Stellate Ganglion Block a Potential Lifesaver in Severe PTSD

Megan Brooks

May 19, 2015

TORONTO ― Case reports are mounting of immediate, durable, and significant relief of severe refractory symptoms of posttraumatic stress disorder (PTSD), according to an anesthesiologist who has seen the benefits firsthand.

Stellate ganglion blockade (SGB) "seems to significantly improve PTSD symptoms as well as significantly reduce or eliminate suicidal ideation in patients with severe PTSD," said Eugene Lipov, MD, of the Advanced Pain Center, Hoffman Estates, Illinois.

Case reports are "steadily growing," he noted, with the total number of patients treated with SGB for PTSD in the literature now well more than 200, with success rates of "around 70%; adding clonidine pushes it into the 80% range."

Here at the American Psychiatric (APA) Association 2015 Annual Meeting, Dr Lipov described three patients who were helped by SGB. All of them underwent a single rightsided SGB injection at the C6 level using 7 cc of local anesthetic under fluoroscopic guidance. PTSD symptoms were assessed using the PTSD Checklist–Military Version (PCL-M). Data on suicidal ideation were collected when available.

"A Changed Man"

The first patient was a soldier with severe PTSD who was severely suicidal for whom traditional therapy had failed. The patient experienced rapid and marked reduction in symptoms following SGB.

"This patient was treated with SGB and became nonsuicidal in 2 days following the procedure," Dr Lipov said. His PCL-M score went from 71 (out of a maximum score of 85) before treatment to 54 1 day after treatment.

However, his symptoms returned 16 days later, and he received a second SGB, which has had a lasting effect. Four years later, his PCL-M was 29; he was "off all drugs, and his wife said he is a changed man," Dr Lipov reported.

The second patient was a soldier who served in the military for 8 years as a truck driver. During two deployments to Iraq, he reported seeing burning and dismembered bodies.

He was admitted to the inpatient psychiatric ward four times for severe PTSD and suicidality. During his final stay, he scored 80 on the PCL-M. Two days following SGB, he was discharged from the ward, his PCL-M having dropped to 18 and his suicidal ideation having completely resolved, Dr Lipov noted. "He has since disappeared from the system."

The third patient was "very interesting," Dr Lipov said. He was blatantly suicidal but refused immediate inpatient care. An initial SGB failed. When SGB works, the clinical effect is often seen in less than 30 minutes, Dr Lipov explained. Not wanting to let the patient go for fear he would complete suicide, Dr Lipov said he opted to "switch techniques for this patient, and immediately did a C6 and C3 sequential block," which led to "complete symptom relief."

Rapid, Dramatic Response

Although Dr Lipov said he is encouraged by the effects he has seen, he cautioned that this is "still an unproven approach. Further work is needed to identify optimal patients for this treatment approach and to understand the mechanisms involved that can produce such a rapid, dramatic, and long-term change in psychological health for PTSD patients with suicidal ideation," Dr Lipov told attendees.

It is hypothesized that trauma leads to an increase in nerve growth factor in the stellate ganglion. This in turn leads to a sprouting of sympathetic nerves, which increases the production of a number of neurotransmitters, including adrenaline and norepinephrine, which makes people anxious. SGB leads to a reduction in nerve growth factor and sprouting of sympathetic nerves, which helps reverse PTSD symptoms, Dr Lipov explained.

A literature review published in 2014 in the Journal of Anesthesia Clinical Research described 24 patients with severe, treatment-refractory PTSD who received SGB. Clinically meaningful improvement in symptoms of PTSD was observed in 18 of 24 patients (75%) after SGB.

However, not all the studies have been positive. Results of a randomized, controlled trial reported at the American Academy of Pain Medicine Annual Meeting in March found that SGB was not superior to sham block, as reported by Medscape Medical News at that time.

Encouraging Data

Retired Col. Elspeth Cameron Ritchie, MD, MPH, chief clinical officer, US Department of Mental Health, Government of the District of Columbia, who heard Dr Lipov's presentation at APA 2015, said she is encouraged by the data on SGB for PTSD, but cautioned that "most of the data we have at the moment are anecdotal."

"We don't know who the block works for and why and how many doses it takes and all of that. But if you talk to patients who have gotten it, it's really been lifesaving for some, so it really is something that needs to be explored further," she commented.

The Department of Defense has earmarked $2 million for a three-center, double-blind, placebo-controlled trial of SGB in severe PTSD.

Dr Lipov and Dr Ritchie report no relevant financial relationships.

American Psychiatric Association (APA) 2015 Annual Meeting. Presented May 16, 2015.

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