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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 30  |  Issue : 3  |  Page : 207-208

Stellate ganglion block for persistent idiopathic facial pain


Department of Anaesthesiology and Pain Medicine, Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune, Maharashtra, India

Date of Web Publication10-Jan-2017

Correspondence Address:
Poonam Patel
102 Salvador Apartment, Fortaleza Complex, Kalyaninagar, Pune - 411 006, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-5333.198065

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  Abstract 

Persistent idiopathic facial pain is a facial pain disorder without any identifiable cause. A patient has persistent facial pain without any objective sign on clinical examination or investigations. There are associated psychological problems such as depression and anxiety. This condition is poorly responsive to therapy with anticonvulsants or analgesics. Stellate ganglion block interrupts the sympathetic supply to head, neck, and upper extremities. This block can be used to alleviate pain of sympathetic origin in head and neck region as well as upper extremities. We report a case of a middle-aged female with persistent idiopathic facial pain on the right side of face with no response to analgesics and anticonvulsants. Her pain was provoked by exposure to cold weather or wind. Assuming a sympathetic component to her pain, we did a right-sided stellate ganglion block for her with local anesthetic and steroid. The patient had significant pain relief (>80%) after the block. This indicates that the sympathetic nervous system plays a major role in initiation and perpetuation of this pain condition. Stellate ganglion block can be done early in such patients both as a diagnostic and therapeutic modality.

Keywords: Atypical facial pain, persistent idiopathic facial pain, stellate ganglion block


How to cite this article:
Patel P, Lokapur MA. Stellate ganglion block for persistent idiopathic facial pain. Indian J Pain 2016;30:207-8

How to cite this URL:
Patel P, Lokapur MA. Stellate ganglion block for persistent idiopathic facial pain. Indian J Pain [serial online] 2016 [cited 2020 Feb 24];30:207-8. Available from: http://www.indianjpain.org/text.asp?2016/30/3/207/198065


  Background Top


Persistent idiopathic facial pain is a facial pain disorder without any identifiable cause. The patient has persistent facial pain without any objective sign on clinical examination or investigations. This condition has been given various terminologies such as atypical facial pain, atypical trigeminal neuralgia, atypical odontalgia, and phantom tooth syndrome. The International Classification of Headache Disorders (2004) coined the term persistent idiopathic facial pain for all such conditions under the heading of central causes of facial pain. [1] Various modalities of treatment have been tried in these patients with minimal success. We report a case of persistent idiopathic facial pain successfully managed with stellate ganglion block.


  Case Report Top


A 42-year-old female was referred to our Pain Clinic at Byramjee Jeejeebhoy Government Medical College and Sassoon Hospital with complaints of unilateral (right sided) facial pain. She had progressively increasing unilateral facial pain and headache for 2 years. The pain was constant, dull aching, and burning in nature aggravated further by exposure to cold weather or wind (NRS 6 TO 9). The pain was relieved on taking rest in a quiet, dark room. On examination, there was no neurodeficit, no allodynia, mouth opening was normal, and pulses around head and neck were normal. The patient demonstrated a pain map involving right forehead, vertex, right face, and upper neck. Her magnetic resonance imaging scan of brain was within normal limits. The patient had inadequate pain relief with anticonvulsants/antidepressants (gabapentin and duloxetine) prescribed by neurologists. The patient had poor relief with gabapentin (1200 mg/day) and duloxetine (60 mg/day) before procedure. Further dose escalation caused severe dizziness, sedation, and unpleasant side effects. She had a history of primary hyperthyroidism (diagnosed 3 years prior) for which she received mecarbazole and radioactive iodine. The treatment was completed 6 months prior, and she was declared asymptomatic with normal thyroid function tests on follow-up.

We performed a right-sided stellate ganglion block for the patient under fluoroscopy guidance with bupivacaine 0.25%, 3 and 2 ml dexamethasone (4 mg/ml) using 22-gauge Quincke's needle at C7 level under aseptic precautions. Nonionic, water-soluble dye was used to confirm the needle position. Postprocedure, the patient had significant pain relief (90%) at 1 week. The patient is on follow-up at our pain clinic. Nine months postprocedure, the pain relief was found to be persistent. The patient was on tablet gabapentin 300 mg thrice a day on follow-up. Gabapentin along with duloxetine even at higher dose failed to provide her pain relief before the procedure, but pain scores were substantially decreased postprocedure on gabapentin alone at lower doses. In case of recurrent pain, the patient will be offered repeat stellate ganglion block with steroid and local anesthetic.


  Conclusion Top


Stellate ganglion is formed by union of inferior cervical ganglion with first thoracic ganglion of the sympathetic chain. It lies in the interspace between C7 and T1 vertebral bodies. Preganglionic sympathetic fibers supplying the head and neck (arise from T1, T2 spinal segments) and upper extremity (arise from T2 to T9 spinal segments) join the sympathetic chain through white rami communicants, and ultimately synapse at the stellate ganglion, middle cervical ganglion, and superior cervical ganglion. The postganglionic fibers for head and neck exit the sympathetic trunk through gray rami communicants and travel along carotid artery for distribution to head and neck region. [2] Sympathetic innervation to head, neck, and upper extremity can be blocked by stellate ganglion block.

Stellate ganglion block is beneficial in Raynaud's disease, postherpetic neuralgia, complex regional pain syndrome, phantom limb pain, vascular headaches, diabetic neuropathy, and refractory angina pectoris. Benefits of Stellate ganglion block in pain states are because of (i) Alteration of sympathetic tone, thus decreasing sympathetically mediated pain. Sympathetic tone plays a role in generation and maintenance of orofacial pain. [3] (ii) Psychological features of chronic pain such as stress and depression are common in facial pain. Stellate ganglion block also alleviates stress in chronic pain. It has proved effective in posttraumatic stress disorder and anxiety states. [4] (iii) In rabbits, stellate ganglion block is shown to decrease formalin-induced nociception by decreasing substance P levels in spinal cord and plasma catecholamine release. [5] In our patient, we presume the relief was due to decreased sympathetic tone and alleviation of anxiety associated with facial pain. Extensive search of literature revealed a very few case reports of this condition.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2 nd edition. Cephalalgia 2004;24 Suppl 1:9-160.  Back to cited text no. 1
    
2.
Prithvi Raj P, Erdine S. Interventional pain procedures in the neck. In: Pain-Relieving Procedures: The Illustrated Guide. 1 st ed. U.K.: Wiley-Blackwell; 2012. p. 207-9.  Back to cited text no. 2
    
3.
Lynch ME, Elgeneidy AK. The role of sympathetic activity in neuropathic orofacial pain. J Orofac Pain 1996;10:297-305.  Back to cited text no. 3
    
4.
Zinzow HM, Brooks J, Stern EB. Efficacy of stellate ganglion block in the treatment of anxiety symptoms from combat-related post-traumatic stress disorder, a case series. Mil Med 2013;178:e357-61.  Back to cited text no. 4
    
5.
Wang QX, Wang XY, Fu NA, Liu JY, Yao SL. Stellate ganglion block inhibits formalin-induced nociceptive responses : m0 echanism of action. Eur J Anaesthesiol 2005;22:913-8.  Back to cited text no. 5
    




 

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