Analgesic efficacy of pre-operative stellate ganglion block on postoperative pain relief: a randomised controlled trial

Prevention of Post-Mastectomy Pain Syndrome: A Review of Recent Literature on Perioperative Interventions

PURPOSE OF REVIEW

Up to 60% of breast cancer patients continue to experience pain three months or more after surgery, with 15 to 25% reporting moderate to severe pain. Post-mastectomy pain syndrome (PMPS) places a high burden on patients. We reviewed recent studies on perioperative interventions to prevent PMPS incidence and severity.

RECENT FINDINGS

Recent studies on pharmacologic and regional anesthetic interventions were reviewed. Only nine of the twenty-three studies included reported a significant improvement in PMPS incidence and/or severity, sometimes with mixed results for similar interventions. Evidence for prevention of PMPS is mixed. Further investigation of impact of variations in dosing is warranted. In addition, promising newer interventions for prevention of PMPS such as cryoneurolysis of intercostal nerves and stellate ganglion block need confirmatory studies.

Efficacy of ultrasound-guided stellate ganglion block in relieving acute postoperative pain: a systematic review and meta-analysis

OBJECTIVE

The efficacy of ultrasound-guided stellate ganglion block (SGB) in alleviating postoperative pain remains unclear. This meta-analysis was performed to determine the efficacy of ultrasound-guided SGB in relieving acute postoperative pain in patients undergoing surgery with general anesthesia.

METHODS

This systematic review and meta-analysis focused on randomized controlled trials comparing SGB with control or placebo. The primary outcome was the pain score at 24 hours after surgery. A random-effects model was used to calculate the mean difference (MD) or risk ratio with a confidence interval (CI) of 95%.

RESULTS

Eight studies involving 470 patients were included in the meta-analysis. The results revealed that ultrasound-guided SGB was significantly associated with a lower pain score at 24 hours after surgery (MD = -0.74; 95% CI = -1.39, -0.08; I2 = 86%; low evidence) and at 8 hours after surgery (MD = -0.65; 95% CI = -1.03, -0.28; I2 = 29%; moderate evidence).

CONCLUSION

Ultrasound-guided SGB is effective in alleviating acute postoperative pain. However, considering the limited number of trials performed to date, more large-scale and high-quality randomized controlled trials are required to confirm these findings.

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.

Stellate ganglion block alleviates postoperative sleep disturbance in patients undergoing radical surgery for gastrointestinal malignancies

STUDY OBJECTIVES

We explored the effects of stellate ganglion block on postoperative sleep disturbance in patients scheduled to undergo radical surgery for gastrointestinal malignancies.

METHODS

Forty such patients were randomly assigned to the control group (Group C) or the preoperative stellate ganglion block treatment group (Group S). Using actigraphy, sleep quality was evaluated on the first night before the operation and first, second, and third postoperative nights. The Pittsburgh Sleep Quality Index scale was used for sleep state assessment on 1 day preoperatively and the first, second, third, fifth, and seventh days postoperatively. Plasma interleukin (IL)-1, IL-6, and IL-10 and melatonin levels were checked at 1 day preoperatively and the first and third days postoperatively. Mean arterial pressure, heart rate, and pulse oxygen saturation (SpO2) were recorded before general anesthesia induction, immediately after tracheal intubation, at the beginning of the operation, 1 and 2 hours after the beginning of the operation, at the end of the operation, immediately after extubation, and 30 minutes after transfer to the postanesthesia care unit.

RESULTS

Compared with Group C, in Group S sleep efficiency, total sleep time, and sleep maintenance were increased and sleep period change index, number of awakenings, wake after sleep onset, and body movements were reduced on the first and second postoperative nights; Pittsburgh Sleep Quality Index scores and occurrence of postoperative sleep disturbance were lower on the first and second nights postoperatively; IL-6 was reduced on the first night postoperatively; IL-1 and IL-10 were reduced on the third night postoperatively; melatonin was increased on the first night postoperatively; and mean arterial pressure and heart rate were decreased before general anesthesia induction, immediately after tracheal intubation, and at the end of the operation (all P < .05). Conclusions: Stellate ganglion block alleviates postoperative sleep disturbance by reducing postoperative inflammatory response, increasing melatonin levels, and stabilizing perioperative hemodynamics in patients undergoing radical surgery for gastrointestinal malignancies.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: The Effect of Stellate Ganglion Block on Postoperative Sleep Disturbance and Cognitive Function in Elderly Surgical Patients; URL: https://clinicaltrials.gov/ct2/show/NCT04800653; Identifier: NCT04800653.

CITATION

Yan S, Wang Y, Yu L, et al. Stellate ganglion block alleviates postoperative sleep disturbance in patients undergoing radical surgery for gastrointestinal malignancies. J Clin Sleep Med. 2023;19(9):1633-1642.

Red blood cell membrane-camouflaged poly(lactic-co-glycolic acid) microparticles as a potential controlled release drug delivery system for local stellate ganglion microinjection

The stellate ganglion (SG) is a part of the sympathetic nervous system that has important regulatory effects on several human tissues and organs in the upper body. SG block and intervention have been clinically and preclinically implemented to manage chronic pain in the upper extremities, neck, head, and upper chest as well as chronic heart failure. However, there has been very limited effort to develop and investigate polymer-based drug delivery systems for local delivery to the SG. In this study, we fabricated red blood cell (RBC) membrane-camouflaged poly(lactic-co-glycolic acid) (PLGA) (PLGAM) microparticles for use as a potential long-term controlled release system for local drug delivery. The structure, size, and surface zeta potential results indicated that the spherical PLGAM microparticles were successfully fabricated. Both PLGA and PLGAM microparticles exhibited biocompatibility with human adipose mesenchymal stem cells (ADMSC) and satellite glial cells and showed hemocompatibility. In addition, both PLGA and PLGAM displayed no significant effects on the secretion of proinflammatory cytokines by human monocyte derived macrophages in vitro. We microinjected microparticles into rat SGs and evaluated the retention time of microparticles and the effects of the microparticles on inflammation in vivo over 21 days. Subsequently, we fabricated drug-loaded PLGAM microparticles by using GW2580, a colony stimulating factor-1 receptor inhibitor, as a model drug and assessed its encapsulation efficiency, drug release profiles, biocompatibility, and anti-inflammatory effects in vitro. Our results demonstrated the potential of PLGAM microparticles for long-term controlled local drug release in the SG. STATEMENT OF SIGNIFICANCE: SG block by locally injecting therapeutics to inhibit the activity of the sympathetic nerves provides a valuable benefit to manage chronic pain and chronic heart failure. We describe the fabrication of RBC membrane-camouflaged PLGA microparticles with cytocompatibility, hemocompatibility, and low immunogenicity, and demonstrate that they can be successfully and safely microinjected into rat SGs. The microparticle retention time within SG is over 21 days without eliciting detectable inflammation. Furthermore, we incorporate a CSF-1R inhibitor as a model drug and demonstrate the capacities of long-term drug release and regulation of macrophage functions. The strategies demonstrate the feasibility to locally microinject therapeutics loaded microparticles into SGs and pave the way for further efficacy and disease treatment evaluation.

Stellate Ganglion Block Improves Postoperative Sleep Quality and Analgesia in Patients with Breast Cancer: A Randomized Controlled Trial

INTRODUCTION

Postoperative impaired sleep quality and pain are associated with adverse outcomes. Stellate ganglion block (SGB) has shown promising results in enhancing sleep quality and alleviating neuropathic pain. This study aimed to investigate the effects of ultrasound-guided SGB on postoperative sleep quality and pain in patients undergoing breast cancer surgery.

METHODS

This study is a parallel-group randomized controlled clinical trial with two groups: SGB and control. Fifty female patients undergoing breast cancer surgery were randomized in a 1:1 ratio to receive preoperative ultrasound-guided single-injection SGB (SGB group) or just an ultrasound scan (control group). All participants were blinded to the group assignment. The primary outcome was postoperative sleep quality, assessed by the St. Mary's Hospital Sleep Questionnaire and actigraphy 2 days postoperatively. The secondary outcome was postoperative pain, measured by the visual analog scale.

RESULTS

A total of 48 patients completed the study, with 23 patients in the control group and 25 in the SGB group. The postoperative St. Mary's Hospital Sleep Questionnaire scores were significantly higher in the SGB group than in the control group on 1 day postoperative (30.88 ± 2.44 versus 27.35 ± 4.12 points, P = 0.001). The SGB also increased the total sleep time and sleep efficiency (main actigraphy indicators) during the first two postoperative nights. Compared with the control group, preoperative SGB reduced postoperative pain and the incidence of breast cancer-related lymphedema (20% versus 52.2%, P = 0.02, odds ratio 0.229, 95% confidence interval 0.064-0.821). There were no adverse events related to SGB.

CONCLUSION

Preoperative ultrasound-guided SGB improves postoperative sleep quality and analgesia in patients undergoing breast cancer surgery. SGB may be a safe and practical treatment to enhance the postoperative quality of life in patients with breast cancer.

TRIAL REGISTRATION

The study was registered in the Chinese Clinical Trial Registry (ChiCTR2100046620, principal investigator: Kai Zeng, date of registration: 23 May 2021).

GENETIC INFLUENCES ON PAIN MECHANISMS

OBJECTIVE

The aim: To review the available results for genetic influences on pain syndrome development.

PATIENTS AND METHODS

Materials and methods: In the period from 2009 to 2020, a total of 45 research papers describing the key points of genetic influences on pain mechanisms in both adults and children were published in Ukrainian and English and they are now included in the PubMed, EMBASE, Cochrane, and Google Scholar research databases.

CONCLUSION

Conclusions: Pain is a comprehensive characteristic of a person; therefore, it is inevitable that several genes with little individual effect interact with each other and environmental factors, influencing pain susceptibility and chronic pain syndrome manifestation. This requires searching for biomarkers for diagnosing and predicting the development of acute and chronic pain syndromes, especially in pediatric practice.

Autonomic Regulation of Nociceptive and Immunologic Changes in a Mouse Model of Complex Regional Pain Syndrome

Chronic pain frequently develops after limb injuries, and its pathogenesis is poorly understood. We explored the hypothesis that the autonomic nervous system regulates adaptive immune system activation and nociceptive sensitization in a mouse model of chronic post-traumatic pain with features of complex regional pain syndrome (CRPS). In studies sympathetic signaling was reduced using 6-hydroxydopamine (6-OHDA) or lofexidine, while parasympathetic signaling was augmented by nicotine administration. Hindpaw allodynia, unweighting, skin temperature, and edema were measured at 3 and 7 weeks after fracture. Hypertrophy of regional lymph nodes and IgM deposition in the skin of injured limbs were followed as indices of adaptive immune system activation. Passive transfer of serum from fracture mice to recipient B cell deficient (muMT) mice was used to assess the formation of pain-related autoantibodies. We observed that 6-OHDA or lofexidine reduced fracture-induced hindpaw nociceptive sensitization and unweighting. Nicotine had similar effects. These treatments also prevented IgM deposition, hypertrophy of popliteal lymph nodes, and the development of pronociceptive serum transfer effects. We conclude that inhibiting sympathetic or augmenting parasympathetic signaling inhibits pro-nociceptive immunological changes accompanying limb fracture. These translational results support the use of similar approaches in trials potentially alleviating persistent post-traumatic pain and, possibly, CRPS. PERSPECTIVE: Selective treatments aimed at autonomic nervous system modulation reduce fracture-related nociceptive and functional sequelae. The same treatment strategies limit pain-supporting immune system activation and the production of pro-nociceptive antibodies. Thus, the therapeutic regulation of autonomic activity after limb injury may reduce the incidence of chronic pain.

Regulation of acute reflectory hyperinflammation in viral and other diseases by means of stellate ganglion block. A conceptual view with a focus on Covid-19

Whereas the autonomic nervous system (ANS) and the immune system used to be assigned separate functions, it has now become clear that the ANS and the immune system (and thereby inflammatory cascades) work closely together. During an acute immune response (e. g., in viral infection like Covid-19) the ANS and the immune system establish a fast interaction resulting in "physiological" inflammation. Based on our knowledge of the modulation of inflammation by the ANS we propose that a reflectory malfunction of the ANS with hyperactivity of the sympathetic nervous system (SNS) may be involved in the generation of acute hyperinflammation. We believe that sympathetic hyperactivity triggers a hyperresponsiveness of the immune system ("cytokine storm") with consecutive tissue damage. These reflectory neuroimmunological and inflammatory cascades constitute a general reaction principle of the organism under the leadership of the ANS and does not only occur in viral infections, although Covid-19 is a typical current example therefore. Within the overreaction several interdependent pathological positive feedback loops can be detected in which the SNS plays an important part. Consequently, there is a chance to regulate the hyperinflammation by influencing the SNS. This can be achieved by a stellate ganglion block (SGB) with local anesthetics, temporarily disrupting the pathological positive feedback loops. Thereafter, the complex neuroimmune system has the chance to reorganize itself. Previous clinical and experimental data have confirmed a favorable outcome in hyperinflammation (including pneumonia) after SGB (measurable e. g. by a reduction in proinflammatory cytokines).

Ultrasound-Guided Stellate Ganglion Block With Preserved Motor Function for Upper Extremity Surgery

While stellate ganglion blockade (SGB) is commonly used in the treatment and management of patients who suffer from chronic pain, we are reporting a case where an ultrasound-guided SGB was used for management of acute perioperative pain for a patient undergoing upper extremity surgery. The patient was classified as the American Society of Anesthesiologists (ASA) class 1, without any significant past medical history, including no history of chronic pain, opioid use, or peripheral neuropathy. The patient was scheduled for tendon repair of the hand following trauma with subsequent lacerations. While general anesthesia, a brachial plexus blockade, or combination of the two are generally used in current practice for upper extremity surgery, these typically do not allow for intraoperative evaluation of motor function. In our case, an ultrasound-guided SGB was used to provide analgesia while still allowing for intraoperative assessment of motor function during the critical components of the repair. This case illustrates the potential advantages of an ultrasound-guided SGB for decreasing acute postoperative pain scores, decreasing overall postoperative pain medication use, as well as maintaining intraoperative motor function in cases where such monitoring may be advantageous and allow for optimal surgical repair.

Visceral versus somatic pain: an educational review of anatomy and clinical implications

Somatic and visceral nociceptive signals travel via different pathways to reach the spinal cord. Additionally, signals regulating visceral blood flow and gastrointestinal tract (GIT) motility travel via efferent sympathetic nerves. To offer optimal pain relief and increase GIT motility and blood flow, we should interfere with all these pathways. These include the afferent nerves that travel with the sympathetic trunks, the somatic fibers that innervate the abdominal wall and part of the parietal peritoneum, and the sympathetic efferent fibers. All somatic and visceral afferent neural and sympathetic efferent pathways are effectively blocked by appropriately placed segmental thoracic epidural blocks (TEBs), whereas well-placed truncal fascial plane blocks evidently do not consistently block the afferent visceral neural pathways nor the sympathetic efferent nerves. It is generally accepted that it would be beneficial to counter the effects of the stress response on the GIT, therefore most enhanced recovery after surgery protocols involve TEB. The TEB failure rate, however, can be high, enticing practitioners to resort to truncal fascial plane blocks. In this educational article, we discuss the differences between visceral and somatic pain, their management and the clinical implications of these differences.

Effect of Stellate Ganglion Block on Intraoperative Propofol and Fentanyl Consumption in Patients with Complex Regional Pain Syndrome Undergoing Surgical Repair of Brachial Plexus Injury: A Randomized, Double-blind, Placebo-controlled Trial

Introduction

Stellate ganglion block (SGB) is commonly performed to treat chronic painful conditions, such as complex regional pain syndrome (CRPS) and postherpetic neuralgia. However, whether it is effective in reducing anesthesia and analgesia requirement during surgery (acute pain) is not known.

Materials and Methods

Sixty American Society of Anesthesiologists (ASA) physical status I and II patients with CRPS type II undergoing surgery for repair of brachial plexus injury were randomized (1:1) to receive SGB with either 10 mL of 0.5% bupivacaine (Group B) or a matching placebo (Group S) before induction of anesthesia.

Results

There was a significant reduction in the requirement of total intraoperative propofol (1659.7 ± 787.5 vs. 2500.7 ± 740.9 mg, P = 0.0003) and fentanyl (190.0 ± 82.5 vs. 327.3 ± 139.3, P = 0.0001) in Group B compared with Group S. Similarly, in Group B, the time to first analgesic was much longer (328 ± 219 vs. 64 ± 116 min, P = 0.000) and postoperative fentanyl requirement for 24 h was lesser compared to Group S (0.6 ± 1.1 vs. 2.1 ± 1.3 μg/kg, P = 0.000).

Conclusion

SGB is effective in reducing the requirement of intraoperative propofol and fentanyl as well as decreasing opioid requirement in the postoperative period in patients with CRPS type II undergoing surgery.

Post-operative pain management modalities employed in clinical trials for adult patients in LMIC; a systematic review

BACKGROUND

Unrelieved postoperative pain afflicts millions each year in low and middle income countries (LMIC). Despite substantial advances in the study of pain, this area remains neglected. Current systematic review was designed to ascertain the types of clinical trials conducted in LMIC on postoperative pain management modalities over the last decade.

METHODS

A comprehensive search was performed in June 2019 on PubMed, Cochrane Library, CINAHL Plus, and Web of Science databases to identify relevant trials on the management of postoperative pain in LMIC. Out of 1450 RCTs, 108 studies were reviewed for quality evidence using structured form of critical appraisal skill program. Total of 51 clinical trials were included after applying inclusion/exclusion criteria.

RESULTS

Results are charted according to the type of surgery. Eleven trials on laparoscopic cholecystectomy used multimodal analgesia including some form of regional analgesia. Different analgesic modalities were studied in 4 trials on thoracotomy, but none used multimodal approach. In 11 trials on laparotomy, multimodal analgesia was employed along with the studied modalities. In 2 trials on hysterectomy, preemptive pregabalin or gabapentin were used for reduction in rescue analgesia. In 13 trials on breast surgical procedures and 10 on orthopaedic surgery, multimodal analgesia was used with some form of regional analgesia.

CONCLUSION

We found that over the past 10 years, clinical trials for postoperative pain modalities have evolved in LMIC according to the current postoperative pain management guidelines i.e. multi-modal approach with some form of regional analgesia. The current review shows that clinical trials were conducted using multimodal analgesia including but not limited to some form of regional analgesia for postoperative pain in LMIC however this research snapshot (of only three countries) may not exactly reflect the clinical practices in all 47 countries. Post Operative Pain Management Modalities Employed in Clinical Trials for Adult Patients in LMIC; A Systematic Review.

The efficacy of ultrasound-guided stellate ganglion block in alleviating postoperative pain and ventricular arrhythmias and its application prospects

Stellate ganglion block (SGB) has been applied in clinic for almost a century as a therapeutic procedure to alleviate pain-related syndromes and vascular deficits in the upper extremities. A great number of causative side effects and complications due to technological insufficiency and anatomical variations called for the popularity of ultrasound-guided SGB which has made tremendous contribution for clinical diagnosis and therapy, primarily in postoperative pain and cardiac and vascular disorders. This work was aimed at systematically summarizing the current clinical application of ultrasound-guided SGB and putting forward the potential prospective application in future. By searching ultrasound-guided SGB-related works on PubMed database, we mainly elucidated the analgesic effect of preoperative SGB in patients undergoing surgical procedures and substantial reduction in patients with ventricular arrhythmias. The volume of local anesthetics used in ultrasound-guided SGB has been diminished in the recent few years' investigations and successful operation of ultrasound-guided SGB could be achieved with minimal safe volume of local anesthetics. This invasive and safe procedure shows vast potential for future development in clinical treatment for autonomic nervous system and autoimmune disorders. We also put forward hypothesis that ultrasound-guided SGB could be applied combined with controlled hypotension to reduce the intraoperative complications in orthopedic surgery such as insufficiency of cerebral blood flow and reflexive tachycardia. Thus, it is of vital essence to improve the professional skills of physicians for the high rate of success and explore more effective measures which could enhance therapeutic effects when combined with ultrasound-guided SGB in alleviating misery of patients.

Ultrasound-guided stellate ganglion block alleviates stress responses and promotes recovery of gastrointestinal function in patients

BACKGROUND

This study aimed to investigate the effect of preoperative ultrasound-guided stellate ganglion block (SGB) on the perioperative stress responses and gastrointestinal functions of patients undergoing laparoscopic colorectal cancer surgery.

METHODS

A total of 60 colorectal cancer patients were enrolled in study and were randomized to be treated with or without SGB therapy. In the SGB group, patients were injected with 7 mL 0.5% ropivacaine in stellate ganglion under ultrasound guidance before anesthesia. Mean artery pressure (MAP), heart rate (HR), recovery of bowel sound and first exhaust, as well as levels of motilin, gastrin, norepinephrine, cortisol, interleukin-6 (IL-6) and C-reactive protein (CRP) were recorded at various time points.

RESULTS

26 patients in the SGB group and 27 patients in the control group were analyzed. No significant differences in MAP or HR were observed between the two groups before, during and after the surgery. SGB promoted recovery of gastrointestinal functions, as evidenced by earlier recovery of bowel sound and first exhaust, as well as increased motilin and gastrin levels. SGB also attenuated stress responses, as shown in reduced norepinephrine, cortisol, IL-6 and CRP levels.

CONCLUSIONS

SGB promotes the recovery of gastrointestinal functions and reduces stress responses of colorectal patients undergoing laparoscopic colorectal cancer surgery.

Evaluation of the Clinical Effect of Color Doppler Ultrasound-Guided Stellate Ganglion Block Combined with Drugs in the Treatment of Cervical Headache

In order to evaluate the clinical effect of color Doppler ultrasound-guided stellate ganglion block combined with drugs in the treatment of cervical headache, a total of 80 patients, who were diagnosed as cervical headache at the hospital designated by this study from December 2017 to December 2018, were selected as study subjects, and were divided into 2 groups of control group and observation group according to random number table method with 40 cases in each group. The control group was treated only with drugs: 0.3 mg gabapentin orally taken 3 times a day, 0.3 mg tizanidine hydrochloride orally taken 3 times a day, and 0.2 mg celecoxib orally taken 3 times a day for a total of 4 continuous weeks; the observation group was treated with ultrasound-guided stellate ganglion block based on the scheme of control group. The degree of patients’ pain was evaluated by visual analogue scale (VAS), which was divided into 0–10 points; the clinical efficacy evaluation was divided into three levels: markedly effective, effective and ineffective. The results showed that the total effective rate of patients’ treatments in observation group was 92.50%, which was significantly higher than that of 72.50% in the control group with statistically significant difference (P < 0.05); there was no statistical difference of patients’ average VAS score between the two groups before the treatment (P > 0.05), while the average VAS score of patients in the observation group after treatment (3.58±1.46) was significantly lower than that in the control group (5.37±1.58) with statistically significant difference (P < 0.05); and there were no serious adverse reactions in both groups. Therefore, it is believed that color Doppler ultrasound-guided stellate ganglion block combined with oral gabapentin, tizanidine hydrochloride, and celecoxib is effective in treating cervical headache. The study results of this paper provides a certain reference for further evaluations of the clinical effect of color Doppler ultrasound-guided stellate ganglion block combined with drugs in the treatment of cervical headache.

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.

Effects of ultrasound guided ganglion stellate blockade on intraoperative and postoperative hemodynamic responses in laparoscopic gynecologic surgery

Introduction

Laparoscopic gynecologic surgery is one of the most well-known procedures. Pneumoperitoneum with carbon dioxide insufflation can cause unfavorable hemodynamic effects due to catecholamine and vasopressin release.

Aim

To examine the effects of stellate ganglion block on hemodynamic response and postoperative pain.

Material and methods

In a prospective double blinded randomized parallel study we included 40 patients with ASA physical status I and II, aged between 18 and 50 years with a gynecologic problem candidate for laparoscopic surgery under general anesthesia. The patients were randomly divided into two groups. Fifteen minutes before anesthesia induction, the patients underwent ultrasound guided stellate ganglion block with 10 ml of lidocaine 1% and the control group underwent stellate ganglion block using 10 ml of distilled water as placebo. After induction of general anesthesia, systolic and diastolic blood pressure and heart rate were recorded, especially after blowing of CO₂ gas, the position change, depletion of CO₂, and tracheal extubation in recovery. The postoperative pain was calculated using the visual analogue scale (VAS) at three times (0, 30, and 24 h after surgery).

Results

Our results showed that mean systolic and diastolic blood pressure and heart rate did not show any significant difference at the measurement times (p > 0.05), and mean VAS of patients in the two groups was significantly different for the three measurement times except 24 h after surgery (p < 0.05).

Conclusions

Stellate ganglion block before laparoscopic gynecologic surgery has no significant effect on intraoperative and postoperative hemodynamic responses; however, it can decrease VAS in the early postoperative period.

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.

Regional anesthesia to ameliorate postoperative analgesia outcomes in pediatric surgical patients: an updated systematic review of randomized controlled trials

Regional anesthesia is becoming increasingly popular among anesthesiologists in the management of postoperative analgesia following pediatric surgery. The main objective of this review was to systematically evaluate the last 5 years of randomized controlled trials on the role of regional anesthesia techniques in alleviating postoperative pain associated with various pediatric surgical procedures. Forty studies on 2,408 pediatric patients were evaluated. The majority of the articles published from 2013 to 2017 reported that the use of regional anesthesia minimized postoperative pain and reduced opioid consumption. Only a few surgical procedures (cholecystectomy, inguinal hernia repair, and non-laparoscopic major abdominal surgery) reported no significant difference in the postoperative pain relief compared with the standard anesthetic management. The growing number of randomized controlled trials in the pediatric literature is very promising; however, additional confirmation is needed to reinforce the use of specific regional anesthesia techniques to provide optimal postoperative pain relief for a few surgical procedures (reconstructive ear surgery, chest wall deformity, hypospadias, umbilical hernia, cleft palate repair) in pediatric patients. More randomized controlled trials are needed to establish regional anesthesia as an essential component of postoperative analgesia management in children.

Effects of Stellate Ganglion Block on Analgesia Produced by Cervical Paravertebral Block as Established by Quantitative Sensory Testing: A Randomized Controlled Trial

Objective

To use quantitative sensory testing (QST) to assess whether a stellate ganglion block (SGB) modulates the analgesia induced by cervical paravertebral block (CPVB).

Design

A prospective double-blind randomized controlled trial.

Setting

Department of Anesthesia, Antwerp University Hospital, October 2011 to December 2015.

Subjects

Twenty-eight adults scheduled for arthroscopy of a nonfractured shoulder were enrolled.

Methods

Participants were randomly assigned to receive either single CPVB (5 mL of levobupivacaine 0.5%) or combined CPVB + SGB (5 mL and 3 mL of levobubivacaine 0.5%, respectively). The detection thresholds for cold/warm sensations and cold/heat pain were established using thermal QST on the C4-C7 dermatomes before local anesthetic infiltration and at 0.5, 6, 10, and 24 hours thereafter. Our primary outcome was the time course of QST thresholds for the different neurosensitive/nociceptive modalities. As secondary and tertiary outcomes, we evaluated the degree of motor block and the time to first administration of rescue analgesics.

Results

We randomized 20 patients. There were no significant differences in the detection thresholds for the neurosensitive/nociceptive modalities, motor block, or timing for rescue analgesics between the groups (P = 0.15-0.94). All patients with CPVB + SGB exhibited Horner's signs, whereas patients in the CPVB group did not exhibit these signs; however, this does not exclude sympathetic block.

Conclusions

We were unable to demonstrate any analgesic benefit of CPVB + SGB in arthroscopic shoulder surgery. It is therefore not unreasonable to suppose that pain from soft tissue injuries without bony lesions is transmitted mainly by somatic nerves with no or only minimal involvement of the sympathetic nervous system.

Effects of ultrasound-guided stellate-ganglion block on sleep and regional cerebral oxygen saturation in patients undergoing breast cancer surgery: a randomized, controlled, double-blinded trial

Numerous factors could contribute to sleep disturbances in women with breast cancer. We hypothesized that stellate ganglion block (SGB) during surgery would preserve sleep after surgery and increase intraoperative regional cerebral oxygen saturation (rSO2) on the blocked side in patients undergoing breast cancer surgery. A randomized, double-blinded, controlled trial was conducted at the First Hospital of China Medical University from January 2016 to September 2016. Ninety-six patients who underwent radical breast cancer surgery requiring general anaesthesia were randomly assigned to one of two study groups: a control group that received a saline SGB and a block group that received a 0.25% ropivacaine hydrochloride SGB. The primary outcome measure was the postoperative sleep profile, which was assessed using the bispectral index on the first postoperative night. The secondary outcome measure was the intraoperative rSO2, monitored was throughout surgery using near-infrared spectroscopy. A total of 91 female patients (mean age: 45 years; range 24-51 years) were included in the study. The duration of sleep was significantly increased by 66.3 min in the ropivacaine-SGB group compared with the saline-SGB group. No differences in rSO2 were observed on either the left or right side of the patients in either group 50 min after anaesthesia induction. We conclude that ropivacaine-SGB combined with general anaesthesia might increase the first postoperative sleep duration without influencing the intraoperative rSO2 in female patients undergoing elective breast cancer surgery. Clinical trials.gov identifier NCT02651519.

Ultrasound-guided Stellate Ganglion Block Improves Gastrointestinal Function After Thoracolumbar Spinal Surgery

PURPOSE

The purpose of this study was to investigate the effects of stellate ganglion block (SGB) on gastrointestinal function after thoracolumbar spinal surgery.

METHODS

Forty patients with thoracolumbar fracture scheduled for posterior spinal surgery were randomly assigned to 2 groups: ultrasound-guided SGB or sham (control group). After induction, ultrasound-guided SGB (n = 20) or a sham procedure (n = 20) was conducted with a 6-mL injection of 1% lidocaine or 0.9% saline, respectively. Primary outcomes were postoperative gastrointestinal function, including auscultation of bowel sounds, incidence and degree of abdominal bloating, flatus time, and paralytic ileus.

FINDINGS

Patients in the SGB group had better gastrointestinal function compared with those in the sham (control) group, as indicated by more regular bowel sounds at 24 and 36 hours postoperatively (80% vs 40%, P = 0.024, and 95% vs 60%, P = 0.023), lesser abdominal bloating (10% vs 45%, P = 0.034), and slightly shorter flatus time (mean [SD], 12.0 [4.4] vs 14.7 [4.6] hours, P = 0.068). Survival analysis based on regular bowel sounds found a significant difference between the 2 groups (P = 0.004). In addition, more patients had higher satisfaction after SGB (85% vs 45%, P = 0.020). No postoperative ileus or mortality occurred.

IMPLICATIONS

In this preliminary study, ultrasound-guided SGB accelerated the return of gastrointestinal transit, alleviated bowel symptoms, and improved patient satisfaction after thoracolumbar spinal surgery. chictr.org.cn identifier: ChiCTR-TRC-14004289.

Tramadol sparing effect of dexmedetomidine as an adjuvant with lignocaine in preoperative stellate ganglion block for postoperative pain relief following upper limb surgeries

Background

Recent literature has established the role of stellate ganglion block (SGB) for management of acute postoperative pain. The effects of dexmedetomidine as an adjuvant to lignocaine in a preoperative SGB for postoperative pain relief have not been evaluated so far.

Methods

The following randomised, double-blinded, control trail included 54 patients scheduled for upper limb orthopaedic surgery under general anaesthesia. Preoperative ultrasound-guided (USG) SGB was performed in all patients. Group I (n = 18) received 3.5 mL of a solution (3 mL 2% lignocaine + 0.5 μg/kg dexmedetomidine for SGB) and 15 mL of intravenous (IV) normal saline (NS). Group II (n = 18) received 3.5 mL of a solution (3 mL 2% lignocaine + 0.5 mL NS for SGB) and 15 mL of IV NS. Group III (n = 18) received 3.5 mL of a solution (3 mL 2% lignocaine + 0.5 mL of NS for SGB) and 0.5 μg/kg dexmedetomidine in 15 mL of IV NS. Postoperatively tramadol consumption and Visual Analogue Scale (VAS) score were recorded up to 48 hours.

Results

The cumulative tramadol consumption at the end of 48 hours (p = 0.01) was significantly reduced in the group I as compared to group II. In group I, postoperative VAS at rest was significantly reduced up to 12 hours postoperatively as compared to group II (p = 0.05). The cumulative tramadol consumption was not reduced significantly in group III compared to group II (p = 0.51).

Conclusion

Dexmedetomidine as an adjuvant to SGB along with lignocaine produced a significant tramadol sparing effect and superior analgesia as compared to IV dexmedetomidine and control group.¹.

Thalamic pain alleviated by stellate ganglion block: A case report

RATIONALE

Thalamic pain is a distressing and treatment-resistant type of central post-stroke pain. Although stellate ganglion block is an established intervention used in pain management, its use in the treatment of thalamic pain has never been reported.

PATIENT CONCERNS

A 66-year-old woman presented with a 3-year history of severe intermittent lancinating pain on the right side of the face and the right hand. The pain started from the ulnar side of the right forearm after a mild ischemic stroke in bilateral basal ganglia and left thalamus. Weeks later, the pain extended to the dorsum of the finger tips and the whole palmar surface, becoming more severe. Meanwhile, there was also pain with similar characteristics emerging on her right face, resembling atypical trigeminal neuralgia.

DIAGNOSES

Thalamic pain was diagnosed.

INTERVENTIONS

After refusing the further invasive treatment, she was suggested to try stellate ganglion block.

OUTCOMES

After a 3-day period of pain free (numerical rating scale: 0) postoperatively, she reported moderate to good pain relief with a numerical rating scale of about 3 to 4 lasting 1 month after the first injection. Pain as well as the quality of life was markedly improved with less dose of analgesic agents.

LESSONS

Stellate ganglion block may be an optional treatment for thalamic pain.

Efficacy and safety of stellate ganglion block in chronic ulcerative colitis

AIM

To investigate the efficacy and safety of stellate ganglion block for the treatment of patients with chronic ulcerative colitis.

METHODS

A total of 120 randomly selected patients with chronic ulcerative colitis treated in Cangzhou Central Hospital from January 2014 to January 2016 were included in this study. These patients were divided into two groups: control group (n = 30), patients received oral sulfasalazine treatment; experimental group (n = 90), patients received stellate ganglion block treatment. Clinical symptoms and disease activity in these two groups were compared before and after treatment using endoscopy. Blood was collected from patients on day 0, 10, 20 and 30 after treatment. Enzyme-linked immunosorbent assay was performed to determine interleukin-8 (IL-8) level. The changes in IL-8 level post-treatment in the two groups were compared using repeated measures analysis of variance.

RESULTS

After treatment, clinical symptoms and disease activity were shown to be alleviated by endoscopy in both the control and experimental groups. However, patients in the control group did not have obvious abdominal pain relief. In addition, the degree of pain relief in the experimental group was statistically better than that in the control group (P < 0.05). Ten days after treatment, IL-8 level was found to be significantly lower in the experimental group than in the control group, and the difference was statistically significant (P < 0.05). In addition, adverse events were significantly higher in the control group than in the experimental group, and the difference was statistically significant (χ² = 33.215, P = 0.000).

CONCLUSION

The application of stellate ganglion block effectively improves treatment efficacy in chronic ulcerative colitis, relieves clinical symptoms in patients, and reduces the level of inflammatory factors. Furthermore, this approach also had a positive impact on the disease to a certain extent.

Management of Hormone Deprivation Symptoms After Cancer

Cancer survivors often experience symptoms related to hormone deprivation, including vasomotor symptoms, genitourinary symptoms, and sexual health concerns. These symptoms can occur due to natural menopause in midlife women, or they can be brought on by oncologic therapies in younger women or men. We searched PubMed for English-language studies from January 1990 through January 2016 to identify relevant articles on the management of hormone deprivation symptoms, including vasomotor, genitourinary, and sexual symptoms in patients with cancer. The search terms used included hormone deprivation, vasomotor symptoms, hot flash, vaginal dryness, sexual dysfunction, and breast cancer. This manuscript provides a comprehensive description of data supporting the treatment of symptoms associated with hormone deprivation.

Progress in Sympathetically Mediated Pathological Pain

Aim of review

Many chronic pain conditions remain difficult to treat, presenting a high burden to society. Conditions such as complex regional pain syndrome may be maintained or exacerbated by sympathetic activity. Understanding the interactions between sympathetic nervous system and sensory system will help to improve the effective management of pathological pain including intractable neuropathic pain and persistent inflammatory pain.

Method

We first described the discovery of abnormal connections between sympathetic and sensory neurons. Subsequently, the functional roles of sympathetic sprouting in altered neuronal excitability and increased pain sensitivity were discussed. The mechanisms of the sympathetic sprouting were focusing on its relationship with neurotrophins, local inflammation, and abnormal spontaneous activity. Finally, we discussed clinical implications and conflicting findings in the laboratory and clinical research with respect to the interaction between sympathetic system and sensory system.

Recent findings

The findings that sprouting of sympathetic fibers into the sensory ganglia (dorsal root ganglion) after peripheral nerve injury, offers a possible explanation of the sympathetic involvement in pain. It is also suggested that releases of adenosine triphosphate (ATP), in addition to norepinephrine, from sympathetic nerve endings play important roles in sympathetic-mediated pain. New evidence indicates the importance of sympathetic innervation in local inflammatory responses.

Summary

Hopefully, this review will reinvigorate the study of sympathetic-sensory interactions in chronic pain conditions, and help to better understand how sympathetic system contributes to this serious clinical problem.