April 30, 2010 — Case reports of immediate, durable, and significant reductions in symptoms of posttraumatic stress disorder (PTSD) are now appearing in the literature following the use of stellate ganglion block (SGB) in severe PTSD unresponsive to medical intervention. A report of 2 PTSD patients who were successfully treated with SGB was published online April 20 in Pain Practice.
Sean Mulvaney, MD, Consortium for Health and Military Performance, Uniformed Service University, Bethesda, Maryland, and colleagues reported the successful use of SGB in 2 patients with symptoms of PTSD. Before receiving the SGB, pretreatment scores on the Posttraumatic Stress Disorder Checklist (PCL) were 76 of a maximum score of 85 for the first patient and 54 in the second patient.
After SGB blockade with ropivacaine delivered at the level of the sixth cervical vertebra on the right side, 1 patient indicated that global feelings of anxiety improved from a pre-SGB level of 8 of 10 to a 2 of 10 after the procedure. Post-SGB PCL scores for the second patient decreased to 24, with the minimum score being 17.
The first patient required a second procedure as symptoms returned some 3 months after initial treatment. After the second SGB 7 months later, his posttreatment score decreased to 23 from a preprocedure high of 67. It has subsequently remained below the PTSD cutoff after 7 additional months of follow-up. Both patients discontinued use of all antidepressant and antipsychotic medications while maintaining their improved PCL score, the study authors note.
Increasingly Prevalent Condition
"Although an admittedly small series of patients, our report points to a potentially effective and readily accessible approach for PTSD treatments," Dr. Mulvaney and colleagues write, "and we believe that further investigation of this intervention is warranted and may provide alternatives and/or complements to current psychological and pharmacological treatments for PTSD, an increasingly prevalent condition in military populations."
For the procedure, the patient is positioned comfortably in the supine position and prepared and draped in a sterile fashion. After confirming radiographically the right C6 transverse process, physicians anesthetize the skin with 1 mL of 2% lidocaine.
"Using an anterior paratracheal approach, a 25-gauge Quincke needle [is] passed under fluoroscopic guidance until it [contacts] the transverse process of the C6 vertebrae and then [is] pulled back 1 mm," the investigators observe. The correct needle position is further confirmed by injecting a radio-opaque dye to monitor spread, and, after negative aspiration, 7 mL of 0.5% ropivacaine is slowly injected to produce a sympathetic blockade.
The patient's right hand is also monitored for 15 minutes after the blockade to confirm that the cervical sympathetic ganglia has been successfully blocked, as reflected by an increase in body temperature of at least 1.5°C.
First to Use SGB
The Walter Reed study was motivated by a report published in 2008 by Eugene Lipov, MD, Northwest Community Hospital, Arlington, Illinois, who was the first to use SGB for the treatment of both hot flushes and later PTSD, his first PTSD patient being treated in 2007. As Dr. Lipov told Medscape Psychiatry, trauma as he sees it leads to an increase in nerve growth factor.
This in turn leads to a sprouting of sympathetic nerves, he adds, which increases the production of a number of neurotransmitters. including adrenaline, which makes people anxious. SGB decreases nerve growth factor and helps reverse PTSD symptoms. Dr. Lipov also noted that physiological changes that occur during trauma can be seen and measured with the help of brain imaging using functional magnetic resonance imaging (MRI).
"These MRI are telling us that the cause of PTSD is physical in nature and is not simply a ‘psychological condition,'" he said. The most common complication from the use of the SGB procedure is seizure, but seizures are not permanent and risks can be reduced by using guided fluoroscopic techniques.
"This independent verification of my results by Walter Reed is going to change how people think about PTSD and spread the word about SGB," Dr. Lipov told Medscape Psychiatry, adding, disappointingly, that his repeated requests for funding to assess SGB more formally in the treatment of PTSD have been turned done. Despite this, Dr. Lipov is currently looking for an additional 18 soldiers with PTSD to undergo SGB in a pilot test study.
"Time [and results] will tell to what degree this time-tested technique will offer efficacious and durable relief for PTSD," Dr. Lipov writes in an accompanying editorial. "Such relief cannot come too soon for those who suffer the symptoms as well as those who stand beside them."
The study authors have disclosed no relevant financial relationships.
Pain Practice. Published online April 20, 2010.
Medscape Medical News © 2010 Medscape, LLC
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Cite this: Stellate Ganglion Blockade Shows Promise as Effective, Durable Treatment for PTSD - Medscape - Apr 30, 2010.