|Year : 2013 | Volume
| Issue : 1 | Page : 33-35
Somatic blockade of contralateral roots of brachial plexus after a stellate ganglion block
Akkamahadevi Patil1, NR Anup2
1 Department of Anesthesiology, JSS Medical College, Mysore, Karnataka, India
2 Junior Resident, JSS Medical College, Mysore, Karnataka, India
|Date of Web Publication||10-Jul-2013|
1095, AVANIKA, E and F Block, Ramakrishna Nagar, Mysore - 22, Karnataka
Source of Support: None, Conflict of Interest: None
The stellate ganglion block is a common procedure performed for management of the Complex Regional Pain Syndrome (CRPS) of the upper limb. Somatic anesthesia of the ipsilateral brachial plexus is a known complication of the stellate ganglion block. We report a case of CRPS of the left upper limb developing somatic blockade of the contralateral brachial plexus following a stellate ganglion block. This case report emphasizes the importance of vigilant monitoring during every procedure, as unusual complications can occur.
Keywords: Complex regional pain syndrome, contralateral brachial plexus block, stellate ganglion block
|How to cite this article:|
Patil A, Anup N R. Somatic blockade of contralateral roots of brachial plexus after a stellate ganglion block. Indian J Pain 2013;27:33-5
| Introduction|| |
Stellate ganglion block is an interventional method for management of Complex Regional Pain Syndrome (CRPS).  Somatic anesthesia of the roots of the brachial plexus on the ipsilateral side is a known complication of stellate ganglion block,  but the brachial plexus block of the contralateral side is unusual. We report one such incident.
| Case Report|| |
A 28-year-old male patient presented to the Surgical Outpatient Department with a burning type of pain on the tip of the left middle finger, discoloration of the left hand, and stiffness of the left wrist from one year, following a carpel tunnel release. A diagnosis of thoracic outlet syndrome was made. An x-ray and computed tomography (CT) scan ruled out the possibility of a cervical rib. Subsequent diagnosis of brachial plexus compression by scalenus anticus was made by the surgical colleagues. Resection of the scalenus anticus was done. The patient had no relief following the surgery and reported back with complaints of severe burning sensation and was referred to the Pain Clinic. The pain was of a continous burning type, disturbing the routine activities and sleep. Pain was rated 8/10 on the Visual Analog Scale (VAS) by the patient. On examination, the patient had discoloration of the left hand, wasting of the left hand muscles, stiffness of the left wrist joint, hyperalgesia, and allodynia. Diagnosis of CRPS was made and the patient was put on tablet Amitriptyline 10 mg and tablet Pregabalin 75 mg daily. A fluoroscopic-guided stellate ganglion block on the left side was planned as a part of the treatment. Informed consent was taken. Monitors like Spo2, electrocardiography (ECG), and Non-Invasive Blood Pressure (NIBP) were connected. A 20G IV cannula was secured on the right hand. The patient was placed supine, with neck extended. The anterior tubercle of the sixth cervical vertebra was palpated, while the carotid artery and sternocleidomastoid muscle were retracted laterally. A 22-gauge needle attached to a syringe containing 0.5 ml of dye was inserted until its tip hit the transverse process medial to the palpating finger. The needle was then withdrawn slightly, and after negative aspiration, the dye was injected The position was confirmed using fluoroscopy. Eight milliliters of 0.5% of plain Bupivacaine with Inj. Methyl prednisolone 40 mg was injected after negative aspiration of blood and cerebrospinal fluid (CSF). Immediately after the block he complained of weakness in the right upper limb, the power of which was 3/5 on subsequent examination. The patient was conscious and all vital parameters were within normal limits. The patient was monitored for one hour, following which he regained power in his right upper limb. On questioning the patient reported that he could feel the drug migrating to the right side.
| Discussion|| |
The term CRPS was coined in 1993, by the International Association for Study of Pain (IASP). Previously it was known as Reflex Sympathetic Dystrophy (CRPS type 1) and Causalgia (CRPS type 2). It is classified as CRPS I - if no specific nerve injury can be identified and CRPS II -- if a specific nerve is damaged. The pathophysiology is poorly understood and a peripheral inflammatory component might play a role. The initiating factors are trauma, mainly hands and feet, and iatrogenic-like arthroscopy, carpal tunnel release, IM injection, and venipuncture. CRPS comprises of five major symptom complexes like, pain, autonomic dysfunction, edema, dystrophy, and atrophy, movement disorders.
Treatment of CRPS includes conservative methods like rehabilitation, psychotherapy, and pharmacotherapy. The commonly used pharmacological agents are alpha blockers (prazosin, phenoxybenzamine), steroids, tricyclic antidepressants, anticonvulsants, clonidine, calcium channel blockers like verapamil, and an N-Methyl D-Aspartate receptor antagonist like ketamine. The interventional line of management includes sympathetic blockade, neurostimulation, and intrathecal drug delivery. 
Our patient probably had CRPS following carpal tunnel release, which was misdiagnosed by the surgeons as a thoracic outlet syndrome, and he was subjected to scalenectomy, with no relief of symptoms. Early referral to the Pain Clinic could have avoided the surgery. Once the patient was referred to the Pain Clinic multimodal management of CRPS was initiated with pharmacotherapy, physiotherapy, and psychotherapy. A diagnostic and therapeutic local anesthetic block of the stellate ganglion was done under fluoroscopic guidance.
The stellate ganglion lies over the neck of the first rib and extends to the interspace between C₇ and T₁. It is related medially to the longus colli muscle, laterally to the scalene muscle, anteriorly to subclavian artery, posteriorly to the transverse process, posterolaterally to the roots of the brachial plexus, and inferiorly to the posterior aspect of the pleura. 
Any minute alteration in needle tip placement can lead to complications like ipsilateral somatic anesthesia of the brachial plexus, hoarseness of voice, phrenic nerve paralysis, esophageal puncture, intradural injection, intra-arterial injection, pneumothorax.  A fluoroscopic-guided block is recommended in order to prevent these complications to some extent.
There are reports of a contralateral spread of the drug following the stellate ganglion block, causing bilateral Horner's syndrome,  but a block of the contralateral brachial plexus is usually not expected.
We encountered one such incident. A retrovisceral (retroesophageal) space containing loose areolar tissue exists between the posterior wall of the esophagus and the prevertebral fascia, which is continous between the two sides.  On account of the previous scalenotomy and fibrosis, the drug may not have reached the same side stellate ganglion, on the contrary it would have passed through the retroesophageal space to the opposite side resulting in a right brachial plexus block.
Another possibility could be an anatomical variation, where the prevertebral layer may be split to enclose a space that is in continuity with the opposite side. Our needle placement might have been a little posterolateral, piercing the prevertebral fascia, and the drug deposited in this space might have migrated to the contralateral side instead of the ipsilateral side, due to post-surgical distortion of the anatomical planes.
This case report highlights the importance of having a thorough anatomical knowledge before performing any procedure. Recognition of the complications and timely management can prevent any untoward outcome.
| Acknowledgment|| |
Dr N.M. Shama Sundar, Professor and Head, Department of Anatomy, JSS Medical College, Mysore.
| References|| |
|1.||Bonica JJ. Sympathetic nerve blocks for pain diagnosis and therapy. New York: Breon Laboratories; 1984. |
|2.||Joshi M. Stellate ganglion block. Textbook of pain. 2 nd ed. 2009. p. 252-61. Hyderabad: Joshi's Institute of Pain Management. 2 nd ed. 2009. p. 377-86. |
|3.||Joshi M. Comple Regional Pain Syndrome. Textbook of Pain Management. In: Chaurasia BD, editor. Human Anatomy. 1 st ed, Vol. 3. Hyderabad: Joshi's Institute of Pain Management; 1979. p. 104-6. |
|4.||Raj PP, Erdine S. Interventional pain procedures in the neck. Pain relieving procedures: The Illustrated guide. 1 st ed. USA: John Wiley and Sons; 2012. p. 207-17. |
|5.||Contralateral spread of local anesthetic with stellate ganglion block. In: Wallace MS, Milohlland AV, editors. Regional Anesthesia and Pain Medicine. Vol. 18. 1993. p. 55-9. |
|6.||Susan S. Neck. Gray's anatomy. 40 th ed. Philadelphia: Churchill Livingstone, Elsevier; 2008. p. 438-40. |
|7.||Murphy TM. Treatment of chronic pain in Anesthesia. In: Miller RD, editor. Philadelphia: Chruchill Livingstone; 1981. p. 1472-4. |