Vishnevsky cervical vagosympathetic block

When is this procedure used?

In operative surgery, cervical vagosympathetic block is performed for severe and life-threatening conditions associated with chest trauma. The main indications include:

• Thoracic injuries and wounds accompanied by closed or open pneumothorax.
• Severe combined trauma involving both the thoracic and abdominal cavities at the same time.

The therapeutic essence boils down to the pharmacological isolation of the injury focus. By blocking neural pathways, the surgeon prevents a cascading surge of pain impulses, thereby protecting the patient from developing a severe complication—pleuropulmonary shock.

Anatomical rationale for level selection

The success of analgesia critically depends on the height of solution injection in the neck tissues. The higher the anesthetic can be distributed, the more reliably a block of two crucial structures will be achieved simultaneously: the vagus nerve (n. vagus) and the sympathetic trunk.

Upper neck level: In this zone, the inferior ganglion of the vagus nerve (ganglion nodosum) and the superior ganglion of the sympathetic trunk are located together within a single fascial layer. Administering the solution here guarantees simultaneous blockade of both nerves.

Lower level (level of the hyoid bone): If the procedure is performed too low, the solution may not produce the expected effect. The fact is that in this area, the nerve trunks have already diverged anatomically and are securely separated by the dense posterior wall of the common fascial sheath. As a result, the injected novocaine can block exclusively the vagus nerve, leaving the sympathetic trunk intact.

Step-by-step execution technique

The procedure requires a thorough knowledge of topographic anatomy and strict adherence to the algorithm.

1. Patient positioning: The patient is placed supine. A bolster is placed under the shoulder blades, and the head is turned as far as possible to the side opposite the intervention. The surgeon stands on the side of the block being performed.
2. Determining the injection point: The landmark is the posterior border of the sternocleidomastoid muscle, slightly above its intersection with the external jugular vein (corresponding to the level of the hyoid bone).
3. Surgical access: Following preliminary skin anesthesia (forming a "lemon peel"), the surgeon uses the left index finger to gently push the sternocleidomastoid muscle along with the vascular bundle medially.
4. Needle insertion: A long needle is inserted into the formed free space. It is directed upward and medially, aiming strictly toward the anterior surface of the spine. After hitting the bone, the needle must be withdrawn back by 0.5 cm so that its tip lies in the loose connective tissue located behind the common fascial sheath of the neurovascular bundle.

Solution administration and safety control

For a complete block, 40 to 50 ml of 0.25% novocaine solution is injected into the prepared fascial space. During this process, the classic "creeping infiltrate" principle is strictly observed: a steady stream of novocaine, preceding the needle tip, hydraulically separates the tissues and gently pushes blood vessels away, preventing accidental injury.

During the injection, the surgeon must perform dynamic safety monitoring:

• When periodically pulling the syringe plunger back, blood must not appear in the barrel (the appearance of blood indicates that the tip has entered a vessel lumen).
• With proper positioning (when the needle is precisely in the loose connective tissue rather than muscle tissue, subcutaneous fat, or a vessel lumen), fluid should not spontaneously leak from the needle hub after disconnecting the syringe.

Efficacy criteria: Horner's syndrome

A correctly performed vagosympathetic block is accompanied by striking clinical manifestations on the side of the procedure. The combination of these signs is called Horner's syndrome. Evaluating the patient's condition, the physician records:

• Enophthalmos — visually noticeable retraction of the eyeball into the orbit.
• Miosis — pronounced pupillary constriction.
• Ptosis — narrowing of the palpebral fissure due to drooping of the upper eyelid.
• Skin changes — hyperemia (redness) with a local increase in skin temperature on the corresponding half of the face.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Topographic anatomy of the fasciae and fascial spaces of the neck in the neurovascular bundle zone.
• Mechanisms of pleuropulmonary shock development in chest trauma.
• Structure of the sympathetic trunk and vagus nerve at the cervical level (ganglion nodosum).
• The principle of the "creeping infiltrate" method and its application in other surgical interventions.

Other topics in the «Neck Surgery» section

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