|Year : 2020 | Volume
| Issue : 3 | Page : 291-298
Ultrasound-guided T2 and T3 paravertebral block versus ultrasound-guided stellate ganglion block in acute upper limb ischemia
Ahmed S Hegab, Gehan F Ezz
Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
|Date of Submission||27-Dec-2017|
|Date of Acceptance||10-Jan-2018|
|Date of Web Publication||29-Sep-2020|
MD Gehan F Ezz
Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, 44519
Source of Support: None, Conflict of Interest: None
Background Accidental intra-arterial injection can cause severe limb ischemia, often resulting in amputation. We reported a number of cases of acute upper limb ischemia with severe pain and ischemia in vascular surgery department for urgent relief of the pain and ischemia. Either ultrasound-guided stellate ganglion block or thoracic paravertebral block was done to protect upper limb from gangrene and amputation.
Purpose The aim of the present study is to compare the effect of ultrasound-guided stellate ganglion block with ultrasound-guided thoracic T2 and T3 paravertebral block in relief of pain and ischemia and also to compare the result of the block and complications.
Patients and methods Forty American Society of Anaesthesiologists status I–II adult patients 16–60 years of age with acute upper limb ischemia and severe pain were admitted to Vascular Surgery Department of Zagazig University Hospital. They were randomly divided into two groups: group S (n=20) where ultrasound-guided stellate ganglion block was done, and group TPV (n=20), where ultrasound-guided thoracic paravertebral block was done. Both groups received 10 ml bupivacaine (0.25%)+16 mg dexamethasone for relief of the pain and ischemia, and the complications that resulted from the procedure were followed and recorded.
Results There was significant decrease in visual analog scale in both groups after the stellate ganglion block and thoracic paravertebral block, with minimal complications with thoracic paravertebral block and relief of pain and ischemia in both groups.
Conclusion Thoracic paravertebral block is a good choice in acute upper limb ischemia with rapid relief of the pain and restoration of peripheral perfusion with minimal complications.
Keywords: stellate ganglion block, thoracic paravertebral block, upper limb ischemia
|How to cite this article:|
Hegab AS, Ezz GF. Ultrasound-guided T2 and T3 paravertebral block versus ultrasound-guided stellate ganglion block in acute upper limb ischemia. Res Opin Anesth Intensive Care 2020;7:291-8
|How to cite this URL:|
Hegab AS, Ezz GF. Ultrasound-guided T2 and T3 paravertebral block versus ultrasound-guided stellate ganglion block in acute upper limb ischemia. Res Opin Anesth Intensive Care [serial online] 2020 [cited 2020 Oct 23];7:291-8. Available from: http://www.roaic.eg.net/text.asp?2020/7/3/291/296612
| Introduction|| |
Unintentional intra-arterial injection of medication, either iatrogenic or self-administered, is a source of considerable morbidity. Normal vascular anatomical proximity, aberrant vasculature, procedurally difficult situations, and medical personnel error all contribute to unintentional cannulation of arteries in an attempt to achieve intravenous access. Delivery of certain medications through arterial access has led to clinically important sequelae, including paresthesias, severe pain, motor dysfunction, compartment syndrome, gangrene, and limb loss .
Stellate ganglion block (SGB) is a possible method to produce sustained arterial and venous vasodilation, the advantage of performing block must be weighed against the risks of the procedure. For example, a SGB by an inexperienced anesthesiologist in a person with an obese neck can be risky, leading to pneumothorax, spinal anesthesia, recurrent laryngeal nerve (RLN) or phrenic nerve paralysis, local anesthetic toxicity, etc. Therefore, these therapies must not be regarded as benign. They may be used if there are no contraindications to the procedure, and as an alternative to more drastic measures in the face of potential tissue necrosis (e.g. surgical revascularization or amputation) .
Ultrasound-guided SGB can improve the safety of the procedure by direct visualization of the related anatomical structures, and therefore can minimize the risk of vascular and soft tissue injury. In addition, ultrasound guidance allows direct monitoring of the spread of the injectate, and hence may minimize complications such as RLN palsy and intrathecal, epidural, or intravascular spread .
The thoracic paravertebral block (TPVB) can be traced back to a seminal article by Eason and Wyatt in 1979, although it was first described by Selheim in 1906 and modified by Lawen in 1911. The conventional technique of TPVB involves inserting the needle perpendicular to all planes, contacting the transverse process, and then walking off it with the needle. The commonly used endpoints for needle insertion include loss of resistance to air or saline, advancing a predetermined distance, or neurostimulation .
This block was performed by loss of resistance tequnique, with the transverse process being an important landmark. Block needle encounters the bone. If it is not encountered, the needle tip might advance further causing pleural puncture . The ultrasound scanning of the transverse process and parietal pleura gives an accurate reading of the depth of the paravertebral space .
Stellate ganglion anatomic consideration
The cervical sympathetic chain is composed of superior, middle, and inferior cervical ganglia. In ∼80% of the population, the inferior cervical ganglion is fused with the first thoracic ganglion, forming the cervicothoracic ganglion, also known as the stellate ganglion .
The stellate ganglion is located medial to the scalene muscles; lateral to the longus colli muscle, esophagus and trachea, along with the RLN in between; anterior to the transverse processes; superior to the subclavian artery and the posterior aspect of the pleura; and posterior to the vertebral vessels at the C7 level (this will increase risk of risk of pneumothorax and vertebral artery injury when performing the blockade at the C7 level .
The stellate ganglion measures ∼2.5 cm in length, 1 cm in width, and 0.5 cm in thickness. It is located posteriorly in the chest in front of the neck of the first rib and may extend to the seventh cervical (C7) vertebral body .
Anatomy of thoracic paravertebral space
The thoracic paravertebral space (TPVS) is a triangular or wedge-shaped space running the length of the thoracic vertebral column bilaterally (see the image below). The TPVS is wider on the left side than on the right.
It is bounded posteriorly by the superior costotransverse ligament (a continuation of the internal intercostal muscle); anteriolaterally by the parietal pleura; and medially by the vertebral bodies, intervertebral foramina, and the intervertebral discs.
In contrast to cervical and lumbar regions, the TPVS is in continuity with adjacent vertebral levels, allowing for spread of local anesthetic. This anatomic property explains why the TPVS may have more utility than cervical or lumbar paravertebral blocks ,.
| Patients and methods|| |
A prospective randomized controlled double-blind study was done after local ethics committee approval and written informed consent. The study was done in Zagazig University Hospital in the period between October 2016 and August 2017 on 40 patients with American Society of Anaesthesiologists (ASA) status I or II in the age group of 18–60 years. Both male and female patients with acute upper limb ischemia were included. They were managed by calling an anesthesiologist to the vascular surgery department for intervention to decrease pain and protect limb from amputation (after unintentional intra-arterial injection of medication).
SGB was done as follows:
- Patients with the following criteria were excluded from our interventions: ASA status III–IV, renal insufficiency (creatinine level>1.5 mg/dl), a history of opioid dependence, pregnancy, morbid obesity (BMI>40 kg/m2), chronic analgesia, history of sensitivity to local anesthetic, bleeding disorders, receiving anticoagulant, or spine or chest wall deformity. All patients were transferred to the operating theater. On arrival to the operating room, patients were connected to the standard monitoring with ECG, noninvasive arterial blood pressure, and pulse oximetry. All patients were premedicated with intravenous midazolam (0.05 mg/kg). Skin temperature probe was attached to the limb. The patients were administered with 10 ml bupivacaine (0.25%)+16 mg dexamethasone for both groups.
- Group S (n=20): SGB was done under ultrasound guidance.
- Group TPV (n=20): TPVB was done under ultrasound guidance.
- Linear transducer (high frequency 6–13 MHz) 22-G spinal needle was used.
Patient was placed in decubitus supine position with the head slightly extended (a small pillow was used between the shoulders) slightly rotated toward the opposite side of the procedure. Sterile dressing was done to the neck, and initial scan was performed to identify structures such as thyroid, carotid artery, and jugular vein. The transverse process at C6 was identified because of its prominent anterior tubercle; below the carotid artery were the longus colli muscle and the lower part of transverse process of C7. which was recognized by its former tuber. Longus colli was found above the transverse process of C6. By using the ultrasound the approximation plane where the needle path heading medially over the longus colli muscle the puncture was done on the plane to see the tip of the needle at all times; the needle was directed medially until it passes through the deep cervical fascia, above the longus colli muscle.
Approximately 10 ml of drug was injected, and after observing the dissection between the carotid artery and the longus colli muscle, the full dose of the drug was given ([Figure 1],[Figure 2],[Figure 3],[Figure 4]).
|Figure 1 Stellate ganglion block before injection of drugs. Blooking needle: arrow heads in blue; carotid artery: red circle; longus colli muscle: green circle; transverse process of C7: brown line.|
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|Figure 2 Stellate ganglion block during injection, injected local anesthetic yellow circle.|
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|Figure 3 T2 paravertebral block before injection of drugs. Blooking needle: arrow heads in blue; paravertebral space: triangular space bounded in yellow; pleura: red line; internal intercostal membrane: brown line.|
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|Figure 4 T2 preverbal block during injection, note downward displacement of pleura.|
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In group TPV, TPV was done at the level of the second and third thoracic vertebra with the patient in the lateral position under complete aseptic condition. Patients were placed in the lateral position. After skin and transducer preparation (curvilinear transducer of frequency 3–5 MHz) in axial plane on the rib at the level of the second and third thoracic vertebrae just lateral to spinous process, the transducer was moved caudally into intercostal space between the adjacent ribs. The thoracic prevertebral space and adjacent intercostal space appear. The thoracic paravertebral space (TPVS) appears as a wedge-shaped hypoechoic layer demarcated by pleura below as hyperechoic lines and internal intercostal membrane above, 22-G spinal needle was used and tip of the needle that appear is essential at all times to avoid inadvertent pleural puncture or entry into intervertebral foramen. This needle was inserted after local anesthetic infiltration of the skin at the outer end of transducer in plane with the ultrasound beam. The bevel of the needle was directed upward toward the transducer to avoid risk of penetration of intercostal vessels, nerves, or pleura. The needle was advanced in lateral to medial direction and advanced till reaching the TPVS through the internal intercostal membrane.
After the injection of local anesthetic, visual analog scale (VAS) assessment was done in both groups. Before and after the block, Analgesia was given before the block was done and after that in the form of 500 mg/8hrs paracetamol and 75 mg ̸12hrs pregabaline when the VAS score was at least 4 at any time after the injection in the first 24 h.
All complications that occur during and after injection were recorded such as Horner’s syndrome and immediate complications like hoarseness of voice, hematoma, and respiratory insufficiency (phrenic nerve affection). Skin temperature of the ipsilateral extremity was recorded. The number of patients who needed supplemental analgesic was recorded.
The pain was assisted by (VAS) visual analogue scale score was recorded at the following intervals: before injection, after injection, and at each successive injection. Horner’s syndrome and immediate complications like hoarseness of voice, hematoma, weakness in the limb, and respiratory insufficiency were recorded. Skin temperature of the ipsilateral extremity was recorded. The number of patients who needed supplemental analgesic was recorded.
Data were tabulated and subjected to computer assisted statistical analysis using the statistical package for social science, version 18.0 (IBM SPSS 18, SPSS Inc., Chicago, Illinois, USA). Continuous data were expressed by mean±SD, whereas categorical data were expressed as frequency and percentage. Student’s t-test was used for comparing the means of continuous data. Categorical data were compared using χ
2. P-value less than 0.05 was considered statistically significant.
| Results|| |
There was no significant difference between the two studied groups regarding demographic data of the study participants ([Table 1]).
Pain VAS scores before and after injections in the two groups are stated as mean±SD in [Table 2]. There was a high statistical significant difference among both studied groups regarding VAS score recorded before and after injection.
|Table 2 Visual analog scale score among group S and TPV group before and after injection|
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One patient in group S (SGB group) developed small hematoma after the injection, with no need for surgical intervention.
Horner’s syndrome (a sign for successful block) and nasal congestion were observed after block within 5–10 min in 20 patients in group S (SGB group) as compared with group TPV, where none of these complications occurred.
The skin temperature of the ipsilateral arm to the block got elevated (1°–3°C) above basal values in both groups, except for two patients in the group S, where skin temperature was not elevated (failure of the SGB).
Temporary hoarseness of voice was recorded in one patient of the group S.
Four patients had parathesia and pumpness in group S as compared with TPV group.
Three patients experienced dyspnea (phrenic nerve block) in group S.
Group thoracic paravertebral block (TPV) showed minimal complication, but hypotension was seen in eight patients as compared with stellate ganglion(S) block, and back pain was seen in six patients as compared with one patient in group S ([Table 3]). Hypotension and back pain were higher in frequency among group TVA than group S, whereas Horner’s syndrome and parathesia were higher in group S than group TVA, and the difference was statistically significant. Overall, 15, 10, and 5% of patients in group S complained of phrenic nerve block, failure of block, and hoarseness of voice, respectively, compared with none in group TVA ([Figure 5]).
| Discussion|| |
Intra-arterial injections are catastrophic problem for the patients, where limb ischemia, necrosis, gangrene or amputations can result, so it is very important to be aware of the symptoms, signs, and immediate treatment options of this unpleasant event. The problem is that no definite guidelines are available so far, and all the recommendations for management of inadvertent intra-arterial injections are based on individual case reports. Treatment of these patients is therefore directed toward symptomatic relief, cessation or reversal of arterial spasm, reestablishment of blood flow, treatment of any complication, and long-term rehabilitation .
Sen et al.  showed that unintentional intra-arterial injection of medication, either iatrogenic or self-administered, is a source of considerable morbidity. Delivery of certain medications via arterial access has led to clinically important sequelae, including paresthesias, severe pain, motor dysfunction, compartment syndrome, gangrene, and limb loss .
In our study, we did SGB under ultrasound guidance in group S and compared the results of this block with the results of TPVB under ultrasound guidance, with the aim of restoring peripheral perfusion and relieving pain. Ultrasonography is a very useful tool that allows for real-time visualization of the vascular structures (carotid and vertebral artery) and the visceral structures (esophagus), and thus helps in preventing puncture injuries . Ultrasound-guided SGB may also improve the safety of the procedure by direct visualization of vascular structures (inferior thyroidal, cervical, vertebral, and carotid arteries) and soft tissue structures (thyroid, esophagus, and nerve roots). Accordingly, the risk of vascular and soft tissue injury may be minimized .
In line with our study, Rastogi and Muhammad  stated that SGB has been used successfully in the treatment of painful conditions of the face and upper extremity. Common indications include painful syndromes of the face and upper extremity CRPS I and II, phantom limb pain, Herpes zoster and postherpetic neuralgia, Herpes zoster and postherpetic neuralgia, Paget’s disease, vascular insufficiency in the upper extremity, obliterative arterial disease (embolic/traumatic), postembolectomy vasospasm, postreimplantation surgery, and postimplantation surgery . The skin temperature of the ipsilateral arm to the block was elevated by 1°–3° above the baseline measurement value after injection, indicating the success of the technique because of the increase in the blood flow owing to the sympathetic effect of SGB. This was clarified by Yamazaki et al.  who used laser-Doppler blood flowmetry to confirm changes in blood flow following SGB.
In the current study, the VAS scores in both groups showed that there were statistical significant differences among the two studied groups regarding VAS scores before and after injection, where there was significant decrease in VAS score after the injection in group S and group TPV. This is in agreement with Nabil Abbas et al.  who reported that fluoroscopic SGB with the classic anterior and oblique approach decreased pain VAS, daily morphine consumption, and areas of allodynia and increased the patient satisfactory score.
Many complications in our study occurred mainly in group S as compared with group TPV such as hematoma, Horner’s syndrome, and phrenic nerve paralysis. Elias and Chakerian  showed that technical complications include injury to the nerves and nearby viscera during insertion of the needle ,,,. Which include injury to the brachial plexus; trauma to the trachea and esophagus (with mediastinal and surgical emphysema); injury to the pleura and lung (pneumothorax and hemothorax, which may require chest tube insertion); and bleeding and local hematoma, which can lead to airway compression.
In the study of Huntoon , it was found that arterial vessels other than the vertebral artery, which also supplies the anterior spinal cord and brain stem, pass directly anterior to the transverse processes at the site of the conventional anterior paratracheal approach. Therefore, the accidental injection or induced spasm of these vessels (and not the vertebral arteries) is responsible for some cases of seizure, hematoma, or other vascular complications during the conventional SGB.
The hoarseness of voice observed in the current study, which probably occurred because of the spread of the local anesthetic to the RLN. However, Hardy and Wells  reported an incidence of 10% with 10-ml local anesthetic solution and up to 80% with 20 ml solution in the classic approach. Kapral et al.  reported RLN palsy in only one patient of 12 patients in whom ultrasonography showed the spread of the local anesthetic between the carotid sheath, thyroid gland, and the esophagus (the anatomic site of the RLN), so bilateral stellate block is not commonly done.
The SGB should be confirmed by the presence of a unilateral Horner syndrome (ptosis, meiosis, anhydrosis, and nasal congestion) which occurred in our study in nearly all patients . Horner’s syndrome is caused by interruption of the occulosympathetic pathway at the site of the CTG or at the site of the ventral sympathetic roots between the eighth cervical and second thoracic spinal nerves .
In this current study, there were three cases in group(s) that experienced dyspnea and respiratory insufficiency (phrenic nerve block). Mahli et al.  stated that the complications of SGB are recurrent laryngeal or phrenic nerve block, pneumothorax, unconsciousness, respiratory paralysis, convulsions, and sometimes severe arterial hypotension, which occurred in their study as well as ours.
In this study, in group S, two cases did not respond to the block and did not gave the effect of sympathectomy (failure of the block); this is with agreement with Kuntz , who stated that the second thoracic nerve is not regarded as contributory to the brachial plexus. An inconsistent intrathoracic ramus joining the second intercostal nerve to the ventral ramus of the of the first thoracic nerve, proximal to the point where the latter gave a large branch to the brachial plexus, was observed, and this nerve was considered to be carrying sympathetic fibers to the brachial plexus without passing through the sympathetic trunk .
TPVB was performed in our study with many advantages of relief of pain, minimal complications (hypotension due to epidural spread and back pain) with the advantage of ultrasound technology. Together with us Schnabel et al.  stated that TPVB has recently undergone resurgence with improvements in ultrasound technology, affording many benefits including direct visualization of local anesthetic spread and pleura, and this decreases the large volume of anesthetic to be injected at fewer levels while still achieving adequate analgesia.
PVB allows for efficient spontaneous breathing and early mobilization, minimizing the risk of postoperative respiratory dysfunction. Schnabel et al.  and Tahiri et al. , in their meta-analysis, evaluated the efficacy and safety of TPVB in breast surgery and also compared TPVB with general anesthesia.
TPVB, when given with sedation, provided effective surgical anesthesia for patients undergoing breast procedures. They also concluded that TPVB alone, or in addition to general anesthesia, provided better postoperative pain control with little adverse effects, when compared with other analgesic options. In addition, when used instead of general anesthesia, TPVB resulted in pain scores that were significantly decreased postoperatively .
TPVB gave rapid pain relief and minimal complications in all cases of the study group.
In our study, we did not find any study performing the TPVB in the management of acute upper limb ischemia.
TPVB gave good and safe results in our study in all cases of the study group.
| Conclusion|| |
The thoracic paravertebral block can be used in acute upper limb ischemia with excellent result and minimal complications as compared with the SGB in acute upper limb ischemia.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Sen S, Chini EN, Brown MJ. Complications after unintentional intra-arterial injection of drugs: risks, outcomes, and management strategies. Mayo Clin Proc 2005; 80:783–795.
Ghouri AF, William M, Kavitha P. Department of Anesthesiology. San Diego, California: University of California at Irvine School of Medicine; 2002.
Peng P, Narouze S. Ultrasound-guided interventional procedures in pain medicine: a review of anatomy, sonoanatomy and procedures. Part I: non-axial structures. Reg Anesth Pain Med. 2009; 34:458–474.
Shibata Y, Nishiwaki K. Ultrasound-guided intercostal approach to thoracic paravertebral block. Anesth Analg 2009; 10:996–997.
Karmakar MK. Thoracic paravertebral block. Anesthesiology 2001; 95:771–780.
Pusch F, Wildling E, Klimscha W, Weinstabl C. Sonographic measurement of needle insertion depth in paravertebral blocks in women. Br J Anaesth 2000; 85:841–843.
Fitzgerald MJT. Neuroanatomy: basic and clinical. 3rd ed. London, UK: WB Saunders; 1996.
Hogan Q, Erickson SJ. Magnetic resonance imaging of the stellate ganglion: normal appearance. Am J Roentgenol 1992; 158:655–659.
Raj PP. Stellate ganglion block. In: Waldman W, editor. Interventional pain management. Philadelphia, PA: Saunders; 1996. pp. 269.
MacIntosh R, Bryce-Smith R. Local analgesia and abdominal surgery. Edinburgh, Scotland: E&S Livingstone; 1962. pp. 6–32.
Kittredge RD. Computed tomographic evaluation of the thoracic prevertebral and paravertebral spaces. J Comput Tomogr 1983; 7:239–250.
Serna–Gutierrez J. Ultrasound-guided stellate ganglion block Bloqueo ganglio estrellado guiado por ultrasonografia. Colombian J Anesthesiol 2015; 43:278–282.
Narouze S. Northeast Ohio Medical University June, 2014
Rastogi R, Muhammad H. 2015; 43:278–282.
Yamazaki J, Nishiyama J, Suzuki T. Use of perfusion index from pulse oximetry to determine efficacy of stellate ganglion block. Local Reg Anesth 2012; 5:9–14.
Nabil Abbas D, Abd El Ghafar EM, Ibrahim WA, Omran AF. Fluoroscopic stellate ganglion block for postmastectomy pain: a comparison of the classic anterior approach and the oblique approach. Clin J Pain 2011; 27:207–213.
Elias M, Chakerian M. Repeated stellate ganglion block using a catheter for pediatric herpes zoster ophthalmicus. Anesthesiology 1994; 80:950–952.
Huntoon MA. The vertebral artery is unlikely to be the sole source of vascular complications occurring during Stellate ganglion block. Pain Pract 2010; 10:25–30.
Hardy PAJ, Wells JCD. Extent of sympathetic blockade after stellate ganglion block with bupivacaine. Pain 1989; 36:193–196.
Kapral S, Krafft P, Gosch M, Fleischmann D, Weinstabl C. Ultrasound imaging for stellate ganglion block: direct visualization of puncture site and local anesthetic spread: a pilot study. Reg Anesth 1995; 20:323–328.
Field R, Keene D, Abdi S. Radiofrequency treatment. Elsevier long lasting analgesic effect of radiofrequency treatment. Current Therapy in Pain. Elsevier; 2009. pp. 596–607.
Skarda RT, Hubbell JAE. Monitoring and emergency therapy, Equine Anesthesia (Second Edition). 2009. pp. 288–314.
Mahli A, Coskun D, Akçali T. Aetiology of convulsions due to stellate ganglion block: a review and report of two cases. Eur J Anaesthesiol 2002; 19:376–380.
Kuntz A. Distribution of the sympathetic rami to the brachial plexus :its relation to sympathectomy affectingthe upper extremity. Arch Surg 1927; 15:871–877.
Schnabel A, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn PK. Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials. Br J Anaesth 2010; 105:842–852.
Tahiri Y, Tran DQH, Bouteaud J, Xu L, Lalonde D, Luc M, Nicolis A. General anaesthesia versus thoracic paravertebral block for breast surgery: a meta-analysis. J Plast Reconstr Aesthet Surg 2011; 64:1261–1269.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]