12774
Original Article
Analgesic efficacy of pre-operative stellate ganglion block on
postoperative pain relief: a randomised controlled trial
N. Kumar,1 D. Thapa,2 S. Gombar,3 V. Ahuja4 and R. Gupta5
1 Junior Resident, 2 Associate Professor, 3 Professor, 4 Assistant Professor, Department of Anaesthesia and Intensive
Care, 5 Professor, Department of Orthopaedics, Government Medical College and Hospital, Chandigarh, India
Summary
We undertook a randomised, double-blind, placebo-controlled study to compare the analgesic efficacy of pre-opera-
tive stellate ganglion block on postoperative pain relief after upper limb orthopaedic surgery. Patients were adminis-
tered a 3-ml injection during ultrasound-guided stellate ganglion block; 15 patients received lidocaine 2% and 15
patients received 0.9% saline. Following the block, all patients received standardised general anaesthesia. Postoperative
analgesia included regular intravenous diclofenac, paracetamol and patient-controlled analgesia with tramadol for
24 h. Patients were observed at 0, 2, 4, 6, 8, 12 and 24 h after surgery for tramadol consumption, cardiovascular vari-
ables and visual analogue scale pain scores at rest and on movement. The mean (SD) hourly tramadol consumption
was significantly reduced in the lidocaine group compared with the saline group at 4 h (8.0 (10.1) mg vs 28.0
(12.6) mg, respectively; p = 0.001), 6 h (5.3 (10.8) mg vs 17.3 (12.7) mg, respectively; p = 0.013) and 8 h (5.3
(11.8) mg vs 21.3 (9.1) mg, respectively; p = 0.001). The cumulative 24-h tramadol consumption was 97.3 (16.6) mg
in the lidocaine group and 150.6 (26.0) mg in the saline group (p = 0.001). There were significant differences in the
pain visual analogue scale at rest at two time points; at 4 h the median (IQR [range]) visual analogue scale scores
were 4 (4–6 [2–8]) in the lidocaine group and 5 (4–6 [2–7]) in the saline group (p = 0.03), and at 6 h visual analogue
scale scores were 3 (3–4 [3–6]) and 4 (4–6 [2–7]), respectively (p = 0.04). Pain visual analogue scale on movement
was lower in the lidocaine group at all time intervals compared with the saline group, but this did not reach statistical
significance. The present study has demonstrated a postoperative tramadol-sparing and analgesic effect of pre-opera-
tive stellate ganglion block in patients undergoing upper limb orthopaedic surgery under general anaesthesia.
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Correspondence to: V. Ahuja
Email: vanitaanupam@yahoo.co.in
Accepted: 14 May 2014
The role of the sympathetic nervous system is well dioxide (AS5; Datex Ohmeda, Helsinki, Finland) was
established in patients with chronic pain states such as placed. Intravenous access was established and patients
complex regional pain syndrome [2]. Recently, received 500 ml saline 0.9% and midazolam 1–2 mg.
McDonnell et al. described the use of pre-operative Randomisation of patients was performed using a
ultrasound-guided stellate ganglion block in four computer-generated random number table. An anaes-
patients having upper limb surgery for trauma, with thesiologist who was not participating in the study
promising results in terms of low postoperative pain opened an opaque envelope and prepared the study
scores and morphine consumption [2]. An editorial drug. The blocks were performed by trained consultant
accompanying their study suggested that these findings anaesthesiologists (DT, VA), or by a resident (NK)
should be confirmed using a well-designed randomised under their direct supervision. The anaesthesiologist
controlled clinical trial [4]. We conducted the present performing the block and the patient were blinded to
randomised trial to compare the efficacy of pre-opera- the study group. Stellate ganglion block was performed
tive stellate ganglion block with lidocaine or saline, under ultrasound guidance with a SonoSite TITANâ
and its effect on tramadol consumption during the first with 5–10 MHz probe (SonoSite Inc, Bothell, WA,
postoperative 24 h, in patients following upper limb USA) using the para-tracheal, out-of-plane technique.
orthopaedic surgery. Doppler imaging was used to rule out any aberrant
vessels along the plane of needle placement. Three mil-
Methods lilitres of either lidocaine 2% (lidocaine group) or sal-
We performed a prospective, randomised, double- ine 0.9% (saline group) was injected at the level of the
blinded, placebo-controlled study between April 2012 C7 vertebra underneath the fascia of the longus colli
and September 2013 after gaining approval from our muscle. Correct localisation of the injection was dem-
Institutional Ethics Committee. We included patients onstrated by expansion of the fascia over the muscle
of ASA physical status 1–2, aged between 18 and [2]. Patients in both groups were observed for any
60 years with an upper limb fracture scheduled for possible adverse effects of the block such as Horner’s
surgery under general anaesthesia. We did not study syndrome, motor or sensory blockade of the upper
patients with a body mass index > 30 kg.m 2, a his- limb, recurrent laryngeal nerve or phrenic nerve block-
tory of substance abuse, inability to understand a pain ade or any other effects for 10 min before induction of
visual analogue scale (VAS), inability to use patient- general anaesthesia.
controlled analgesia (PCA), allergy to lidocaine, General anaesthesia was induced with intravenous
chronic sympathetic-mediated pain syndromes affect- fentanyl 2 lg.kg 1 and propofol 2–3 mg.kg 1, and ve-
ing the upper limb or trauma other than to the curonium 0.1 mg.kg 1 was administered to provide
affected limb. muscle paralysis. After tracheal intubation, anaesthesia
Patients were evaluated a day before surgery to was maintained with nitrous oxide:oxygen 60:40 and
assess their fitness for the proposed surgical procedure isoflurane 1–2%, and intermittent boluses of vecuroni-
under general anaesthesia, and written informed um were administered as required. Twenty minutes
consent was obtained at this stage. Patients were before the end of surgery, tramadol 1 mg.kg 1 and
instructed on the use of the PCA pump and the pain ondansetron 0.1 mg.kg 1 were administered intrave-
VAS the day before surgery, and were reminded before nously. At the end of surgery, residual neuromuscular
transfer to the operating theatre and in the post- blockade was reversed with intravenous neostigmine
anaesthesia care unit. All patients were fasted for 8 h 50 lg.kg 1 plus glycopyrronium 10 lg.kg 1.
pre-operatively and premedicated with oral alprazolam Routine postoperative analgesia included tramadol
0.25 mg and ranitidine 150 mg the night before and PCA, intravenous paracetamol 1 g every 6 h and intra-
2 h before surgery. venous diclofenac 75 mg every 12 h. Tramadol was
In the operating theatre, mandatory monitoring administered via a PCA pump (Master PCA; Fresenius
including non-invasive blood pressure, heart rate, con- Kabi, Bad Homburg, Germany) with a bolus of 20 mg,
tinuous ECG, oxygen saturation and end-tidal carbon lockout time of 20 min and a maximum dose
≤ 400 mg.24 h 1 [5]. Intravenous ondansetron 4 mg was significantly lower than that in the saline group
three times.day 1 and ranitidine 50 mg twice.day 1 150.6 (26.0) mg (p = 0.001). There were significant
were also administered. differences in hourly tramadol consumption between
Postoperative measurements were made at 0, 2, 4, the two groups at 4, 6 and 8 h (Fig. 2). The VAS
6, 8, 12 and 24 h postoperatively consisting of tram- scores at rest were lower in the lidocaine group at 4
adol consumption, cardiovascular variables, pain VAS and 6 h only (Table 2).
at rest and movement, sedation, nausea, vomiting, and Heart rate was lower in the lidocaine group at 2, 4
any adverse effects. Sedation was assessed using a and 8 h, and mean arterial pressure at 4 h (Fig. 3).
four-point scale (0: completely alert; 1: sleepy occa- There were no differences in respiratory rate. None of
sionally but rousable; 2: asleep often but rousable; 3: the patients demonstrated motor or sensory blockade
asleep and unrousable) [6]. Nausea and vomiting were in the arm, shivering, pruritus, Horner’s syndrome or
assessed using a four-point scale (0: no nausea and other adverse effects.
vomiting; 1: slight nausea resolving without treatment;
2: slight nausea and/or vomiting responding to treat- Discussion
ment; 3: nausea and/or vomiting not responding to Postoperative pain has both neuropathic and inflam-
treatment) [7]. matory components [2]. We suggest that in the pres-
Sample size was calculated based on a previous ent study, stellate ganglion block relieved the
study [8], in which the mean (SD) 24-h consumption of neuropathic (sympathetic) component and the sys-
PCA tramadol was 267 (91) mg. We considered a 50% temic analgesics relieved the inflammatory component.
reduction in tramadol consumption as significant. To Kakazu & Julka have suggested the possible involve-
demonstrate this difference at p < 0.05 with a power of ment of the sympathetic nervous system in acute pain
90%, the study required 12 patients per group. To cater following humerus fracture [9]. They found reduction
for a 20% dropout rate, we enrolled 15 patients per in pain VAS scores from 10 to 0 within 5 min of stel-
group. The statistical analysis was performed using Sta- late ganglion block placement [9]. In the case series of
tistical Package for Social Sciences (version 15.0 for McDonnell et al., excellent postoperative analgesia with
Windows; SPSS Inc, Chicago, IL, USA). For normally low morphine consumption was provided for 48 h fol-
distributed data, means were compared using an inde- lowing stellate ganglion block with lidocaine [2]. The
pendent sample t-test. For skewed data, the Mann– expected duration of analgesia of stellate ganglion
Whitney test was applied. For time-related variables, block is up to 72 h when performed in patients with
repeated measures ANOVA was applied. Proportions chronic pain [10, 11]. Our study was intended to ver-
were compared using chi-squared or Fisher’s exact test ify the role of sympathetic block in treatment of early
as appropriate. All statistical tests were two-sided and a postoperative pain and, therefore, we did not continue
value of p ≤ 0.05 was considered statistically significant. observations beyond 24 h. Further studies will be
required to establish any longer term benefits of this
Results approach.
A total of 40 patients were screened during the trial, We found a significant reduction in pain VAS at
of whom 10 patients were not studied as they did not rest in the lidocaine group compared with the saline
fulfil the inclusion criteria (Fig. 1), leaving 15 patients group. A plausible explanation is that the sympathetic
in the lidocaine group and 15 in the saline group. The nervous system, which is normally inactive, becomes
lidocaine group included 11 patients with a fractured activated following injury or surgery [12]. The role of
shaft of humerus and four with fractures of radius and stellate ganglion block is well established in patients
ulna, and the saline group included seven and eight with chronic pain as it interrupts the pain cycle,
patients in the respective groups. Table 1 shows the reduces sympathetic tone, prevents central sensitisation
physical characteristics of the patients. and helps to restore normal somatic sensation [12, 13].
The mean (SD) total tramadol consumption over The reduction in resting pain in the lidocaine group
24 h was 97.3 (16.6) mg in the lidocaine group, which might be due to improved blood flow and washing out
of inflammatory mediators in the blocked arm [2], producing motor or sensory blockade, allowing the
thus modulating and attenuating the neuropathic com- surgeon to assess the operated arm in the immediate
ponent of Ad and C-fibres in the deeper muscles [2, postoperative period [3]. The use of a low volume of
14–17]. Our observation that there was only marginal
difference in pain VAS on movement could have mul- Table 1 Comparison of characteristics of 30 patients
tiple mechanisms related to a greater pain response in receiving stellate ganglion block with lidocaine or sal-
postoperative patients [18, 19]. A continuous release of ine. Values are mean (SD) or number (proportion).
inflammatory mediators in the peripheral tissue might
Lidocaine Saline
sensitise functional and dormant nociceptors responsi- (n = 15) (n = 15)
ble for somatic pain on movement [20]; these mecha- Age; years 37.5 (10.2) 38.6 (13.2)
nisms would not be directly influenced by stellate Male 10 (66%) 12 (80%)
ganglion block. Height; cm 168.1 (7.1) 176.6 (25.6)
2
Body mass index; kg.m 24.6 (3.3) 23.8 (4.7)
Stellate ganglion block provides an additional Weight; kg 69.4 (7.3) 71.9 (10.2)
advantage over conventional nerve block of not
Table 2 Comparison of visual analogue scale pain scores at rest and during movement in 30 patients receiving
lidocaine or saline for stellate ganglion block. Values are median (IQR [range]).
Rest Movement
*p = 0.03.
**p = 0.04.
90 * *
85
80 Competing interests
75 No external funding and no competing interests
70 declared.
65
60
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