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      Bi-national survey of Korea and Japan related to the injection site for ultrasound-guided stellate ganglion blocks and anatomic comparisons using cadaver dissection

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          Abstract

          The aims of this study were to investigate the current clinical practice of ultrasound (US)-guided stellate ganglion block (SGB) using a bi-national survey of Korea and Japan, and to clarify the anatomical relation of the cervical sympathetic trunk with the prevertebral fascia at the level of cervical vertebrae. The current clinical practice of US-guided SGB in Korea and Japan was investigated using an Internet survey, which received 206 (10.2%) replies from Korea and 97 (8.8%) replies from Japan. The survey questionnaire addressed the actual clinical practice for US-guided SGB, including where the tip of the injection needle is placed. Additionally, 16 half necks of 8 embalmed cadavers were used in an anatomical study. An in-plane needle approach technique and administering 5 ml of local anesthetic were preferred in both countries. However, the type of local anesthetic differed, being lidocaine in Korea and mepivacaine in Japan. The final position of the needle tip also clearly differed in an US image, being predominantly positioned above the prevertebral fascia in Korea (39.3%) and under the prevertebral fascia in Japan (59.8%). In all of the anatomic dissections, the cervical sympathetic trunk was over the prevertebral fascia at the level of the sixth vertebra and under the prevertebral fascia at the level of the seventh vertebra. These results are expected to improve the knowledge on the current clinical practice and to suggest future studies.

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          Most cited references 20

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          Cervical sympathetic and stellate ganglion blocks.

          Sympathetic blocks in the cervical and upper thoracic region are commonly used techniques for a variety of diagnostic, therapeutic and prognostic purposes. Stellate ganglion block is the common nomenclature utilized, however, stellate ganglion is present in only 80% of the population, thus, either lower cervical sympathetic block or upper thoracic sympathetic block is an appropriate term. The cervical sympathetic ganglia are identified as the superior, middle, intermediate and the inferior cervical sympathetic ganglion. The superior cervical ganglia are approximately 3 to 5 cm in length and situated on the longus capitus muscle anterior to the transverse process of the second, third, and rarely the fourth cervical vertebrae; the middle cervical ganglia are the smallest of the cervical ganglia situated on the longus colli muscle, anterior to the base of the transverse process of the sixth vertebrae; and the intermediate cervical ganglia which are more consistent in position and are located on the medial side of the vertebral artery. The inferior cervical ganglia, when present, are located on the transverse process of the C7 vertebrae, whereas the first thoracic ganglia are situated in front of the neck of the first rib. In 70% to 80% of the population they are fused together forming the stellate ganglion. Stellate ganglion block or lower cervical sympathetic block has been advocated for both diagnostic, therapeutic, and prognostic purposes for a variety of conditions. Even though multiple techniques are advocated in performing this block, fluoroscopically guided sympathetic blocks are more appropriate. Complications of stellate ganglion block include complications related to the technique, infection, and pharmacological complications related to the drugs utilized. Cervical sympathetic or stellate ganglion block is a very commonly performed procedure. If performed correctly, this can provide good therapeutic, prognostic, and diagnostic values.
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            Ultrasound-guided stellate ganglion block: safety and efficacy.

             Samer Narouze (2014)
            Cervical sympathetic and stellate ganglion blocks (SGB) provide a valuable diagnostic and therapeutic benefit to sympathetically maintained pain syndromes in the head, neck, and upper extremity. With the ongoing efforts to improve the safety of the procedure, the techniques for SGB have evolved over time, from the use of the standard blind technique, to fluoroscopy, and recently to the ultrasound (US)-guided approach. Over the past few years, there has been a growing interest in the ultrasound-guided technique and the many advantages that it might offer. Fluoroscopy is a reliable method for identifying bony surfaces, which facilitates identifying the C6 and C7 transverse processes. However, this is only a surrogate marker for the cervical sympathetic trunk. The ideal placement of the needle tip should be anterolateral to the longus colli muscle, deep to the prevertebral fascia (to avoid spread along the carotid sheath) but superficial to the fascia investing the longus colli muscle (to avoid injecting into the muscle substance). Identifying the correct fascial plane can be achieved with ultrasound guidance, thus facilitating the caudal spread of the injectate to reach the stellate ganglion at C7-T1 level, even if the needle is placed at C6 level. This allows for a more effective and precise sympathetic block with the use of a small injectate volume. Ultrasound-guided SGB may also improve the safety of the procedure by direct visualization of vascular structures (inferior thyroidal, cervical, vertebral, and carotid arteries) and soft tissue structures (thyroid, esophagus, and nerve roots). Accordingly, the risk of vascular and soft tissue injury may be minimized.
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              Development and validation of a new technique for ultrasound-guided stellate ganglion block.

              Although the stellate ganglion is located anteriorly to the first rib, anesthetic block is routinely performed at the C6 level. Ultrasonography allegedly improves accuracy of needle placement and spread of injectate. The technique is relatively new, and the optimal approach has not been determined. Moreover, the location of the cervical sympathetic trunk relative to the prevertebral fascia is debatable. Three-dimensional sonography was performed on 10 healthy volunteers, and image reconstruction was completed. On the basis of analysis of pertinent anatomy, a lateral trajectory for needle placement was simulated. Accuracy was tested by injection of methylene blue in cadavers. A clinical validation study was then conducted. A block needle was inserted according to the predetermined lateral path, and 5 mL of a mixture of bupivacaine and iohexol was injected. Spread of the contrast agent was verified fluoroscopically. Image reconstruction revealed that the cervical sympathetic trunk is located posterolaterally to the prevertebral fascia on the surface of the longus colli muscle. The mean anteroposterior width of the muscle at the C6 level was 11 mm. The lateral approach does not interfere with any visceral or nerve structures. Anatomic dissection in cadavers confirmed entirely subfascial spread of the dye and staining of the sympathetic trunk. The contrast agent spread was seen in all patients between the C4 and T1 levels in a typical prevertebral pattern. This study revealed that, at the C6 level, the cervical sympathetic trunk lies entirely subfascially. Subfascial injection via the lateral approach ensures reliable spread of a solution to the stellate ganglion.
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                Author and article information

                Contributors
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: ResourcesRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Data curation
                Role: Data curation
                Role: Data curationRole: Formal analysis
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SoftwareRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                1 May 2020
                2020
                : 15
                : 5
                Affiliations
                [1 ] Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea
                [2 ] Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
                [3 ] Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
                [4 ] Department of Anesthesiology, Kansai Medical University, Hirakata City, Osaka, Japan
                [5 ] Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, Wonkwang University Hospital, Iksan, Korea
                [6 ] Wonkwang Institute of Science, Wonkwang University School of Medicine, Iksan, Korea
                [7 ] Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
                University Magna Graecia of Catanzaro, ITALY
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Article
                PONE-D-19-23153
                10.1371/journal.pone.0232586
                7194360
                32357174
                © 2020 Won et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 6, Tables: 0, Pages: 10
                Product
                Funding
                The authors received no specific funding for this work.
                Categories
                Research Article
                Biology and Life Sciences
                Anatomy
                Biological Tissue
                Ganglia
                Medicine and Health Sciences
                Anatomy
                Biological Tissue
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                People and Places
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                Asia
                Japan
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                Medicine and Health Sciences
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                Anesthetics
                Medicine and Health Sciences
                Pain Management
                Anesthetics
                Biology and Life Sciences
                Anatomy
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                Computer and Information Sciences
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                All relevant data are within the manuscript and its Supporting Information files.

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