An Unusual Complication of Sinus Arrest Following Right-Sided Stellate Ganglion Block: A Case Report

Abstract:   We present a case of a 29-year-old female patient who had presented to us for the management of her chronic right shoulder–hand pain and developed a sinus arrest following a right-sided stellate ganglion block (RSGB). This patient on receiving a diagnostic RSGB via the anterior paratracheal (C6) approach developed sinus arrest followed by apnea and unconsciousness. On institution of resuscitative measures involving tracheal intubation, positive pressure ventilation, cardiac massage, and intravenous atropine, spontaneous cardiac activity recovered in about 3 minutes. Other signs and symptoms resolved fully in a total of 10 minutes. She had persistent postural hypotension lasting for about 24 hours requiring bed rest and was discharged about 36 hours after the procedure, without any adverse sequelae. As the sinus node is supplied by the right-sided sympathetic chain, its blockade probably resulted in unopposed parasympathetic activity leading to asystole. Available evidence of the role of right stellate ganglion in regulation of cardiac electrophysiology and functioning is also discussed.     

Migraine Headache Following Stellate Ganglion Block for Reflex Sympathetic Dystrophy

The alteration of extracranial blood flow in conjunction with clinical signs of autonomic nervous system dysfunction have led to various explanations concerning the pathophysiology of migraine headache.
Reflex sympathetic dystrophy, a painful disorder of the sympathetic nervous system, can be treated by blocking the sympathetic nerves located in the stellate ganglion, resulting in vasodilation, ptosis, miosis, and anhydrosis. In theory, these changes could trigger a migraine headache attack secondary to autonomic dysfunction reflecting an imbalance between sympathetic and parasympathetic nervous systems. This may be especially true in a patient with a previous history of meningitis that may have resulted in a disorder of cerebrovescular regulation. We report a 56-year-old man with no previous history of migraine who developed migraine with aura after a stellate ganglion block. Those episodic headaches occurred with decreasing frequency end severity for over 6 months, with eventual complete resolution. This interesting phenomenon has not been reported in the English literature and may help to better understand the pathophysiology of migraine.     

Comparative Reproducibility of QT, QT Peak, and T Peak-T End Intervals and Dispersion in Normal Subjects, Patients with Myocardial Infarction, and Patients with Hypertrophic Cardiomyopathy

Abnormal repolarizaiion is associated with arrhythmogenesis. Because of controversies in existing methodology, new computerized methods may provide more reliable tools for the noninvasive assessment of myocardial repolarization from the surface electrocardiogram (ECC). Measurement of the interval between the peak and the end of the T wave (TpTe interval) has been suggested for the detection of repolarization abnormalities, but its clinical value has not been fully studied. The intrasubject reproducibility and reliability of automatic measurements of QT, QT peak, and TpTe interval and dispersion were assessed in 70 normal subjects, 49 patients with acute myocardial infarction (5th day; MI), and 37 patients with hypertrophic cardiomyopathy (HC). Measurements were performed automatically in a set of 10 ECCs obtained from each subject using a commercial software package (Marquette Medical Systems, Milwaukee, WI, U.S.A.). Compared to normal subjects, all intervals were significantly longer in HC patients (P < 0.001 for QT and QTp; p < 0.05 for TpTe); in MI patients, this difference was only significant for the maximum QT and QTp intervals (P < 0.05). In both patient groups, the QT and QTp dispersion was significantly greater compared to normal subjects (P < 0.05) but no consistent difference was observed in the TpTe dispersion among all three groups. In all subjects, the reproducibility of automatic measurement of QT and QTp intervals was high (coefficient of variation, CV, 1%-2%) and slightly lower for that of TpTe interval (2%–5%; p < 0.05). The reproducibility of QT, QTp, and TpTe dispersion was lower (12%–24%, 18%–28%, 16%–23% in normal subjects, MI and HC patients, respectively). The reliability of automatic measurement of QT, QTp, and TpTe intervals is high but the reproducibility of the repeated measurements of QT, QTp and TpTe dispersion is comparatively low.     

Persistent Functional Atrioventricular Block in Two Patients with Prolonged QT Intervals; Elucidation of the Mechanism of Block

This article describes two infants with prolonged QT interval and intermittent second-degree atrioventricular block. An asymptomatic 14-month-old child with persistent 2:1 atrioventricular conduction since birth underwent electrophysiology study including measurements with a contact monophasic action potential catheter. During 2:1 conduction, atrioventricular block occurred distal to the site of the His-bundle recording. Monophasic action potential duration was closely related to prior RR intervals. Single premature atrial or ventricular depolarizations during 1:1 conduction followed by a pause, lead to monophasic action potential prolongation and subsequent 2:1 atrioventricular conduction, which was perpetuated by the resulting long RR intervals. Paired premature ventricular contractions or short bursts of ventricular pacing elicited monophasic action potential shortening and subsequent 1:1 atrioventricular conduction that was perpetuated by the resulting short RR intervals. A second infant presented at birth with a prolonged QT interval, ventricular tachycardia, and episodes of second-degree atrioventricular block with persistent 2:1 atrioventricular conduction. The atrioventricular block was repeatedly elicited by single premature ventricular contractions and terminated by ventricular couplets. We conclude that the atrioventricular block in both patients is functional in nature and results from the interrelationships between ventricular rate, action potential duration, and His-Purkinje system refractoriness.     

Contingency Learning Deficits and Generalization in Chronic Unilateral Hand Pain Patients

Contingency learning, in particular the formation of danger beliefs, underpins conditioned fear and avoidance behavior, yet equally important is the formation of safety beliefs. That is, when threat beliefs and accompanying fear/avoidance spread to technically safe cues, it might cause disability. Indeed, such overgeneralization has been advanced as a transdiagnostic pathologic marker, but it has not been investigated in chronic pain. Using a novel hand pain scenario contingency learning task, we tested the hypotheses that chronic hand pain patients demonstrate less differential pain expectancy judgments because of poor safety learning and demonstrate broader generalization gradients than healthy controls. Participants viewed digitized 3-dimensional hands in different postures presented in random order (conditioned stimulus [CS]) and rated the likelihood that a fictive patient would feel pain when moving the hand into that posture. Subsequently, the outcome (pain/no pain) was presented on the screen. One hand posture was followed by pain (CS+), another was not (CS−). Generalization was tested using novel hand postures (generalization stimuli) that varied in how similar they were to the original conditioned stimuli. Patients, but not healthy controls, demonstrated a contingency learning deficit determined by impaired safety learning, but not by exaggerated pain expectancy toward the CS+. Patients showed flatter, asymmetric generalization gradients than the healthy controls did, with higher pain expectancy for novel postures that were more similar to the original CS−. The results clearly uphold our hypotheses and suggest that contingency learning deficits might be important in the development and maintenance of the chronic pain–related disability.     

Stellate Ganglion Block in the Treatment of Post‐traumatic Stress Disorder: A Review of Historical and Recent Literature

Concerns over the rising prevalence of post‐traumatic stress disorder (PTSD), particularly among military service members returning from combat, and over barriers that hinder individuals from seeking out or adhering to standard therapies have contributed to interest in alternative therapies for the disorder. A novel alternative therapy for PTSD—stellate ganglion block (SGB)—may be considered lacking in formal evidence of efficacy despite having shown considerable promise. This review of the recent and historical literature related to SGB finds evidence of substantial beneficial psychiatric effects and substantiates that this fast‐acting, somatic treatment may provide positive results for patients with PTSD and may reduce barriers to therapy, particularly among military populations.     

带状疱疹后神经痛患者应用星状神经节阻滞联合选择性神经根阻滞的疗效观察及对其睡眠质量的影响

目的:观察星状神经节阻滞(Stellate Ganglion Block,SGB)联合选择性神经根阻滞治疗对带状疱疹后神经痛(Post-herpetic Neuralgia,PHN)患者的疗效及睡眠质量的影响.方法:选取2018年9月至2020年7月上海市嘉定区中医医院收治的PHN患者95例作为研究对象,按照随机数字表...     

Attentional Biases Toward Sensory Pain Words in Acute and Chronic Pain Patients

Attentional biases towards pain-related words of chronic and acute low back pain (LBP) patients were compared with healthy pain-free controls. Specifically, the aims were to determine: 1) whether chronic LBP patients demonstrate attentional biases compared to pain-free controls; 2) whether observed biases are also present in those with acute LBP; and 3) whether observed biases are associated with pain-related fear among the pain groups. Four groups were recruited: 1) acute LBP patients; 2) chronic LBP patients from physiotherapy practices; 3) chronic LBP patients from a tertiary referral pain-management center; and 4) healthy pain-free controls. Participants were assessed on the dot-probe computer task for attentional bias to pain-related words. All 3 pain groups demonstrated biases compared to controls on sensory but not on affective, disability, or threat words. Among the pain groups, those with low and moderate levels of fear of (re)injury demonstrated biases towards sensory pain words that were absent in those with high levels of fear, which is counterintuitive to what the fear of (re)injury model suggests. These results suggest that the experience of pain, rather than duration, is the primary indicator of the presence of pain-related biases.     

The Use of Stellate Ganglion Block in the Treatment of Panic/Anxiety Symptoms with Combat‐Related Post‐Traumatic Stress Disorder; Preliminary Results of Long‐Term Follow‐Up: A Case Series

Objective: Report the successful use of stellate ganglion blocks (SGBs) in two patients experiencing symptoms of post‐traumatic stress disorder (PTSD). Background: Successful treatment of PTSD with SGB has been reported previously. A similar protocol was employed at Walter Reed Army Medical Center to treat two soldiers with chronic, combat‐related PTSD. Methods: Both patients received a SGB on the right side at C6 level. The patients' PTSD symptoms were evaluated using the Post‐traumatic Stress Disorder Checklist (PCL). The PCL was administered the day prior to treatment, to establish a baseline, and the day after treatment. The PCL was also utilized during follow‐up visits to quantify the patient's symptomotology. The SGB was administered by an anesthesiologist and the psychometric tests administered by a psychologist. Results: Both patients experienced immediate, significant and durable relief as measured by the PCL (score minimum 17, maximum 85). In both instances, the pre‐treatment score suggested a PTSD diagnosis whereas the post‐treatment scores did not. One patient requested repeat treatment after 3 months, and the post‐treatment score remained below the PTSD cutoff after 7 additional months of follow‐up. Both patients discontinued all antidepressant and antipsychotic medications while maintaining their improved PCL score. Conclusion: Selective blockade of the right stellate ganglion at C6 level is a safe and minimally invasive procedure that may provide durable relief from PTSD symptoms, allowing the safe discontinuation of psychiatric medications. ?     

老年冠心病患者腹腔镜胆囊切除术中CO2气腹对心率变异性的影响及星状神经节阻滞对气腹的干预作用

【目的】观察老年冠心病患者在腹腔镜胆囊切除术（TVLC）中CO2气腹对心率变异性的影响以及术前经右侧星状神经节阻滞对CO2气腹的干预作用。【方法】选择2008年5月至2008年12月择期在全麻下行TVLC的老年冠心病患者60例。随机分为两组,对照组和右侧星状神经节阻滞组（R-SGB组）各30例。分别于麻醉后SGB前（T0）、SGB后（T1）、气腹后10min（T2）、20min（T3）和30min（T4）记录HR、MAP并分析患者的心率变异性（heart rate variability,HRV）。HRV通过功率谱分析：低频率（LF）,高频率（HF）,LF／HF比率,总能量（TP）。【结果】CO2气腹后老年冠心病患者LF、LF／HF、TP均升高（P〈0．05）。R-SGB组气腹后各时点LF、LF／HF、TP升高低于对照组（P〈0．05）。两组HF未见明显改变（P〉0．05）。【结论】CO2气腹使老年冠心病患者交感神经活性显著升高,右侧星状神经节阻滞可减轻CO2气腹时的心血管反应,维持CO2气腹时的交感／迷走神经张力的均衡。     

Screening for Addiction in Patients with Chronic Pain and “Problematic” Substance Use: Evaluation of a Pilot Assessment Tool

Assessing for the presence of addiction in the chronic pain patient receiving chronic opioid analgesia is a challenging clinical task. This paper presents a recently developed screening tool for addictive disease in chronic pain patients, and pilot efficacy data describing its ability to do so. In a small sample of patients (n = 52) referred from a multidisciplinary pain center for “problematic” medication use, responses to the screening questionnaire were compared between patients who met combined diagnostic criteria for a substance use disorder and those who did not, as assessed by a trained addiction medicine specialist. Responses of addicted patients significantly differed from those of nonaddicted patients on multiple screening items, with the two groups easily differentiated by total questionnaire score. Further, three key screening indicators were identified as excellent predictors for the presence of addictive disease in this sample of chronic pain patients.     

Pain Self‐Efficacy and Fear of Movement are Similarly Associated with Pain Intensity and Disability in Italian Patients with Chronic Low Back Pain

The purpose of this study was to investigate cross‐sectional associations of pain self‐efficacy and fear of movement with pain intensity and disability in Italian patients with chronic low back pain (CLBP). One hundred and three adult outpatients with nonspecific CLBP were included in the study. Socio‐demographic and clinical characteristics were assessed, together with Italian versions of self‐reported questionnaires to measure the four constructs of interest. Multiple linear regression models were built with psychosocial constructs as main determinants, and pain intensity and disability as outcomes. Potential confounding of socio‐demographic and clinical characteristics was assessed. Pain self‐efficacy and fear of movement displayed moderate correlations with pain intensity (r = ?0.41 and 0.42, respectively) and disability (?0.55 and 0.54). Association models adjusted for pain intensity showed that both pain self‐efficacy (β = ?0.35, 95% CI = ?0.5; ?0.2, R² = 41%) and fear of movement (β = 0.65, 95% CI = 0.36; 0.93, R² = 40%) are significantly and strongly associated with disability. Pain self‐efficacy was no longer significantly associated with pain intensity when disability was added as a confounder to the model, whereas fear of movement retained its significant association (β = 0.06, 95% CI = 0.00;0.11, R² = 30%). No other variables acted as confounders in these associations. Pain self‐efficacy and fear of movement are very similarly associated with main outcomes in this sample of Italian patients with CLBP. The results of this study suggest that both psychosocial constructs should be considered in clinical management. Future studies should investigate whether these findings can be replicated in other samples, in longitudinal designs and if other variables not measured in this study confound the associations.     

The Effect of Pain Catastrophizing on Outcomes: A Developmental Perspective Across Children,Adolescents, and Young Adults With Chronic Pain

Pain catastrophizing is one of the most powerful predictors of poor outcomes in youth and adults with pain; however, little is known about differential effects of pain catastrophizing on outcomes as a function of age. The current study examined the predictive value of pain catastrophizing on pain interference and pain intensity across children, adolescents, and 2 age groups of young adults with chronic pain. Cross-sectional data are presented from the adult and pediatric Collaborative Health Outcomes Information Registry (CHOIR), including measures of pain catastrophizing, pain intensity, pain interference, and emotional distress from 1,028 individuals with chronic pain. Results revealed that age moderated the relation between pain catastrophizing and pain interference, with the strength of these effects declining with age. The effect of pain catastrophizing on pain interference was strongest in adolescents and relatively weak in all 3 other groups. Emotional distress was the strongest predictor of pain interference for children, whereas pain intensity was the strongest predictor for both adult groups. Pain catastrophizing was found to predict pain intensity and, although age was a significant moderator, statistical findings were weak. Developmental considerations and clinical implications regarding the utility of the construct of pain catastrophizing across age groups are discussed.

Prospective, Randomized, Single-Blind, Sham Treatment-Controlled Study of the Safety and Efficacy of an Electromagnetic Field Device for the Treatment of Chronic Low Back Pain: A Pilot Study

Objectives: To evaluate the efficacy and safety of therapeutic electromagnetic fields (TEMF) on chronic low back pain. Secondary objectives included the investigation of the effects of TEMF on psychometric measures. Setting: Pain Research center in an Urban Academic Rehabilitation Facility. Design: Prospective, randomized, single‐blind, placebo (sham) treatment‐controlled design in which participants were evaluated over a 6‐week period. A total of 40 subjects were randomly assigned: 20 subjects to 15 milliTESLA (mT) treatment using a prototype electromagnetic field device and 20 to sham treatment. Interventions: After a 2‐week baseline period, eligible individuals were randomized to one of the treatment groups (sham or 15 mT) for six 30‐minute treatments over 2 weeks, then a 2‐week follow‐up period. Outcome Measures: The primary outcome measure was the self‐report of pain severity using a 100 mm visual analog scale collected using a twice daily McGill Pain Questionnaire—Short Form. Several secondary measures were assessed. Results: Both groups (15 mT and sham) improved over time (P < 0.05). Although groups were similar during the treatment period, treated subjects (TEMF of 15 mT) improved significantly over sham treatment during the 2‐week follow‐up period (20.5% reduction in pain; F_1,34 = 10.62, P = 0.003). There were no reported serious adverse events. Conclusions: This study demonstrates that TEMF may be an effective and safe modality for the treatment of chronic low back pain disorders. More studies are needed to test this hypothesis.