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Stellate Ganglion Block for Non-Pain Indications: A Scoping Review
Guy Feigin1, Sofia Velasco Figueroa1, Marina F. Englesakis2, Rohan D’Souza3, Yasmine
Hoydonckx1, Anuj Bhatia1
1Department of Anesthesia and Pain Medicine, University of Toronto, University Health
Network – Toronto Western Hospital, Toronto, Ontario, Canada
2Library & Information Services, University Health Network, Toronto, Ontario, Canada
3Department of Obstetrics & Gynaecology and Department of Health Research Methods,
Evidence and Impact, McMaster University, Hamilton, Ontario Canada; Department of
Obstetrics and Gynaecology and Lunenfeld Tanenbaum Research Institute, Ontario, Canada
Address correspondence to:
Anuj Bhatia MBBS MD PhD FRCA FFPMRCA FRCPC FIPP CIPS EDRA ASRA-PUMC
Toronto Western Hospital, McL 2-405, Department of Anesthesia and Pain Management,
Toronto Western Hospital - University Health Network and University of Toronto
399 Bathurst Street, Toronto, Ontario, Canada M5T 2S8
Phone: (416) 603-5118
Fax: (416) 603-6494
Email: anuj.bhatia@uhn.ca
Funding: Internal funding from Departments of Anesthesia and Pain Medicine, University
Health Network – Toronto Western Hospital.
Conflicts of Interest: The authors declare no conflict of interest.
Page 1 of 63 Pain Medicine
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© The Author(s) 2023. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights
reserved. For permissions, please e-mail: journals.permissions@oup.com
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Running head: Stellate ganglion block for non-pain indications.
Abbreviations: SGB (stellate ganglion block), US (ultrasound)
Keywords: stellate ganglion block, sympathetic nervous system, arrhythmias, post-traumatic
stress disorder (PTSD), deafness, menopause, lymphedema, vascular insufficiency
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ABSTRACT
Introduction: Stellate ganglion block (SGB) is performed to relieve head, face, neck, or upper
limb pain, several non-pain indications for performing this block have emerged over the years.
To date, there was no attempt to synthesize evidence on SGB for treating non-pain indications.
This scoping review presents a summary of the efficacy and adverse effects of SGB when
performed for six non-pain indications.
Methods: This scoping review was accomplished using Arksey and O’Malley framework.
Literature search was conducted for relevant articles in medical databases to identify publications
on SGB and specified study types. Two reviewers independently assessed the risk of bias for
randomized controlled trials (RCTs), non-randomized comparative studies, and case series.
Results were summarized and recommendations were made based on the strength of available
evidence using the US Preventative Services Task Force grading system.
Results: Twenty-four studies (19 RCTs and 5 non-randomized studies) were included in this
review. Based on the evidence, SGB is recommended for obtunding cardiovascular sympathetic
stimulation, improving perfusion in limbs, and alleviating menopausal symptoms with a Grade B
or C recommendation and a moderate-to-low level of certainty. There was insufficient evidence
to recommend SGB for the other indications.
Conclusions: SGB can be considered for obtunding cardiovascular sympathetic stimulation and
stress response, reducing vascular tone to improve vascular insufficiency in the limbs and
perioperative hemodynamic stability, and alleviating hot flashes in menopause, in conditions
refractory to conventional medical management.
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INTRODUCTION
Stellate ganglion block (SGB) is performed by anesthesiologists and pain physicians for a variety
of pain conditions affecting the head, neck, and upper limbs. However, there has been a growing
interest in the role of this procedure for non-pain indications over the last 20 years (Figure 1).
The SGB is formed by fusion of the inferior cervical and first thoracic sympathetic ganglion. It
lies anterior to the transversus process of C7 and superior border of the first rib and
posteromedial to the carotid artery. The ganglion is covered by the prevertebral fascia which is a
layer of the deep cervical fascia. Sympathetic fibers for the head, neck, thoracic viscera, and
upper limbs synapse in the stellate ganglion, explaining the role of blocking the SGB to treat
pain and other conditions in these locations (1). SGB can be performed using anatomic
landmarks, or under fluoroscopy or ultrasound guidance and the target is usually the middle
cervical sympathetic ganglion on the surface of the longus colli at the level of the sixth cervical
vertebra with the injectate flowing caudally resulting in an SGB (2).
The confluence of sympathetic nerves at the stellate ganglion makes it a target to block for
pathological conditions that are sustained by increased activity of the sympathetic nervous
system. Regional anesthesiologists and Pain Medicine physicians are often approached by
specialists including cardiologists, gynecologists, psychiatrists, otorhinolaryngologists and even
directly by patients with requests to perform SGB to treat or ameliorate these sympathetically-
driven syndromes, usually because of a recent publication on the success in relieving the
syndrome in question with SGB. Our recent search in medical literature databases for indications
for performing SGB revealed indications that can be grouped into six pathological conditions:
cardiovascular sympathetic stimulation and perioperative stress response, increased vascular tone
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resulting in vascular insufficiency of the upper extremity and perioperative hemodynamic
instability, hot flashes of menopause, inadequate lymphatic outflow from the upper extremity
following treatments for breast cancer, post-traumatic stress disorder (PTSD), and sudden
deafness due to sensorineural hearing loss. To date, no attempt has been made to collect and
synthesize the evidence on the role of SGB for treating these six non-pain indications.
In response to this surge of enthusiasm for the role of SGB for these non-pain indications, we
performed a scoping review with the objectives of identifying the rationale and evidence for the
role of SGB in these diverse syndromes. We summarize here the impact of SGB for each
indication, provide our evaluation of the available evidence, and assign a level of certainty to
each recommendation.
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METHODS
This scoping review was performed according to the Arksey and O’Malley’s framework for
conducting a scoping review (4) with modifications proposed by Levac et al (5). We specified
the research questions followed by identification of the relevant literature, selection of the
studies, and we mapped the data and synthesized it to report the results.
Search strategies and terms: We conducted a comprehensive search of the literature from
database inception to October 23, 2020, with a repeat search on Oct 09, 2022, with the assistance
of a medical information specialist (ME). The following databases were searched: MEDLINE,
MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations, Embase
Classic+Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of
Systematic Reviews, and APAPsycINFO (all using the OvidSP Platform). We searched for case
reports and series, non-randomized and randomized trials, systematic reviews and meta-analysis,
using combinations of subject headings and keyword terms for: "stellate ganglion block" or
"stellate ganglion AND nerve block". More keywords were selected based on the literature found
in the initial search. We restricted our search to papers in English, Spanish and Italian, involving
only human subjects. The details of the search strategies are provided in Supplement 2 and a
summary of the search history record is presented in Supplement 3. Further, based on the
feedback from the Reviewers on the initial version of the manuscript, three additional
publications were found on November 19, 2022 on the role of SGB in attenuating long COVID-
related symptoms. A summary of the main findings of these publications was included in the
Discussion section.
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Eligibility criteria: A population, concept, and context (PCC) approach was followed for this
scoping review (4,5).
Population: Studies on human adult subjects, 18 years of age or older, with the six pre-defined
indications for SGB (as below) were included.
Concept: The concept of interest was the role of SGB in the treatment of six conditions -
obtunding cardiovascular sympathetic stimulation and stress response, reducing vascular tone to
improve vascular perfusion in the limbs or to optimize perioperative hemodynamic stability,
alleviating hot flashes in menopause, relieving lymphedema of the upper extremity following
treatment for breast cancer, alleviating symptoms of post-traumatic stress disorder, and treating
sudden deafness due to sensorineural hearing loss. Publications on any type or dose of injectate
and one or more SGB treatments using anatomic landmarks, ultrasound, and fluoroscopy
guidance were accepted for inclusion in this review.
Context: The context of interest was to assess the efficacy and adverse effects of SGB for each
individual indication in comparative (controlled or uncontrolled, randomized or non-randomized)
clinical trial settings.
Article selection and inclusion: A comprehensive search of the medical databases mentioned
above was conducted by a medical information specialist (MFE). Two reviewers (GF and SVF)
screened articles from the initial search for inclusion or exclusion using the Covidence platform
(Covidence, Melbourne, Victoria, Australia). The senior author (AB) mediated any disagreement
between the two screeners. Reference lists of included papers were hand-searched and relevant
papers were included if the inclusion criteria were met. Full texts of papers that appeared to be
relevant interest were then perused.
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Data extraction: Extracted data included characteristics of studies (publication year, design),
participants (number, mean age, gender distribution, details of the non-pain condition),
interventions and comparators (type of injectate, dose, guidance technique), outcomes and
adverse effects. The data were entered into pre-specified tables on a standardized data collection
form in Microsoft Word after pilot-testing. We performed a descriptive analysis in which we
summarized results of each included study without meta-analyzing the data because of the
expected paucity of the number of studies for each indication for SGB and the heterogeneity in
assessing the types of outcomes and the timelines. In the Results section, we have provided a
brief rationale for the use of SGB for each of the six indications examined in this review.
Assessment of the risk of bias: Two reviewers (GF and SVF) independently assessed the risk of
bias for randomized controlled trials using the Cochrane Risk of Bias tool 2.0 (6). Any
disagreement was resolved through discussion with the senior author (AB). The Cochrane Risk
of Bias tool 2.0 includes the following domains for assessing bias: randomization process,
deviations from intended interventions, missing outcome data, measurement of the outcome, and
selection of the reported result. Each domain was classified as low, some concerns, or high risk
of bias for each study. A decision to classify overall bias as one of three categories was made
using the following criteria: “High” for trials with a high risk of bias on one or more key
domains; “Some concerns” for trials with some concerns for risk of bias on one or more key
domains; “Low” for trials without a high risk or concerns of bias on any key domain. The
Robins-I tool was used to assess the risk of bias in non-randomized comparative studies (7,8).
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Recommendations: We summarized our recommendations for each indication, graded on a
scale from A to D, or as insufficient, according to the US Preventative Services Task Force
grading of evidence guidelines, with the level of certainty rated as high, medium or low
(Supplement 1) (3). This system, which has been modified for use in interventional pain
management guidelines drafted by major national and international pain societies, was chosen
over others because of its flexibility, which permits high-grade recommendations in absence of
high-quality level I studies.
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RESULTS
Search results
We found 1374 citations through our initial search and 3 records from manual search of
literature. After removal of duplicates, 1053 records remained and were title and abstract
screened as per our selection criteria. Another 575 records were excluded because of lack of
relevance or absence of information about our topic of interest. Full-texts of the remaining 478
articles was assessed for eligibility and another 454 were excluded because they did not meet the
eligibility criteria, leaving 24 studies that fulfilled our inclusion criteria (Figure 2). Nineteen of
these studies were randomized controlled studies (RCTs) and five were non-randomized
comparative trials (NRCTs). We present here a brief rationale for the indication for SGB for each
of the six non-pain indications of interest and a summary of the results for each indication. We
have also provided our recommendation on the role of SGB for each indication and we have
suggested areas of further research.
Indication 1: SGB for obtunding cardiovascular sympathetic stimulation and stress response
Rationale: Preganglionic fibers mediating neurotransmission to the heart synapse on
postganglionic neurons within the stellate and adjacent ganglia in the sympathetic chain.
Pharmacologic blockade or ablation of the stellate ganglion can decrease the sinus node firing
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rate, conduction across the atrioventricular node, and the ventricular fibrillation threshold with a
shift in cardiac autonomic balance to parasympathetic over sympathetic activity (9).
We found five randomized controlled trials (RCT) that enrolled 433 patients (9-13) on the role of
SGB for decreasing the incidence of arrhythmias in surgical settings [coronary artery bypass
graft (CABG) surgery (10), lung lobectomy (12), and thoracoscopic surgery (13)] and atrial
irritability (9) (Supplement 4: Table 1). There was also one RCT on decreasing the
cardiovascular stress response with SGB during induction of anesthesia and intubation (11).
Unilateral SGB (usually left side) was performed in all the five studies with 4 to 10 mLs of local
anesthetic (LA), comparators were injection of saline or no injection, and outcomes were
evaluated up to two months after SGB. Although there were some concerns regarding
randomization in the RCTs (12,13,17) (Supplement 5: Table 1), the overall ROB of the included
RCTs was low. Patients who received SGB had a lower incidence (10,12,13) and duration (9) of
arrhythmias in the surgical settings, and the refractory periods of the atria were prolonged. A
decrease in the cardiovascular sympathetic responses during anesthesia induction and tracheal
intubation in elderly patients with SGB were also reported (11).
Recommendation: Based on the available evidence, it may be reasonable to consider
performing unilateral SGB on the left side to obtund cardiovascular sympathetic stimulation and
its sequelae (Grade B recommendation, moderate level of certainty). This intervention should be
considered early to prevent and treat arrhythmias in the perioperative and non-operative settings
if patients fail to respond to pharmacological management. Further research should involve
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evaluation of the impact of SGB (as compared to no or sham injection) on the serum levels of
catecholamines and on cardiac function by transesophageal or transthoracic echocardiography.
Indication 2: SGB for reducing vascular tone to improve vascular perfusion in the limbs and
optimize perioperative hemodynamic stability
Rationale: Blockade of the cervical sympathetic ganglia (including the stellate) inhibits
sympathetic nerve fibers to the heart and vasculature of the head and upper limbs, thereby
resulting in vasodilation, lowered blood pressure, and increased blood flow.
We found seven RCTs (a total of 455 patients) (14-16,18-21) and one non-randomized study (17)
(Supplement 4: Table 2) that investigated pre-emptive SGB for knee arthroscopy involving the
use of a tourniquet (14), laparoscopic cholecystectomy (15,16), coronary artery bypass surgery
(17), and laparoscopic gynecologic surgery (18) with the main objective of preventing or
decreasing the incidence of hypertension and maintaining perioperative hemodynamic stability.
SGB was also used to enhance arterial blood flow to the arteriovenous fistula created for
hemodialysis (19,20), and for preventing spasm of the radial artery graft used for coronary artery
bypass surgery (21). Unilateral SGB were performed in all cases, with a volume of 7 to 15 mLs
of LA, and comparators were injection of water, intramuscular LA, or no injection. Outcomes
were evaluated up to one month after SGB. There were some concerns around appropriate
randomization in the seven RCTs (11-13, 15-18) and the risk of bias was high for the one non-
randomized study (14) (Supplement 5: Tables 1 and 2). Overall, as compared to the control
groups, subjects who received SGB had improvement in hemodynamic stability and increase in
blood flow in the arteriovenous fistula.
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Recommendation: Based on the available evidence, we endorse the consideration of unilateral
SGB to reduce vascular tone resulting in increased blood flow and perioperative hemodynamic
stability (Recommendation: Grade B, moderate level of certainty). This intervention should be
offered early on to enhance blood flow in arteriovenous fistulas and coronary arterial grafts and
to improve perioperative hemodynamic stability. Further research should involve evaluation of
the impact of SGB (as compared to no or sham injection) on the serum levels of catecholamines
and of stress hormones in perioperative settings for which hemodynamic stability is vital.
Indication 3: SGB for alleviating hot flashes in menopause
Rationale: Vasomotor symptoms (VMS) - hot flashes, night sweats, and sleep disturbance -
affect up to 90% of women during menopause (22). Stellate ganglion block (SGB) has been used
to alleviate VMS with suppression of sympathetic nervous system activity and modulation of
norepinephrine levels in thermoregulatory areas in the brain as the proposed mechanisms of
action (22).
We found three RCTs (40 patients each) (22-24) on the use of SGB for obtunding VMS
(Supplement 4: Table 3). Two of these studies were in breast cancer survivors who had
premature menopause because of chemotherapy (23,24) and one RCT was on women with
natural or surgical menopause (22). Unilateral SGB were performed in all cases, with an average
volume of 5 to 10 mLs of LA, comparators were injection of saline (25) or oral medications
{pregabalin (16) and paroxetine (20)}, and outcomes were evaluated up to one month after SGB.
One RCT (22) had a low risk of bias but there were some concerns about randomization in the
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other two RCTs (23,24) (Supplement 5: Table 1). The use of SGB was associated with a
significant reduction in the frequency of VMS as compared to pregabalin (23) and saline (22) at
three to six months after the interventions but paroxetine provided similar benefits as SGB in the
other RCT (24).
Recommendations: Based on the available evidence, unilateral SGB can be considered to
alleviate menopausal VMS in patients who are reluctant or unable to take paroxetine
(Recommendation: Grade C, low level of certainty). Further research should focus on measuring
the duration of benefit from SGB as compared to a sham injection and or oral pharmacologic
treatments.
Indication 4: SGB for relieving lymphedema of the upper extremity following treatment for
breast cancer
Rationale: Breast cancer-related lymphedema (BCRL) of the ipsilateral upper extremity is
common with an incidence of 20% following mastectomy and axillary lymph node biopsy,
dissection or radiation treatment performed for breast cancer. Damage to the lymphatic system
following these interventions results in accumulation of fluid in the extravascular compartments.
Improvement in the autonomic regulation of lymphatic vessels through a temporary blockade of
the sympathetic fibers innervating these vessels is proposed as the mechanism of beneficial
effect of SGB for BCRL (26).
We found two RCTs (total 60 patients) (25,26) that evaluated the use of SGB as a treatment for
BCRL (Supplement 4: Table 4). Unilateral SGB were performed in all cases with 4 to 5 mLs of
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LA and the comparators were a combination of low or high dose steroids with LA (25) or
decongestive therapy (26). Three consecutive SGB were performed in each of the RCTs with one
to two weeks between procedures. One RCT (25) had a low risk of bias but there was a high risk
of bias in the other RCT due to poor quality of randomization (26) (Supplement 5: Table 1). In
the first RCT, there was a reduction in the circumference of the upper extremity following SGB
in all three groups with some additional benefit from using steroids with LA as compared to only
LA (25). The second RCT that compared SGB against complex decongestive therapy (CDT)
showed benefit in both groups but there was no difference between the two groups (26).
Recommendation: The available evidence for recommending unilateral SGB to alleviate BCRL
is insufficient and further research is recommended (Recommendation: Grade I, low level of
certainty).
Indication 5: SGB for alleviating symptoms of post-traumatic stress disorder
Rationale: Posttraumatic stress disorder (PTSD) is the chronic or pathological hyperarousal that
is brought on by witnessing or experiencing severe trauma and it has a lifetime prevalence of
8%. In PTSD, the sympathetic nervous system is known to be chronically hyper-activated (27).
SGB can suppress this hyper-activation by downregulating norepinephrine and/or nerve growth
factor thereby mitigating symptoms (especially nightmares and startle reactions) in patients with
PTSD (27).
We found two RCTs (total of 229 patients) (27,28) that evaluated the use of SGB to ameliorate
symptoms of PTSD (Supplement 4: Table 5). Unilateral (right side) one to two SGB were
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performed in both RCTs with 5 to 10 mLs of LA and the comparators were an injection of saline
in the stellate ganglion. One RCT (28) had a low risk of bias but there were concerns regarding
deviations from the protocol for the other RCT (27) (Supplement 5: Table 1). There was no
improvement in PTSD symptoms after the use of a single SGB injection in one RCT (27). In the
other RCT, two SGB procedures with LA administered two weeks apart were successful in
reducing the severity of PTSD symptoms for two months but the saline group also reported
improvement (28).
Recommendation: The available evidence for recommending a right-sided unilateral SGB to
alleviate PTSD symptoms is insufficient, and further research is required (Recommendation:
Grade I, low level of certainty).
Indication 6: SGB for treating sudden deafness due to sensorineural hearing loss
Rationale: Sudden deafness due to sensorineural hearing loss (SNHL) is hypothesized to be due
to diverse pathologic processes with circulatory disorders in the inner ear being a likely causative
factor. SGB and blocks of the cervical sympathetic chain at the superior and middle ganglia can
provide ipsilateral vasodilation in the head and neck, including the inner ear, thereby improving
hearing in patients with sudden onset deafness.
We found four non-randomized studies (29-32) (total of 392 patients) on the use of SGB as a
treatment for idiopathic sudden deafness due to SNHL (Supplement 4: Table 6). SGB was with 5
to 8 mLs of LA and the comparator treatments included epidural injections (29), medications
including steroids (30,31), and prostaglandins (32). SGB was also combined with hyperbaric
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oxygen in two studies (30,32). The risk of bias was high for all four studies because of the
possibility of confounding, concerns around selection of participants, and misclassification of
interventions (Supplement 5: Table 2). Epidural injection was superior to SGB in one study (29)
for improvement in hearing measured immediately after the interventions but there was no clear
trend for the superiority of SGB over comparator treatments in the other three studies (30-32).
Recommendation: The available evidence for recommending SGB to treat sudden deafness due
to sensorineural hearing loss is insufficient. This intervention should be tested in larger RCTs
that have a longer follow-up duration with measured outcomes including audiometry and
participants’ impression of change (Recommendation: Grade I, low level of certainty).
Adverse effects of SGB reported in publications included in this review
There was a higher incidence of hoarseness in SGB as compared to controls (25.6% vs 9.1%;
p=0.042) in two studies evaluating SGB for obtunding cardiovascular sympathetic stimulation
and stress response (13) and for improving blood flow in the AV fistula (19). The study by
Rahimi and colleagues (19) also reported shortness of breath, a hematoma, and reduced muscle
strength in one patient each in the SGB group (19). A case of pneumothorax as a complication of
SGB was reported in one study (31).
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DISCUSSION
This scoping review provides a comprehensive summary of the role of SGB in the treatment of
six common non-pain indications. We performed a comprehensive literature search, we included
only comparative studies, summarized the evidence, and we made recommendations for clinical
practice and further research. We found evidence with low-to-moderate certainty to support the
use of SGB for the following indications: cardiovascular sympathetic stimulation and
perioperative stress response, increased vascular tone resulting in vascular insufficiency of the
upper extremity and perioperative hemodynamic instability, and menopausal VMS. However,
there was insufficient evidence to recommend SGB for improving inadequate lymphatic outflow
from the upper extremity following treatments for breast cancer, symptoms of post-traumatic
stress disorder (PTSD), and sudden deafness due to sensorineural hearing loss.
There are multiple reviews on the role of SGB for pain indications. However, to the best of our
knowledge, this review is the first to synthesize literature on the role of SGB for non-pain
indications. We conducted a scoping review to describe and map current evidence to identify
areas for future research. There has been a resurgence in the indications for SGB following
description of ultrasound-guided techniques for performing this procedure (33). The anatomy
around the site for performing stellate ganglion at the level of the transverse process of the sixth
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cervical (C6) vertebra includes common carotid, vertebral, inferior thyroid, and deep cervical
arteries, internal jugular vein, esophagus, pleura, and the cervical nerve roots. Use of ultrasound
to ensure accuracy of injectate with volumes of up to 5 mLs (33), injection at C6 level with
spread from C4 to T1 levels, and ultrasound imaging to minimize the risk of complications is
recommended (3). Table 1 lists some additional recommendations from included studies with
rationale for improving outcomes with SGB for the indications discussed in this scoping review.
Moreover, there are recent reports of SGB being employed to treat symptoms of “Long COVID”.
These symptoms include fatigue, orthostatic intolerance, brain fog, anosmia, and ageusia or
dysgeusia and are believed to be due to the effect of pro-inflammatory cytokines on the
autonomous nervous system. Bilateral SGB performed 48 to 72 hours apart can reduce the
severity of Long COVID symptoms by attenuating dysautonomia with sustained benefit for up to
two months after SGB (34-36).
This review does have some limitations. It is possible that we may have overlooked SGB for
non-pain indications published in languages other than English, Spanish and Italian. Due to the
heterogeneity of the studies on SGB in terms of technique, differences in the use of local
anesthetics, in follow-up and outcome reports, it is not possible to establish firm conclusions on
the efficacy and safety of SGB based on the current data. Further, the studies included in this
review did not specifically evaluate safety as an outcome of interest.
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In conclusion, this scoping review summarizes current available evidence on the use of SGB for
non-pain indications. More rigorous research with larger, well-designed RCTs and monitoring
of long-term outcomes is required for evaluating the role of SGB for non-pain indications.
Authorship statement
All six authors helped design the study, conduct the study, analyze the data, and write the article.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This research was supported by internal funding from the Department of Anesthesia and Pain
Medicine at Toronto Western Hospital.
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Figure 1. Trend of the number of publications on stellate ganglion block from 2003 to 2021 on
PubMed (https://pubmed-ncbi-nlm-nih-
gov.myaccess.library.utoronto.ca/?term=stellate+ganglion+block. Accessed on May 1, 2022).
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From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-
Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097
For more information, visit www.prisma-statement.org.
PRISMA Flow Diagram
Records identified through database
searching
(n = 1374)
Medline = 539
Medline ePubs = 95
Embase = 502
CCTR = 214
CDSR = 1
PsycINFO = 23
Screening
Included
Eligibility
Identification
Additional records identified
(n = 3)
Duplicates removed
(n = 324)
Records screened
(n = 1053)
Records excluded
(n =575)
Full-text articles assessed
for eligibility
(n = 478)
Full-text articles excluded,
with reasons (n = 454):
Reviews
Just abstract
Description of block
effects
Duplicates
Another language
Paediatric population
Adjuvant to SGB
Commentaries
Editorial
Different interventions
Letter to the editor
Clinical guideline
1 Protocol
1 Wrong indication
1 Medical hypothesis
122 Low level of evidence
or different indication
Studies included in
qualitative synthesis
(n =24)
Studies included in
quantitative synthesis
(n=0)
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Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for
Scoping Reviews (PRISMA-ScR) Checklist
SECTION
ITEM
PRISMA-ScR CHECKLIST ITEM
REPORTED
ON PAGE #
TITLE
Title
1
Identify the report as a scoping review.
1
ABSTRACT
Structured
summary
2
Provide a structured summary that includes (as
applicable): background, objectives, eligibility criteria,
sources of evidence, charting methods, results, and
conclusions that relate to the review questions and
objectives.
3
INTRODUCTION
Rationale
3
Describe the rationale for the review in the context of
what is already known. Explain why the review
questions/objectives lend themselves to a scoping
review approach.
4,5
Objectives
4
Provide an explicit statement of the questions and
objectives being addressed with reference to their key
elements (e.g., population or participants, concepts,
and context) or other relevant key elements used to
conceptualize the review questions and/or objectives.
5
METHODS
Protocol and
registration
5
Indicate whether a review protocol exists; state if and
where it can be accessed (e.g., a Web address); and if
available, provide registration information, including
the registration number.
6
Eligibility criteria
6
Specify characteristics of the sources of evidence
used as eligibility criteria (e.g., years considered,
language, and publication status), and provide a
rationale.
6,7
Information
sources*
7
Describe all information sources in the search (e.g.,
databases with dates of coverage and contact with
authors to identify additional sources), as well as the
date the most recent search was executed.
6
Search
8
Present the full electronic search strategy for at least 1
database, including any limits used, such that it could
be repeated.
6
Selection of
sources of
evidence†
9
State the process for selecting sources of evidence
(i.e., screening and eligibility) included in the scoping
review.
7
Data charting
process‡
10
Describe the methods of charting data from the
included sources of evidence (e.g., calibrated forms or
forms that have been tested by the team before their
use, and whether data charting was done
independently or in duplicate) and any processes for
obtaining and confirming data from investigators.
7
Data items
11
List and define all variables for which data were
sought and any assumptions and simplifications made.
7
Critical appraisal of
individual sources
of evidence§
12
If done, provide a rationale for conducting a critical
appraisal of included sources of evidence; describe
the methods used and how this information was used
in any data synthesis (if appropriate).
8
Page 28 of 63
Official Journal of the American Academy of Pain Medicine
Pain Medicine
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SECTION
ITEM
PRISMA-ScR CHECKLIST ITEM
REPORTED
ON PAGE #
Synthesis of
results
13
Describe the methods of handling and summarizing
the data that were charted.
8,9
RESULTS
Selection of
sources of
evidence
14
Give numbers of sources of evidence screened,
assessed for eligibility, and included in the review, with
reasons for exclusions at each stage, ideally using a
flow diagram.
10
Characteristics of
sources of
evidence
15
For each source of evidence, present characteristics
for which data were charted and provide the citations.
10
Critical appraisal
within sources of
evidence
16
If done, present data on critical appraisal of included
sources of evidence (see item 12).
8
Results of
individual sources
of evidence
17
For each included source of evidence, present the
relevant data that were charted that relate to the
review questions and objectives.
10
Synthesis of
results
18
Summarize and/or present the charting results as they
relate to the review questions and objectives.
10-17
DISCUSSION
Summary of
evidence
19
Summarize the main results (including an overview of
concepts, themes, and types of evidence available),
link to the review questions and objectives, and
consider the relevance to key groups.
18,19
Limitations
20
Discuss the limitations of the scoping review process.
19
Conclusions
21
Provide a general interpretation of the results with
respect to the review questions and objectives, as well
as potential implications and/or next steps.
19
FUNDING
Funding
22
Describe sources of funding for the included sources
of evidence, as well as sources of funding for the
scoping review. Describe the role of the funders of the
scoping review.
20
JBI = Joanna Briggs Institute; PRISMA-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analyses
extension for Scoping Reviews.
* Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media
platforms, and Web sites.
† A more inclusive/heterogeneous term used to account for the different types of evidence or data sources (e.g.,
quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping
review as opposed to only studies. This is not to be confused with information sources (see first footnote).
‡ The frameworks by Arksey and O’Malley (6) and Levac and colleagues (7) and the JBI guidance (4, 5) refer to the
process of data extraction in a scoping review as data charting.
§ The process of systematically examining research evidence to assess its validity, results, and relevance before
using it to inform a decision. This term is used for items 12 and 19 instead of "risk of bias" (which is more applicable
to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used
in a scoping review (e.g., quantitative and/or qualitative research, expert opinion, and policy document).
From: Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews
(PRISMAScR): Checklist and Explanation. Ann Intern Med. 2018;169:467–473. doi: 10.7326/M18-0850.
Page 29 of 63
Official Journal of the American Academy of Pain Medicine
Pain Medicine
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Table 1. Recommendations for improving outcomes for non-pain indications of stellate ganglion
block.
Recommendation
Rationale/Focus of further research
Use of ultrasound guidance
Increase accuracy and safety
Limit injectate volumes to 2-5
mLs of local anesthetic
Avoid blockade of surrounding neural structures (recurrent
laryngeal nerve, vagus nerve, cervical nerve roots, brachial
plexus)
Repeat procedures
Enhance and prolong benefit from the procedure however
optimum interval between procedures is unclear
Consider sympathetic block
under fluoroscopic guidance for
the second thoracic vertebral
levels if SGB fails for upper
limb indications
Some patients have sympathetic nerve supply to the upper
limb from the intrathoracic ramus (nerve of Kuntz)
between the second intercostal nerve and the ventral ramus
of the first thoracic nerve
Use objective markers to ensure
sympatholytic effect of SGB
Check for presence of Horner’s syndrome and rise in
temperature of the upper limb (ideally > 1 C)25 on the side
ipsilateral to the block
Page 63 of 63
Official Journal of the American Academy of Pain Medicine
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