Stellate Ganglion Block: Fluoroscopic Guidance

Abstract

Contrast injected at the C6 level has consistently reached the C7-T1 interspace, which is the commonly accepted location of the stellate ganglion. Ideal injectate spread should extend inferiorly to T2 for upper limb symptoms. The anterior (foraminal) oblique approach is advantageous over the traditional (i.e., paratracheal) approach because it provides an unobstructed trajectory view (i.e., it does not require pushing vascular structures out of the way and radiating the interventionalist’s hands).

Keywords

CRPS, causalgia, Fluoroscopy, Ganglion, Horner’s Syndrome, PTSD, RSD, Stellate, Sympathetic Block

Note: Please see pages ii , iii for a list of anatomic terms/abbreviations used throughout this book.

Contrast injected at the C6 level has consistently reached the C7-T1 interspace, which is the commonly accepted location of the stellate ganglion. Ideal injectate spread should extend inferiorly to T2 for upper limb symptoms. The anterior (foraminal) oblique approach is advantageous over the traditional (i.e., paratracheal) approach because it provides an unobstructed trajectory view (i.e., it does not require pushing vascular structures out of the way and radiating the interventionalist’s hands).

Trajectory View ( Fig. 28A.1 )

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The patient is placed in a supine position.

Fig. 28A.1

A, Fluoroscopic image of the trajectory view with the needle tip in position at or slightly medial to the uncinate line at the junction of the uncinate process and the vertebral body. Because this is the trajectory view, the needle entry position should be parallel to the C-arm beam. B, Radiopaque structures, trajectory view. C, Radiolucent structures, trajectory view.
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Using the posteroanterior view, confirm the C6 level by counting cephalad from T1.
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Tilt the C-arm image intensifier to line up the superior C6 vertebral end plate of the targeted vertebral body (see Chapter 3 ).
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Oblique the C-arm image intensifier ipsilaterally to obtain a foraminal oblique view (see Chapter 3 ). With this trajectory view, count down from the most cephalad C3 neural foramen (NF) (AKA C2-C3 NF) to confirm the level of the C6 vertebral body.
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The targeted structure, which is the junction of the vertebral body and the uncinate process (at or slightly medial to the uncinate line), can then be optimally visualized.