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Intracellular recordings from the stellate ganglion of the cat.

1. Intracellular recordings were made, in vitro, and in situ, from neurones of the cat stellate ganglion. 2. Preganglionic stimulation, in vitro, via the T3 ramus or post-ganglionic stimulation via the ventral ansa, dorsal ansa or stellate cardiac nerve evoked graded synaptic responses which led to the discharge of one or more action potentials. Since the conduction velocities of fibres converging onto a single cell may vary, their convergence may mean that there is an interaction in the stellate ganglion between functionally different pathways. 3. Most neurones in the stellate ganglion receive synaptic input from fibres of both central and peripheral origin. 4. Intracellular recordings were made, in situ, from neurones of the cat stellate ganglion attached via the stellate cardiac nerve to the rest of the animal. When peripheral sympathetic afferent input to the stellate ganglion was increased by occluding the descending aorta, some of the neurones exhibited an increase in excitatory post-synaptic potentials (e.p.s.p.s) and/or action potentials. Most of the synaptic input recorded from the ganglion cells in situ had a close relationship with the cardiac cycle and/or respiration. 5. These data and our previous studies support the contention that sympathetic efferent nerve activity can be modified by peripheral excitatory inputs and that these neural connexions may function as pathways for a peripheral reflex at the level of the paravertebral ganglion.

Action Potentials↗

The effects of morphine on sympathetic transmission in the stellate ganglion of the cat.

The aim of this study was to investigate which of the processes involved in synaptic transmission are affected by morphine in concentrations comparable to those used during surgical procedures. The effects of morphine sulfate on ganglionic transmission were studied in the stellate ganglion of the cat using intracellular and extracellular recordings in vitro. The neurons of the stellate ganglion were depolarized using preganglionic nerve stimulation, postganglionic nerve stimulation, and intracellular stimulation before and after introduction of morphine sulfate (up to 20 micrograms/mL). Tissue concentrations of morphine were estimated using radiolabeled morphine. Axonal transmission and the excitability of the postganglionic neurons to direct intracellular stimulation was not affected at the concentrations of morphine studied. In addition, morphine had a dose-dependent depolarizing effect on the resting membrane potential of most of the neurons in the stellate ganglion. Such neuronal depolarizations alone could initially produce excitation in some cell populations, followed by inhibition, secondary to the membrane depolarization, leading to depression of sympathetic nerve activity. The overall ganglionic transmission as recorded using an evoked potential was biphasic. At low doses morphine facilitated transmission, while at larger doses morphine attenuated evoked potentials. These effects do not appear to be mediated through classical opiate receptors since they are not blocked by naloxone.

Animals↗

The effects of selective stellate ganglion manipulation on ventricular refractoriness and excitability.

The effects of selective stellate ganglion stimulation or stellectomy on ventricular excitability were studied in 30 open chest mongrel dogs anesthetized with alpha-chloralose. The effective refractory period (ERP) and strength interval curves (stimulus intensity [S2] = twice the diastolic threshold [ERP], and 2, 3, 5, 7, and 14 mA) were determined using bipolar epicardial electrodes placed in the mid-anterior wall of the right ventricle (RV) and the mid-posterolateral wall of the left ventricle (LV) during left stellate ganglion stimulation (LSGSt, n = 8) or right stellate ganglion stimulation (RSGSt, n = 8), or after left stellectomy (LSGEx, n = 7) or right stellectomy (RSGEx, n = 7). LSGEx prolonged ERP-LV (172 +/- 9 vs 167 +/- 8 msec, P < 0.05) and ERP-RV (163 +/- 10 vs 158 +/- 14 msec, P < 0.05). RSGEx prolonged ERP-LV (168 +/- 17 vs 162 +/- 15 msec, P < 0.01) and ERP-RV (166 +/- 14 vs 160 +/- 13 msec, P < 0.01), and the times of the strength interval curves obtained for each S2 intensity in both ventricles. LSGSt decreased ERP-LV (157 +/- 11 vs 163 +/- 12 msec, P < 0.01) and ERP-RV (147 +/- 18 vs 157 +/- 17 msec, P < 0.05), and the times of the strength interval curves obtained for each S2 intensity in both ventricles. RSGSt did not significantly decreased ERP-LV (152 +/- 11 vs 156 +/- 9 msec); however, it significantly shortened the times of the strength interval curves obtained for S2 intensities of 2 and 7 mA in the LV, and shortened ERP-RV (139 +/- 10 vs 145 +/- 7 msec, P < 0.01) and the times of the strength interval curve for S2 intensities of 2, 3, and 5 mA in the RV. A significant interaction (MANOVA test) was observed between the ventricle studied and the ganglion stimulated for S2 intensities of 2 and 3 mA, and between the effect of stimulation and the ganglion stimulated for S2 intensities of 3 and 14 mA. To conclude, selective stellectomy prolonged epicardial ventricular refractoriness in both the mid-anterior wall of the RV and the mid-posterolateral wall of the LV; the magnitude of the epicardial excitability variations in both areas was different during selective stellate ganglion stimulation.

Analysis of Variance↗

Computerized axial tomography to define the distribution of solution after stellate ganglion nerve block.

STUDY OBJECTIVE: To define the spread of local anesthetic after C6 stellate ganglion nerve block using computerized axial tomography (CAT). DESIGN: Prospective, open descriptive study. SETTING: Outpatient pain consult center. PATIENTS: 10 ASA status I patients undergoing stellate ganglion nerve blocks for sympathetically maintained pain. INTERVENTIONS: Radiocontrast and local anesthetic was given in 5 ml increments to 20 ml total volume for C6 stellate ganglion nerve blocks in eight patients and C7 in two patients. MEASUREMENTS AND MAIN RESULTS: CAT scanning was performed at baseline and after 5, 10, 15, and 20 ml of injectate was administered. Cervical level and pattern of injectate spread was recorded after each increment. Neck pressure above C6 did not promote caudal spread. One half of the injections were beneath prevertebral fascia. Injections on top of the fascia spread more diffusely around C6. All injections in high volume reached the medial aspect of T1 around the head, not neck, of the first rib. CONCLUSIONS: Solutions injected for C6 stellate ganglion nerve block concentrate medial to the stellate ganglion at T1. Thus, they must produce upper extremity sympathectomy by a mechanism other than contact with the ganglion.

Adult↗

Stellate ganglion block inhibits formalin-induced nociceptive responses: mechanism of action.

BACKGROUND AND OBJECTIVE: Stellate ganglion block has been extensively used in clinical practice for the management of painful conditions such as cephalic, facial and upper limb pains yet its mechanism of action and its analgesic efficacy are poorly understood. METHOD: Formalin (3% 0.2 mL) was injected into the plantar region of the right upper limb paw in rabbits and 50 min after this injection, saline or bupivacaine 2.5% 0.5 mL was administered via a chronic implantation catheter near the right stellate ganglion. Behavioural modification, changes in heart rate and plasma norepinephrine release at different time points after formalin and bupivacaine or saline injection were observed. Finally, the cervical spinal cord was harvested and immunostaining for substance P and c-Fos was performed. RESULTS: Formalin caused stress noxious behavioural changes and a significant increase in heart rate and norepinephrine release. These changes were inhibited by bupivacaine stellate ganglion block but not by saline injection. Immunoreactants of substance P were significantly decreased by formalin injection compared with that in controls. However, with bupivacaine injection, substance P levels were restored though not reaching the levels seen in the controls. Formalin injection also caused a significant increase of c-Fos expression in cervical spinal cord. This increase was not affected by stellate ganglion block. CONCLUSION: Stellate ganglion block can effectively alleviate nociceptive responses induced by formalin injection. The mechanism of its action may involve reduction of substance P in the spinal cord and plasma catecholamine release caused by noxious stimuli.

Analgesia↗

Stellate ganglion block does not change the tympanic membrane temperatures of either block or unblock sides in male volunteers.

STUDY OBJECTIVES: To test the effect of stellate ganglion block on tympanic membrane temperatures. DESIGN: Prospective, observational study. SETTING: Department of Anesthesia, Yamanashi Medical University, Yamanashi, Japan. SUBJECTS: 7 healthy male volunteers. INTERVENTIONS: Stellate ganglion block, 6 ml of 1% mepivacaine hydrochloride, was administered. MEASUREMENTS AND MAIN RESULTS: Application of temperature probes (right and left tympanic membranes, eight adhesive right skin-surface temperatures at the chest, upper arm, digital fingertip, lateral calf, thigh, and great toe) was followed by a 30-minute control period. Temperatures were recorded every 15 minutes for 30 minutes before stellate ganglion block and every 5 minutes for 40 minutes after the block. The right tympanic membrane temperature increased slightly but not significantly compared with the left tympanic membrane temperature 10 minutes after stellate ganglion block and subsequently. Right skin-surface temperature gradients at the upper limb decreased slightly but not significantly after stellate ganglion block. Similarly, right skin-surface temperature gradients at the lower limb decreased slightly but not significantly after stellate ganglion block. CONCLUSIONS: Stellate ganglion block does not change the tympanic membrane temperatures of either block or unblock sides.

Adult↗

Aetiology of convulsions due to stellate ganglion block: a review and report of two cases.

Stellate ganglion block is a selective sympathetic block that affects the ipsilateral head, neck, upper extremity and upper part of the thorax. Convulsions are a recognized complication of intra-arterial injection during stellate ganglion block. As central nervous system toxicity depends ultimately on the concentration of the local anaesthetics presented to the brain, the likely causative factors are discussed as well as the types of toxic symptoms and their onset times. The paper considers the aetiological factors of such convulsions resulting from stellate ganglion block in two patients.

Adult↗

[A possibility of central diffusion during stellate ganglion blockade: "the sheath of the spinal rachidian nerve"].

Stellate ganglion block is a common treatment for neuropathic pain. The technique is not without potentially severe complications when a paratracheal approach is used. A 33-year-old woman complained of atypical facial pain of 15 years' duration with pain intensity of 6 to 8 on a visual analog scale and no pain-free periods upon use of inadequate analgesia. One minute after performing a second stellate ganglion block the patient showed signs of apnea and paralysis of the upper extremities and face, with no involvement of oculomotor muscles or the lower extremities, and no loss of consciousness. Assisted ventilation was started. Signs and symptoms resolved fully after 15 minutes. A few days later, the patient reported having perceived paresthesia in the affected zone during the procedure. Central spread of a portion of local anesthetic by way of the spinal nerve sheath toward the subarachnoid space may cause partial cervical and basal nuclear blockade. Signs would be apnea, involvement of the upper extremities and facial muscles, although paresthesia during the injection is the only evidence supporting this hypothesis. Bone contact and negative aspiration while performing a stellate ganglion block do not guarantee avoidance of complications.

Adult↗

Neuronal projections to the guinea pig stellate ganglion investigated by retrograde tracing.

Previous electrophysiological studies have revealed a peripheral sensory input to the stellate ganglion which does not originate from the dorsal root ganglia. The present retrograde tracing study aimed at evaluating whether the parent cell bodies are located in the periphery, i.e. in mediastinal ganglia. Following injection of Fast blue or wheat germ agglutinin-horseradish peroxidase into the right stellate ganglion of the guinea pig, retrogradely labelled cell bodies were observed in the intermediolateral and intercalated nuclei of the spinal cord as well as in dorsal root ganglia at segmental levels C8 to T6. In another case, the stellate ganglion was resected and replaced by a sponge soaked with 10 microliters of Fast blue. Labelling of preganglionic and sensory neurons parallelled that obtained by tracer injections. In neither case, however, were retrogradely labelled neurons found within or around the thoracic viscera (thymus, trachea, bronchi, esophagus, heart, great vessels of upper mediastinum) when these were cut serially en bloc. Controls performed by injection of Fast blue into the inferior mesenteric ganglion and investigation of the distal colon showed that our experimental protocol was able to visualize a peripheral projection towards a sympathetic ganglion--in this case from myenteric ganglia to the inferior mesenteric ganglion. We conclude that, in contrast to the circuitry connecting prevertebral sympathetic ganglia with the gut, the neuronal cell bodies providing peripheral sensory input from thoracic viscera to the right stellate ganglion most likely are not located within the mediastinal ganglia. Instead, they may reside within the stellate ganglion itself.

Amidines↗

[Complications and side effects of stellate ganglion blockade. Results of a questionnaire survey].

Stellate ganglion blockade (SGB) is an established method in the therapy of chronic pain syndromes. Complications are rare but can be life-threatening (inadvertant subarachnoid or intra-arterial injection). Since no data are currently available as to the incidence of complications, we sent questionnaires to 76 departments of anaesthesiology in West Germany to evaluate this issue. RESULTS. Thirty-nine questionnaires (51%) were returned, representing approximately 45,000 SGBs; 82% of the departments prefer bupivacaine for SGB. The incidence of severe complications was 1.7 in 1000 blockades. Most of these were CNS complications (i.e., convulsions). A high subarachnoid block was reported in 6 cases, high epidural blockade in 3, pneumothorax in 9, and allergic reactions in 2. All departments conduct aspiration tests before injection; 94% take precautionary measures in case of respiratory failure (oxygen, ventilating devices); 73% do not perform SGB without an assistant and an anticonvulsant drug at hand; 72% place an intravenous line before SGB; 28% use ECG monitoring routinely; and 53% administer a test dose of 0.5-2 ml local anaesthetic. DISCUSSION. Severe complications following SGB are rare. Potentially life-threatening complications usually arise from inadvertant subarachnoid or intra-arterial injection. Aspiration tests and test doses obviously do not guarantee proper administration. Placement of an intravenous line, ECG monitoring, and the presence of an assistant are strongly recommended. Anticonvulsant drugs as well as drugs and equipment for intubation and resuscitation should be immediately available. The administration of very low doses of opioids to the stellate ganglion has been shown to have similar therapeutic results to local anaesthetic blocks, whereas the incidence of side effects and complications is lower. Therefore, the administration of opioids to sympathetic ganglia could provide an alternative therapeutic regimen for the future.

Adult↗

Efficacy of stellate ganglion block: a clinical study with bupivacaine.

BACKGROUND AND OBJECTIVES: When administering stellate ganglion blocks (e.g., to pain patients), it may be essential to know whether the sympathetic block is complete. The aim of the present study was to study the efficacy of stellate ganglion blocks using different concentrations and volumes of local anesthetic and different sites of injection. METHODS: Fifty-four stellate ganglion blocks (cervicothoracic sympathetic blocks) were performed for relief of chronic pain in 30 patients, all with a pre-block palmar skin temperature 32 degrees C or lower. Bupivacaine in random combinations of concentration (high, 5 mg/ml; low, 2.5 mg/ml), volume (high, 15-20 ml; low, 5-10 ml), and site of injection (C6 or C7) was used. The efficacy of these combinations was assessed by registering the following changes in effector organ activity: (1) observed signs (e.g., Horner's syndrome: miosis, ptosis, enophthalmos, and reddening of the sclera) and (2) objective measurements of changes in skin temperature, skin blood flow (laser Doppler flowmetry), skin resistance response, and in skin resistance level. RESULTS: Only 15 of 54 blocks met four of the five criteria for an effective block: a Horner's syndrome in combination with an increased skin temperature (to > or = 34 degrees C), increased skin blood flow ( > or = 50%), and completely abolished skin resistance response on both the radial and the ulnar sides of the blocked hand. Only six of those 54 met all five criteria: they also had an increase ( > or = 13%) in skin resistance level on the radial and ulnar sides. Injection toward C7 instead of injection toward C6, and high concentration instead of low, seemed to be more advantageous, whereas volume seemed to be of less importance. A relationship between pre-block skin temperature and the rise in temperature during the block was found. CONCLUSIONS: It was difficult to achieve a block that met all five established criteria. When assessing the efficacy of a stellate ganglion block, it is essential to evaluate the effects on vasoconstrictor and sudomotor fibers.

Adult↗

The spread of solutions during stellate ganglion block.

BACKGROUND AND OBJECTIVE: Though cervical paratracheal injections for the purpose of sympathetic block are customarily referred to as stellate ganglion blocks, there is no documentation of the actual site of local anesthetic action. The objective of this study is to test whether solution travels to the stellate ganglion during injections commonly used to anesthetize it. METHODS: In eight volunteers, magnetic resonance imaging was used to delineate the distribution of 15 ml saline injected by an anterior paratracheal technique at the sixth and seventh cervical vertebral levels. RESULTS: Injectate was not delivered to the stellate ganglion but rather passed anterior to it. CONCLUSIONS: The findings suggest that sympathetic neural block during stellate ganglion block may take place at sites other than the stellate ganglion.

Adult↗

[Changes of tympanic temperature by stellate ganglion block].

The effects of stellate ganglion block (SGB) on the temperature of tympanic membrane were determined clinically. Thirty patients received SGB with 8 ml of 1 % mepivacaine. The tympanic temperature was measured using radiation non-contact tympanic membrane thermometer before and after administration of SGB for 30 min on the side where SGB was given. Before SGB the tympanic temperature was 37.29 +/- 0.08 degrees C, and there was no difference in the readings between the two sides. The tympanic temperature dropped significantly 5 min after SGB and reached its lowest value of 36.90 +/- 0.08 degrees C 15 min later. This drop persisted for more than 30 min after SGB. The fact that therapeutic effect of SGB is partly due to vasodilation and improvement in blood flow to the affected region was demonstrated, but these effects in internal carotid arterial system have not yet been studied in detail. Tympanic temperature has been proposed as a valid index of brain temperature in man. The mechanism of brain cooling has been suggested that countercurrent heat exchange takes place between carotid and jugular blood flow. Therefore the result of the study suggests that SGB could enhance an increase in the brain blood flow.

Adolescent↗

Electrophysiological and morphological characterization of neurons in stellate ganglion of cats.

We have studied the general morphology of cat stellate ganglion cells in relation to the synaptic input that each neuron receives. Horseradish peroxidase (HRP) was injected intracellularly into single neurons of the isolated cat stellate ganglia. Neurons of the stellate ganglion receive synaptic information from central and peripheral nerves. Electrical stimulation of the preganglionic nerves (T3 ramus), and postganglionic stimulation of the ventral or dorsal ansa subclavia, evoked graded excitatory responses that led to the discharge of one or more action potentials. The neurons receiving synaptic input from preganglionic and postganglionic nerves have a complex dendritic morphology. These neurons were located close to the postganglionic nerves and had an axon emerging from these nerves. Other neurons located closer to the preganglionic nerves had no identifiable axons leaving the ganglion and could not be excited antidromically by electrical stimulation. These neurons appear to be interneurons. These results indicate that neurons of the cat stellate ganglion are organized in a complex fashion that could be important in the integrative properties of these neurons.

Animals↗

Regional intravenous guanethidine vs. stellate ganglion block in reflex sympathetic dystrophies: a randomized trial.

Regional intravenous guanethidine blocks and stellate ganglion blocks have been compared in a randomized trial. Nineteen patients, randomly allocated to two groups of therapy and exhibiting severe reflex sympathetic dystrophy following peripheral nerve lesions, have been treated. The performance of the intravenous guanethidine block is of longer duration and superior to stellate ganglion block, as regards some early pharmacological effects (skin temperatures and amplitude of plethysmographic waves recorded before blockade and 15 min, 60 min, 24 h, 48 h after institution of the block). In fact the intravenous guanethidine group shows a persistent and significant increase of the skin temperature and of the plethysmographic traces in the blocked side 24 h and 48 h after blockade in comparison with the patients treated with stellate ganglion block. Concerning the therapeutic effects (changes in pain scores and clinical signs--hyperpathia, allodynia, vasomotor disturbances, trophic changes, oedema and limited motion), recorded at the end of treatment and 1 month and 3 months follow-up, an intravenous guanethidine block carried out every 4 days up to a total of 4 blocks is comparable with a stellate ganglion block every day up to a total of 8 blocks. The results of this study show that regional sympathetic block with guanethidine is a good therapeutic tool in the treatment of reflex dystrophies, especially on account of its negligible risks and contraindications.

Adult↗

A case of cervical spondylitis during stellate ganglion block.

We report a case of cervical spondylitis that developed during treatment with a series of stellate ganglion blocks. A 65-year-old man was scheduled for 10 sessions of stellate ganglion block for treatment of right-sided deafness of sudden onset due to Ramsay Hunt syndrome. Administration of betamethasone was started 5 days before the first block and was continued for 6 weeks. After disinfection of the skin by povidone iodine, each stellate ganglion block was performed via the paratracheal approach. The first four block sessions were uneventful. However, during the fifth session, the patient complained of neck pain. After 10 sessions, the deafness improved and the patient was discharged from the hospital. Three weeks after discharge, he was readmitted for sustained neck and bilateral shoulder pain and numbness of the right hand. Cervical roentgenography and magnetic resonance imaging revealed spondylitis of C5 and C6. Antibiotics were administered for 2 weeks. The inflammatory variables on blood examination improved, but cervical roentgenography performed 8 weeks after the last block showed that the vertebral body of C6 was nearly completely destroyed. Four months after the last block, the vertebral bodies of C5 and C6 had fused. This case indicates that when stellate ganglion block is performed in patients who are taking a corticosteroid, the disinfection procedure must be strictly followed and that if the patient complains of neck or shoulder pain, cervical roentgenography or magnetic resonance imaging or both should be immediately performed to assess the presence of spondylitis.

Aged↗

Clinical and physiologic evaluation of stellate ganglion blockade for complex regional pain syndrome type I.

OBJECTIVE: The efficacy of peripheral sympathetic interruption after stellate ganglion blockade was assessed by a sympathetic function test. Results were compared with clinical signs such as temperature changes, pain reduction, and the development of Horner syndrome to evaluate the correlation with clinical investigations. DESIGN: Stellate ganglion blockade with local anesthetics was carried out via an anterior paratracheal approach in 33 patients suffering from complex regional pain syndrome type I. Patients were examined before and after the procedure. For assessment of sympathetic nervous function, the vasoconstrictor response to sympathetic stimuli was assessed using laser Doppler flowmetry. Clinical parameters like surface temperature changes (thermography), pain relief (visual analogue scale), and Horner syndrome were monitored. RESULTS: Twenty-three (70%) of 33 patients developed an increase in temperature difference between the treated hand and the contralateral hand of more than 1.5 degreesC after the procedure, which is a clinical sign of sympathicolysis. In 48% (n = 11) of these patients, the sympathetic function test showed an undisturbed sympathetic nervous function. In 10 patients, no significant increase in temperature difference was observed. Although these patients presented with a normal sympathetic vasoconstrictor response, 4 felt pain relief of more than 50%, suggesting a placebo effect. Only 7 patients with pain relief revealed both clinical sympathicolysis and extinguished sympathetic nervous function and qualified for sympathetically maintained pain. CONCLUSIONS: Clinical investigation is not reliable in the assessment of stellate ganglion blockade. Proof of sympathetically maintained pain based on pain relief after stellate ganglion blockade is not conclusive.

Adult↗