1433 - Stellate Ganglion Block at C5: Advantages and Effects of Ultrasound vs Fluoroscopy a Case Report

Case Diagnosis: Chronic regional pain syndrome treated with ultrasound and fluoroscopy guided stellate ganglion block

Case Description: We present the case of a 42-year-old woman with a left middle cerebral artery stroke who developed complex regional pain syndrome of the right upper extremity. She underwent a right stellate ganglion block performed with combined ultrasound and fluoroscopic guidance. Fluoroscopy was utilized to localize C6 and confirm final needle position, while ultrasound allowed for safe needle advancement.  After injecting 2 cc of contrast under fluoroscopic and ultrasound visualization, final needle placement was found to be at C5 with flow caudally towards C7-T1. Subsequently, 5 cc of 0.2% ropivacaine was administered. This resulted in a temperature rise of approximately 2°C and significant pain reduction in the affected limb.

Discussions: A stellate ganglion block is used to provide effective pain and symptom relief in conditions such as complex regional pain syndrome. Traditionally, this procedure has been performed under fluoroscopic guidance at C6. However, the use of ultrasound has improved both accuracy and safety while avoiding critical structures such as the carotid artery, internal jugular vein, and brachial plexus. Using ultrasound can reduce the likelihood of complications, including vascular injury or inadvertent puncture of adjacent structures, making ultrasound-guided stellate ganglion blocks a safer and more reliable approach.

Conclusions: When performing a stellate ganglion block under ultrasound, the C6 vertebra is typically targeted as the vertebral artery is protected at this level. In our case, however, the C6 anterior tubercle was not clearly visualized with ultrasound, thus the procedure was performed at C5. Fluoroscopy was then used to confirm appropriate contrast spread extending to C7-T1, ensuring adequate coverage. This case highlights an alternative approach, demonstrating that a stellate ganglion block can be effectively and safely performed at C5 using ultrasound when patient anatomy limits a safe injection or needle trajectory at C6.