Cervical and Thoracic Sympathetic Chain and Related Interventions

Neuropathic pain can present challenges for clinicians in terms of diagnosis and treatment. The most common among these conditions is complex regional pain syndrome (CRPS) which is often diagnosed using the Budapest criteria. The stellate ganglion block has been the most well recognized interventional procedure utilized in treatment of the condition in the upper extremity. There are multiple techniques for performing the stellate ganglion block and multiple choices for injectate. Most commonly, local anesthetic is injected using either fluoroscopic or ultrasound guidance adjacent to the stellate ganglion. In patients with short-lived response to the injection, radiofrequency treatment of the ganglion has also been performed with encouraging results. The fibers of Kuntz arise from the upper thoracic sympathetics that bypass the stellate ganglion and can be part of the pain pathway of the upper extremity. Thoracic sympathetic blocks and radiofrequency treatment can be performed at the T2 or T3 level in an effort to treat CRPS of the upper extremity. Both procedures are highly technical interventional techniques and require significant training in order to safely perform. Both treatments have shown efficacy in treatment of CRPS and multiple other indications that the pain clinician should familiarize themselves.