Unusual case of contralateral Horner’s syndrome following stellate-ganglion block: a case report and review of the literature
A 47-year-old female presented to our institution with right-hand pain secondary to Raynaud’s phenomenon. Her pain persisted despite medical management. Physical examination revealed cold skin, hyperalgesia, allodynia, pink-to-purple discoloration of her right hand, and symmetric pupillary size. She was scheduled for a right-side SGB. The patient was placed in the supine position with her neck hyperextended and her jaw slightly opened. Monitored anesthesia care and intravenous sedation was initiated. The skin and subcutaneous tissue in the right paratracheal area was anesthetized using 3 mL lidocaine 1% at the level just above the C6 transverse process (Chassaignac’s tubercle). The right carotid artery was retracted laterally using the index and middle finger from the nondominant hand, and was then advanced posteriorly squeezing the subcutaneous tissues towards the C6 transverse process. With the dominant hand, a syringe with a 22-gauge short-bevel needle was advanced perpendicularly down until Chassaignac’s tubercle was felt at a depth of about 2 cm. The needle was then withdrawn 1–2 mm. After confirming a negative aspiration, a total of 10 mL local anesthetic (lidocaine 1.5% and bupivacaine 0.5% at 1:1 ratio) was injected with intermittent aspiration. After the procedure, the patient experienced significant pain relief and subjective warmth in her right upper extremity, as well as ptosis, miosis, and conjunctival injection (Horner’s syndrome) on the left, contralateral side. Right-extremity temperature was measured using surface-temperature monitoring, and showed an increase from 32.4°C to 34.7°C. Right pupillary size was noted to be unchanged from baseline examination, and no facial flushing was noted. At the patient’s 2-week follow up visit, she had continued pain relief and did not require additional pain medications.