Anesth Pain Med.  2020 Oct;15(4):486-491. 10.17085/apm.20052.

Incidence of inadvertent intercostal or epidural spread during thoracic sympathetic ganglion block

• Hong JH
• Yi SW
• Kim JS

• KMID: 2508412
• DOI: http://doi.org/10.17085/apm.20052

Abstract

Background
Sympathetic blocks (SBs) have been used widely to relieve the symptoms of sympathetically maintained pain (SMP). The thoracic sympathetic ganglion is not separated from somatic nerves by muscles and connective tissue. The upper thoracic ganglion runs along the posterior surface of the vertebral column in close proximity to the adjacent epidural region. This anatomical difference leads to frequent epidural and intercostal spread in cases of thoracic SBs. The purpose of this study was to investigate the incidence of inadvertent intercostal and epidural injections during thoracic SBs.
Methods
Twenty-two patients who were suffering from complex regional pain syndrome or lymphedema after breast cancer surgery were managed with two or three times of thoracic SBs. Therefore, injections of 63 thoracic SBs from 22 patients were enrolled in this study. An investigator who did not attend the procedure evaluated the occurrence of intercostal or epidural spread using anteroposterior fluoroscopic images.
Results
The overall incidence of inadvertent intercostal or epidural spread of contrast was 47.5%. Among the inadvertent injections, intercostal spread (34.9%) was more frequent than epidural spread (12.6%). Only 52.5% of the thoracic SBs demonstrated successful contrast spread without any inadvertent spread. The mean difference in skin temperature between the blocked and unblocked sides was 2.5 ± 1.8ºC. Fifty-nine (93.6%) injections demonstrated more than 1.5ºC difference.
Conclusions
Thoracic SBs showed a high incidence (47.5%) of inadvertent epidural or intercostal injection. Thus, special attention is required for the diagnosis of SMP or the injection of any neurolytic agent around sympathetic ganglion.

Keyword

Anatomical difference; Inadvertent injection; Injection, epidural, intercostal; Skin temperature; Sympathetic blocks; Sympathetically maintained pain; Thoracic sympathetic ganglion

Figure

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  Fig. 1. Patterns of thoracic sympathetic block (SB) showing successful SB without any inadvertent spread (A), thoracic SB with intercostal spread (B), and thoracic SB with epidural spread (C). White arrows in (B) and (C) indicates intercostal and epidural spreads, respectively.

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  Fig. 2. Degree of skin temperature increase between blocked and unblocked side measured at volar side of thumb. Values are presented as mean ± SD. T0: before thoracic sympathetic block (SB), T5: 5 min after thoracic SB, T10: 10 min after thoracic SB, T20: 20 min after thoracic SB.

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