We read with interest the review article by Dr. Reuben entitled “Preventing the Development of Complex Regional Pain Syndrome after Surgery.”1The author mentioned that in his practice, he administers a stellate ganglion block to patients with a history of complex regional pain syndrome (CRPS) undergoing upper extremity surgical procedures in an effort to prevent its recurrence. Although the literature supports this practice, the efficacy of a stellate ganglion block has broader applications to patients without  a history of CRPS. No study has examined its use in the acute postoperative setting. Nevertheless, we report the first case using a stellate ganglion block to treat acute postoperative pain successfully in a patient without a history of CRPS who underwent an open reduction and internal fixation of his left humerus.

A 46-yr-old, 70-kg male with a medical history significant for recent cocaine abuse underwent general anesthesia for an open reduction and internal fixation of a left humerus fracture. The 3-h intraoperative course was uneventful during a 3% desflurane in 50% nitrous and oxygen anesthetic. Fentanyl, 500 μg, and 5 mg morphine were also given intraoperatively. In the postanesthesia care unit, an additional 20 mg morphine was titrated for pain relief, although to no avail: The patient’s pain score remained 10 out of 10. On further evaluation, his left upper extremity appeared cold, clammy, and edematous, whereas the pain characteristic was described as burning.

After informed consent, a left stellate ganglion block was performed using 10 ml bupivacaine, 0.25%, with a sterile technique. Pain relief (0 out of 10) was achieved 5 min after injection. Evidence of successful blockade included ptosis and miosis, temperature increase in the ipsilateral extremity, and an increase in perfusion index.

Numerous publications in the literature support the use of a stellate ganglion block for chronic sympathetically mediated pain; however, to the best of our knowledge, we report the first case in which a stellate ganglion block was used in the acute postoperative setting. Furthermore, the success of the block in absence of a history of CRPS illustrates primary prevention—interventions to prevent a disease from occurring. Activation of the sympathetic pain pathways could have taken place before the patient’s operating room visit or even intraoperatively. Nevertheless, the challenge is to recognize the clinical symptoms that differentiate acute CRPS from postsurgical pain, despite the close resemblance.2Further review of the case revealed that the patient’s fracture was a week old, which may have contributed to an alteration of central nociceptive processing pathways, thus increasing his risk for development of postsurgical CRPS.3Overall, we share the same enthusiasm of Dr. Ruben on regional anesthetic techniques to prevent the occurrence of CRPS. In our clinical practice, it is not only important to focus on CRPS prevention, but also to understand the pathophysiology so that we know which patients are at greatest risk.

* Harbor-UCLA Medical Center, Torrance, California. ckakazu@hotmail.com

Reuben SS: Preventing the development of complex regional pain syndrome after surgery. Anesthesiology 2004; 101:1215–24
Birklein F, Kunzel W, Sieweke N: Despite clinical similarities there are significant differences between acute limb trauma and complex regional pain syndrome I (CRPS I). Pain 2001; 93:165–71
Gracely RH, Lynch SA, Bennett GJ: Painful neuropathy: Altered central processing maintained dynamically by peripheral input. Pain 1992; 51:175–94