Epidural approach to paravertebral thoracic sympathetic block as an alternative to stellate ganglion block

Abstract

Rationale:Evidence from cadaveric studies note that the sympathetic nerves from the second and third thoracic ganglia bypass the stellate ganglion in 20% of the population. We present a novel alternative technique for sympathetic blockade of upper extremity via thoracic epidural approach.Patient concerns:The patient-reported anxiety about “the placement of the needle in the front of the neck” and severe pain secondary to complex regional pain syndrome.Diagnoses:Complex regional pain syndrome type-1 with involvement of upper extremity.Interventions:A patient with upper extremity complex regional pain syndrome underwent sympathetic blockade of the upper extremity via thoracic epidural approach with advancement of a catheter through neural foramen and positioning the catheter tip in the upper thoracic paravertebral space.Outcomes:Clinical signs of successful sympathetic blockade of upper extremity were consistently observed after each block utilizing this alternative technique multiple times in a single patient.Lessons:Thoracic paravertebral block via thoracic epidural approach and catheter use may be an alternative technique for upper extremity sympathetic blockade. Potential advantages of this technique include complete sympathetic blockade of upper extremity for both diagnostic and therapeutic purposes, patient comfort with more effective local anesthetic administration for needle entry site, and potentially reduced risk of pneumothorax and inadvertent intravascular injection.