|Ahead of print publication
Ultrasound -guided stellate ganglion block: A miracle for patients of systemic lupus erythematosus with vasculitis
Yashwant Nankar1, Aparna Bagle1, Archana Nankar2, Shilpa Deshmukh1
1 Department of Anaesthesia, Dr D Y Patil Medical College, Dr D Y Patil Vidypeeth, Pune, Maharashtra, India
2 Consultant pain physician, Dr D Y Patil Medical College, Dr D Y Patil Vidypeeth, Pune, Maharashtra, India
|Date of Submission||28-Oct-2020|
|Date of Decision||17-Feb-2021|
|Date of Acceptance||19-Feb-2021|
Department of Anaesthesia, Dr D Y Patil Medical College, Dr D Y Patil Vidypeeth, Pimpri, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
In patients of systemic lupus erythematosus (SLE) with vasculitis, along with medical management, stellate ganglion block (SGB) is also recommended frequently to improve the vascularity of the upper limb and in some instances prevent the gangrene of fingers. In this article, we described the management of a SLE patient presented with progressive gangrene of the finger. Ultrasound-guided SGB was successfully given in this patient to relieve pain and improve vascularity, which also helped in healing of ischemic ulcer on digits.
Keywords: Stellate ganglion block, systemic lupus erythematosus, ultrasound, vasculitis
|How to cite this URL:|
Nankar Y, Bagle A, Nankar A, Deshmukh S. Ultrasound -guided stellate ganglion block: A miracle for patients of systemic lupus erythematosus with vasculitis. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 May 10]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=315362
| Introduction|| |
Systemic lupus erythematosus (SLE) is a complex systemic autoimmune disease with multiorgan involvement and wide variety of clinical and serological manifestations. SLE is rare, with an incidence of 2.2–5.6 cases/100,000 person and a prevalence of 24–207 cases/100,000 person, and it is more common in women.
Vasculitis prevalence in SLE is reported to be between 11% and 36%. A diverse clinical spectrum, due to inflammatory involvement of vessels of all sizes, is present. Even though cutaneous lesions, representing small vessel involvement, are the most frequent, medium and large vessel vasculitis may present with visceral affection, with life-threatening manifestations such as mesenteric vasculitis, pulmonary hemorrhage, or mononeuritis multiplex, with detrimental consequences. Early recognition and an appropriate treatment are crucial. Recent studies have shown that vasculitis in patients with SLE may present in different clinical forms based on the organ involved and the size of the affected vessel.
Vasculitis, characterized by the presence of inflammatory cell infiltration and subsequent necrosis of blood vessel walls, is the characteristic processes involved in the clinical evolution of SLE. The histological presentation is a severe pandermal vasculitis often accompanied by thrombosis with resultant cutaneous infarction which may cause loss of digits in patients and to prevent this, along with medical management sympathetic ganglion block is also given.,
In this article, we describe the management of a SLE patient with Ultrasonography (USG) stellate ganglion block (SGB) who presented with intense pain and progressive gangrene of fingers. USG-guided SGB was successfully given to relieve pain, improve vascularity and prevent impending loss of digits with no complications. The use of ultrasound to perform the block is more effective than the landmark technique due to the correct anatomical deposition of drug.
| Case Report|| |
A 35-year-old female, weighing 55 kg, with a height of 155 cm, housewife, presented to our Pain Clinic in the Department of Anesthesia. The patient reported with nonhealing wound and black spots on three fingers of the right hand with severe burning type of pain, numerical rating score (NRS) 9, and restriction of movements in all the digits of her right hand for the last 1 month. She had sleepless nights and was very anxious. Being a housewife, she required her fingers primarily while working in the house, which was getting hampered due to her illness.
The patient was apparently alright 1 year ago when she gradually developed pain in the right hand and discoloration and pigmentation on digits of the right hand. She was diagnosed as a case of SLE with antiphospholipid syndrome and on treatment, mycophenolate mofetil 500 mg, prednisolone 5 mg, hydroxychloroquine (200 mg), nicardia (10 mg), and ecosprin (75 mg) for 1 year.
As her pain was not responding to conventional analgesics, for management of pain and impending gangrene of her fingers, she was referred to the pain clinic of our anesthesia department.
The pain was more severe in the right hand involving the index, middle, and ring fingers with bluish discoloration of fingers at the tip. Pain was severe at night and aggravated by use of finger and exposure to cold. She was emotionally depressed (felt like committing suicide) as she was unable to perform her daily activities. On examination, allodynia and hyperalgesia were present. The distal fingers were thin with contractures and showed signs of atrophy, ulceration, and discoloration.
Her systemic examination revealed no respiratory or cardiac problem. There was no history of any significant illness or surgery in past. Her radial pulse was felt in the right hand but was very feeble. The pulsations were normal in other extremities. Her blood investigations revealed normal reports except erythrocyte sedimentation rate which was 30 mm at the end of 1 h. Her chest X-ray was normal.
On physical examination, she showed gangrenous changes in the terminal part of the right middle and index finger with multiple black spots in the rest of the fingers [Figure 1].
Investigations showed anemia, hypothyroidism, positive for beta 2 glycoprotein 1 immunoglobulin M, antinuclear antibody (1:640), and negative for RA rheumatoid factor. The rest of her investigations was within normal limits.
Her anticoagulation treatment was withheld for 7 days before the procedure. The patient was counseled and written informed consent was obtained after explaining risks and benefits of cervical SGB under ultrasound (USG) guidance. She was admitted in the hospital for SGB on the right side.
On the day of the procedure, after confirming nil by mouth status, the patient was taken inside the operation theater (OT) and placed in supine position on the OT table and regular monitors (electrocardiogram, noninvasive blood pressure, and SpO2) were attached on the left hand. Intravenous cannula was secured on the left wrist. With the help of temperature monitoring probe, temperature of both hands at the wrist was recorded before the block and repeated 5 min after block.
The patient was placed in supine position with a slight head tilt on the left side. The procedure area was prepared. Then, a probe was placed over the right side of the neck at the level of the cricoid cartilage, and the transverse process of the C6 vertebra along with the longus colli muscle was identified. USG probe moved little caudally, C7 vertebra, carotid artery, and longus colli muscle identified. Stellate ganglion was located with the ultrasound (Company-Hitachi, Model-Arietta 750) guidance with a linear probe of 13-5 MHz. The block was performed with in line technique. Target was decided anterior to longus colli muscle [Figure 2]. After deciding the target site, under USG guidance, a 22G 1½ inch hypodermic needle attached to a 10-cm extension line was inserted at the site after local anesthetic injection of 1% lignocaine 1cc.
|Figure 2: Ultrasound view of stellate ganglion block showing CA: Carotid artery, LC: Longus colli muscle and needle approaching target|
Click here to view
The needle was inserted from lateral to medial side of the neck, on the right side placing the needle tip between longus colli muscle and carotid sheath at level C7 vertebra–the anatomical location of the stellate ganglion. After negative aspiration for blood or air, saline was injected to ensure the needle tip is not placed either in the adjoining vessels or within the carotid sheath to avoid phrenic nerve palsy. In addition, precaution was taken to avoid deposition of drug in longus colli muscle, which would result in an ineffective block.
A total volume of 5 ml of 0.25% bupivacaine (isobaric) and methylprednisolone 40 mg was injected and confirmed by hydrodissection under USG guidance.
Within 5 min, the patient developed Horner's syndrome evidenced by redness of the eye, pupillary dilatation, and lacrimation on the right side, which confirmed the accuracy of the block. The patient gave immediate pain relief feedback. Five minutes after the block, her NRS decreased to 2, and the temperature dropped by 2°C on the right hand. The patient was monitored for all vital parameters, difficulty in breathing, hoarseness of voice, and any untoward side effects. The patient monitored in the recovery room till the symptoms of Horner's syndrome were subsided and then shifted to the ward.
On the next day morning, she reported NRS 3, she was discharged and advised to continue previous medications and follow-up in the pain clinic.
In about a week, the gangrene of the patient's fingers started improving [Figure 3]. The blackness of fingers and pain completely regressed. Supportive treatment to keep all limbs warm with gloves/socks was ensured and enforced at all times. Medical management was continued as per guidance of rheumatologist and she was advised to attain pain clinic every month for follow-up.
On regular follow-up, the patient had pain score NRS 0–1 and blackening of her fingers reversed to normal skin, [Figure 4] and [Figure 5] however she lost the distal part of the terminal phalanx of the right index finger which was worst affected when she first reported to us. Nevertheless, this did not affect her household work; she was happy in performing her daily activities successfully. She is under follow-up with us for the last 1 year with no similar complaints.
| Discussion|| |
Vasculitis in SLE is mainly limited to skin manifestations, but in rare cases, it causes necrosis and gangrene of digits. Critical limb ischemia is associated with ischemic pain to prevent this along with medical management sympathetic ganglion blocks are given.
The treatment goal in the SLE patients with vasculitis leading to ischemia of digits is to restore the insufficient arterial circulation caused by sympathetically mediated vasospasm or vascular occlusion and pain relief.,
The stellate ganglion is formed by fusion of the lower cervical and upper first thoracic sympathetic ganglion. Anatomically, it is located medial to the scalene muscles; lateral to the longus colli muscle, esophagus, trachea, recurrent laryngeal nerve; anterior to the C7 transverse process and prevertebral fascia; superior to the subclavian artery; and posterior to the vertebral vessels., Stellate ganglion intervention is indicated for the treatment of various pain syndromes such as complex regional pain management, vascular insufficiency, hyperhidrosis, phantom pain, postherpetic neuralgia, cancer pain, cardiac arrhythmias, orofacial pain, and vascular headache.,,,,,,
In the present case, the patient was suffering from cutaneous vasculitis. If the progression of vasculitis is not halted in such patients, it may result in digit loss.
The SGB is a cervical sympathetic ganglion which when blocked by local anesthetic agents, halts its sympathetic discharge resulting in dilatation of peripheral vessels preventing progression of gangrene in digits.,,, SGB is performed by depositing local anesthetic between longus colli muscle and carotid sheath at level C6 or C7 vertebra–the anatomical location of the ganglion. The use of ultrasound to perform this block has been found to be more effective and safer than the landmark technique because of the prevention of drug deposition in closely located blood vessels such as the carotid artery, vertebral artery, and inferior thyroid vessels. Ultrasound technique also avoids needle injury to the esophagus when performed on the left side. Incidence of hoarseness, which is caused by blockade of the vagus nerve in the carotid sheath or of recurrent laryngeal nerve, which lies medial to the carotid sheath, is also decreased as one can visualize the needle tip position. Phrenic nerve injury is infrequent, as it lies lateral to the location of the stellate ganglion.
In the present case, the SGB was considered, as there was severe pain, restriction of movement, and impending gangrene in the fingers of the right hand which if not treated immediately would have resulted in the loss of digits. Block was performed under ultrasound guidance with necessary precautions, meticulous planning, and monitoring as recommended. Block was performed by a senior experienced anesthesiologist under monitoring in the OT with all resuscitative equipment and 20% lipid ready in the event of any catastrophe. The single-shot right USG-guided SGB alleviated the symptoms completely. The volume of drug in USG-guided nerve block is considerably less than when landmark block is given, as was done in the present patient.
Supportive treatment to keep all limbs warm with gloves was ensured and enforced at all times. Medical management was continued.
To conclude, SGB with ultrasound guidance under strict monitoring is a useful procedure for the patient of SLE with vasculitis of fingers to relieve pain, improve healing, and prevent digital loss. It should be offered as a key component in their overall management.
Declaration of patient consent
The author certifies that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her names and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]