Place the patient sitting.

Place the linear high-frequency probe in the axial plane and identify the transverse proces of vertebra C7 – the only transverse process with no anterior tubercle

Make a parallel shift cranially while counting the transverse processes until the desired level is reached

Identify the deepest concavity of the articular pillar as the most flat and echogenic part of the articular pillar (see next page)

Check for blood vessels with color Doppler

Insert the needle in-plane from the posterior end of the probe until the needle tip touches the deepest concavity of the articular pillar.

Inject 0.5 mL of local anaesthetic.

The stellate ganglion is part of the sympathetic trunk. At the level of the transverse process of the C6 vertebral body, the sympathetic trunk runs in a cleavage of the prevertebral layer of the deep cervical fascia (between the deep cervical fascia proper and the alar fascia), medial to the carotid sheath (that contains the common carotid artery, the internal jugular vein and the vagus nerve (X)), and anterior to the colli longus muscle.

Kapral S et al: Ultrasound imaging for stellate ganglion block: Direct visualization of puncture site and local anesthetic spread. Regional anesthesia 20(4): 323-328 (1995)

Gray rami contain postganglionic sympathetic fibres from each ganglion of the sympathetic trunk to the adjacent spinal nerves (somatic fibre) or to internal organs (visceral fibres – only in some cervical and thoracic segments). In the cervical spine region, the gray rami penetrate the prevertebral layer of the deep cervical fascia and also the longus colli muscle on their way to the spinal nerves of the brachial plexus.

White rami are only present from T1-L2. I.e. they are not present in the cervical spine segment. They contain efferent preganglionic sympathetic fibres from the ipsilateral intermediolateral cell column (only present from T1-L2) of the spinal cord. These preganglionic fibres synapse with ganglia of the sympathetic trunk either at the same level or ascend or descend within the sympathetic trunk before they synapse. The white rami also contain afferent sympathetic fibres from the cell bodies in the dorsal root ganglia.

At the level of the Chassaignac’s tubercle (the anterior tubercle of transverse process of vertebra C6) the sympathetic trunk is typically enclosed by split layers of the prevertebral fascia. It is not possible to visualize the sympathetic trunk sonographically. Local anaesthetic should be deposited on both sides of the prevertebral fascia.

Diagnostic procedure to test whether the medial branches mediate spinal pain

Usually performed with fluoroscopy

Ultrasound guidance is a reliable alternative to fluoroscopy

Reflex dystrophia of the upper limb.

It is important to visualize the inferior gluteal artery medially next to the sacral margin. It indicates the correct level of needle insertion and it is a safeguard that allows you to avoid piercing the artery during needle insertion.

Bendtsen TF, L

The sympathetic trunks are paired chains of ganglionated nerve strands descending anterior to the vertebral column. They start separately at the base of the skull as plexuses around the internal carotid artery on each side and they end at the coccygeal bone where they fuse as the ganglion impar.

The sympathetic trunks are part of the autonomic nervous system. On each side white rami run from the spinal cord to the sympathetic trunk, and gray rami run from the sympathetic trunk to each spinal nerve.

The inferior cervical ganglion of the sympathetic trunk is oftentimes fused with the first thoracic paravertebral ganglion. The fused ganglion is called “the stellate ganglion”.

The sympathetic trunk descends anterior to the longus colli muscle, which is anterior to the transverse processes of the cervical vertebral bodies. The longus colli muscle origins from the anterior tubercles and transverse processes of vertebrae C3-T3 and inserts on the anterior tubercles of transverse processes C5-C6 and the anterior surfaces of the vertebral bodies C2-C4 and atlas.