Stellate Ganglion Block: A Procedure to Help Regulate the Sympathetic Nervous System

What are the Sympathetic Nervous System and the Stellate Ganglion?

The autonomic system controls the functions in your body that you do not have to ‘think’ about: breathing, blood pressure, pulse, digesting your food, etc.. It has two parts: the sympathetic and parasympathetic nervous systems. The sympathetic nervous system directs raising blood pressure and heart rate, sweating, contracting blood vessels and other processes related to stress response. It is commonly referred to as the ‘fight or flight’ system. The parasympathetic system does the opposite by lowering blood pressure, slowing heart rate and relaxing blood vessels. It is commonly called the ‘rest and digest’ system (the vagus nerve is one of the major parts of the parasympathetic system).

The sympathetic nervous system does good things for us like maintaining our blood pressure when we stand up or making adaptive changes in our heart rate and muscle metabolism that allow us to exercise. However, many imbalances and symptoms can occur when it is chronically activated. In our modern life, it is easy for our sympathetic nervous system to become overstimulated: ‘turned-on’ at high volume, for too long. The sympathetic nervous system response we get when chased by a tiger or when we have to deal with financial or emotional stress will cause the same reaction. Unlike being chased by a tiger (which eventually ends, for better or worse) the stress we experience on a day-to-day basis seems never ending. Other things that contribute to chronic, overactivation or the sympathetic nervous system include:

• Exposure to toxins (mold toxin, heavy metal, plastics, volatile solvents, etc.)
• Chronic infections (Lyme disease, Epstein Barr, etc.)
• Dysbiosis/Imbalance of bacteria in the gut
• Nutrient deficiencies
• Intensive treatments for medical problems (chemotherapy, radiation and certain other types of drugs)
• Any type of chronic mental, emotional or physical stress
  

People who are experiencing symptoms of an overactive sympathetic nervous system usually have several of these factors which led to the dysfunction.

A ‘ganglion’ is a group of nerves, that looks a bit like a web if you were to magnify it. We have ganglia (plural of ganglion) all over our bodies and they serve various functions. The Stellate Ganglion is a part of the sympathetic nervous system. It is located on both sides of the neck, behind the carotid arteries. It is a location where we can access the sympathetic nervous system directly to help control its output and activity.

How does the Stellate Ganglion Block Work?

The stellate ganglion block is an ultrasound guided injection of local anesthesia into the area surrounding the stellate ganglion. An ultrasound is used to be sure no other vital structures (veins, arteries, glands, etc.) are injured in the process. The needle used is very thin and only a small amount of local anesthetic is necessary to obtain the desired effects. The stellate ganglion exists on both sides of the neck, but only one side is injected at a time. Typically, patients will return to the office 3-7 days after the first side is injected to have the same procedure performed on the opposite side.

What conditions can be helped with a Stellate Ganglion Block?

The stellate ganglion block is useful for a wide variety of conditions caused by imbalance between the sympathetic and parasympathetic nervous systems. This results in many different diagnoses/symptoms. While the stellate ganglion block is not FDA approved to treat any specific condition, good evidence in the medical literature exists to help alleviate the symptoms of the following conditions:

• Anxiety and Post-Traumatic Stress Disorder (PTSD) (1)(2)(3)
• Chronic Migraine (4)(5)
  
• Menopausal Hot Flashes (6)
• Heart Arrhythmias (7)(8)
• Complex Regional Pain Syndrome (upper extremity) (9)(10)

Are there any risks of Stellate Ganglion Block?

With any type of procedure, there are always risks to consider. The procedure is done with ultrasound guidance to be sure any serious complications is avoided. In the case of stellate ganglion block, the common risks are:

• Horner’s Syndrome: the pupil of the eye on the side of the block becomes very small (constricted). This is a normal effect of blocking the sympathetic nerves and can be used as a sign that the procedure is ‘working’. It does not occur during every procedure, but patients should be aware of it as a possible side effect. The pupil will return to normal when the anesthetic wears off.
• Dysphonia/change in voice: the nerves which control the vocal cords can also be affected as they are very close to the sympathetic ganglion. The patient’s voice may become hoarse, rough or weak. This is temporary and the voice will return to normal after the anesthetic wears off.
  

More significant, rare complications include:

• Damage/puncture of any surrounding tissues: thyroid, trachea, esophagus
• Damage/puncture of a blood vessel leading to bleeding or a hematoma (bruising/blood clot)
• Temporary paralysis of other nerve groups: brachial plexus (controls the arm), phrenic nerve (controls the diaphragm)
  • Note: The phrenic nerve controls the diaphragm which allows us to breathe. When a single side is affected, the other side will compensate and the patient will continue to breathe, but it may feel difficult or labored. This is temporary and will resolve when the anesthesia wears off.

Who should not do a Stellate Ganglion Block?

Stellate ganglion block is not advisable for anyone with the following conditions:

• Recent myocardial infarction (heart attack)
• Anti-coagulated patients (taking blood thinners)
• Patients with coagulopathy (impaired ability to make blood clots)
• Glaucoma
• Pre-existing phrenic nerve palsy
• Severe phobia/anxiety with needles, blood draw or injection procedures
  

What is the follow up for Stellate Ganglion Block?

The patient’s progress will be monitored the day after the procedure to be sure they are doing well. Most patients feel some relief of their symptoms very soon after the first injection, many feel better immediately.

We perform only one side per procedure. After 3-7 days, the patient can return to the office to have the second side injected for a ‘complete’ procedure. The effects of the stellate ganglion block may last anywhere from a week up to several months. Patients may repeat the procedure as often as necessary. The medications used are not toxic, given in low doses and are rapidly removed from the body so it is safe to do multiple procedures over time.

If you are interested in stellate ganglion block as a part of your treatment plan, please call our office to schedule a consult. During the consult, we will review your complete medical history, current health concerns and ongoing medical treatments to see if you are a good candidate for the procedure.

(1)   Li Y, Loshak H. Stellate Ganglion Block for the Treatment of Post-Traumatic Stress Disorder, Depression, and Anxiety [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2021 Mar. PMID: 34255448.
(2)   Lynch JH, Mulvaney SW, Bryan CJ, Hernandez D. Stellate Ganglion Block Reduces Anxiety Symptoms by Half: A Case Series of 285 Patients. J Pers Med. 2023 Jun 6;13(6):958. doi: 10.3390/jpm13060958. PMID: 37373947; PMCID: PMC10303073.
(3)   Rae Olmsted KL, Bartoszek M, Mulvaney S, McLean B, Turabi A, Young R, Kim E, Vandermaas-Peeler R, Morgan JK, Constantinescu O, Kane S, Nguyen C, Hirsch S, Munoz B, Wallace D, Croxford J, Lynch JH, White R, Walters BB. Effect of Stellate Ganglion Block Tre.
(4)  Yu B, Zhang W, Zhao C, Xing Y, Meng L, Luo F. Effectiveness, safety, and predictors of response to ultrasound-guided stellate ganglion blockades for the treatment of patients with chronic migraine: A retrospective and observational study. Pain Pract. 2023.
(5)  Yu B, Hou S, Xing Y, Jia Z, Luo F. Ultrasound-guided stellate ganglion block for the treatment of migraine in elderly patients: A retrospective and observational study. Headache. 2023 Jun;63(6):763-770. doi: 10.1111/head.14537. Epub 2023 Jun 14. PMID: 373.
(6)  Lee YS, Wie C, Pew S, Kling JM. Stellate ganglion block as a treatment for vasomotor symptoms: Clinical application. Cleve Clin J Med. 2022 Mar 1;89(3):147-153. doi: 10.3949/ccjm.89a.21032. PMID: 35232827.
(7)   Feigin G, Velasco Figueroa S, Englesakis MF, D'Souza R, Hoydonckx Y, Bhatia A. Stellate ganglion block for non-pain indications: a scoping review. Pain Med. 2023 Jul 5;24(7):775-781. doi: 10.1093/pm/pnad011. PMID: 36727500.
(8)  Wen S, Chen L, Wang TH, Dong L, Zhu ZQ, Xiong LL. The efficacy of ultrasound-guided stellate ganglion block in alleviating postoperative pain and ventricular arrhythmias and its application prospects. Neurol Sci. 2021 Aug;42(8):3121-3133. doi: 10.1007/s10.
(9)  Wie C, Gupta R, Maloney J, Pew S, Freeman J, Strand N. Interventional Modalities to Treat Complex Regional Pain Syndrome. Curr Pain Headache Rep. 2021 Feb 3;25(2):10. doi: 10.1007/s11916-020-00904-5. PMID: 33537907.
(10)  Toshniwal G, Sunder R, Thomas R, Dureja GP. Management of complex regional pain syndrome type I in upper extremity-evaluation of continuous stellate ganglion block and continuous infraclavicular brachial plexus block: a pilot study. Pain Med. 2012 Jan;13(.