Stellate ganglion block inhibits formalin-induced nociceptive responses: mechanism of action

Ultrasound-guided stellate ganglion block benefits the postoperative recovery of patients undergoing laparoscopic colorectal surgery: a single-center, double-blinded, randomized controlled clinical trial

BACKGROUND

With the increasing prevalence of colorectal cancer (CRC), optimizing perioperative management is of paramount importance. This study investigates the potential of stellate ganglion block (SGB), known for its stress response-mediating effects, in improving postoperative recovery. We postulate that preoperative SGB may enhance the postoperative recovery of patients undergoing laparoscopic CRC surgery.

METHODS

We conducted a randomized controlled trial of 57 patients undergoing laparoscopic colorectal cancer surgery at a single center. Patients, aged 18-70 years, were randomly assigned to receive either preoperative SGB or standard care. SGB group patients received 10 mL of 0.2% ropivacaine under ultrasound guidance prior to surgery. Primary outcome was time to flatus, with secondary outcomes encompassing time to defecation, lying in bed time, visual analog scale (VAS) pain score, hospital stays, patient costs, intraoperative and postoperative complications, and 3-year mortality. A per-protocol analysis was used.

RESULTS

Twenty-nine patients in the SGB group and 28 patients in the control group were analyzed. The SGB group exhibited a significantly shorter time to flatus (mean [SD] hour, 20.52 [9.18] vs. 27.93 [11.69]; p = 0.012), accompanied by decreased plasma cortisol levels (mean [SD], postoperatively, 4.01 [3.42] vs 7.75 [3.13], p = 0.02). Notably, postoperative pain was effectively managed, evident by lower VAS scores at 6 h post-surgery in SGB-treated patients (mean [SD], 4.70 [0.91] vs 5.35 [1.32]; p = 0.040). Furthermore, patients in the SGB group experienced reduced hospital stay length (mean [SD], day, 6.61 [1.57] vs 8.72 [5.13], p = 0.042).

CONCLUSIONS

Preoperative SGB emerges as a promising approach to enhance the postoperative recovery of patients undergoing laparoscopic CRC surgery.

CLINICAL TRIAL REGISTRATION

ChiCTR1900028404, Principal investigator: Xia Feng, Date of registration: 12/20/2019.

Postoperative stellate ganglion block to reduce myocardial injury after laparoscopic radical resection for colorectal cancer: protocol for a randomised trial

INTRODUCTION

Stellate ganglion block (SGB) is usually used in the department of algiatry. But preoperative SGB may reduce adverse cardiovascular events in high-risk patients, although evidence remains sparse. Therefore, we aim to determine whether a single-shot postoperative SGB can reduce the incidence of myocardial injury after non-cardiac surgery (MINS) and improve recovery in patients undergoing laparoscopic radical resection for colorectal cancer.

METHODS AND ANALYSIS

This is an investigator-initiated, single-centre, randomised, two-arm clinical trial enrolling patients aged over 45 years and scheduled for elective laparoscopic radical colorectal surgery with at least one risk factor for MINS. A total of 950 eligible patients will be randomised into a routine or block groups. The primary outcome is the incidence of MINS. The secondary outcomes include the Visual Analogue Scale of pain during rest and movement, the incidence of delirium, quality of recovery (QOR) assessed by QOR-15, and sleep quality assessed by Richards Campbell Sleep Questionnaire. Tertiary outcomes include time to first flatus, gastrointestinal complications such as anastomotic leak or ileus, length of hospital stay, collapse incidence of severe cardiovascular and cerebrovascular complications of myocardial infarction, cardiac arrest, ischaemic or haemorrhagic stroke, and all-cause mortality within 30 days after the operation.

ETHICS AND DISSEMINATION

The protocol was approved by Medical Ethics Committee of the China-Japan Union Hospital, Jilin University (Approval number: 2021081018) prior to recruitment. The study will be performed according to the guidelines of the Declaration of Helsinki. The findings of this study will be published and presented through various scientific forums.

TRIAL REGISTRATION NUMBER

ChiCTR2200055319.

Stellate ganglion intervention for chronic pain: A review

Stellate ganglion (SG) intervention is currently widely being studied in many kinds of chronic pain. As one of the convenient ways to treat the sympathetic nervous system, the indications for stellate ganglion intervention (SGI) include complex regional pain syndrome, postherpetic neuralgia, cancer pain of different origins, orofacial pain, and so forth. SGI refers to the reversible or irreversible blocking of the cervical sympathetic trunk, cervical sympathetic ganglion, and their innervation range through noninvasive or minimally invasive treatment. Current treatment options include stellate ganglion block (SGB), SG pulsed radiofrequency, continuous radiofrequency treatment, and noninvasive SGB. In particular, SGB continues to be one of the most studied methods in chronic pain management. However, a single SGB usually provides only short-term effects; repeated SGB may result in complications such as hoarseness, light-headedness, and vessel or nerve injury. Meanwhile, the mechanism of SGI is still unclear. This review discusses the research progress of SGI methods, effectiveness, complications, and possible mechanisms in the management of chronic pain.

Preoperative Stellate Ganglion Block for Perioperative Pain in Lateralized Head and Neck Cancer: Preliminary Results

Patients with head and neck cancer represent a vulnerable population at particular risk of opioid dependence due to frequent histories of substance abuse, requirement of extensive surgery, and the synergistic toxicity of multimodal therapy. Regional anesthetic techniques have been used by other surgical disciplines to facilitate early recovery after surgery and decrease postoperative patient narcotic requirements. This pilot study investigates the efficacy of a preoperative regional analgesia using stellate ganglion block in lateralized head and neck cancer surgery. From our early results, stellate ganglion blockade may hold promise as an effective preoperative intervention for controlling early postoperative pain, lessening narcotic requirements, and improving quality of life.

Pulsed radiofrequency of superior cervical ganglion for treatment of painful post-traumatic trigeminal neuropathy (PTTN): A case series report

Objective: Painful post-traumatic trigeminal neuropathy (PTTN) is a clinical pain syndrome that occurs due to injuries to the peripheral branches of the trigeminal nerve and is characterized by a deep burning pain and accompanied by positive and negative neurological signs. In patients with recalcitrant PTTN, the sympathetic nervous system is a potential therapeutic target. The aim of this study was to investigate the therapeutic response of PTTN patients to pulsed radiofrequency treatment (PRF) of the superior cervical sympathetic ganglion (SCG).Methods: Thirty-five patients with PTTN who had a history of severe disabling facial neuropathic pain underwent PRF of the SCG under a new lateral fluoroscopic approach.Results: The patients' pain intensity post-PRF was 3.94 (± 3.11), compared with 8.82 (± 1.27) pre-PRF (p < .001).Conclusion: PRF of the SCG could be an effective method to treat chronic PTTN.

Effect of Stellate Ganglion Block on the Regional Hemodynamics of the Upper Extremity: A Randomized Controlled Trial

BACKGROUND

The success of stellate ganglion block (SGB) is traditionally determined on the basis of findings such as Horner's syndrome, temperature rise in the face, hyperemia of the tympanic membrane, and nasal congestion. However, decreases in vascular resistance and increases in blood flow in the arm may be more meaningful findings. To date, the effect of SGB on the regional hemodynamics of the arm has not been evaluated using pulsed-wave Doppler ultrasound.

METHODS

A total of 52 patients who were to undergo orthopedic surgery of the forearm were randomly assigned to either the mepivacaine group (SGB with 5 mL of 0.5% mepivacaine) or the saline group (SGB with 5 mL of normal saline). Before surgery, a single anesthesiologist performed a SGB under ultrasound guidance. The temperature of the upper extremity and the resistance index and blood flow in the brachial artery were measured before SGB, 15 and 30 minutes after SGB, and 1 hour after surgery. The severity of pain, requirement for rescue analgesics, and side effects of the local anesthetic agent were all documented.

RESULTS

After SGB, the resistance index decreased significantly and the blood flow increased significantly in the brachial artery of members of the mepivacaine group (15 minutes: P = .004 and P < .001, respectively; 30 minutes: P < .001 and P < .001, respectively). However, these values normalized after surgery. The severity of pain, need for rescue analgesics, and incidence of adverse effects were not significantly different between the 2 groups.

CONCLUSIONS

Although SGB did not decrease the pain associated with forearm surgery, ultrasound-guided SGB did increase blood flow and decrease vascular resistance in the arm. Therefore, pulsed-wave Doppler may be used to monitor the success of SGB.

CT-Guided Stellate Ganglion Pulsed Radiofrequency Stimulation for Facial and Upper Limb Postherpetic Neuralgia

Objective: Postherpetic neuralgia (PHN) is the most common complication of herpes zoster, manifesting as a persistent, spontaneous, knife-like pain or paroxysmal burning that seriously affects a patient’s quality of life. An effective treatment of PHN is lacking. This retrospective study examined the efficacy and safety of stellate ganglion (SG) pulsed radiofrequency (PRF) on facial and upper limb PHN.

Methods: Eighty-four patients with PHN on the face or upper limbs were enrolled for the study. Patients were randomly divided into two surgical groups according to the order of enrollment; one group underwent SG block (SG-B group, n = 42) and the other underwent SG pulsed radiofrequency (SG-P group, n = 42). After surgery, patients were followed at 1 week, 2 weeks, 1 month, 3 months, and 6 months. Observation at each follow-up included basic patient characteristics, visual analog scale (VAS), quality of life (QOL) using Physical Component Summary (PCS), and Mental Component Summary (MCS) to assess, total effective rate, complications and side effects.

Results: Compared with preoperative values, VAS decreased in both groups after surgery (P < 0.05). In the SG-B group, VAS increased after 1 month, while in the SG-P group, VAS gradually decreased at later follow-up time points. VAS decreased more significantly in the SG-P group after 1 month (P < 0.05). PCS and MCS increased in both groups after the operation, and the difference was significant compared with preoperative values (P < 0.05). The total effective rates of the SG-B and SG-P groups were 64.3 and 83.3%, respectively. The total effective rate of the SG-P group was higher than that of the SG-B group (P < 0.05). The incidence of complications and side effects in the SG-B group was higher than that in the SG-P group (P < 0.05).

Conclusion: SG pulsed radiofrequency treatment of facial and upper limb PHN is safe and effective. It is a treatment method worth promoting.

Therapeutic potential of stellate ganglion block in orofacial pain: a mini review

Orofacial pain is a common complaint of patients that causes distress and compromises the quality of life. It has many etiologies including trauma, interventional procedures, nerve injury, varicella-zoster (shingles), tumor, and vascular and idiopathic factors. It has been demonstrated that the sympathetic nervous system is usually involved in various orofacial pain disorders such as postherpetic neuralgia, complex regional pain syndromes, and atypical facial pain. The stellate sympathetic ganglion innervates the head, neck, and upper extremity. In this review article, the effect of stellate ganglion block and its mechanism of action in orofacial pain disorders are discussed.

Effects on hemodynamic variables and echocardiographic parameters after a stellate ganglion block in 15 healthy volunteers

BACKGROUND

The sympathetic nervous system has an important role in generating pain. Various pathomechanisms are involved that respond well to the application of local anesthetics (LA), for example to the stellate ganglion block (SGB).

OBJECTIVES

We wanted to know more about the effects of SGB on cardiovascular parameters.

METHODS

We included 15 healthy volunteers; another 15 healthy volunteers as a control group (sham injection of LA). In order to produce a more precise SGB, we employed only a small volume of LA (3mL), a LA with a lower permeability (procaine 1%), and a modified injection technique. Systolic and diastolic blood pressure (SBP, DBP), heart rate (HR), and echocardiographic parameters were recorded before and after SGB. We also investigated whether there are side differences (left and right SBG).

RESULTS

At baseline all parameters were within the normal range. After performing right and left SGB DBP significantly increased (on the right side from 68.73±8.61 to 73.53±11.10, p=0.015; on the left side from 70.66±13.01 to 77.93±10.40, p=0.003). In the control group no increase in DBP was observed. No side-specific differences were found, except a significant reduction in the maximum velocity of myocardial contraction during the systole with left-sided SGB.

CONCLUSIONS

Even with our methods we could not prevent the simultaneous occurrence of a partial parasympatholytic effect. For this reason, the SGB has only minor hemodynamic effects, which is desirable as it enhances the safety of the SGB.

Stellate ganglion pulsed radiofrequency ablation for stretch induced complex regional pain syndrome type II

Complex regional pain syndrome (CRPS) following injury or nerve damage, as its name signifies, is a challenging entity, and its successful management requires a multidisciplinary approach. It not only manifests as severe pain, but also gives rise to functional disability, lack of sleep, lack of enjoyment of life and poor quality of life. Various pain interventional techniques have been described in the literature for the management of CRPS ranging from sympathetic blocks to spinal cord stimulator. A 34-year-old liver transplant donor, who developed position-induced right upper limb neuropathic pain suggestive of CRPS type II was managed initially with medications and later with stellate ganglion block under fluoroscopic guidance at cervical C7 position. Following an initial significant improvement in pain and allodynia, which was transient, a pulsed radiofrequency ablation of stellate ganglion was performed successfully to provide prolonged and sustained pain relief, which persisted up to 14 months of follow-up.

The effect of stellate ganglion block on the atypical facial pain

Atypical facial pain (AFP) is a type of facial pain which does not fulfill any other diagnosis. It has several features such as no objective signs, no obvious explanation of the cause and poor response to treatments. We report a case of a female patient with AFP on the left maxillary area. The pain was increased by cold innocuous stimulation and thermography showed that the temperature on the painful area was significantly decreased. The pain was successfully alleviated by stellate ganglion block (SGB). Therefore, SGB can be effectively used to treat AFP.

Radiofrequency ablation of stellate ganglion in a patient with complex regional pain syndrome

Complex regional pain syndrome (CRPS) is characterized by a combination of sensory, motor, vasomotor, pseudomotor dysfunctions and trophic signs. We describe the use of radiofrequency (RF) ablation of Stellate ganglion (SG) under fluoroscopy, for long-term suppression of sympathetic nervous system, in a patient having CRPS-not otherwise specified. Although the effects of thermal RF neurolysis may be partial or temporary, they may promote better conditions toward rehabilitation. The beneficial effect obtained by the RF neurolysis of SG in this particular patient strongly advocates the use of this mode of therapy in patients with CRPS.

Utility of stellate ganglion block in atypical facial pain: a case report and consideration of its possible mechanisms

We present this report of a young patient with chronic severe atypical facial pain who was successfully controlled with stellate ganglion block under ultrasound guidance. The patient had a history of severe disabling, unilateral, facial neuropathic pain with minimal response to analgesic medications. Upon assessment the patient had features suggestive of trigeminal neuralgia, although postherpetic neuralgia could not be ruled out. As a diagnostic test intervention, stellate ganglion block was tried under ultrasound guidance. The patient showed significant improvement in pain control and functional disability lasting beyond 10 weeks. Subsequent blocks reinforced the analgesia. Atypical facial pain has several differential diagnoses. The involvement of sympathetic system in its causation or sustenance is uncertain. Stellate ganglion block achieves sympathetic block of cervicofacial structures, and its blockade has been shown to affect chronic pain conditions. Although its mechanism is not clear, one has to consider its possible role in conditions of stress apart from directly controlling the sympathetic activity. There is certainly a role in exploring the potential benefits of stellate ganglion block in such clinical conditions. The technique of stellate block under ultrasound is also described, as it influences the safety and precision of the block.

Cervical sympathetic block regulates early systemic inflammatory response in severe trauma patients

Background

This aim of this study was to investigate the effects of one-side cervical sympathetic block on early inflammatory response in severe trauma patients.

Material/Methods

Thirty severe trauma patients with injury severity score (ISS) of 16 to 25 were randomly divided into treatment and control groups (n=15 each). Patients in the treatment group underwent a right-side stellate ganglion block (SGB) using 8 mL 0.75% ropivacaine for 4 times, with the first injection within 12 hr of admission and the other 3 injections were 12 hr, 24 hr and 48 hr later. The same procedures were performed for the control group except that normal saline was injected instead of ropivacaine. Blood was collected before injection and at 6 hr, 24 hr, and 72 hr after the first SGB for serum interleukin (IL)-1β, IL-4, IL-6, IL-10 and TNF-α measurement.

Results

The concentrations of IL-1β, IL-6, and TNF-α between 24 hr to 72 hr after SGB were all significantly lower than those in the control group (all P values <0.01). However, there was no significant difference in the concentrations of anti-inflammatory IL-4 and IL-10 between treatment and control groups. There was no obvious impact of SGB on breathing and circulation except for a slower heart rate 10 to 50 min after injection (P<0.01).

Conclusions

SGB regulates early inflammatory response through inhibition of the proinflammatory cytokines IL-1β, IL-6, and TNF-α during severe trauma. SGB has no impact on the levels of anti-inflammatory cytokines IL-4 and IL-10.

Central α-adrenoceptors contribute to mustard oil-induced central sensitization in the rat medullary dorsal horn

Our previous studies have demonstrated that application of the inflammatory irritant mustard oil (MO) to the tooth pulp produces trigeminal central sensitization that includes increases in mechanoreceptive field size and responses to noxious stimuli and decrease in activation threshold in brainstem nociceptive neurons of trigeminal subnucleus caudalis (the medullary dorsal horn, MDH). The aim of the present study was to test if central noradrenergic processes are involved in the central sensitization of MDH neurons and if α1-adrenoceptors or α2-adrenoceptors or both are involved. In urethane/α-chloralose-anesthetized rats, the activity of extracellularly recorded and functionally identified single nociceptive neurons in the MDH was studied. Continuous intrathecal (i.t.) superfusion of the adrenergic modulator guanethidine and α-adrenoceptor blocker phentolamine or selective α1-adrenoceptor antagonist prazosin over the medulla strongly attenuated all three MO-induced parameters of central sensitization in the MDH nociceptive neurons, compared to phosphate-buffered saline (as vehicle control). In contrast, i.t. superfusion of the selective α2-adrenoceptor antagonist yohimbine had little effect on the mechanoreceptive field expansion and the decreased mechanical activation threshold, and indeed facilitated responses to noxious stimuli of sensitized nociceptive neurons. Superfusion of each of the four chemicals alone did not affect baseline nociceptive neuronal properties. These findings provide the first documentation of the involvement of central noradrenergic processes in MDH in the development of the central sensitization, and that α1- and α2-adrenoceptors may be differentially involved.

Stellate ganglion block: a therapeutic alternative for patients with medically refractory inappropriate sinus tachycardia?

Inappropriate sinus tachycardia (IST) is a clinical syndrome characterized by presence of non-paroxysmal tachyarrhythmia manifesting with increased resting heart rate and exaggerated or persistent response to exercise or position. When IST is intolerable and medically refractory, invasive therapies such as sinus node modification or atrioventricular node ablation with placement of permanent pacemaker are tried to control symptoms. We present a 34 year old patient with symptomatic IST unresponsive to medical therapy who underwent anesthetic block of the right and left stellate ganglia. At four month follow up the patient demonstrated sustained improvement in heart rate and reported freedom from previous symptoms.