Image-guided combined ultrasound and fluoroscopy technique for stellate ganglion blocks

Stellate ganglion blocks (SGBs) have long been employed in the management of various conditions, including complex regional pain syndrome, phantom limb pain,1 post-herpetic neuralgia, postcardiotomy cardiogenic shock,2 ventricular tachyarrhythmias,3 peripheral vascular disease, and post-traumatic stress disorder (PTSD),4 lung protection for patients undergoing one-lung ventilation, hot flushes, acute postoperative pain,5 and painful diabetic polyneuropathy. Historically, described in the 1920s, SGB blocks have been performed blindly by palpating the C6 transverse process or Chassaignac tubercle and injecting local anesthetic at the junction of the transverse process and vertebral body medially. While effective, this method carried a significant risk of complications, such as inadvertent vascular or neural injury and pneumothorax.6 Fluoroscopy improved safety by visualizing bony landmarks, while ultrasound provided real-time imaging of soft tissues and vascular structures. However, each modality has limitations: Fluoroscopy cannot visualize soft tissues, and ultrasound struggles with bony landmarks. A dual-modality approach combining ultrasound and fluoroscopy leverages their strengths, improving safety, accuracy, and efficacy in SGB procedures.