Sympathetic Blockade

  • Miles Day
  • Rafael Justiz
  • Audra Day
  • Maxim S. Eckmann


Percutaneous blockade of the sympathetic nervous system is a key component of a pain management physician’s skill set. These blocks can be used for diagnostic and therapeutic purposes and are generally indicated when conservative and pharmacological therapy is partially effective or ineffective in alleviating a patient’s chronic pain. More definitive treatment can be accomplished through radiofrequency or chemical neurolysis. Detailed knowledge of the relevant anatomy is key as this will theoretically improve efficacy and minimize complications.


Sympathetic nervous system Anatomy Fluoroscopy Ultrasound Nerve block Radiofrequency thermocoagulation Neurolysis 


  1. 1.
    Guyatt G, Gutterman D, Bauman M, et al. Grading strength of recommendation and quality of evidence in clinical guidelines: report from an American College of Physician’s Task Force. Chest. 2006;129:174–81.CrossRefPubMedGoogle Scholar
  2. 2.
    Konen A. Unexpected effects due to radiofrequency thermocoagulation of the sphenopalatine ganglion: two case reports. Curr Rev Pain. 2000;10:30–3.Google Scholar
  3. 3.
    Day M. Sympathetic blocks: the evidence. Pain Pract. 2008;8:98–109.CrossRefPubMedGoogle Scholar
  4. 4.
    Narouze S, Kapural L, Casanova J, Mikhail N. Sphenopalatine radiofrequency ablation for the management of chronic cluster headache. Headache. 2009;49:571–7.CrossRefPubMedGoogle Scholar
  5. 5.
    Lipov EG, Joshi JR, Sanders S, Slavin KV. A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD). Med Hypotheses. 2009;72:657–61.CrossRefPubMedGoogle Scholar
  6. 6.
    Peterson RC, Patel L, Cubert K, Gulati A. Serial stellate ganglion blocks for intractable postherpetic itching in a pediatric patient: a case report. Pain Physician. 2009;12:629–32.PubMedGoogle Scholar
  7. 7.
    Chester M, Hammond C, Leach A. Long-term benefits of stellate ganglion block in severe chronic refractory angina. Pain. 2000;87:103–5.CrossRefPubMedGoogle Scholar
  8. 8.
    Ateş Y, Asik I, Ozgencil E, et al. Evaluation of the longus coli muscle in relation to stellate ganglion block. Reg Anesth Pain Med. 2009;34:219–23.CrossRefPubMedGoogle Scholar
  9. 9.
    Narouze S, Vydyanathan A, Patel N. Ultrasound-guided stellate ganglion block successfully prevented esophageal puncture. Pain Physician. 2007;10:747–52.PubMedGoogle Scholar
  10. 10.
    Pather N, Partab P, Singh B, Satyapal KS. Cervico-thoracic ganglion: its clinical implications. Clin Anat. 2006;19:323–6.CrossRefPubMedGoogle Scholar
  11. 11.
    Feigl GC, Rosmarin W, Stelzl A, et al. Comparison of different injectate volumes for stellate ganglion block: an anatomic and radiologic study. Reg Anesth Pain Med. 2007;32(3):203–8.PubMedGoogle Scholar
  12. 12.
    Narouze S. Letter to the editor: Beware of the “serpentine” inferior thyroid artery while performing stellate ganglion block. Anesth Analg. 2009;109:289–90.CrossRefPubMedGoogle Scholar
  13. 13.
    Bhatia A, Flamer D, Peng PW. Evaluation of sonoanatomy relevant to performing stellate ganglion blocks using anterior and lateral simulated approaches: an observational study. Can J Anaesth. 2012;59:1040–7.CrossRefPubMedGoogle Scholar
  14. 14.
    Gofeld M, Bhatia A, Abbas S, Ganapathy S, Johnson M. Development and validation of a new technique for ultrasound-guided stellate ganglion block. Reg Anesth Pain Med. 2009;34:475–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Joeng ES, Jeong YC, Park BJ, Kang S, Yang SN, Yoon JS. Sonoanatomical change of phrenic nerve according to posture during ultrasound-guided stellate ganglion block. Ann Rehabil Med. 2016;40:244–51.CrossRefPubMedCentralPubMedGoogle Scholar
  16. 16.
    Anderson SR. T2 and T3 sympathetic block and neurolysis. In: Raj PP, Lou L, Erdine S, Staats PS, Waldman SD, editors. Radiographic imaging for regional anesthesia and pain management. Philadelphia, PA: Churchill Livingstone; 2003. p. 132–7.Google Scholar
  17. 17.
    Racz G. Techniques of neurolysis. Boston: Kluwer Academic; 1989.CrossRefGoogle Scholar
  18. 18.
    Higa K, Hirata K, Hirota K, Nitahara K, Shono S. Retropharyngeal hematoma after stellate ganglion block. Anesthesiology. 2006;105:1238–45.CrossRefPubMedGoogle Scholar
  19. 19.
    Hoşten T, Gürkan Y, Solak M, Toker K. A case of Horner’s syndrome following lateral sagittal infraclavicular block. Agri. 2008;20:45–8.PubMedGoogle Scholar
  20. 20.
    Salviggio I, Adducci E, Dell’Aquila L, Rinaldi S, Marini M, Zappia L, et al. Facial pain: a possible therapy with stellate ganglion block. Pain Med. 2008;9:958–62.CrossRefGoogle Scholar
  21. 21.
    Kumar N, Thapa D, Gombar S, Ahuja V, Gupta R. Analgesic efficacy of pre-operative stellate ganglion block on postoperative pain relief: a randomized controlled trial. Anaesthesia. 2014;69:954–66.CrossRefPubMedGoogle Scholar
  22. 22.
    Singh B, Ramsaroop L, Partab P, Moodley J, Satyapal K. Anatomical variations of the second thoracic ganglion. Surg Radiol Anat. 2005;27:119–22.CrossRefPubMedGoogle Scholar
  23. 23.
    Ramsaroop L, Partab P, Singh B, Satyapal KS. Thoracic origin of a sympathetic supply to the upper limb: the ‘nerve of Kuntz’ revisited. J Anat. 2001;199:675–82.CrossRefPubMedCentralPubMedGoogle Scholar
  24. 24.
    Yarzebski JL, Wilkinson HA. T2 and T3 sympathetic ganglia in the adult human: a cadaver and clinical-radiographic study and its clinical application. Neurosurgery. 1987;21:339–42.CrossRefPubMedGoogle Scholar
  25. 25.
    Cho HM, Lee DY, Sung SW. Anatomical variations of rami communicantes in the upper thoracic sympathetic trunk. Eur J Cardiothorac Surg. 2005;27:320–4.CrossRefPubMedGoogle Scholar
  26. 26.
    Rocha R, Teixeira M, Yeng L, Cantara M, Faria V, Liggieri V, et al. Thoracic sympathetic block for the treatment of complex regional pain syndrome type 1: a double blind randomized controlled study. Pain. 2014;155:2274–81.CrossRefGoogle Scholar
  27. 27.
    Gest TR, Hildebrandt S. The pattern of the thoracic splanchnic nerves as they pass through the diaphragm. Clin Anat. 2009;22:809–14.CrossRefPubMedGoogle Scholar
  28. 28.
    Rathmell JP, Gallant JM, Brown DL. Computed tomography and the anatomy of celiac plexus block. Reg Anesth Pain Med. 2000;25:411–6.CrossRefPubMedGoogle Scholar
  29. 29.
    Loukas M, Klaassen Z, Merbs W, et al. A review of the thoracic splanchnic nerves and celiac ganglia. Clin Anat. 2010;23:512–22.CrossRefPubMedGoogle Scholar
  30. 30.
    Tadros M, Elia R. Ultrasound-guided celiac plexus neurolysis in advanced upper abdominal cancer pain. Egypt J Radiol Nucl Med. 2005;46:993–8.CrossRefGoogle Scholar
  31. 31.
    Seishima M, Kanoh H, Izumi T, et al. A refractory case of secondary erythermalgia successfully treated with lumbar sympathetic ganglion block. Br J Dermatol. 2000;143:868–72.CrossRefPubMedGoogle Scholar
  32. 32.
    Bonica JJ. The management of pain. Philadelphia: Lee and Febiger; 1953.Google Scholar
  33. 33.
    Bradley KS. Observations on the surgical anatomy of the thoraco-lumbar sympathetic system. Aust N Z J Surg. 1951;20:272–7.CrossRefPubMedGoogle Scholar
  34. 34.
    Umeda S, Arai T, Hatano Y, et al. Cadaver anatomic analysis of the best site for chemical lumbar sympathectomy. Anesth Analg. 1987;66:643–6.CrossRefPubMedGoogle Scholar
  35. 35.
    Rocco AG, Palombi D, Raeke D. Anatomy of the lumbar sympathetic chain. Reg Anesth. 1995;20:13–9.PubMedGoogle Scholar
  36. 36.
    Murata Y, Takahashi K, Yamagata M, et al. Variations in the number and position of human lumbar sympathetic ganglia and rami communicantes. Clin Anat. 2003;16:108–13.CrossRefPubMedGoogle Scholar
  37. 37.
    Mirilas P, Skandalakis JE. Surgical anatomy of the retroperitoneal spaces, part V: surgical applications and complications. Am Surg. 2010;76:358–64.PubMedGoogle Scholar
  38. 38.
    Cousins MJ, Reeve TS, Glynn CJ, et al. Neurolytic lumbar sympathetic blockade: duration of denervation and relief of rest pain. Anaesth Intensive Care. 1979;7:121–35.PubMedGoogle Scholar
  39. 39.
    Haynsworth RF Jr, Noe CE. Percutaneous lumbar sympathectomy: a comparison of radiofrequency denervation versus phenol neurolysis. Anesthesiology. 1991;74:459–63.CrossRefPubMedGoogle Scholar
  40. 40.
    Manjunath PS, Jayalakshmi TS, Dureja GP, Prevost AT. Management of lower limb complex regional pain syndrome type 1: an evaluation of percutaneous radiofrequency thermal lumbar sympathectomy versus phenol lumbar sympathetic neurolysis – a pilot study. Anesth Analg. 2008;106:647–9.CrossRefPubMedGoogle Scholar
  41. 41.
    Datta S, Pai U. Paradiscal extraforaminal technique for lumbar sympathetic block: report of a proposed new technique utilizing a cadaver study. Pain Physician. 2004;7:53–7.PubMedGoogle Scholar
  42. 42.
    Stanton-Hicks M. Lumbar sympathetic nerve block and neurolysis. In: Waldman SD, editor. Interventional pain management. 2nd ed. Philadelphia: W.B. Saunders; 2001. p. 485–92.Google Scholar
  43. 43.
    Sayson SC, Ramamurthy S, Hoffman J. Incidence of genitofemoral nerve block during lumbar sympathetic block: comparison of two lumbar injection sites. Reg Anesth. 1997;22:569–74.PubMedGoogle Scholar
  44. 44.
    Dirim A, Kumsar S. Iatrogenic ureteral injury due to lumbar sympathetic block. Scand J Urol Nephrol. 2008;42:395–6.CrossRefPubMedGoogle Scholar
  45. 45.
    Plancarte R, de Leon-Casasola OA, El-Helaly M, et al. Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Reg Anesth. 1997;22:562–8.PubMedGoogle Scholar
  46. 46.
    Mauroy B, Demondion X, Bizet B, et al. The female inferior hypogastric (= pelvic) plexus: anatomical and radiological description of the plexus and its afferences – applications to pelvic surgery. Surg Radiol Anat. 2007;29:55–66.CrossRefPubMedGoogle Scholar
  47. 47.
    Ali M, Johnson IP, Hobson J, et al. Anatomy of the pelvic plexus and innervation of the pros- tate gland. Clin Anat. 2004;17:123–9.CrossRefPubMedGoogle Scholar
  48. 48.
    Gofeld M, Lee CW. Ultrasound-guided superior hypogastric plexus block: a cadaveric feasibility study with fluoroscopic confirmation. Pain Pract. 2017;17(2):192–6.CrossRefPubMedGoogle Scholar
  49. 49.
    Mishra S, Bhatnagar S, Rana SP, et al. Efficacy of the anterior ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain in advanced gynecological cancer patients. Pain Med. 2013;14:837–42.CrossRefPubMedGoogle Scholar
  50. 50.
    Lim SJ, Park HJ, Lee SH, Moon DE. Ganglion impar block with botulinum toxin type a for chronic perineal pain – a case report. Korean J Pain. 2010;23:65–9.CrossRefPubMedCentralPubMedGoogle Scholar
  51. 51.
    Ellinas H, Sethna NF. Ganglion impar block for management of chronic coccydynia in an adolescent. Paediatr Anaesth. 2009;19:1137–8.CrossRefPubMedGoogle Scholar
  52. 52.
    Foye PM. Ganglion impar injection techniques for coccydynia (coccyx pain) and pelvic pain. Anesthesiology. 2007;106:1062–3.CrossRefPubMedGoogle Scholar
  53. 53.
    Yeo SN, Chong JL. A case report on the treatment of intractable anal pain from metastatic carcinoma of the cervix. Ann Acad Med Singap. 2001;30:632–5.PubMedGoogle Scholar
  54. 54.
    Eker HE, Cok OY, Kocum A, et al. Trans-sacrococcygeal approach to ganglion impar for pelvic cancer pain: a report of 3 cases. Reg Anesth Pain Med. 2008;33:381–2.PubMedGoogle Scholar
  55. 55.
    Agarwal-Kozlowski K, Lorke DE, Habermann CR, et al. CT-guided blocks and neuroablation of the ganglion impar (Walther) in perineal pain: anatomy, technique, safety, and efficacy. Clin J Pain. 2009;25:570–6.CrossRefPubMedGoogle Scholar
  56. 56.
    Oh CS, Chung IH, Ji HJ, Yoon DM. Clinical implications of topographic anatomy on the ganglion impar. Anesthesiology. 2004;101:249–50.CrossRefPubMedGoogle Scholar
  57. 57.
    Datir A, Connell D. CT-guided injection for ganglion impar blockade: a radiological approach to the management of coccydynia. Clin Radiol. 2010;65:21–5.CrossRefPubMedGoogle Scholar
  58. 58.
    Plancarte R, Amescua C, Patt RB, Allende S. Presacral blockade of the ganglion of Walther (ganglion impar). Anesthesiology. 1990;73:A751.Google Scholar
  59. 59.
    Wemm K Jr, Saberski L. Modified approach to block the ganglion impar (ganglion of Walther). Reg Anesth. 1995;20:544–5.PubMedGoogle Scholar
  60. 60.
    Toshniwal GR, Dureja GP, Prashanth SM. Trans-sacrococcygeal approach to ganglion impar block for management of chronic perineal pain: a prospective observational study. Pain Physician. 2007;10:661–6.PubMedGoogle Scholar
  61. 61.
    Huang JJ. Another modified approach to the ganglion of Walther block (ganglion of Impar). J Clin Anesth. 2003;15:282–3.CrossRefPubMedGoogle Scholar
  62. 62.
    Foye PM, Patel SI. Paracoccygeal corkscrew approach to ganglion impar injections for tailbone pain. Pain Pract. 2009;9:317–21.CrossRefPubMedGoogle Scholar
  63. 63.
    Nebab EG, Florence IM. An alternate needle geometry for interruption of the ganglion impar. Anesthesiology. 1997;86:1213–4.CrossRefPubMedGoogle Scholar
  64. 64.
    Reig E, Abejón D, del Pozo C, Insausti J, Contreras R. Thermocoagulation of the ganglion impar or ganglion of Walther: description of a modified approach. Preliminary results in chronic, nononcological pain. Pain Pract. 2005;5:103–10.CrossRefPubMedGoogle Scholar
  65. 65.
    Usta B, Gozdemir M, Sert H, et al. Fluoroscopically guided ganglion impar block by pulsed radiofrequency for relieving coccydynia. J Pain Symptom Manag. 2010;39:e1–2.CrossRefGoogle Scholar
  66. 66.
    Lin CS, Cheng JK, Hsu YW, Chen CC, Lao HC, Huang CJ, et al. Ultrasound-guided ganglion impar block: a technical report. Pain Med. 2010;11:390–4.CrossRefPubMedGoogle Scholar
  67. 67.
    Marker DR, U-Thainual P, Ungi T, Flammang A, Fichtinger G, Iordachita II, et al. MR-guided perineural injection of the ganglion impar: technical considerations and feasibility. Skelet Radiol. 2016;45:591–7.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Miles Day
    • 1
  • Rafael Justiz
    • 2
  • Audra Day
    • 3
  • Maxim S. Eckmann
    • 4
  1. 1.Department of AnesthesiologyTexas Tech University Health Sciences CenterLubbockUSA
  2. 2.Anesthesiology and Pain MedicineUniversity of Oklahoma Health Sciences CenterOklahoma CityUSA
  3. 3.Kinesiology and Sports ManagementTexas Tech UniversityLubbockUSA
  4. 4.Department of AnesthesiologyUT Health San AntonioSan AntonioUSA

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