Select SGB Scientific Articles

Stellate ganglion block used to treat symptoms associated with combat-related post-traumatic stress disorder: a case series of 166 patients

ABSTRACT

Objective: Report the successful use of stellate ganglion blocks (SGBs) in 166 active duty service members with multiple combat deployments experiencing anxiety symptoms associated with post-traumatic stress disorder (PTSD).

Background: Successful treatment of PTSD symptoms with SGB has been reported previously. This is the largest published case series evaluating SGB with a minimum of 3 months follow-up.

Methods: Following clinical interview including administration of the PTSD Checklist (PCL), 166 service members with symptoms of PTSD elected to receive a SGB. All patients received a SGB on the right side at the level of the sixth cervical vertebrae (C6). The PCL was administered the day before treatment to establish a baseline, repeated 1 week later, and then monthly out to 3 months. A positive response was considered to be an improvement in the PCL score by 10 or greater points. Follow-up PCL scores from 3 to 6 months were obtained and analyzed for 166 patients.

Results: In a military population with multiple combat deployments, over 70% of the patients treated had a clinically significant improvement in their PCL score which persisted beyond 3 to 6 months postprocedure.

Conclusion: Selective blockade of the right cervical sympathetic chain at the C6 level is a safe and minimally invasive procedure that may provide durable relief from anxiety symptoms associated with PTSD.

A Review of the Use of Stellate Ganglion Block in the Treatment of PTSD

ABSTRACT

Current treatments for PTSD are often not effective or acceptable to the patient. There are a number of emerging new treatments. One promising new one is stellate ganglion block, an anesthetic treatment for pain which relieves symp- toms of severe and chronic PTSD in some patients. The focus of this chapter is to summarize clinical evidence available for the effectiveness of cervical sympathetic ganglion injection called stellate ganglion block (SGB), as well as demonstrate possible clinical applications of its use. Cervical sympathetic blockade involves injecting a local anesthetic next to a group of nerves (ganglion) in the neck. The technique has been used clinically since 1925 with very few side effects. Finally, the neurobiology of SGB is discussed. Challenges to the use of SGB include the lack of randomized clinical trials and practitioners familiar with the use of SGB for PTSD.

Effect of Stellate Ganglion Block Treatment on Posttraumatic Stress Disorder Symptoms: A Randomized Clinical Trial

ABSTRACT

Importance  This is the first multisite, randomized clinical trial of stellate ganglion block (SGB) outcomes on posttraumatic stress disorder (PTSD) symptoms.

Objective  To determine whether paired SGB treatments at 0 and 2 weeks would result in improvement in mean Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) total symptom severity scores from baseline to 8 weeks.

Design, Setting, and Participants  This multisite, blinded, sham-procedure, randomized clinical trial used a 2:1 SGB:sham ratio and was conducted from May 2016 through March 2018 in 3 US Army Interdisciplinary Pain Management Centers. Only physicians performing the procedures and the procedure nurses were aware of the intervention (but not the participants or assessors); their interactions with the participants were scripted and limited to the 2 interventions. Active-duty service members on stable psychotropic medication dosages who had a PTSD Checklist–Civilian Version (PCL-C) score of 32 or more at screening were included. Key exclusion criteria included a prior SGB treatment, selected psychiatric disorders or substance use disorders, moderate or severe traumatic brain injury, or suicidal ideation in the prior 2 months.

Interventions  Paired right-sided SGB or sham procedures at weeks 0 and 2.

Main Outcomes and Measures  Improvement of 10 or more points on mean CAPS-5 total symptom severity scores from baseline to 8 weeks, adjusted for site and baseline total symptom severity scores (planned a priori).

Results  Of 190 screened individuals, 113 (59.5%; 100 male and 13 female participants; mean [SD] age, 37.3 [6.7] years) were eligible and randomized (74 to SGB and 39 to sham treatment), and 108 (95.6% of 113) completed the study. Baseline characteristics were similar in the SGB and sham treatment groups, with mean (SD) CAPS-5 scores of 37.6 (11.2) and 39.8 (14.4), respectively (on a scale of 0-80); 91 (80.0%) met CAPS-5 PTSD criteria. In an intent-to-treat analysis, adjusted mean total symptom severity score change was −12.6 points (95% CI, −15.5 to −9.7 points) for the group receiving SGB treatments, compared with −6.1 points (95% CI, −9.8 to −2.3 points) for those receiving sham treatment (P = .01).

Conclusions and Relevance  In this trial of active-duty service members with PTSD symptoms (at a clinical threshold and subthreshold), 2 SGB treatments 2 weeks apart were effective in reducing CAPS-5 total symptom severity scores over 8 weeks. The mild-moderate baseline level of PTSD symptom severity and short follow-up time limit the generalizability of these findings, but the study suggests that SGB merits further trials as a PTSD treatment adjunct.

Cervical Sympathetic Blockade Produces a Significant Reduction in Suicidal Ideation in a PTSD Cohort: A Case Series of 254 Patients

ABSTRACT

Background: Suicide is estimated to account for 1.4% of deaths worldwide, making it among one the leading causes of premature death. Stellate ganglion block (SGB) has been shown to reduce suicidal ideation in a single case report of a patient with comorbid post-traumatic stress disorder (PTSD) and suicidal ideation.

Aims: To report a significant reduction of suicidal ideation using cervical sympathetic block (CSB), a more advanced version of SGB, in a cohort of patients with PTSD.

Methods: 254 patients were evaluated for suicidal ideation via pre- and post-suicide risk assessments by using the Depressive Symptom Index - Suicidality Subscale (DSI-SS) as part of a pre- and post-treatment clinical interview. Further included were other psychiatric measures. Patients received CSB as per clinic protocol. Results: Overall, the patients had an average DSI-SS reduction of 43.8%, PCL-5 reduction of 31.7%, GAD-7 reduction of 22.5%, and PHQ-9 reduction of 35.5%, following CSB.

Limitations: Lack of control, given this is an open-labeled, case series study.

Conclusion: Cervical sympathetic block is a safe and minimally invasive procedure that may provide significant reduction in suicidal ideation as well as symptoms of PTSD.

Comparison C6 Stellate Ganglion versus C6 and C4 Cervical Sympathetic Chain Blocks for Treatment of Posttraumatic Stress Disorder (PTSD): Analysis of 147 Patients

Abstract

Objective: Determine whether a two-level cervical sympathetic chain block may be more effective than a standard C6 level stellate ganglion block (SGB) for the treatment of posttraumatic stress disorder (PTSD).

Background: A right-sided SGB has many medical publications supporting its safety and efficacy for the treatment of PTSD. However, in clinical practice, some patients do not respond to a C6 level SGB as anticipated. Currently, there are no published reports describing a two-level sympathetic block (2LSB) as a treatment modality. Thus, the purpose of this investigation is to initially assess safety and efficacy of this novel procedure as compared to the standard procedure.

Methods: The PTSD Checklist (PCL-5) is routinely collected for patients prior to SGB or 2LSB for PTSD. We retrospectively evaluated baseline (T0) and 4 weeks (T1) PCL-5 scores in post-SGB/2LSB in our center.

Results: One-hundred and forty-seven of 328 consecutive subjects underwent SGB (group 1) or 2LCB (group 2), in 51 females 96 males, (17 to 75 years). The mean improvement in PCL-5 scores at T1 for the SGB was 25.2 (20.40246-29.84997 CI 95%) (p<0.001) (N = 103) and 2LSB was 31.78 (26.05481- 37.49065 CI 95%) (p<0.001) (N = 44). Although the improvement was greater in group 2, there was no significant difference between group 1 and 2 at T1. There were no adverse events or complications reported in either group.

Conclusions: Single SGB and 2LSB were both effective in treating PTSD. A 2LSB is safe and may be more effective than a standard SGB in the treatment of PTSD. Further research on this treatment modality is required before conclusions on the effectiveness of a 2LSB for the treatment of PTSD symptoms can be made.

The Successful Use of Left-sided Stellate Ganglion Block in Patients That Fail to Respond to Right-sided Stellate Ganglion Block for the Treatment of Post-traumatic Stress Disorder Symptoms: A Retrospective Analysis of 205 Patients

Abstract

Introduction: Ultrasound-guided stellate ganglion block (SGB) is an injection of local anesthetic (8mL of 0.5% ropivacaine) in the neck to temporarily block the cervical sympathetic trunk which controls the body's fight-or-flight response. This outpatient procedure takes less than thirty minutes and is immediately effective. Our goal was to determine if a left-sided stellate ganglion block is effective for treating posttraumatic stress disorder (PTSD) symptoms. While right-sided SGB has been extensively studied, left-sided SGB has not been formally evaluated for this indication.

Materials and methods: Our hypothesis was that patients who fail to improve following a right-sided SGB will report significant improvement following a left-sided SGB. A retrospective chart review was conducted for patients who received SGB for PTSD symptoms between August 2019 and March 2020. All procedures were performed at an established musculoskeletal practice by the same anesthesia/pain fellowship-trained physician. Subjects included those who underwent a left-sided SGB (LSGB) only after non-response to a right-sided SGB (RSGB). Non-response was defined as less than 10 points of improvement on a PTSD Checklist (PCL-5).

Results: Out of 205 patients, 20 did not respond to an RSGB and were included in our analysis. Ten of these patients subsequently received an LSGB, and 90% responded favorably (PCL-5 mean improvement = 28.3 points).

Conclusions: Based on our sample of 205 patients receiving SGB for PTSD, we concluded that at least 4.4% did not respond to a right-sided SGB but did have a significant response to a left-sided SGB.

Utility of Cervical Sympathetic Block in Treating Post-Traumatic Stress Disorder in Multiple Cohorts: A Retrospective Analysis

Background: Post-traumatic stress disorder (PTSD) is a prevalent and debilitating condition in the United States. Success rates for evidence-based therapies are inconsistent, and many suffer in silence due to the stigmata associated with seeking traditional mental health care. This has led clinicians to explore new therapeutic options, with cervical sympathetic blockade (CSB), performed at the stellate and/or superior cervical ganglion levels, recently emerging as a promising treatment option. Rapid therapeutic onset, improved compliance, and high clinical efficacy rates have made this an attractive approach for both providers and patients. However, to date, CSB as a treatment of PTSD has primarily been used in male patients with military-related trauma.

Objective: To evaluate the efficacy of CSB as a treatment option for PTSD in both genders and multiple etiologies of psychological trauma.

Study Design: Retrospective cohort study.

Setting: An established anesthesia pain clinic in Chicago, IL, USA.

Methods: Following retroactive IRB approval, 484 consecutive cases of patients diagnosed with PTSD and treated with CSB, performed by a single provider (December 2016 – February 2020) were analyzed. The primary outcome measurement was the PTSD Checklist Score version DSM IV (PCL-4). Patient demographic and clinical information collected included age, gender, type of trauma leading to PTSD, history of suicidal attempts, and psychiatric medication use.

Results: After exclusion of cases due to missing data points, 327 patients were included in the final statistical analysis, having completed both PCL-4 pre and post CSB, between 7- and 30-days post- intervention. The patient population included military men (n = 97), civilian men (n = 85), military women (n = 13) and civilian women (n = 132). We identified 21 types of self-reported trauma leading to PTSD. Average decrease in PCL score for men and women was 28.59 and 29.2, respectively. Statistical analysis of the male population with a military background showed a significantly greater change in corresponding PCL scores than civilians (PCL-M change = -31.83 vs PCL-C change = -24.89). Likewise, women who had a military background had a significantly greater reduction in PCL score than civilians (39.15 vs 28.23). Statistically significant improvements in PTSD symptoms were noted independent of the causative trauma type, gender, age greater than 20, previous suicide attempts, or use of prescription medications for PTSD. Among the 21 types of reported trauma, 19 types reached statistical significance.

Limitations: Limitations include the limited scope of observation giving exclusive focus on pre- and post-PCL data, the limited duration of observation, the self-reported nature of the patient-provided data, and the provision of treatment by a single physician.

Conclusion: CSB seems to be an effective treatment for PTSD symptoms irrespective of gender, trauma type, PTSD-related drug use, suicide attempt, or age.

Effect of Stellate Ganglion Block on Specific Symptom Clusters for Treatment of Post-Traumatic Stress Disorder

Abstract

This study assessed which symptoms are most impacted following stellate ganglion block (SGB) used to treat post-traumatic stress disorder (PTSD) symptoms. 30 active military service members with combat-related PTSD self-referred to their physician and psychologist. Patients were offered a SGB as part of their treatment program. Primary outcome was the magnitude of change for the 17 items on the PTSD Checklist-Military (PCL-M), which was administered the week before SGB, 1 week after SGB, and 2 to 4 months later. Mean PCL-M score decreased from 49 at baseline to 32, 1 week after the procedure (p < 0.001). 2 to 4 months after SGB, patients maintained an average PCL-M of 32. Patients reported greatest improvement in the first week after SGB for the following symptoms: irritability or angry outbursts, difficulty concentrating, and sleep disturbance. 2 to 4 months later, patients reported greatest improvement in the following: feeling distant or cut off, feeling emotionally numb, irritability or angry outbursts, and difficulty concentrating. SGB is a safe procedure that may provide extended relief for all clusters of PTSD symptoms. As a result of the significant reduction in hyperarousal and avoidance symptoms observed, this study supports incorporation of SGB into PTSD treatment plans.

The Effect of Bilateral, Two-Level Cervical Sympathetic Chain Blocks on Specific Symptom Clusters for Traumatic Brain Injury, Independent of Concomitant PTSD Symptoms

Abstract

Background/Objectives: The aim of this study was to determine if performing ultrasound-guided, bilateral, two-level cervical sympathetic chain blocks (2LCSBs) (performed on subsequent days) improves symptoms associated with traumatic brain injury (TBI) that do not overlap with posttraumatic stress disorder (PTSD).

Methods: A retrospective chart review was conducted between August 2022 and February 2023. We identified twenty patients who received bilateral 2LCSBs for PTSD and anxiety symptoms and who also had a history of TBI. Neurobehavioral Symptom Inventory (NSI) scores were collected at baseline, one week, and one month post treatment in 13 males and 7 females. A sub-analysis of the first ten questions of the NSI, which we identified as not overlapping with PTSD or anxiety symptoms, generated an NSI sub-score.

Results: Out of 20 patients, all showed improvement in their NSI scores and NSI sub-scores. The NSI sub-scores had a baseline average of 15.45 (on a 40-point scale); the average score at one week post treatment was 8.30; and that at one month post treatment was 7.80. This represents a 49.51% improvement in TBI symptoms which did not overlap with PTSD or anxiety symptoms between baseline and one month.

Conclusions: The use of bilateral 2LCSBs may be helpful in treating patients with TBI, regardless of the presence of comorbid PTSD symptoms.

Efficacy of combined subanesthetic ketamine infusion and cervical sympathetic blockade as a symptomatic treatment of PTSD/TBI in a special forces patient with a 1-year follow-up: A case report

Abstract

Co-occurrence of posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) symptoms are particularly prevalent in the special operations forces' community, along with other related conditions (e.g., endocrine dysregulation, sleep disorders, chronic pain). Ketamine infusion (KI) has been shown to increase neuroplasticity as well as memory improvement and cervical sympathetic block (CSB) has been shown to improve cognitive function, reduce sympathetic overactivity, and improve other symptoms of PTSD. We want to report the efficacious use of a single intervention consisting of bilateral CSB technique with subanesthetic KI X5 in a Special Operations Forces patient, diagnosed with PTSD with comorbid TBI, evaluated during treatment and at 1-year follow-up. We postulated KI and CSB would have a synergistic effect. Our patient received KI starting at 0.5 mg/kg, which was escalated daily. KI was combined with right-sided ultrasound-guided CSB (C6 and C4 levels). This was followed the next day by left-sided CSB and KI. Patient's PTSD symptoms were evaluated using the Posttraumatic Stress Disorder Checklist (PCL-5), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), suicidal ideation and other related factors by Concise Health Risk Tracking Self Report (CHRTSR). All measures were assessed prior to treatment, during treatment, and 394 days after. KI combined with CSB showed immediate and prolonged benefits 394 days later regarding the symptoms of PTSD, anxiety, depression, suicidal ideation, and cognitive deterioration (patient report). KI combined with CSB can markedly reduce symptoms of PTSD, psychiatric comorbidities, and cognitive dysfunction.

A Review of Stellate Ganglion Block as an Adjunctive Treatment Modality

ABSTRACT

Peripheral nerve blocks are becoming increasingly used as adjunctive treatment modalities for a variety of conditions refractory to medical management. Right or left stellate ganglion blocks (SGB) are a specific type of peripheral nerve block that target the sympathetic blockade of neuronal impulses using the injection of local anesthetic and steroids into nerve bundles in the cervical area.

This review article is intended to summarize the common uses of stellate ganglion blocks and explain the procedural technique, which has evolved with technological advances in ultrasonography. The similarities between these disease processes are centered around sympathetic hyperactivity. This sympathetic overdrive state is created by increased levels of nerve growth factor (NGF), which causes a cascade of sympathetic sprouting resulting in increased norepinephrine (NE) systemically. Reversal of this cascade by local anesthetic injection into the stellate ganglion thereby reduces NGF and sympathetic sprouting subsequently lowering overall norepinephrine levels. This is the unifying theory by which SGB is able to provide resolution for the varied clinical conditions described in this article.

This review article discusses the physiology of several conditions where stellate ganglion blocks are being investigated as an adjunct treatment modality, including anosmia, PTSD, long-COVID, chronic fatigue syndrome, menopausal hot flashes, and ventricular tachyarrhythmias. Overall, the current literature supporting the use of stellate ganglion blocks for several esoteric conditions is limited; however, case reports to date have shown promising evidence-based results supporting their use as an adjunctive treatment among patients with refractory symptoms to existing treatment algorithms.

In conclusion, SGB should be considered among patients with refractory symptoms for medical management in the conditions discussed in this article. Further research is needed to delineate which patients will benefit from the use of SGB, the use of subsequent blocks and timelines in between injections, and unilateral versus bilateral blockade.

Stellate Ganglion Block for Long COVID Symptom Management: A Case Report

ABSTRACT

Stellate ganglion block (SGB) is gaining increasing acceptance as a treatment modality for various medical conditions. It works by blocking neuronal transmissions which in turn alleviates sympathetically-driven disease processes. Many of the prolonged sequelae of long COVID are thought to be mediated by dysregulation of the autonomic nervous system, and SGB is being investigated as a potential option for symptomatic management of long COVID. This case report demonstrates the efficacy of SGB in a previously healthy patient for the management of long COVID symptoms including fatigue, post-exertional malaise, shortness of breath, and gastrointestinal symptoms.

Stellate Ganglion Block for Anosmia and Dysgeusia Due to Long COVID

ABSTRACT

Anosmia and parosmia refer to the loss or dysfunction of smell, respectively. Dysgeusia refers to taste disturbance. The coronavirus disease 2019 (COVID-19) pandemic and the subsequent phenomenon of Long COVID syndrome have been associated with an increased incidence of anosmia and dysgeusia. Smell and taste disturbances associated with COVID-19 are usually self-limiting but can persist for longer periods in some cases. Imbalances of the autonomic nervous system, especially dysregulation of the sympathetic system, are implicated in the persistence of anosmia and dysgeusia post-COVID-19 infection. Stellate ganglion block (SGB) can diminish the increased sympathetic activity and potentially resolve anosmia and dysgeusia occurring due to Long COVID. The authors report the successful resolution of persistent anosmia and dysgeusia due to Long COVID in a female patient after she underwent SGB.

Stellate Ganglion Block Reduces Anxiety Symptoms by Half: A Case Series of 285 Patients

ABSTRACT

Stellate ganglion block (SGB) is a procedure involving the injection of a local anesthetic surrounding the stellate ganglion to inhibit sympathetic outflow. The objective of this review was to summarize existing evidence on the use of SGB in adults with psychiatric disorders. A systematic search identified 17 published studies and 4 registered clinical trials. Eighty-eight percent of published studies, including 2 randomized controlled trials (RCTs), used SGB for posttraumatic stress disorder (PTSD), although its use for schizophrenia spectrum disorders was also explored. Administration of 1 to 2 SGBs using right-sided laterality with 0.5% ropivacaine was most common. Preliminary evidence from clinical trials and case studies supports the feasibility of SGB for treating psychiatric disorders involving dysregulation of the sympathetic nervous system, although effectiveness evidence from RCTs is mixed. One RCT concluded that improvement in PTSD symptoms was significant, while the other concluded that it was nonsignificant. Improvements were noted within 5 minutes of SGB and lasted 1 month or longer. Registered clinical trials are exploring the use of SGB in new psychiatric disorders, including major depressive disorder and borderline personality disorder. More studies with larger sample sizes and alternate protocols are needed to further explore therapeutic potential of SGB for psychiatric disorders.

Efficacy and safety of stellate ganglion block with different volumes of ropivacaine to improve sleep quality in patients with insomnia: a comparative study

ABSTRACT

OBJECTIVE: The aim of this study was to compare the efficacy and safety of ultrasound-guided stellate ganglion block (SGB) with different volumes of 0.375% ropivacaine on sleep quality in patients with insomnia.

PATIENTS AND METHODS: A total of 80 patients who were selected to undergo SGB for the treatment of insomnia were enrolled. The patients were divided into saline control group, and low-volume (4 mL), medium-volume (6 mL), and high-volume (8 mL) ropivacaine injection groups according to the random table method. The treatment included 7 blocks with once every three days. The left and right stellate ganglions are alternately blocked. The onset and maintenance time of Horner syndrome, the degree of carotid artery dilation and blood flow velocity before and 20 minutes after the first block, the occurrence of complications such as drug crossing of the midline of the artery and hoarse throat were recorded, and the improvement of sleep disorders was evaluated with the Pittsburgh Sleep Quality Index Scale.

RESULTS: Horner syndrome occurred in 100% of all volumes of ropivacaine block. The ipsilateral internal carotid artery was dilated and was accompanied by increased blood flow. The degree of dilation and increase in blood flow were not affected by the volumes of drug injection. There were no serious complications in any group, but the incidences of hoarseness and dysphagia were higher in the medium- and high-volume groups than those in the low-volume group (all p < 0.05). Compared with the low- and medium-volume groups, the high-volume group had a faster onset of action, longer maintenance time, and the highest chance of the drug crossing the artery (all p < 0.05). Compared to those before the pre-block and in the control groups, insomnia was improved in all volume groups after the block with nonsignificant intergroup differences.

CONCLUSIONS: 4 mL of 0.375% ropivacaine for ultrasound-guided SGB is sufficient to improve the sleep quality of insomnia patients, whose overall risk is lower than block with 6 mL or 8 mL of ropivacaine.