When Liverpool and Alexander re-ligated the vertebral artery to treat cancer in 1883, they accidentally injured the sympathetic nerves, but they got a significant therapeutic effect. Surgical operations have been used to cut the sympathetic nerves of the neck for many years. In 1920 began to promote non-surgical percutaneous stellate ganglion block therapy. It soon became a versatile treatment. Wakasugi Fumiji pointed out that stellate ganglion block has become the most widely used treatment method for pain in Japan.
In recent years, there have been many studies on the mechanism of stellate ganglion block. The research results show that the role of shape ganglion block involves the autonomic nervous system, endocrine system and immune system, and has a regulatory effect on the functions of the above systems. The blocking method helps to maintain the stability of the environment in the body, so that many autonomic disorders can be corrected. For example, this method is used to treat primary, hypertension and hypotension, hypothermia, and hypothermia, hyperhidrosis and hypohidrosis or anhidrosis, weight gain or loss, hyperthyroidism or hypothyroidism, and extremity pain Syndrome or acral cyanosis, narcolepsy or insomnia, overeating disorder and anti-eating disorder or loss of appetite. The function of the disorder tends to be normal, and good results have been achieved. At present, it is mostly believed that the blocking effect of stellate ganglion mainly includes central nervous function and peripheral nerve function. It maintains normal autonomic, endocrine and immune functions by regulating the stable function of the thalamus to maintain the internal environment. ; Its peripheral nerve function is due to the inhibition of the function of the preganglionic and postganglionic fibers at the block site, and the cardiovascular movement, glandular secretion, muscle tension, bronchoconstriction and pain transmission controlled by the sympathetic nerve fibers in the distribution area are also inhibited. This peripheral effect has been used to treat some diseases of the head and neck, upper limbs, shoulders, heart and lungs. With the in-depth research on the function of stellate ganglia, it is reasonable to believe that this method may become an important clinical treatment in the 21st century.
1 Anatomy and Physiology The cervical sympathetic ganglion is located behind the cervical vascular sheath. Generally, there are three sympathetic ganglia on each side in front of the transverse process of the cervical spine. They are called the superior cervical ganglia, the middle cervical ganglia, and the lower cervical ganglia. The inferior cervical ganglion also becomes the stellate ganglion or the cervical thoracic ganglion. Its shape is irregular and larger than the middle cervical ganglion. It is located between the base of the transverse process of the seventh cervical vertebra and the first rib neck, and behind the vertebral artery. On the inside of the scalene muscle group, the lung tip is below it. The stellate ganglion is ovoid in shape, about 2cm long and 1cm wide. The lower boundary of the stellate ganglion is located behind the pleura and is surrounded by loose cellulite and adipose tissue. In addition, the stellate ganglion also sends out the gray communicating branches, connecting the seventh and eighth cervical nerves and the first thoracic nerve. It also sends out branches to surround the subclavian artery and its branches to form a plexus, and follow the artery to the first segment of the axillary artery . The other branches of this section respectively surround the vertebral artery to form a vertebral artery plexus, which goes up along the vertebral artery. Enter the cranial cavity and surround the vertebral artery and basilar artery until the posterior cerebral artery, where it meets the nerve plexus from the internal carotid artery. The hypocardial nerve from the stellate ganglion descends along the back of the subclavian artery and the front of the trachea, joining the heart plexus and participating in the activities of the heart.
(1) Anterior approach puncture method (paratracheal approach method) The patient takes a supine pillow under the shoulder. Routine skin disinfection, the surgeon is on the left side, first use the index and middle fingers of the left hand to push the common carotid artery and sternocleidomastoid muscle to the outside. Use a 7-gauge needle to insert the needle perpendicular to the skin near the esophagus and above the sternoclavicular joint at the front edge of the sternocleidomastoid muscle (the cricoid cartilage plane is equivalent to the transverse process of the sixth cervical vertebra). Normal patients can touch the first finger with the tip of the index finger. Seven cervical vertebra transverse process, guide the needle, puncture about 2 to 3 cm to touch the bone, indicating that the needle tip has reached the anterolateral aspect of the seventh cervical vertebra transverse process, withdraw the needle a little (0.2～0.4mm), suck back and inject without blood For local anesthetics, it should be noted that there is no abnormal feeling when puncturing the stellate ganglion, so there is no need to look for abnormal feelings.
The concentration and dose of the injected drug should be determined according to the needs of treatment. Generally 0.5～1% lidocaine or 0.25～0.375% bupivacaine～10ml can be injected. If you want to block the upper and middle cervical sympathetic nerve nodes and the first to fourth thoracic parasympathetic nerves at the same time, 1% lidocaine can be injected 20 ml of caine, or 30 ml of 0.5% lidocaine, the liquid spreads along the fascial space, blocking the sympathetic nerves of the entire neck and upper chest.
The sign of successful block is Horner’s syndrome on the side of the injection drug, which is manifested by miosis, drooping eyelids, sunken eyeballs, nasal congestion, conjunctival hyperemia, redness of the face, no sweat, and a sense of warmth.
(2) High lateral entry puncture method The patient lies on his back with his head turned to the opposite side, and the skin is routinely disinfected. The surgeon is located at the left puncture point at the intersection of the posterior edge of the sternocleidomastoid muscle and the external jugular vein, which is equivalent to the level of the cricoid cartilage or the transverse process of the sixth cervical vertebra. The No. 7 puncture needle is inserted perpendicular to the skin, so that the needle touches the transverse process of the sixth cervical vertebra, then withdraw the needle a little, and the needle tail is inclined at 45 degrees to the head. The needle tip passes through the front side of the transverse process of the sixth cervical vertebra. The direction of the transverse process of the seven cervical vertebrae is advanced about 1cm, and the local anesthetic can be injected by sucking back the bloodless and cerebrospinal fluid.
3 Indications The indications of the stellate ganglia are very wide, and can be classified as follows:
(1) Systemic diseases Autonomic dysfunction, essential hypertension, essential hypotension, hyperthyroidism, hypothyroidism, anorexia, overeating disorder, abnormal postural blood pressure, insomnia, systemic hyperhidrosis , Dizziness, generalized white ringworm, skin itching, seborrheic dermatitis, post-stroke pain, multiple sclerosis, myasthenia gravis, herpes zoster, herpes simplex, infectious mononucleosis, chronic fatigue syndrome, reflex Sympathetic atrophy, phantom limb pain, amputated limb pain, diabetes.
(2) Head disorders: alopecia, headache (including migraine, tension headache, cluster headache, temporal arteritis headache), cerebral thrombosis, cerebral vasospasm, cerebral infarction, etc.
(3) Facial disorders: Peripheral facial nerve palsy, atypical facial pain, masticatory muscle syndrome, mandibular joint syndrome.
(4) Eye diseases: Retinal vascular occlusion, retinitis pigmentosa, uveitis, optic neuritis, cystic macular swelling, corneal ulcers, cataracts, pupil tension, floaters, visual fatigue, refractive abnormalities.
(5) Otolaryngology diseases: Chronic paranasal sinusitis, acute paranasal sinusitis, allergic rhinitis, sudden unpleasant hearing, exudative otitis media, Meniere's disease, benign paroxysmal vertigo, nasal congestion, tonsillitis, tinnitus, throat Department of paresthesia, olfactory disorders.
(6) Oral diseases Pain after tooth extraction, tongue pain, endooral inflammation, glossitis, cheilitis, dry mouth mucosa.
(7) Neck, shoulder and upper limb diseases, upper limb blood circulation disorders (such as Raynaud's disease, Raynaud's syndrome, acute arterial occlusive disease, cervical shoulder-arm syndrome, traumatic neck syndrome, thoracic outlet syndrome, shoulder joint Peripheral inflammation, postoperative edema, post-mastectomy syndrome) tennis elbow, tenosynovitis, cervical spondylosis, arthritis, palm hyperhidrosis, frostbite, frostbite, perithyroiditis, longitudinal split, underarm odor.
(8) Circulatory system diseases Myocardial infarction, angina pectoris, sinus tachycardia, cardiac neurosis.
(9) Respiratory system diseases Chronic bronchitis, pulmonary embolism, pulmonary edema, hyperventilation syndrome, bronchial asthma.
(10) Digestive system diseases Allergic enteritis, ulcerative colitis, gastritis, gastric ulcer, Crohn's disease, peptic ulcer, constipation, diarrhea, hemorrhoids, etc.
(11) Obstetrics and Gynecology Diseases Menstrual abnormalities, premenstrual tension, dysmenorrhea, menopausal syndrome, autonomic dysfunction after hysterectomy, and female infertility.
(12) Urinary diseases Neurological frequency of urination, nocturia, urinary incontinence, pyelonephritis, IgA nephropathy, migrating kidney, prostatitis, and male infertility.
(13) Lumbar and lower extremity disorders: low back pain, knee joint pain, tinea pedis, red acrogia, corns, frostbite and frostbite.
4 Comorbidities The complications of stellate ganglion block include those related to local anesthetics and those related to operation.
(1) Complications related to local anesthetics: Local anesthetic reactions will occur when the drugs are injected into the blood vessel; a small number of reactions are sensitive to local anesthetics; some local anesthetics are added with hormones or other drugs. Multiple injections may cause damage to the stellate ganglia. Awaiting further research and evaluation.
(2) Complications related to the operation technique The puncture needle damages the blood vessels in the neck and causes local hematoma. When the blood is sucked back, the puncture needle should be pulled out and compressed to stop the bleeding. Puncture of the puncture needle into the subarachnoid space or even injection of drugs is an extremely serious comorbidity. Inappropriate puncture angle or low puncture site can cause pneumothorax or blood pneumothorax. The aseptic operation is not strict and can cause infection and deep abscess.
A case of neurotic tinnitus suffered from persistent Horner’s syndrome after 9 times of stellate ganglion block and could not recover. The analysis of the cause found that the operator was not skilled in the puncture, and he deliberately looked for bony signs during the puncture. Repeated puncture 4 to 5 times, plexus and damage the sympathetic nerve chain. In this case, the stellate ganglion block was continued for another week, and the symptoms of ptosis were relieved, but the pupil was still smaller than the contralateral side.
As long as you master the correct operation method and operate carefully, you can completely avoid the above-mentioned complications related to the operation. Over the past five years, Jihui Medical University in Japan has performed more than 70,000 stellate ganglion blocks. No complications occurred. Among the 7,667 stellate ganglion blocks performed by a scholar within 6 months, only one case When vomiting and nausea are reported during the obstruction period, for beginners, experienced physicians should give guidance, and inexperienced physicians should first master the anterior approach puncture method.
With the popularization of pain treatment, many pain specialists began to use stellate ganglion block and achieved satisfactory results. Some of these beginners lack guidance, are unskilled in technology, and have a relatively high incidence of complications.A doctor experienced two consecutive cases of sudden dizziness, decreased breathing, restlessness, and blood pressure drop after the injection of the drug in less than two months. It was considered that the drug entered the subarachnoid space by mistake. Even in some large hospitals, stellate ganglion block is often complicated by complications. A provincial hospital summarized 41 cases of 92 stellate ganglion blocks within 2 months. Blood was seen in 23 cases during the puncture procedure. Hand numbness occurred in 6 cases, hoarseness occurred in 4 cases, and 1 case occurred in 3 cases. Transient dizziness. Although they are short-lived, they should be paid attention to. The author advocates repeated withdrawal during the operation, which can prevent complications from entering the blood vessel and subarachnoid space by mistake. For obese patients or some patients with poor puncture, there is no need to look for bone markers too much. You can inject 1 to 2 ml of local anesthetic first, observe the blocking effect, and then inject the rest of the liquid medicine.
Generally speaking, stellate ganglion block can be fully completed with local anesthetics. This is a common method at home and abroad. However, in order to improve the therapeutic effect, some doctors add traditional Chinese medicine, hormones, vasodilators, etc. to the medicinal solution, which seems to have no sufficient theoretical and experimental basis. For permanent blockade of stellate ganglia with ethanol to treat refractory upper extremity vasospasm disease, the indications must be strictly selected, and the patient and family members must be explained in detail with regard to possible comorbidities, only after consent is obtained. When implementing ethanol to block stellate ganglia, use low-concentration ethanol and procaine solution. The ethanol concentration can start from 30%, and the metering can start from 0.3 ml. Repeat observations. Once the blocking effect appears, stop adding ethanol The concentration and dosage. Before and after the block, repeatedly observe the changes in the congestion time of the finger on the affected side. When the congestion time of the finger is shortened, it indicates that the blocking effect is produced. No need to inject ethanol.
5 "Precautions" People with bleeding tendency should use stellate ganglion block with caution. Observe for 10 to 15 minutes after the organization, and leave the hospital if there is no adverse reaction. Be careful not to block both stellate ganglia at the same time to prevent cardiopulmonary accidents.
Quoted from https://baike.baidu.com/view/2857966.htm
Attachment: The magical stellate ganglion block
A female patient has been troubled by migraines for seven or eight years. All examinations are normal, but medication, injections, and rest are not effective. After the tortuous treatment, she went to the hospital for a stellate ganglion block with an attitude of trying. After several treatments, she said with emotion that in these years, I have never been so relaxed. Lao Zhang has a long-term headache, insomnia, high and low blood pressure, and restlessness all day. After examination, he found that one side of the cerebral blood flow was reduced, and the planetary ganglion was delayed. The night’s sleep was significantly improved. Go to the hospital and ask for another injection. So, what is going on with stellate ganglion block?
Maybe people are not familiar with it. There are two systems of nerves in the human body. When we need something, we can stretch out our hands to take things, we can walk with our legs up, and people can move freely under the control of the motor nerves of the brain. But can we make the heart beat slower and the stomach and intestines move faster? Can't. It turns out that in addition to the brain's nervous system that controls movement, there is also a nervous system that is not directed by people's ideology. It "does its own way" and is called autonomic nerves. The autonomic nerve is in charge of people's visceral movement. When we exercise, it automatically speeds up the heartbeat and transports more blood. When we are cold, it constricts the blood vessels to save heat. But it also has a command disorder. For example, sometimes regardless of whether people need it or not, it causes continuous contraction of blood vessels, rapid heartbeat, and symptoms such as headache, insomnia, palpitation, shortness of breath, dry stool, and general discomfort.
The stellate ganglion is located on both sides of the human neck. Because it is shaped like a star, it is named stellate ganglion. It belongs to the sympathetic chain of the autonomic nerve, which is mainly formed by the fusion of the 7th and 8th sympathetic ganglia and the 1st thoracic sympathetic ganglion. It is the main sympathetic ganglion that innervates the head and face, neck, upper chest and upper limbs. More than 100 years ago, two surgeons inadvertently damaged the stellate ganglion during an operation on a tumor patient. As a result, something unexpected happened: the tumor patient’s pain was significantly reduced after the operation and his general condition improved. . This phenomenon attracted the attention of medical scientists, and doctors began to treat the disease by cutting this nerve. Later, people used drug injection instead of surgical cutting, which is called stellate ganglion block.
Stellate ganglion block (SGB) can block the preganglionic and postganglionic fibers of the sympathetic ganglion, so the cardiovascular movement, glandular secretion, muscle tone, bronchoconstriction and the nerve fibers that transmit pain under the control of these sympathetic ganglia are blocked. Hysteresis, which can improve the circulatory disturbance, hyperalgesia, and abnormal sweating caused by sympathetic nerve overexcitement. Therefore, its clinical indications are quite wide, such as: herpes zoster, burning pain, hyperhidrosis, headache, cerebral vasospasm, cerebral thrombosis, cerebral infarction, peripheral facial nerve numbness, trigeminal neuralgia, allergic rhinitis , Optic neuritis, corneal ulcers, sudden deafness, tinnitus, vertigo, frozen shoulder, cervical spondylosis, chronic constipation, phantom limb pain, indefinite report syndrome, etc.
After decades of research and discussion, the treatment range of stellate ganglion block is more and more extensive, and the treatment effect is more accurate. In developed countries, Japan SGB accounts for 50% to 80% of all nerve blocks, but it has not been widely used in China for a long time. The most critical problem is that because the location of stellate ganglion block is special, it requires very skilled doctors to operate it, and concerns about complications also make some doctors or patients reluctant to perform SGB, which hinders the promotion of SGB And development. However, due to medical needs, stellate ganglion block technology has become increasingly popular in major hospitals in China in recent years, and more and more diseases are treated with stellate ganglion block, such as more common diseases: migraine, tension Headache, cerebrovascular disease, cervical spondylosis, pain after herpes zoster, cardiac neurosis, etc., treated with this method have a certain effect. We believe that the use of stellate ganglion block, a practical treatment technique, will help more people get rid of the disease and improve the quality of life.
Quoted from https://wenda.tianya.cn/wenda/thread?tid=79831b0455d16e25&from=bottomThread