Assistant Professor University of Alabama at Birmingham
Jonas Kruse, B.S.: No financial relationships to disclose
Theresa Caridi, MD: Boston Scientific: Consultant (Ongoing), Speaking and Teaching (Ongoing); Cook Inc: Speaking and Teaching (Ongoing); PENUMBRA INC: Speaking and Teaching (Terminated); Terumo Medical: Speaking and Teaching (Ongoing); Trisalus Life Sciences: Advisory Committee or Review Panel Member (Ongoing); Varian Interventional Solutions: Speaking and Teaching (Ongoing)
Andrew Gunn, MD: Boston Scientific: Consultant (Ongoing), Speaking and Teaching (Ongoing); Penumbra: Research Grant Recipient (Ongoing); Varian: Consultant (Ongoing), Research Grant Recipient (Ongoing), Speaking and Teaching (Ongoing)
Review the indications and contraindications for stellate ganglion, interscalene, and phrenic nerve blocks
Describe the procedure for stellate ganglion, interscalene, and phrenic nerve blocks
Background: Stellate ganglion, interscalene and phrenic nerve blocks are useful procedures for the modern interventional radiologist and provide significant clinical benefit when performed correctly. Stellate ganglion blocks can be used for patients with complex regional pain syndrome, post-operative shoulder pain, and upper extremity pain. Interscalene blocks can be used for neurogenic thoracic outlet syndrome(nTOS), both diagnostically and therapeutically. Phrenic nerve blocks can be used for intractable, medically resistant hiccups. Herein we present a technical overview on how to perform these procedures.
Clinical Findings/Procedure Details: Stellate Ganglion Block: Utilizing an ipsilateral oblique view, a 25G needle is inserted and carefully advanced in a lateral-to-medial fashion under fluoroscopy towards the C6 uncovertebral junction (joint of Luschka). After trialing a small dose of contrast to confirm extravascular position, 10cc of local anesthetic is injected with or without steroids. Ipsilateral Horner’s is expected in a successful block.
Interscalene Triangle Block: Using an ultrasound, the brachial plexus cords are identified between the anterior scalene and middle scalene. A 25G needle is advanced under US guidance in posterior to anterior fashion until the tip is within the perineural echogenic fat. A total of 5-10cc of local anesthetic with steroid is injected into the region under US guidance.
Phrenic Nerve Block: Phrenic nerve can be identified as a small, hypoechoic structure on ultrasound crossing the anterior scalene posterior to the sternocleidomastoid. Blockade using 5-10cc of local anesthetic can result in cessation of hiccups. A sniff test under fluoroscopy can also be used to determine success of phrenic block.
Conclusion and/or Teaching Points:
Fluoroscopic stellate ganglion blocks should be employed by interventional radiologists in the treatment of CRPS I, as well as many other conditions
Ipsilateral Horner's syndrome and upper extremity warming are indications of a successful stellate ganglion block
Interscalene triangle block can be useful for diagnosis and potential symptomatic treatment of nTOS
Phrenic nerve blockade can be reasonably achieved under image guidance and provides significant benefit to patients with shoulder pain and intractable hiccups