Efficacy and Safety of Ultrasound-Guided Pulsed Radiofrequency Therapy of Stellate Ganglion on Refractory Painful Diabetic Peripheral Neuropathy

Background

The best tool for the management of pain associated with distal symmetric peripheral neuropathy (DSPN) is a matter of debate. Therefore, the study aimed to explore whether ultrasound-guided pulsed radiofrequency (PRF) therapy of the stellate ganglion (SG) in type 2 diabetes mellitus (T2DM) patients with painful DSPN could decrease pain severity and the need for analgesics.

Methods

Fifty-six T2DM patients with refractory painful DSPN were enrolled in this study, who then received bilateral ultrasound-guided PRF therapy of SG. The patients completed visual analog scale (VAS), simplified McGill pain questionnaire (SF-MPQ), Toronto clinical score system (TCSS), sleep duration at night (SDN), pain disability index (PDI), Karnofsky performance status (KPS), and depression screening scale (PHQ-9). After procedures, the degree of perceived pain relief, numbness relief and chills relief of the patients, and side effects were assessed. All patients underwent evaluation after the last procedure at 1, 4, 12 and 24-week follow-up periods.

Results

The postoperative VAS, SF-MPQ, TCSS, PDI and PHQ-9 scores were significantly lower, while the KPS values higher than the preoperative (P<0.05). The postoperative SDN was longer than the preoperative (P<0.05). The degree of perceived pain relief, chills relief, and numbness relief at 4, 12, and 24 weeks were lower than that at 1 week after the procedures (P<0.05). The postoperative rates of administration of analgesic were lower than those of preoperative period (P<0.05). The significant effective rates at 1, 4, 12, and 24 weeks after the procedure were 67.86%, 42.86%, 21.43%, and 17.86% and the total effective rates were 89.29%, 71.43%, 46.43%, and 32.14%. No serious complication was observed.

Conclusion

Ultrasound-guided stellate ganglion PRF therapy can effectively relieve pain and improve the quality of life in T2DM patients with refractory painful DSPN.

Effects of phototherapy in patients with idiopathic facial palsy: Scoping review

Phototherapy has emerged as a promising treatment for Bell's palsy, offering potential improvements in facial nerve function and overall well-being. In this study, we selected seven relevant studies involving 306 patients with subacute or acute Bell's palsy from PubMed, EMBASE, Web of Science, and Scopus before June 5, 2024. Low-level laser therapy (LLLT) efficacy for facial nerve paralysis was assessed in seven studies. Two studies lacked standard deviation data, precluding meta-analysis. Sunnybrook scores favored LLLT (mean difference [MD] = 17.42, 95 % confidence interval [CI]: 4.00-30.84, p = 0.011). However, Facial Disability Index results showed no significant difference (MD = 12.16, 95 % CI: -0.60 to 24.92, p = 0.061) between LLLT and control. LLLT, particularly with wavelengths of 830 or 850 nm administered over 6 weeks, may lead to beneficial outcomes. Combining LLLT with exercise therapy appears to be effective．LLLT demonstrates promise as a management option for Bell's palsy, potentially offering advantages over other treatments, particularly in patients with comorbidities, such as diabetes. Phototherapy devices currently used in Japan offer non-invasive treatment with minimal patient burden. The safety and therapeutic efficacy of these devices have been confirmed as a potential treatment for facial nerve paralysis.

Stellate ganglion block beyond chronic pain: A literature review on its application in painful and non-painful conditions

Cervical sympathetic or stellate ganglion blocks (SGBs) have been commonly used in the treatment of painful conditions like complex regional pain syndrome (CRPS). However, there is literature to suggest its utility in managing non-painful conditions as well. The focus of this literature review is to provide an overview of indications for SGB for painful and non-painful conditions. We identified published journal articles in the past 25 years from Embase and PubMed databases with the keywords "cervical sympathetic block, stellate ganglion blocks, cervical sympathetic chain, and cervical sympathetic trunk". A total of 1556 articles were obtained from a literature search among which 311 articles were reviewed. Among painful conditions, there is a lack of evidence in favor of or against the use of SGB for CRPS despite its common use. SGB can provide postoperative analgesia in selective surgeries and can be effective in temporary pain control of refractory angina and the acute phase of herpes zoster infection. Among non-painful conditions, SGB may have beneficial effects on the management of post-traumatic stress disorder (PTSD), refractory ventricular arrhythmias, hot flashes in postmenopausal women, and breast cancer-related lymphedema. Additionally, there have been various case reports illustrating the benefits of SGB in the management of cerebral vasospasm, upper limb erythromelalgia, thalamic and central post-stroke pain, palmar hyperhidrosis, orofacial pain, etc. In our review of literature, we found that SGB can be useful in the management of various non-painful conditions beyond the well-known treatment for CRPS, although further studies are required to prove its efficacy.

Case report: A new treatment for restless leg syndrome: three cases

Restless legs syndrome is a movement disorder that seriously affects the quality of life of patients. It is characterized by marked discomfort mainly occurring in the deep tissues of the lower extremities, including deep muscle or bone chafing, as well as crawling sensations or pulling sensations. These sensations often cause patients to awaken after falling asleep and to feel the urge to walk around, which seriously affects their sleep quality. Patients with restless leg syndrome exhibit significantly enhanced sympathetic nerve activity and immune disorders, while stellate ganglion blockage can block sympathetic nerves and regulate immune cells and cytokines to maintain immune system homeostasis. We report three patients with restless legs syndrome complicated with severe nephrotic syndrome. After treatment with stellate ganglion block, the symptoms in the restless legs were relieved within 1 month, and the quality of sleep was significantly improved. Our findings suggest that stellate ganglion block has broad promise in the management of restless legs syndrome patients with severe comorbidities.

Clinical Efficacy Evaluation of Ultrasound-Guided C2 Dorsal Root Nerve Pulsed Radiofrequency Combined with Stellate Ganglion Block in the Treatment of Cervicogenic Headache: A Retrospective Cohort Study

Purpose

To explore the therapeutic effect of C2 dorsal root ganglion pulsed radiofrequency (PRF) combined with stellate ganglion block (SGB) in patients with cervicogenic headache (CEH).

Patients and Methods

We retrospectively reviewed 90 patients diagnosed with CEH who were admitted to our hospital between May 2019 and May 2022. All patients were divided into three groups (n = 30 each) according to the actual treatment method used: ultrasound-guided SGB, ultrasound-guided C2 dorsal root ganglion PRF treatment, and ultrasound-guided C2 dorsal root ganglion PRF combined with SGB treatment. Patients' pain intensity, sleep, and mood changes were assessed by statistically analyzing their pain visual analog scale (VAS), Pittsburgh Sleep Quality Inventory (PSQI), and short-form McGill Pain Questionnaire affective item scores before and after treatment.

Results

The post-treatment VAS, PSQI, and McGill scores were significantly decreased in all patients (P < 0.05), and all three scores in ultrasound-guided C2 dorsal root ganglion PRF combined with SGB were lower than those in ultrasound-guided SGB alone and ultrasound-guided C2 dorsal root ganglion PRF alone (P < 0.05).

Conclusion

The use of ultrasound-guided C2 dorsal root ganglion PRF combined with SGB in patients with CHE is effective in alleviating pain and improving sleep, and deserves to be replicated in the clinic.

Sympathectomy Ameliorates CFA-Induced Mechanical Allodynia via Modulating Phenotype of Macrophages in Sensory Ganglion in Mice

BACKGROUND

The sympathetic nervous system (SNS) is suggested to be involved in some forms of pain, but the mechanisms of which are incompletely known. Moreover, there is a lack of information on the regulatory role of the SNS on macrophages in sensory ganglion, which plays an important role in pain development. The present study aims to investigate the effects of the SNS on orofacial inflammatory pain and examine, if any, how the SNS influences trigeminal ganglion (TG) macrophage responses.

METHODS

Sympathectomy was performed on male C57BL/6 mice before receiving a local injection of Complete Freund's adjuvant (CFA) to induce inflammatory pain. Effects of sympathectomy on orofacial pain were examined by Von Frey test and c-Fos expression. Polarization of TG macrophage was evaluated by immunohistochemistry and the level of norepinephrine (NE) in the TG were determined by liquid chromatography. Sympathetic signaling to TG macrophages were predicted based on single-cell analysis.

RESULTS

CFA injection induced a significant increase in mechanical allodynia, the number of c-Fos-positive neuron, and the level of NE in TG, which were largely reduced by sympathectomy. The number of M1 macrophages was markedly increased by CFA and was largely reduced by sympathectomy from 1 to 14 days post-injection. Single-cell RNA sequencing analysis and immunofluorescence staining showed that TG macrophages mainly express β2 adrenergic receptors for NE. Cell-cell communication analysis predicted sympathetic signaling that may modulate macrophage phenotypes, including Colony-stimulating factor-1, Migration inhibitory factor, Pleiotrophin and Nicotinamide phosphoribosyl transferase.

CONCLUSION

The SNS may involve in CFA-induced mechanical allodynia via modulating macrophage phenotypes in the TG. Targeting sympathetic activation might be useful in treating some painful conditions in the orofacial region.

Stellate ganglion block as an intervention in refractory eosinophilic granulomatosis with polyangiitis: a case report

Background

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare vasculitis. Although glucocorticoid therapy with or without immunosuppressants leads to remission in the majority of cases, most EGPA patients remain dependent on glucocorticoid therapy and experience frequent relapses. Here, we report a case of refractory EGPA which responded to stellate ganglion blocks (SGBs).

Case presentation

A 32-year-old woman with aggravated wheezing, purpura, numbness of multiple fingers, and epigastric and abdominal pain was referred to our clinic. Laboratory and radiographic studies led to the diagnosis of EGPA. After an initial favorable response to glucocorticoid and immunosuppressant therapy, she experienced a relapse during a glucocorticoid taper. We found that SGB brought symptomatic relief and impeded disease progression. The mechanism of action of SGB on EGPA is undetermined, but may be related to vasodilation, immune modulation, and central nervous system regulation.

Conclusions

This report not only proposes a novel treatment modality for EGPA, but also provides a clinical reference point for further in-depth studies of SGB in multiple immune-linked disorders.

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.

Tonic-clonic seizure during the ultrasound-guided stellate ganglion block because of an injection into an unrecognized variant vertebral artery: A case report

RATIONALE

Recent years have witnessed a marked improvement in the safety and accuracy of nerve blocks with the help of ultrasound and other visualization technologies. This study reports a challenging case of a severe complication during the ultrasound-guided stellate ganglion block.

PATIENT CONCERNS

A 28-year-old male patient with refractory migraine complained episodic pulsatile pain with photophobia, haphalgesia of the scalp for 3 years.

INTERVENTIONS

Ultrasound-guided stellate ganglion block with 4 ml of 1% lidocaine was administrated.

OUTCOMES

A sudden loss of consciousness and tonic-clonic seizure was occurred after negative aspiration and test dose. Further sonographic examination revealed a variation in the left vertebral artery, which remained unrecognized during the needle insertion because of its sliding ability under the differential pressure applied by the probe.

LESSONS

Inadvertent intra-arterial injection of a local anesthetic agent could be minimized under the ultrasound guidance with various protective strategies, including the determination of any prior variation, optimizing the block route, maintaining a constant probe pressure, and using saline for the test dosage. This case resulted in the implementation of new protocols of the ultrasound-guided stellate ganglion block in our department.

Peripheral sympathetic mechanisms in orofacial pain

Sympathetic nervous system (SNS) is a part of the autonomic nervous system which involuntarily regulates internal body functions. It appears to modulate the processing of nociceptive information. Many orofacial pain conditions involve inflammation of orofacial tissues and/or injury of nerve, some of which might be attributed to SNS. Thus, the aim of this review was to bring together the data available regarding the peripheral sympathetic mechanisms involved in orofacial pain. A clearer understanding of SNS–sensory interactions in orofacial pain may provide a basis for novel therapeutic strategies for conditions that respond poorly to conventional treatments.

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.

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.

Successful treatment of severe sympathetically maintained pain following anterior spine surgery

Sympathetic dysfunction is one of the possible complications of anterior spine surgery; however, it has been underestimated as a cause of complications. We report two successful experiences of treating severe dysesthetic pain occurring after anterior spine surgery, by performing a sympathetic block. The first patient experienced a burning and stabbing pain in the contralateral upper extremity of approach side used in anterior cervical discectomy and fusion, and underwent a stellate ganglion block with a significant relief of his pain. The second patient complained of a cold sensation and severe unexpected pain in the lower extremity of the contralateral side after anterior lumbar interbody fusion and was treated with lumbar sympathetic block. We aimed to describe sympathetically maintained pain as one of the important causes of early postoperative pain and the treatment option chosen for these cases in detail.

Stellate ganglion block promotes recovery of Bell's palsy in patients with diabetes mellitus

CONCLUSION

Stellate ganglion block (SGB) is effective for treatment of Bell's palsy in patients with diabetes mellitus.

BACKGROUND

Corticosteroids are widely used for treatment of Bell's palsy in patients with diabetes mellitus but may induce complications like hyperglycemia, which calls for an alternative therapy. This study aimed to ascertain the effect of SGB on Bell's palsy in patients with diabetes mellitus.

METHODS

This randomized and single-blinded clinical trial involved 96 diabetic patients with Bell's palsy that were randomly divided into a control group (n = 48) and a treatment group (SGB group, n = 48). The House-Brackmann scale and facial disability index (FDI, including FDIP and FDIS) were observed before treatment and at 1 and 3 months after treatment for assessment of the outcome.

RESULTS

No statistically significant difference was found between the two groups before treatment as regards the House-Brackmann scale and FDI. There was a statistically significant difference in FDIP score in the two groups after treatment in comparison with before treatment. The FDIS score showed a statistical difference between the two groups after treatment.