An Unusual Complication of Stellate Ganglion Block; Xerosis

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					KÜ Tıp Fak Derg 2007; 9(3)                                                                                                  49
ISSN 1302-3314
Case Report
              An Unusual Complication of Stellate Ganglion Block; Xerosis

                Berkant ÖZPOLAT*, Cansel ATINKAYA*, Kamil AYRANCILAR**
*Kırıkkale University Faculty of Medicine, Department of Thoracic Surgery, Kırıkkale, TURKEY.
**Kırıkkale University Faculty of Medicine, Department of Cardiovascular Surgery, Kırıkkale, TURKEY
Stellate ganglion block is commonly used prior to surgery, to evaluate the efficacy and outcome of planned thoracic
sympathectomy in patients with Raynaud’s disease where medical treatment is ineffective.
A 20-year-old woman diagnosed as Raynaud’s disease, with limitation of finger movements, extreme dryness, hiperkeratosis and
pain in the palmar region of her right upper extremity a week after stellate ganglion block is presented.
Key words: Sympathectomy; Raynaud Disease; Sympathetic Ganglion

   Raynaud’s phenomenon is characterized by                              finger movements of her right hand after a week. Her
episodic digital ischemia provoked by cold1.                             physical examination revealed a dry, scaly and
Treatment is mostly prophylactic but the symptoms                        fissured skin on the palm of the hand. Liquid paraffin
may progress despite conservative or medical                             and hydrating creams were applied with a satisfactory
treatment 2. Symphatectomy may be performed in                           outcome. Six month follow up showed that, the
such cases. Stellate ganglion block is commonly used                     patient was in good condition and paraffin treatment
to evaluate the outcome of thoracic sympathectomy                        was occasionally necessary.
(TS) in patients with Raynaud’s disease3.
   We report an unusual complication of stellate                         Discussion
                                                                             Raynaud's syndrome affects 20% to 25% of the
ganglion block, presenting with extreme dryness,
                                                                         population in cool and damp climates4. Clinically, it
hiperkeratosis and pain resulting in limitation of
                                                                         presents with the classical color triad sequence of
finger movements, in the palmar region of a patient
                                                                         pallor due to vasospasm, cyanosis from venostasis,
with Raynaud’s disease. No such case has been
                                                                         and redness caused by reactive hyperemia following
reported in the literature before.
                                                                         the return of blood flow 1 .
Case Report                                                                  In Raynaud’s disease, treatment is mostly
   A 20-year-old woman was admitted to the hospital                      prophylactic by avoiding cold exposure or by the use
with complains of coldness, cyanosis and pain of both                    of vasospastic drugs.        Medical treatment with
hands and fingers. Her symptoms increase upon                            calcium-channel blockers has also been used. The
exposure to cold. On physical examination her hands                      symptoms may progress and digital ulcerations
were cold, cyanotic and wet. A cold water test was                       develop despite conservative or medical treatment. In
positive for classical color triad sequence for                          such cases where medical and prophylactic treatment
Raynaud's phenomenon.             Chest and cervical                     fails, TS may be considered. TS may relieve
radiography, complete blood count, sedimentation                         symptoms in most of the patients; however
rate, thyroid function test and routine biochemical test                 controversy still exists about the efficacy of the
results were all normal. She was diagnosed as                            procedure2. The majority of patients with Raynaud’s
Raynaud’s disease and received nifedipine (30mg                          phenomenon have an excellent immediate effect of
daily) and acetylsalicylic (300mg daily) for six                         TS and one third achieve a long lasting effect, where
months. The dose of nifedipine has to be doubled                         there are some reports stating that side effects are
after then without any further clinical improvement.                     frequent and the late term results are not satisfactory
The      symptoms       progressed      and    surgical                        .
symphatectomy was offered.                                                   Stellate ganglion block or lower cervical
   Before the surgical intervention the patient was                      sympathetic block has been advocated for diagnostic,
consulted to the anesthesia department and a right                       therapeutic, and prognostic purposes for Raynaud’s
stellate ganglion block was performed under                              phenomenon 3.
fluoroscopy via right paratracheal approach. A single
dose 10 ml bupivacain (Marcaine 0.5%, AstraZeneca)
was injected without any complication. Paresthesia
of the involved extremity was not reported during and
after the injection. The procedure was accepted as
effective and she was placed on the surgery list.
However, she came back with complaint of excessive
dryness (Figure 1) and pain causing limitation of
KÜ Tıp Fak Derg 2007; 9(3)                                                                                   50
ISSN 1302-3314
Case Report
                                                           antipruritics will help to restore the lipid lamellae,
                                                           improve skin hydration, skin elasticity 8. Similarly,
                                                           intensive liquid paraffin treatment and hydrating
                                                           agents were used for treatment in our case.
                                                              Stellate ganglion block could be performed prior to
                                                           thoracic symphatectomy for patients with Raynaud
                                                           disease; however patients must be informed for
                                                           possible rare complications of the procedure.
                                                              This report demonstrates a rare complication of
                                                           stellate ganglion block prior to thoracic
                                                           sypmhatectomy, presenting excessive dryness
                                                           resulting in limitation of finger movements, managed
                                                           by intensive liquid paraffin and hydrating agent
Figure 1. Excessive dryness of right hand
   Complication rate of stellate ganglion block is             1. Belch      J.     Raynaud’s      phenomenon.
1.7/1000 6. Complications may be classified as                    Cardiovasc Res 1997;33:25–30.
technical, infective and pharmacological. Among                2. Thune TH, Ladegaard L, and Licht PB.
technical complications brachial plexus injury,                   Thoracoscopic         sympathectomy        for
perforation of trachea, esophagus and pleura, among               Raynaud’s phenomenon—A long term
infectious complications localized abscess formation,             follow-up study. Eur J Vasc Endovasc Surg
cellulitis, osteomyelitis of transverse process of                2006;32:198–202.
vertebra is reported and rarely seen 3 . In our case,          3. Elias M. Cervical sympathetic and stellate
physical examination, blood and radiologic tests                  ganglion blocks. Pain Physician 2000;3:294-
demonstrated no evidence of local hematoma,                       304.
infection or abscess formation that may be                     4. Landry GJ, Edwards JM, Porter JM. Current
responsible for late compression of the ganglion that             management of Raynaud's syndrome. Adv
excludes the technical complication. Pharmacological              Surg 1996;30:333-347.
complications include voice disturbances, phrenic              5. Ellis H. Transthoracic sympathectomy. Br J
nerve paralysis, somatic blockage of brachial plexus              Hosp Med 1986 Jan;35(1):50-51.
subclinically, intra-arterial injections to CNS causing        6. Wulf H, Maier C. Complications and side
paralysis, high spinal blockage, air embolism, loose              effects of stellate ganglion blockade. Results
of cardioaccelerating activity. Vasovagal syncope is              of a questionnaire survey. Anaesthesist
another rare complication 3. Recovery of finger                   1992;41:146-151.
movements after intensive liquid paraffin treatment            7. Forrest JB. An unusual complication after
and hydrating agents excluded a motor neural injury.              stellate ganglion block by the paratracheal
Recurrence of Raynaud’s disease symptoms excluded                 approach: a case report. Canad Anaesth Soc
the local anesthetic toxicity due to over dosage or               J 1976;23:435-439.
hypersensitivity.                                              8. Proksch E, Lachapelle JM. The management
   Stellate ganglion block via paratracheal approach is           of dry skin with topical emollients-recent
mostly preferred as the technique is simple and when              perspectives. J Dtsch Dermatol Ges
low dose of local anesthetics are used its safe.                  2005;3:768-74.
Fluoroscopy guided interventions increase the success
rate 7. Fluoroscopy guided stellate ganglion block via
paratracheal approach was also used in our case.           Corresponding Author:
   Long term excessive dryness and limitation of           Berkant ÖZPOLAT
finger movements were rare and unique                      Kırıkkale University Faculty of Medicine,
complications of stellate ganglion block, and were not     Department of Thoracic Surgery, Kırıkkale,
presented in the literature. The dry, scaly and fissured   TURKEY.
skin is characteristic of xerosis which is due to the      Address: Tirebolu sokak 24/6 Y. Ayrancı, Ankara,
impairment of stratum corneum intercellular lipid          TURKEY
bilayers and natural moisturizing factor. The use of       E-mail address:,
lipids, physiological lipids, humectants and

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