Stellate ganglion block (SGB) was first used in the 1920s as a therapeutic modality for the treatment of chronic pain. Physicians are trained to administer local anesthetics via injection into the patient's neck to treat pain in the head, arms and hands. However, new research suggests that SGB, an injection at the level of the 6th or 7th cervical vertebra, can be helpful for treating symptoms of post-traumatic stress disorder (PTSD).
Eugene G. Lipov, MD, a Chicago-based anesthesiologist and pain management specialist who also volunteers as a consultant to the U.S. Navy, was the first physician nationally to pioneer administration of SGB to treat PTSD symptoms among veterans of the most recent conflicts in Iraq and Afghanistan. An article based on his research with a case series of patients will be published in the February 2012 edition of the military's top medical journal, Military Medicine. Co-authors on the study titled "A novel application of stellate ganglion block: preliminary observations for the treatment of post-traumatic stress disorder" include Dr. Lipov as well as Commander Eric T. Stedje-Larsen, MD, an anesthesiologist and pain management physician at Naval Medical Center San Diego (NMCSD) in San Diego who is currently deployed as the Officer in Charge of Fleet Surgical Team FIVE aboard the USS Makin Island; Captain Anita H. Hickey, MD, Director of Pain Research and Integrative Pain Medicine in the Department of
Anesthesiology at NMCSD; and Maryam Navaie, Dr.P.H., President and CEO of Advance Health Solutions in La Jolla, Calif.
The authors discuss SGB as a treatment for PTSD and how the new evidence could impact care for patients in the future.
Developing the treatment
The idea for treating PTSD with SGB came to Dr. Lipov after his brother (also a physician) suggested that hot flashes can be treated with the injection. Dr. Lipov and his brother published an article on his findings, however several criticisms of the treatment stymied further research. The negative criticisms focused on the lack of basic science knowledge about how and why the injection worked in patients with hot flashes; the critics said physicians shouldn't use the injection if they didn't know how it worked.
Dr. Lipov met that challenge and spent several months researching the mechanisms of the stellate ganglion and why the block might work. After reviewing more than 3,000 articles on the topic, he was able to explain the mechanics of SGB in a hypothetical paper. Essentially, after a patient goes through stress, such as right before menopause or a traumatic event, the nerve growth factor (NGF) increases (e.g., estrogen reduction leads to increases in NGF), resulting in increased levels of norepinephrine in the brain.
The stellate ganglion is part of the sympathetic nervous system which governs our "fight or flight" response. This response is activated with severe trauma or threat to one's self. PTSD is associated with severe traumatic events outside of the realm of what would be considered normal human experience. As the sympathetic nervous system controls blood flow to our brain, vital organs and musculoskeletal system, its continuous activation is associated with breakdown in multiple systems which negatively affect mind, body and emotions.
"When we have a large scale event that we see as horrifying and threatening to our lives, our sympathetic nervous system is activated on a large scale," says Dr. Hickey. "We often think of this as a one time event, but such an event can result in a persistent or continual activation of the vast network of cells which make up the central and peripheral nervous system and affect the individual with PTSD at a global level. If the areas of the brain which react to fear are continually reactivated, other parts of the brain that are in charge of more logical thinking are shut down. So, someone with PTSD recognize things as dangerous or fearful, even if they are not. This reaction also shuts down parts of the brain which normally allow us to experience pleasure and reward, often resulting in high-risk behavior and use of drugs or alcohol in individuals experiencing PTSD. If we block all the factors perpetuating this experience, we allow the brain to be normalized, in theory."
NGF release has been shown to be increased following exposure to fear and trauma and is associated with increased growth of sympathetic nerve endings. At the stellate ganglion, NGF produces norepinephrine. "If you put a local anesthetic on the stellate ganglion, it reduces nerve growth factor and new growth dies off resulting in reduced levels of norepinephrine," says Dr. Lipov. This cascade of events has been shown in experiments with rats in the literature. Further, if NGF is reduced, new nerve growth dies off. "This is why we are able to get rid of the symptoms of menopause and PTSD with the stellate ganglion block."
Dr. Stedje-Larsen reviewed Dr. Lipov's data on using SGB therapy for PTSD and is optimistic about possibilities for the future. "This is a brand new therapy for PTSD and it's really research and time that will determine whether this is a revolutionary or evolutionary treatment for PTSD," he says. "We have a handful of case studies and reports, and much more vigorous research is needed to drill down into who would benefit most from this treatment. The initial results from this case series are very promising in regard to its use as a treatment for PTSD."
How the block is administered
When he understood how the block worked, Dr. Lipov realized it could be beneficial for patients with PTSD. SGB is traditionally administered as a blind injection to the C7 vertebrae with a local anesthetic dose of 10 to 15 cc. However, when Dr. Lipov performs the injection for PTSD patients, he uses fluoroscopy to guide his needle and injects the C6 vertebrae instead, which is further away from the lung and arteries in the neck and only 7 cc are used thus making the procedure safer. The physician can use less local anesthetic if he or she can visually guide the injection.
"The stellate ganglion is a headquarters for nerves of the sympathetic nervous system," says Dr. Stedje-Larsen. "There are certain points all along the body outside of the vertebral bodies with these collections; this makes it an attractive target for placing medicine because it also has extensions into key regions of the brain that have a part in PTSD."
The needle usually goes 1 ½ inches deep into the patient's body to reach the stellate ganglion. Once in the right position, a local anesthetic, such as ropivocaine, is released. The average follow-up for patients in the soon to be published Military Medicine study was 17 ½ days and the study showed that a substantial proportion of the patients experienced relief at least until that time.
Fellowship-trained anesthesiologists and interventional pain management physicians are the most qualified to administer the injection. To date, Dr. Lipov has treated around 50 patients, primarily veterans, suffering from PTSD with SGB and none of his patients have reported side effects yet. In addition to military members, the injections have successfully helped civilians with PTSD symptoms, such as women who have been traumatized due to violence such as sexual abuse.
What we know
From the few cases that have been performed, physicians can discern that SGB may help alleviate many of the symptoms of PTSD, pending appropriate treatment.
The first military member Dr. Lipov treated with PTSD was a veteran of Iraq who was threatening his wife's life even after going through standard therapy and medication management for his condition for several years. After receiving SGB, the patient did not experience any episodes of aggression associated with his PTSD for four months. At the four month mark, he began experiencing a resurgence of symptoms and underwent a second SGB injection. The second injection was administered more than three years ago and the patient hasn't reported any further symptoms related to PTSD since.
At this time, none of Dr. Lipov's patients have reported negative side effects from their SGB injections and most are able to experience relief for several months after one or two injections, he says.
Where the difference lies
Traditional treatment for PTSD is psychotherapy and medication management, which are both heavily dependent on patient compliance. Patients must motivate themselves to take their medications correctly and attend therapy or counseling sessions to reap any benefit from these treatments. However, SGB is an invasive injection performed by the physician requiring no ongoing treatment participation from patients themselves to experience relief.
"There is no other treatment for PTSD that is invasive, so SGB is unique in that respect," says Dr. Stedje-Larsen. PTSD symptoms typically fall into three different clusters — hyperarousal, avoidance and re-experiencing. SGB has been shown to have positive effects in reducing both hyperarousal and avoidance, meaning it can keep outside stimulus from reminding the patient of a traumatic event and thereby, helps the patient overcome the need to self-isolate. However, SGB doesn't keep people from re-experiencing the traumatic event, so the memory of the event still exists.
"SGB seems to be helping to reset the sympathetic nervous system that is responsible for symptoms of hyperarousal and avoidance," says Dr. Navaie. "After treatment, patients can maintain relationships with others and go to work as they did before the traumatic event. However, it doesn't erase their memories or eliminate the traumatic event."
Eliminating hyperarousal and avoidance symptoms could bridge the compliance gap many PTSD sufferers are currently experiencing with traditional treatments, even if SGB doesn't completely alleviate all symptoms.
"With hyperarousal and avoidance symptoms, many people don't want to engage in therapy or take medication and they become depressed," says Dr. Stedje-Larsen. "SGB may not be a silver bullet for curing PTSD, but it may be a catalyst for more effective standard treatment. I see SGB as an adjunct to other therapies — not a replacement."
Social and economic impact
If larger patient samples show SGB as an effective treatment for PTSD, the injection could have huge social and economic ramifications for the United States. The results of a RAND study suggest traditional PTSD treatment (therapy and medication) costs $6,000-$20,000 per veteran experiencing symptoms. Another book by an economics Nobel laureate suggests disability payment for veterans of the Iraq and Afghanistan conflicts could be close to $600 billion over the next 20 years without a significant change in treatment pathways.
"PTSD patients usually must take multiple pills and manage rather complex medication schedules, all of which can be emotionally taxing for someone who is already exhausted and challenged," says Dr. Navaie. "Psychotherapy also requires a lot from the patient — the patient usually has to drive to their therapist's office several times per week or month over an extended period of time. When you don't feel well and you want to isolate yourself, it becomes easy to see why many of these patients are non-compliant."
SGB injections cost $2,000-$3,000 per patient, which is far less than the costs currently associated with treating PTSD via standard therapies. Additionally, PTSD patients who received SGB are able to return to work and maintain a more economically productive lifestyle than they were living prior to the injection. Both of these factors could have a major impact on healthcare spending and quality of life for military veterans and other people suffering from PTSD.
"We hope this treatment is going to have huge ramifications for those suffering from PTSD and change the face of medicine," says Dr. Lipov. "SGB could knock down the cost of treatment, disability and time spent struggling with traditional treatments."
From a public health perspective, there are several advantages of SGB for PTSD. When people are unable to comply with traditional treatments for PTSD, there is an increased risk of suicide. "These patients have tried everything and given up hope," says Dr. Navaie. "With our new more passive treatment option, you have a five to 10 minute procedure which gives the patient symptom relief. In terms of patient compliance, SGB as the passive approach has the probability of succeeding in those patients who have failed to respond to methods requiring active participation."
There is also a social stigma associated with PTSD, which makes life more difficult for people who suffer from it. Since standard treatment includes therapy and taking medication, people have associated the disorder with mental disability. However, this new research and treatment offers a biologic treatment that eliminates the social stigma associated with treatment.
"When you say PTSD is the result of a biological cascade of events, people are more receptive to you," says Dr. Navaie. "Often, PTSD is under diagnosed because of the stigma associated with mental disorders. There is a significant under representation of the prevalence of the condition, but if we can offer a biologic explanation and a biologic treatment more people may benefit in the future."
Where research is headed
The study being published in Military Medicine in February is a great start, but the patient sample size is small and long-term outcomes associated with SGB treatment are still unknown. Physicians need to conduct further research on SGB's effects on PTSD symptoms and severity before we will fully understand how the injection will impact different patients. The most appropriate patient indications, long term impact and potential side effects of the injection are still relatively unknown and prevent many physicians from administering the injection for non-traditional indications.
"In this initial study, Dr. Lipov wasn't trying to determine the duration of the treatment; he just noted the effect," says Dr. Stedje-Larsen. "It would be interesting to get a larger cohort and see how long it lasts and how effective it is. We want to see whether we can build an effective treatment schedule and discover who would be the best candidate for the injection. However, this is a good first step and I am honored to have been a major contributor to it."
The best way to investigate the effectiveness of any treatment is following evidence- based guidelines with randomized, controlled clinical trials. At present, Dr. Hickey is involved in one such study funded by the U.S. Bureau of Medicine and Surgery analyzing the impact of SGB injections as compared to placebo injections for treating PTSD on active duty military service men and women through the Naval Medical Center at San Diego. "We are conducting the first prospective placebo controlled study comparing SGB to a placebo for PTSD," says Dr. Hickey. "We are using saline as the placebo and understand there is always the possibility for the placebo effect. We have a powerful ability to believe that something will make us better and create a spontaneous improvement or healing response. We want to see what the placebo effect is with SGB."
In the future, physicians and researchers pioneering SGB treatment for PTSD will analyze the study designs in existing literature and design stronger studies to create treatment protocols that guide best practices. "The medical community will be able to see that these results can be reliably reproduced based on based on sufficient numbers of patients at multiple sites having demonstrating a similar response to the treatment," says Dr. Hickey.
Related Articles on Pain Management:
8 Statistics on Pain Management Case Revenue by Number of Operating Rooms
5 Changes for Outpatient Anesthesia in 2012: Thoughts From Dr. Gilbert Drozdow
5 Ways to Safeguard Against Opioid Abuse and Diversion From Robert Saenz, CEO of Tulsa Pain Consultants
Eugene G. Lipov, MD, a Chicago-based anesthesiologist and pain management specialist who also volunteers as a consultant to the U.S. Navy, was the first physician nationally to pioneer administration of SGB to treat PTSD symptoms among veterans of the most recent conflicts in Iraq and Afghanistan. An article based on his research with a case series of patients will be published in the February 2012 edition of the military's top medical journal, Military Medicine. Co-authors on the study titled "A novel application of stellate ganglion block: preliminary observations for the treatment of post-traumatic stress disorder" include Dr. Lipov as well as Commander Eric T. Stedje-Larsen, MD, an anesthesiologist and pain management physician at Naval Medical Center San Diego (NMCSD) in San Diego who is currently deployed as the Officer in Charge of Fleet Surgical Team FIVE aboard the USS Makin Island; Captain Anita H. Hickey, MD, Director of Pain Research and Integrative Pain Medicine in the Department of
Anesthesiology at NMCSD; and Maryam Navaie, Dr.P.H., President and CEO of Advance Health Solutions in La Jolla, Calif.
The authors discuss SGB as a treatment for PTSD and how the new evidence could impact care for patients in the future.
Developing the treatment
The idea for treating PTSD with SGB came to Dr. Lipov after his brother (also a physician) suggested that hot flashes can be treated with the injection. Dr. Lipov and his brother published an article on his findings, however several criticisms of the treatment stymied further research. The negative criticisms focused on the lack of basic science knowledge about how and why the injection worked in patients with hot flashes; the critics said physicians shouldn't use the injection if they didn't know how it worked.
Dr. Lipov met that challenge and spent several months researching the mechanisms of the stellate ganglion and why the block might work. After reviewing more than 3,000 articles on the topic, he was able to explain the mechanics of SGB in a hypothetical paper. Essentially, after a patient goes through stress, such as right before menopause or a traumatic event, the nerve growth factor (NGF) increases (e.g., estrogen reduction leads to increases in NGF), resulting in increased levels of norepinephrine in the brain.
The stellate ganglion is part of the sympathetic nervous system which governs our "fight or flight" response. This response is activated with severe trauma or threat to one's self. PTSD is associated with severe traumatic events outside of the realm of what would be considered normal human experience. As the sympathetic nervous system controls blood flow to our brain, vital organs and musculoskeletal system, its continuous activation is associated with breakdown in multiple systems which negatively affect mind, body and emotions.
"When we have a large scale event that we see as horrifying and threatening to our lives, our sympathetic nervous system is activated on a large scale," says Dr. Hickey. "We often think of this as a one time event, but such an event can result in a persistent or continual activation of the vast network of cells which make up the central and peripheral nervous system and affect the individual with PTSD at a global level. If the areas of the brain which react to fear are continually reactivated, other parts of the brain that are in charge of more logical thinking are shut down. So, someone with PTSD recognize things as dangerous or fearful, even if they are not. This reaction also shuts down parts of the brain which normally allow us to experience pleasure and reward, often resulting in high-risk behavior and use of drugs or alcohol in individuals experiencing PTSD. If we block all the factors perpetuating this experience, we allow the brain to be normalized, in theory."
NGF release has been shown to be increased following exposure to fear and trauma and is associated with increased growth of sympathetic nerve endings. At the stellate ganglion, NGF produces norepinephrine. "If you put a local anesthetic on the stellate ganglion, it reduces nerve growth factor and new growth dies off resulting in reduced levels of norepinephrine," says Dr. Lipov. This cascade of events has been shown in experiments with rats in the literature. Further, if NGF is reduced, new nerve growth dies off. "This is why we are able to get rid of the symptoms of menopause and PTSD with the stellate ganglion block."
Dr. Stedje-Larsen reviewed Dr. Lipov's data on using SGB therapy for PTSD and is optimistic about possibilities for the future. "This is a brand new therapy for PTSD and it's really research and time that will determine whether this is a revolutionary or evolutionary treatment for PTSD," he says. "We have a handful of case studies and reports, and much more vigorous research is needed to drill down into who would benefit most from this treatment. The initial results from this case series are very promising in regard to its use as a treatment for PTSD."
How the block is administered
When he understood how the block worked, Dr. Lipov realized it could be beneficial for patients with PTSD. SGB is traditionally administered as a blind injection to the C7 vertebrae with a local anesthetic dose of 10 to 15 cc. However, when Dr. Lipov performs the injection for PTSD patients, he uses fluoroscopy to guide his needle and injects the C6 vertebrae instead, which is further away from the lung and arteries in the neck and only 7 cc are used thus making the procedure safer. The physician can use less local anesthetic if he or she can visually guide the injection.
"The stellate ganglion is a headquarters for nerves of the sympathetic nervous system," says Dr. Stedje-Larsen. "There are certain points all along the body outside of the vertebral bodies with these collections; this makes it an attractive target for placing medicine because it also has extensions into key regions of the brain that have a part in PTSD."
The needle usually goes 1 ½ inches deep into the patient's body to reach the stellate ganglion. Once in the right position, a local anesthetic, such as ropivocaine, is released. The average follow-up for patients in the soon to be published Military Medicine study was 17 ½ days and the study showed that a substantial proportion of the patients experienced relief at least until that time.
Fellowship-trained anesthesiologists and interventional pain management physicians are the most qualified to administer the injection. To date, Dr. Lipov has treated around 50 patients, primarily veterans, suffering from PTSD with SGB and none of his patients have reported side effects yet. In addition to military members, the injections have successfully helped civilians with PTSD symptoms, such as women who have been traumatized due to violence such as sexual abuse.
What we know
From the few cases that have been performed, physicians can discern that SGB may help alleviate many of the symptoms of PTSD, pending appropriate treatment.
The first military member Dr. Lipov treated with PTSD was a veteran of Iraq who was threatening his wife's life even after going through standard therapy and medication management for his condition for several years. After receiving SGB, the patient did not experience any episodes of aggression associated with his PTSD for four months. At the four month mark, he began experiencing a resurgence of symptoms and underwent a second SGB injection. The second injection was administered more than three years ago and the patient hasn't reported any further symptoms related to PTSD since.
At this time, none of Dr. Lipov's patients have reported negative side effects from their SGB injections and most are able to experience relief for several months after one or two injections, he says.
Where the difference lies
Traditional treatment for PTSD is psychotherapy and medication management, which are both heavily dependent on patient compliance. Patients must motivate themselves to take their medications correctly and attend therapy or counseling sessions to reap any benefit from these treatments. However, SGB is an invasive injection performed by the physician requiring no ongoing treatment participation from patients themselves to experience relief.
"There is no other treatment for PTSD that is invasive, so SGB is unique in that respect," says Dr. Stedje-Larsen. PTSD symptoms typically fall into three different clusters — hyperarousal, avoidance and re-experiencing. SGB has been shown to have positive effects in reducing both hyperarousal and avoidance, meaning it can keep outside stimulus from reminding the patient of a traumatic event and thereby, helps the patient overcome the need to self-isolate. However, SGB doesn't keep people from re-experiencing the traumatic event, so the memory of the event still exists.
"SGB seems to be helping to reset the sympathetic nervous system that is responsible for symptoms of hyperarousal and avoidance," says Dr. Navaie. "After treatment, patients can maintain relationships with others and go to work as they did before the traumatic event. However, it doesn't erase their memories or eliminate the traumatic event."
Eliminating hyperarousal and avoidance symptoms could bridge the compliance gap many PTSD sufferers are currently experiencing with traditional treatments, even if SGB doesn't completely alleviate all symptoms.
"With hyperarousal and avoidance symptoms, many people don't want to engage in therapy or take medication and they become depressed," says Dr. Stedje-Larsen. "SGB may not be a silver bullet for curing PTSD, but it may be a catalyst for more effective standard treatment. I see SGB as an adjunct to other therapies — not a replacement."
Social and economic impact
If larger patient samples show SGB as an effective treatment for PTSD, the injection could have huge social and economic ramifications for the United States. The results of a RAND study suggest traditional PTSD treatment (therapy and medication) costs $6,000-$20,000 per veteran experiencing symptoms. Another book by an economics Nobel laureate suggests disability payment for veterans of the Iraq and Afghanistan conflicts could be close to $600 billion over the next 20 years without a significant change in treatment pathways.
"PTSD patients usually must take multiple pills and manage rather complex medication schedules, all of which can be emotionally taxing for someone who is already exhausted and challenged," says Dr. Navaie. "Psychotherapy also requires a lot from the patient — the patient usually has to drive to their therapist's office several times per week or month over an extended period of time. When you don't feel well and you want to isolate yourself, it becomes easy to see why many of these patients are non-compliant."
SGB injections cost $2,000-$3,000 per patient, which is far less than the costs currently associated with treating PTSD via standard therapies. Additionally, PTSD patients who received SGB are able to return to work and maintain a more economically productive lifestyle than they were living prior to the injection. Both of these factors could have a major impact on healthcare spending and quality of life for military veterans and other people suffering from PTSD.
"We hope this treatment is going to have huge ramifications for those suffering from PTSD and change the face of medicine," says Dr. Lipov. "SGB could knock down the cost of treatment, disability and time spent struggling with traditional treatments."
From a public health perspective, there are several advantages of SGB for PTSD. When people are unable to comply with traditional treatments for PTSD, there is an increased risk of suicide. "These patients have tried everything and given up hope," says Dr. Navaie. "With our new more passive treatment option, you have a five to 10 minute procedure which gives the patient symptom relief. In terms of patient compliance, SGB as the passive approach has the probability of succeeding in those patients who have failed to respond to methods requiring active participation."
There is also a social stigma associated with PTSD, which makes life more difficult for people who suffer from it. Since standard treatment includes therapy and taking medication, people have associated the disorder with mental disability. However, this new research and treatment offers a biologic treatment that eliminates the social stigma associated with treatment.
"When you say PTSD is the result of a biological cascade of events, people are more receptive to you," says Dr. Navaie. "Often, PTSD is under diagnosed because of the stigma associated with mental disorders. There is a significant under representation of the prevalence of the condition, but if we can offer a biologic explanation and a biologic treatment more people may benefit in the future."
Where research is headed
The study being published in Military Medicine in February is a great start, but the patient sample size is small and long-term outcomes associated with SGB treatment are still unknown. Physicians need to conduct further research on SGB's effects on PTSD symptoms and severity before we will fully understand how the injection will impact different patients. The most appropriate patient indications, long term impact and potential side effects of the injection are still relatively unknown and prevent many physicians from administering the injection for non-traditional indications.
"In this initial study, Dr. Lipov wasn't trying to determine the duration of the treatment; he just noted the effect," says Dr. Stedje-Larsen. "It would be interesting to get a larger cohort and see how long it lasts and how effective it is. We want to see whether we can build an effective treatment schedule and discover who would be the best candidate for the injection. However, this is a good first step and I am honored to have been a major contributor to it."
The best way to investigate the effectiveness of any treatment is following evidence- based guidelines with randomized, controlled clinical trials. At present, Dr. Hickey is involved in one such study funded by the U.S. Bureau of Medicine and Surgery analyzing the impact of SGB injections as compared to placebo injections for treating PTSD on active duty military service men and women through the Naval Medical Center at San Diego. "We are conducting the first prospective placebo controlled study comparing SGB to a placebo for PTSD," says Dr. Hickey. "We are using saline as the placebo and understand there is always the possibility for the placebo effect. We have a powerful ability to believe that something will make us better and create a spontaneous improvement or healing response. We want to see what the placebo effect is with SGB."
In the future, physicians and researchers pioneering SGB treatment for PTSD will analyze the study designs in existing literature and design stronger studies to create treatment protocols that guide best practices. "The medical community will be able to see that these results can be reliably reproduced based on based on sufficient numbers of patients at multiple sites having demonstrating a similar response to the treatment," says Dr. Hickey.
Related Articles on Pain Management:
8 Statistics on Pain Management Case Revenue by Number of Operating Rooms
5 Changes for Outpatient Anesthesia in 2012: Thoughts From Dr. Gilbert Drozdow
5 Ways to Safeguard Against Opioid Abuse and Diversion From Robert Saenz, CEO of Tulsa Pain Consultants