Caroline Helwick

October 13, 2014

NEW ORLEANS — Stellate ganglion block appears to be a fast-acting and effective treatment for chronic, extreme post-traumatic stress disorder (PTSD), according to a single-center study.

Although the effect wanes within several months, "the improvements far outlasted what we would expect from stellate ganglion block, which is usually used as a temporary nerve block and typically lasts 3 to 5 hours," said lead investigator Michael Alkire, MD, from the from Long Beach Veterans Affairs Healthcare System in California.

The study results were presented here at Anesthesiology 2014.

The investigators evaluated 12 veterans with combat-related PTSD that had lasted longer than a year who were showing symptoms of hyperarousal. Patients underwent a single right-sided stellate ganglion block using 7 cc of 2% lidocaine and 0.25% bupivacaine under fluoroscopic guidance.

Investigators assessed PTSD symptoms at baseline and four times in the subsequent 6 months with the Clinician-Administered PTSD Scale (CAPS), obtained after a 2-hour structured interview, and the Post-Traumatic Stress Self Report (PSS-SR). On the CAP scale, a score of 20 is considered mild and a score of 80 indicates extreme PTSD. The mean score for the study patients was 78.

"Think of the shell-shocked patients you see in documentaries of soldiers after World War I. That's what our guys were like," Dr Alkire said.

Researchers assessed depressive symptoms with the Beck Depression Inventory, version 2 (BDI-II). They evaluated anxiety and psychological pain with validated instruments and followed patients for 6 months.

Robust Response

The stellate ganglion blocks were "greatly effective in helping" nine of the 12 (75%) subjects, Dr Alkire reported.

"We found three types of responses. A few subjects were immediate nonresponders. Five generally felt better right away and their scores continued to improve. Four subjects were what one might call 'miracle cures'; they essentially returned to normal within a few minutes, before they even got off the fluoroscopy table," he reported. "They felt like they had never been to war. One even watched a TV program on the 10th anniversary of the Iraq war."

For those who responded, "the positive effects were evident often within minutes, and resulted in a significant reduction in both CAPS and PSS-SR scores at 1 week," Dr Alkire added.

For many, symptoms continued to ameliorate, and by 1 month, their CAPS scores approached a level indicating normal to mild PTSD. At 1 month, mean CAPS score was significantly lower for responders than for nonresponders (30 vs 85; P = .001).

Anxiety, depression, and psychological pain scores generally paralleled the overall CAPS response, and were significantly reduced by the block. Mean BID-II scores at 1 month were also lower for responders than for nonresponders (15 vs 35; P < .05).

The difference in PTSD improvement lost statistical significance at 6 months (although numerical differences were observed), but the findings remained significant for depression (P < .005).

"The improvement in depression was so great and so rapid that it may rival electroconvulsive therapy," Dr Alkire noted.

When the relief of PTSD symptoms begins to wane, subjects can be retreated with good results.

Although the neurophysiologic rationale for the efficacy of this strategy remains unknown, it has been postulated that changes in sympathetic and parasympathetic tone and neurohumoral factors might be contributors.

"I believe, based on our work in emotional memory, that we are flipping the switch that is flipped when you startle, exactly in the opposite direction," Dr Alkire explained. "We are changing the sympathetic and parasympathetic tone almost instantly with the block. Blocking the sympathetics allows the parasympathetics to come out."

Dr Alkire indicated that stellate ganglion blocks are now being used to treat severe PTSD cases at his center. "We now use this as a special tool to help patients for whom nothing else works."

No Control

Interest in the strategy was high among meeting attendees, but there was general concern about the lack of a control group.

This study is "a very good start," said session moderator Honorio Benzon, MD, professor of anesthesiology at Northwestern University in Chicago. However, to be conclusive, the stellate ganglion block would need to go head to head with a placebo injection. "You need to do a sham procedure," he said.

Dr Benzon pointed out that one way to be sure the intervention is truly effective is to look for signs of sympathetic blockade and to correlate these with clinical response. "You really have to look not only at Horner's syndrome [indicative of sympathetic deficiency], but also for signs of sympathetic blockade, and correlate these with the degree of relief," he said.

Dr Alkire and Dr Benzon have disclosed no relevant financial relationships.

Anesthesiology 2014 from the American Society of Anesthesiologists (ASA): Abstract A1046. Presented October 11, 2014.

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