Stellate Ganglion Block

The sympathetic nervous system (SNS) directly controls involuntary human homeostatic activities and has a major role in neuropathic, vascular and visceral pain. Sympathetically maintained pain occurs in a variety of vascular pathologies such as occlusive arterial diseases, diabetes mellitus or venous ulceration and neuropathic conditions such as complex regional pain syndrome (CRPS), postherpetic neuralgia and after peripheral nerve lesions.

Sympathetic blocks in the cervical and upper thoracic region are commonly used techniques for a variety of diagnostic, therapeutic and prognostic purposes. Stellate ganglion block is the common nomenclature utilized, however, stellate ganglion is present in only 80% of the population, thus, either lower cervical sympathetic block or upper thoracic sympathetic block is an appropriate term.

At Pain Spa Dr Krishna is very experienced in interventional treatments. Dr Krishna always performs stellate ganglion block under ultrasound guidance for greater accuracy and improved safety. Ultrasound provides the added advantage of visualizing the surrounding structures including muscles, nerves and blood vessels.

Relevant Anatomy

The cervical ganglia are identified as the superior, middle, intermediate, and inferior cervical sympathetic ganglia. In 80% of the population, the inferior cervical ganglia and the first thoracic ganglia fuse together to form the stellate ganglia. The inferior cervical ganglia when present as distinct structures are located on the transverse process of C7 vertebra. The first thoracic ganglia lie in the front of the neck of the first rib. When they are fused together, they form the stellate ganglia.

The stellate ganglion is oval in shape and measures 2.5 cm long, 1 cm wide and .5 cm thick and is usually located behind the subclavian artery in the front of the first rib.

All the sympathetic nerves that supply the head and neck and most of those that supply the upper extremity traverse through the stellate ganglion. Thus, stellate ganglion block produces a more complete sympathetic denervation to the head and neck structures.


Stellate ganglion block has been advocated for diagnostic, therapeutic and prognostic purposes for a variety of conditions, including:

Neuropathic pain disorders of the head, neck, and upper extremities

  • Complex Regional Pain Syndrome Type I (Reflex Sympathetic Dystrophy)
  • Complex Regional Pain Syndrome Type II (Causalgia)
  • Acute Herpes Zoster and post herpetic neuralgia
  • Post-amputation stump pain
  • Phantom limb pain
  • Radiation neuritis
  • Peripheral neuropathy
  • Atypical facial pain
  • Trigeminal neuralgia
  • Mastectomy pain and upper limb edema

Vascular insufficiency disorders of the head, neck, and upper extremities

  • Acute peripheral ischemia
  • Vasospasm and frostbite
  • Erythromelalgia
  • Scleroderma
  • Raynaud’s disease
  • Acrocyanosis
  • Buerger disease
  • Temporal arteritis
  • Arterial embolization from intra-arterial injection
  • Vascular headaches  (cluster, migraine)

Unique Indications

  • Hyperhidrosis
  • Meniere syndrome
  • Angina pectoris
  • Hot flashes
  • Post-traumatic stress disorders

Technique for stellate ganglion block

Multiple approaches have been used to localize the stellate ganglia. These include blind technique, plain fluoroscopic guidance and use of ultrasound. Traditionally these blocks have been performed either by using surface landmarks or by using a fluoroscopy-guided technique. Computerized tomography (CT) and magnetic resonance imaging (MRI) approaches have been described, these techniques are not practical in daily clinical practice. Recently, however, there has been a growing interest in using an ultrasound-guided technique because of the many advantages that this technique might offer.


Ultrasound guided stellate ganglion block

Ultrasound-guided SGB can improve the safety of the procedure by direct visualization of the related anatomical structures and, accordingly, the risk of vascular and soft tissue injury may be minimized. In addition, ultrasound guidance will allow direct monitoring of the spread of the injectate and hence may minimize complications such as recurrent laryngeal nerve (RLN) palsy and intrathecal, epidural or intravascular spread.

The procedure is usually done on an outpatient basis. Stellate ganglion block  injection is performed under ultrasound guidance to ensure accuracy of needle placement. Patients need to be aware that the outcome of the procedure is variable and they may not receive the desired benefits. Similarly, they must be aware of the transient nature of the therapeutic benefits and that there may need repeat injections.

Generally a mixture of local anaesthetic and steroid is injected. The local anaesthetic agent within the injectate may act on the nociceptive fibres, whereas corticosteroids may prolong the effects of the injection.


Complications are rare, particularly if the injections are performed using a precise needle-positioning technique. Possible complications include bruising, infection, hematoma, nerve injury and reaction to the injectates. Infection can be avoided with appropriate aseptic precautions. Severe allergic reactions to local anaesthetics are uncommon. Steroid injections may produce local reactions, occurring most often immediately after injection. These local reactions last for 24 to 48 hours, and are relieved by application of ice packs. Post-procedural pain flare-up may occasionally occur, and may be treated with painkillers.

It is important to know that stellate ganglion block can be associated with a number of serious complications as the stellate ganglion is located in close proximity to various vital structures. These complications include:

  • Intravascular injection
  • Subarachnoid injection
  • Pneumothorax
  • Retropharyngeal hematoma
  • Esophageal penetration
  • Mediastinal infection
  • Discitis


Stellate ganglion block is an innovate procedure that can be used in the management of a variety of chronic pain conditions including CRPS, phantom pain, facial pain and post herpetic neuralgia. More recently it has been used in management of hot flushes and post-traumatic stress disorder. Ultrasound technique has added a new dimension to this procedure, making it very safe and accurate. However it is important to note that in some cases injection treatment may not provide the desired results or the pain relief may not be sustained. At Pain Spa Dr Krishna is very experienced in interventional treatments. Dr Krishna always performs stellate ganglion block under ultrasound guidance for greater accuracy and improved safety. Ultrasound provides the added advantage of visualizing the surrounding structures including muscles, nerves and blood vessels.

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