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Background and AimsStellate ganglion block (SGB) is conventionally performed at the C6 vertebral level; however, this method poses the risk of accidental nerve blockade and vascular injury. We propose a novel approach, first-rib neck SGB (1RN-SGB), that effectively minimises these risks (figure 1).Methods[Case series] Ten patients underwent 1RN-SGB with 3–5 mL of 1% lidocaine after confirmation of contrast imaging using 3–4 mL of iohexol. Clinical outcomes, adverse effects, and extent of contrast spread were recorded. [Cadaveric study] 1RN-SGB was performed on four Thiel-embalmed cadavers (six sides) with 3 or 6 mL of 0.4% indigo carmine injected. Dye spread and nerve involvement were assessed by dissection.Results[Case series] 1RN-SGB successfully achieved pain relief in all patients with Horner’s sign. Two patients reported paralysis of the ulnar side of the hand and forearm. No additional adverse events were reported. Contrast spread reached adjacent to the T1 vertebra (figure 2). [Cadaveric study] The stellate ganglion was completely stained with 6 mL of dye but only on the lateral surface by 3 mL (figure 3). The sympathetic trunk was consistently stained at C7-T2. Recurrent laryngeal, vagus, and phrenic nerves were not stained. C8 and T1 nerves were stained in all cadavers.Abstract EP158 Figure 1The ultrasound image and the procedure of 1RN-SGB[Image Omitted. See PDF.]Abstract EP158 Figure 2The contrast spread after injection of 4 mL of iohexol[Image Omitted. See PDF.]Abstract EP158 Figure 3The dye spread after injection of 3 mL of 0.4% indigo carmine[Image Omitted. See PDF.]ConclusionsAlthough 1RN-SGB demonstrates consistent effects, its pathway may differ from that of conventional SGB. 1RN-SGB effectively reduces severe complications; however, it is crucial to note the unintentional blockade of C8 and T1 nerves.