Necessity of an exact anatomical understanding for the better pain practice

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.

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. 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. 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. 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.

Background This study was performed to reveal the relationships between the cross-sectional areas (CSAs) of the paraspinal muscles and the severity of low back pain (LBP), including the level of disability. Methods This single-center cross-sectional study was conducted on 164 patients with chronic LBP. The effects of demographic characteristics, posture, level of physical activity, disc herniation type, and sarcopenia risk on the CSAs of paraspinal muscles were evaluated along with the relationship between the CSAs and severity of pain and disability in all patients. The CSAs of paraspinal muscles were evaluated using the software program Image J 1.53. Results A negative significant correlation was found between age and the paraspinal muscle’s CSA ( P < 0.05), whereas a positive correlation was present between the level of physical activity and the CSA of the paraspinal muscle at the L2-3 and L3-4 levels. The CSAs of paraspinal muscles in patients with sarcopenia risk was significantly lower than those in patients without sarcopenia risk ( P < 0.05). The CSAs of paraspinal muscles at the L2-3 and L3-4 levels in obese patients were significantly higher than those in overweight patients ( P = 0.028, P = 0.026, respectively). There was no relationship between the CSAs of paraspinal muscles and pain intensity or disability. Conclusions Although this study did not find a relationship between paraspinal CSAs and pain or disability, treatment regimens for preventing paraspinal muscles from atrophy may aid pain physicians in relieving pain, restoring function, and preventing recurrence in patients with chronic LBP.