetic blocks are utilized for CPRS of the lower extremities, herpes zoster, amputation stump pain and inoperable peripheral vascular vasospastic diseases of the lower limb. Superior hypogastric blocks are utilized for pelvic pain, and pelvic organs cancer pain (uterus, cervix, bladder, prostate, urethra, testes and ovaries). Impar ganglion blocks are utilized in coccydynia. Results The sympathetic nervous system has been implicated in numerous pain syndromes including neuropathic, vascular and visceral pain. In relation to this, in order to determine the sympathetic role in the transmission of pain and to manage these algic syndromes, sympathetic ganglia are targeted for local anesthetic blocks, for diagnostic, prognostic, and therapeutic purposes, balanced in a more complex pain treatment strategy, in the treatment of CRPS and other pain conditions. Safe and precise performance of these blocks requires knowledge of the loco-regional anatomy, accurate imaging guidance, and rigorous technique. Elements of relevant fluoroscopic and cross sectional anatomy, as well as procedural technique elements are discussed and displayed. Conclusion This educational exhibit summarizes the indications, the anatomy and the techniques, under Fluoroscopy or CT guidance, for the sympathetic blocks. Competing interests None.

An acute rise in aortic pressure causes ventricular arrhythmias which are suppressed by β adrenergic antagonism.1 2 The fact that these arrhythmias occur in isolated heart preparations,2 and after stellate ganglion excision,1 excludes the possibility that the effectiveness of β blockade could be caused by the blocking of a reflex with sympathetic efferent limb. In order to find the reason for this, we utilised the well established chronically denervated canine preparation3 in which the ventricles are almost completely depleted of catecholamines. The corresponding clinical situation is cardiac transplantation, but our study could not be performed ethically in such patients. Beagle dogs, weighing between 13.7–17.0 kg of either sex, were denervated under 1.5% halothane in N2O/O2, removing the parasympathetic preganglionic neurones and the sympathetic postganglionic neurones. Adequate postoperative pain killing drugs were administered routinely. The study was made after 3–4 …

Necropsy studies were done on six patients with idiopathic paralysis agitans, one with multiple system atrophy including features of Parkinsonism, and one control. Autonomic functions had been evaluated during life to a varying degree. Intra-arterial blood pressure studies were carried out on two patients with paralysis agitans (cases 4 and 6) and the one with multiple system atrophy (case 7). Lewy bodies with or without cell loss were seen in the sympathetic ganglia of five cases of paralysis agitans. Three of these had orthostatic hypotension and the severity of the lesion approximately correlated with the degree of hypotension. It is concluded that the lesions of the sympathetic ganglia may play a major role in the production of orthostatic hypotension in idiopathic paralysis agitans.

We report a case of quinine overdose in a 47-year-old man who presented with blindness. Fundus photography demonstrates the acute and subsequent retinal changes, and his visual recovery to normal acuity with visual field constriction is documented. Pupillary and electrodiagnostic findings are recorded. Stellate ganglion block has been widely advocated as a helpful therapeutic measure, but out patient was treated with a unilateral stellate ganglion block without apparent benefit to that eye. From a review of the literature we believe that quinine produces its effects by toxicity on the retina rather than by vasoconstriction and that stellate ganglion block probably does not alter the natural history of the retinal toxicity.