Ultrasound-guided stellate ganglion block successfully prevented esophageal puncture

Stellate ganglion block is utilized in the diagnosis and management of various vascular disorders and sympathetically mediated pain in the upper extremity, head and neck. The cervical sympathetic chain is composed of superior, middle, intermediate, and inferior cervical ganglia. However, in approximately 80% of the population, the inferior cervical ganglion is fused with the first thoracic ganglion, forming the stellate ganglion also known as cervicothoracic ganglion. The stellate ganglion lies medial to the scalene muscles, lateral to the longus coli muscle, esophagus and trachea along with the recurrent laryngeal nerve, anterior to the transverse processes and prevertebral fascia, superior to the subclavian artery and the posterior aspect of the plura, and posterior to the vertebral vessels at C7 level. Consequently, inadvertent placement of the needle into the vertebral artery, thyroid, neural tissues, or esophagus can occur with the fluoroscopic or blind approach. While fluoroscopy is a reliable method for identifying boney structures, ultrasound may identify the vertebral vessels, thyroid gland and vessels, longus coli muscles, nerve roots and the esophagus. Thus, ultrasound may prevent inadvertent placement of the needle into these structures as might happen with either the blind technique or fluoroscopic technique. A patient with complex regional pain syndrome type I of the left upper extremity was scheduled for left stellate ganglion block with the anterior paratracheal approach under fluoroscopy. Real-time ultrasound imaging prevented inadvertent injury to the esophagus as well as the thyroid gland and vessels. Ultrasound-guided block may improve patient safety by avoiding the soft tissue structures in the needle path that can't be readily seen by fluoroscopy. This may be particularly useful in the patient with asymptomatic pharyngoesophageal diverticulum (Zenker diverticulum).