Neurological Associates

Pain Management Center

Vero Beach, Florida

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RSD PUZZLE #62
AXILLARY NERVE BLOCK

My doctor wants to do axillary nerve block. What are the risk? Does it work?

The axillary nerve block is quite effective and safe. It is far superior to stellate ganglion block. It is an easy nerve block which take much less time than stellate ganglion block, it is far less painful, and it has minimal if an complications.

The rate of success with axillary nerve block for the upper extremities is close to 100%. this is the kind of success rate the stellate ganglion block cannot match.

According to the late Dr. J.J. Bonica who is considered the father of chronic pain management, as he specifies in his book, the stellate ganglion blocks in the best of hands (which would be Dr. Bonica) has a 25% rate of failure[1]. This is because the stellate ganglion has a very vague anatomical structure which is different from patient to patient. So, it usually takes a few or several sticks before the ganglion block is done. A truly successful stellate ganglion block is accompanied by Horner's syndrome, by Horner's syndrome is successfully achieved in around 75% of the patients who undergo the block. It also has other serious complications which would be redundant
to repeat here.

The worst feature of the stellate ganglion block is the fact that repeated stellate ganglion blocks result in the bombardment and traumatic needle damage to the stellate ganglion sympathetic nerve cells. God created those nerve cells not to be needled and destroyed.

Quite frequently, after several stellate ganglion blocks, the patient develops sympathetically independent pain (SIP) in a patient who before the ganglion blocks had sympathetically maintained pain (SMP). This confuses the clinician and because a successful block doesn't help the patient anymore, the patient is accused of being a malingerer or not having "RSD anymore".

Frequently in such patients the hand and forearm become warm and stay warm because of the virtual sympathectomy due to the needling of the stellate ganglion. However, amazingly some people continue with doing blocks even though the stellate ganglion has been totally destroyed and the patient has undergone an traumatic sympathectomy verified by warm and dry hand and forearm.

The axillary nerve block does no have any of these complications because the drug is done by infusation of the blocking agent around the trunk of the nerve following the axillary and brachial artery down to the arm.

On the other hand, there is one limitation for axillary nerve block and that is it does not do anything for sympathetic dysfunction or RSD involving cranio-cervical region (head and neck).However in such cases with cranio-cervical RSD (for example oral surgical complications ending in RSD, the sever vascular headaches are mistaken for cluster headaches which are due to RSD), the patients can undergo sphenopalatine (SPG) ganglion block with more effective sympathetic nerve blockage developed for the head and face than stellate ganglion block.

In our clinic, we rarely resort to stellate ganglion block. Instead, the patient undergoes other alternatives of axillary nerve block, BEIR block (as long as the needle is not inserted in the area of nerve damage). any combination of stellate ganglion as well as epidural and paravertebral nerve blocks in the cervical spine regions. Also in patients with more severe and more complicated sympathetic dysfunction, the patients undergo both SPG and axillary nerve blocks which are quite effective.

We have to realize that RSD in not just a hyperactive sympathetic dysfunction but a distorted and pathological sympathetic dysfunction. That's why some patients have warmer extremities and some patients have colder extremities. The damage to the sympathetic ganglia be it in the form of sympathectomy, chemical sympathectomy (both these sympathectomies are cardinal sins), or stellate ganglion blocks are damaging and can complicate the chronic RSD pain further rather than helping the patient.


H. Hooshmand, M.D.

Reference:

1. Bonica JJ: The management of pain. Philadelphia: Lea and Feibiger. 1953.

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Copyright © 1997-2006 H. Hooshmand, M.D. No part of this publication may be reproduced, transmitted, stored in a retrieval system other than this specific media, transcribed, or translated into any language without the expressed written permission from the author; H. Hooshmand, M.D. and Eric Phillips and CMNE. This material is for informational and education purposes. It is not meant to take the place of your physician. Before starting, changing, or stopping any treatments or medicines consult your physician.

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The material on the Neurological Associates Pain Management Center Homepage and all it's associated, linked or reference pages is for informational and education purposes. It is not meant to take the place of your physician. Before starting, changing, or stopping any treatments or medicines consult your physician. H. Hooshmand, M.D., Neurological Associates Pain Management Center and Associates will not be held liable for any damage or loss as a result of information provided on this page or associated documentation. Again, this WEB SITE is simply published as an information source and should not be used to treat or make judgments on RSD/CRPS. All associated material on this web site may not be copied, reproduced or quoted without expressed written permission from the owner; Copyright © 1999-2006 H. Hooshmand,M.D.

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This page was last updated on 3/11/2000.