American Society of Regional Anesthesia and Pain Medicine May 2017 - 10

Stellate Ganglion Block for Posttraumatic Stress Disorder:
A Call for Clinical Caution and Continued Research

A

53-year-old man, retired United
States Naval Officer with more
than five combat deployments in
support of special operations suffered
from posttraumatic stress disorder
(PTSD)-like symptoms for 12 years
before entering into the study protocol.
Initially, medications enabled him to
continue on active duty service; however,
upon retiring from the military, he noted
that his PTSD symptoms became more
apparent. Although he had received
Ian Fowler, MD, CDR, MC, USN
Robert Hackworth, MD
Steven Hanling, MD, CDR, MC, USN
standard of care mental health visits'
Director Pain Medicine Center &
Staff Pain Medicine Physician
Navy Pain Medicine Specialty
medications and group, family, and
Fellowship Program
and Anesthesiologist
Leader
individual counseling for PTSD, he
Staff Pain Medicine Physician
Staff Pain Medicine Physician
ultimately suffered what he called a
and Anesthesiologist
and Anesthesiologist
"nervous breakdown," resulting in
Naval Medical Center San Diego
self-medication with alcohol and social
San Diego, California
isolation from his wife and children. He
was formally diagnosed with PTSD in
Section Editor: Brian Harrington, MD
2010. In 2012 he heard about a study
for a rapid treatment for PTSD called the
stellate ganglion block (SGB) that could be performed in less than a While the Institute of Medicine seemingly downplays the role of
day. He subsequently sought out the treatment and entered into the medications, the Veteran Affairs/Department of Defense emphasizes
study protocol.
the use of medications in their clinical practice guidelines.
He described the procedure as very tolerable, especially in light
of his decreased symptoms, which he explained as a sense
of wellness and a lifting of his anxiety after treatment No. 1
(placebo). He noted that he felt the best he had in over a decade.
He continued to feel good about participating in the study after his
subsequent procedure (active SGB treatment) and noted similar, but
less dramatic, results as compared to the first procedure. In fact,
he felt so good that he was able to go on a trip with his family for
several weeks. During the trip he suffered a significant relapse of
symptoms that he described as rapid onset over the course of a
day. The patient notes that he would gladly undergo such a simple
procedure multiple times if he could continue to see the same
reduction in symptoms that he had with both injections.
It is estimated that 7 to 8 of 10 Americans will suffer from PTSD.
Military populations suffer PTSD at rates estimated at 11-15%
since Vietnam, Gulf War, and Operations Iraqi Freedom and Enduring
Freedom, and it is estimated to occur at up to rates of 35% if the
operational tempo seen in the last decade is maintained.1,2
Yet, current evidence-based PTSD therapies are not without
challenges and have limited reach and impact.3 Overall, existing
evidence-based treatments have a 30-40% success rate.4,5
However, existing treatment guidelines have often disagreed
on first-line therapy. For instance, there is disagreement on the
role that pharmacotherapy should play in the treatment of PTSD.

10
2

Regardless of the treatment guideline chosen, there is a sense that
patients have to overcome significant obstacles to receive current
evidenced-based treatment options. These obstacles include the
stigmata of seeking mental health care, profound pharmacological
side effects, and perhaps most insurmountable-the time
commitment of weeks, months, and even years necessary for
effective therapy.
This has led physicians to explore the potential benefits of
alternative therapies for improved clinical management of PTSD in
order to find more rapid treatments with longer durations of effect.
SGB case reports indicating immediate, dramatic, and sustained
benefit have led to widespread lay press endorsement of the
treatments, with reports appearing on Fox News, Time Magazine,
and endorsements by Oprah Winfrey. The idea that a one-time
SGB could cure PTSD has become so pervasive in society that the
authors' team has been approached by a Congressman and leaders
of military units requesting that their patients be flown to the
treatment facility in order to receive an SGB.
Although case reports are becoming more common, the block itself
has been around for decades and used primarily for indications
related to vascular and pain-related conditions. Side effects are
rare but can be catastrophic; these include rapid-onset seizures,
stroke, respiratory compromise secondary to phrenic and recurrent

American Society of Regional Anesthesia and Pain Medicine
2017



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