Thoracic paravertebral block in ineffective stellate ganglion block in a patient of long-standing systemic sclerosis: A case report

Dear Editors, Stellate ganglion block (SGB) sometimes needs to be performed multiple times to reverse Raynaud’s syndrome (RP).[1] Infrequently, SGB is found ineffective attributed to “Nerve of Kuntz.”[2] T2 sympathectomy may be effective in this; however, it is invasive and technically challenging due to the close proximity of major vessels and the heart. Thoracic paravertebral block (TPVB), an easy block, may be considered an alternative due to sympathetic, sensory, and motor block.[3] A 39-year-old female, diagnosed case of systemic sclerosis (SS) and on treatment with cilastazole, calcium channel blockers, and aspirin, was referred to the pain outpatient department (OPD) for pain and gangrene in bilateral upper limb digits in 1997. The patient has received multiple bilateral SGBs since then, which abates pain and/or gangrene on every occasion. In December 2022, she reported pain numerical rating scale (PNRS) 9 in bilateral fingers for which bilateral ultrasound SGB with 5 ml of 0.25% ropivacaine with 15 ug clonidine was given on each side with a gap of 4 h. Immediate resolution of symptoms was reported on the left side but there was a failure of response on the right side. The next day, right ultrasound TPVB at T2-T3 level was given with 5 ml of 0.25% ropivacaine and 15 ug clonidine [Figure 1]. PNRS reduced to 1-2. In the next two months, ultrasound-guided right T2-T3 TPVB and left SGB were given four times, approximately every two weeks, which resulted in PNRS 0-1 after every block. With the advent of summer season, she remains pain-free and is in follow-up.Figure 1: Ultrasound-guided thoracic paravertebral block. TP transverse process. PVS: paravertebral spaceRP occurs in over 90% of patients with SS. Moderate to severe cases may need SGB, which sometimes fails attributed to “nerve of Kuntz”, an alternative sympathetic pathway with a variable intrathoracic ramus between the second intercostal nerve and the ventral ramus of the first thoracic nerve, proximal to the point where the latter gives a large branch to the brachial plexus, escaping SGB which is performed at C6 or C7 level.[4] T2 sympathectomy may be performed in such cases with open or video-assisted thoracoscopy; however, this requires operation theatre with the C arm and is technically challenging due to the close proximity of the heart and major vessels.[5] RP may also be treated with cervical epidural analgesia (bilateral effect) and continuous peripheral nerve blocks (supraclavicular and interscalene brachial plexus block) however this causes motor blockade.[5] TPVB produces unilateral sensory, motor, and sympathetic blockade and can easily be performed multiple times in OPD.[4] Ultrasound guided thoracic paravertebral block was used for sympathetic blockade for upper extremity neuropathic pain.[5] We are unable to fully explain how the previously effective multiple SGB failed to respond. A probable explanation is recent hypersensitive alternate nerve connections between sympathetic and intercostal nerves developed over a decade with multiple previous SGBs. This phenomenon may be further explored. To conclude, patients of acute RP with ineffective SGB in previously multiple effective SGB may be administered TPVB for remission of RP. Patient consent Consent has been taken from the patient for publication of this report. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.