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Stellate ganglion block

If you are considering having a stellate ganglion block or have a procedure planned, it is important to know all you can about it. This includes:

why you need this procedure
what it will be like
how it will affect you
what risks are involved
any alternatives.

The information here is a guide to common medical practice. Each hospital and doctor will have slightly different ways of doing things, so you should follow their guidance where it is different from the information given here. Because all patients, conditions and treatments vary it cannot cover everything. Use this information when making your treatment choices with your doctors. You should mention any worries you have. Remember that you can ask for more information at any time.

What is the problem?

You have pain in either your head, face, neck, arm or perhaps your heart. The pain involves the sympathetic nerves in this area. The sympathetic nerves control the things we do not need to think about, such as digestion, blood pressure and heart rate. This group of nerves does not normally send pain messages, but they become ‘switched-on’ in certain conditions. We do not know why this happens but have learnt to recognise the times when it does.

Pain from the sympathetic nerves does not respond to the usual painkillers that we may use for simple pain, like a headache. Neither does it respond to stronger painkillers that we might use for a broken bone. Sympathetic pain seems to be there all the time, sometimes getting worse and sometimes easing off. The pain may be affected by heat or cold and may change with the weather.

If the pain affects your arm the skin can be seen to go pale or even mottled. There may be hair loss and the skin may take on a smooth, featureless appearance. Unfortunately, there is no exact test to confirm the diagnosis. The doctor recognises a pattern in the description of the pain, which is often sharp, stabbing or shooting, and by the appearance of the skin.

What is a stellate ganglion block?

A stellate ganglion block is an injection around a nerve junction or ‘cross-roads’ where many nerves meet, called the stellate ganglion. This crossroads can sometimes be responsible for sending pain messages to the brain. Pain from the head, face, neck, arm and even the heart can send pain messages through this point.

By injecting local anaesthetic and sometimes anti-inflammatory steroids around this place, the pain messages can be blocked and the pain reduced.

If used, only a small amount of steroid is needed and it will not cause any of the side effects sometimes associated with taking steroid tablets. They are not the same kind of steroids that athletes may take.

What is the stellate ganglion?

There is a group of nerves in the body called sympathetic nerves. They control the things we do not need to think about such as sweating, blood pressure and heart rate. A ganglion is a bundle of nerves that comes together in a particular place sending out many branches. In this case, the sympathetic nerves to the head, face, neck, arm and heart all come together at this star-shaped ganglion. Stellate means star-shaped; so this particular bundle of sympathetic nerves is named the stellate ganglion. The nerves are located on either side of the voice box, at the base of the neck.

Blocking of these sympathetic nerves also causes the blood vessels in the arm to get wider (dilate). This will improve the blood supply in patients who have pain due to poor circulation. This is useful in conditions such as Raynaud's disease.

What has gone wrong?

Your sympathetic nerves have started sending pain messages. It is not at all clear why this happens. When this happens we can reduce the pain by blocking the activity of the sympathetic nerves.

The aims

The aim of the procedure is to reduce the signals sent by the sympathetic nerves and so reduce the pain. As stated, the procedure will also improve the circulation of the arm and may improve pain caused by ischaemia, which is a poor blood supply.

The benefits

Your pain should be reduced and you should be able to move around more easily. If successful, the treatment can avoid the need for tablet medications.

Are there any alternatives?

By the time that you consider having the stellate ganglion block you should have already tried other more simple treatments. These include rest and both painkilling and anti-inflammatory tablets.

You may have also tried a transcutaneous electrical nerve stimulation (TENS) machine for the pain. This works by sending soothing pulses across the surface of the skin and along the nerve fibres. The pulses prevent pain signals reaching the brain. They also stimulate your body to produce higher levels of its own natural painkillers, called endorphins.

What if you do nothing?

If you do nothing there are several things that may happen:

With time and rest the pain may settle on its own
The pain and difficulty in performing daily activities may remain the same
The pain may increase and spread
The pain may cause your posture to get worse, making daily activities and even sleeping more difficult

Who should have it done?

The following groups of patients should have the procedure done:

Patients with pain in the area covered by the stellate ganglion, which has failed to respond to standard treatments. The pain could be in the head, face, neck, arm or heart
Patients with pain in the area covered by the stellate ganglion, with symptoms suggesting that the sympathetic nerves are involved

Who should not have it done?

Each patient has the final decision on whether to proceed or not. If you are unhappy about the procedure for any reason you should not continue.

There are specific medical situations when a stellate ganglion block should not be done and they are as follows:

When a patient is on medication that prevents blood from clotting, such as warfarin. This would lead to more bleeding than normal. It may be possible to stop the medication a few days before the procedure. This will need to be discussed with your doctor
When a patient is suffering from an illness that prevents blood from clotting, such as haemophilia. This would also lead to more bleeding than normal
When there is infection of the skin over the site where the needle needs to be put in. This could lead to infection in the deeper tissues

Author: Dr Sean White FRCA. Consultant in pain and anaesthesia.