American Society of Regional Anesthesia and Pain Medicine November 2017 - 56

To the Editor
Stellate Ganglion Block for Posttraumatic
Stress Disorder: A Call for the Complete
Story, and Continued Research
I read with interest the report of Hanling et al1 in the May issue of
the ASRA News "Stellate Ganglion Block for Posttraumatic Stress
Disorder: A Call for Clinical Caution and Continued Research." The
authors suggested in the report that stellate ganglion block (SGB)
lacks efficacy for the treatment of posttraumatic stress disorder
(PTSD). Essentially, the ASRA News article was a summary of a
2016 publication in Regional Anesthesia and Pain Medicine, where
the first randomized, blinded, sham-controlled study was performed
at the Naval Medical Center San Diego.2 The purpose of the current
communication is to clarify certain comments as to SGB use for
PTSD treatment.
From a historical perspective, we were the first to report the use of
SGB for treating PTSD in 2008.3 The following should be noted:
1. SGB should be performed on the right side to address
PTSD: "This is likely because initial case series happened
to be performed on the right side in the patients with pain
conditions."1 Actually, our 2010 article discussed SGB as
being performed by using right-sided preference and that this
was necessary because of the known right-sided amygdala
activation noted in PTSD4 as well as subsequent descriptions
by Alkire et al5 in 2015. Furthermore, SGB was used to treat
PTSD because of a rational prediction of the effect, based on
the work of Telaranta6 with endoscopic thoracic sympathectomy
used to treat anxiety and PTSD. The history of the evolution
of SGB as a viable treatment for PTSD was documented in a
2012 publication by our team in the peer-reviewed Journal of
Affective Disorder.7
2. "Correlation with current functional MRI (fMRI) studies has
not provided a convincing model to date."1 That is true;
however, no fMRI studies have been conducted to assess this
issue. Yet, neuroimaging studies have been done and were
published by Alkire et al5 in 2015. They used two separate
fluorodeoxyglucose positron-emission tomography (PET) brain
scans, the first prior to SGB and the second post SGB. PET is
considered by some as being more specific than fMRI for the
diagnosis of PTSD. The patients in the PET study were drawn
from the VA Long Beach Healthcare System in Long Beach,
California. The authors' conclusions were as follows: "SGB had
efficacy for significantly reducing PTSD symptoms in a rapid
and sustained manner."5 The right amygdala and hippocampal
areas appear to be relatively overactive when PTSD symptoms
are prominent and become deactivated following SGB.5 Alkire et
al5 used the Clinically Administered PTSD Scale (CAPS) as the
diagnostic and follow-up tool for PTSD (as did Hanling et al1 in
their study). On follow-up, Alkire et al5 were able to demonstrate

56

CAPS reduction that mirrored
right-sided amygdala
deactivation. The 2016 report
by Hanling et alx has recently
been evaluated by a Veterans
Administration evidencebased synthesis program.8
The determinations of this
synthesis are summarized
below.
The study essentially compared
Eugene Lipov, MD
ultrasound-guided SGB with 5 mL
Medical Director
of 0.5% ropivacaine to an inactive
Pain Clinic
sham SGB procedure performed
Department of Anesthesiology
with normal saline solution in 42
Illinois Masonic Medical Center
male military participants with
Chicago, Illinois
both combat and noncombat
PTSD. SGB was administered on
the right side of the neck, generally at the C6 level.8
Although in previous case series the most commonly used
anesthetic type and dosage have been 7 mL of ropivacaine or a
bupivacaine 0.5% solution, this trial used 0.5% ropivacaine, a
28% lower dose, and provided no rationale for doing so. Although
the stellate ganglion is typically located anatomically between
C6 and C7, the level of target needle placement was C5 to C6
in this study. 8 Although the study authors confirmed that the
injection was typically at C6, some could have been at C5 and
may have missed the stellate ganglion. 8 The use of saline instead
of an active control that mimicked the side effects of SGB was
potentially inadequate and may have reduced the effectiveness
of the blinding, as patients may have been able to easily tell if
they received local anesthetic SGB or the sham block, based
on the occurrence of the Horner's syndrome-expected ptosis.
Effectiveness of the blinding was not formally assessed. 8 Finally,
there were more active-duty participants in the SGB group (96%
vs 73%), attrition was high overall (57%)-primarily because
they were "lost to follow-up at 3 month post treatment or
completed outside of 3 month posttreatment window"-and was
higher in the SGB group (67% vs 40%), and the study did not
report on or account for potential between-group differences in
concurrent PTSD treatments. 8 "Because these findings come from
a single study with imprecise findings, moderate methodological
limitations, and did not directly focus on clinically relevant
outcomes or use the most commonly administration techniques
and anesthetics, they provide an insufficient basis upon which
to draw conclusions about SGB for the treatment of PTSD in
Veterans." 8 At the conclusion of the ASRA News article by Hanling
et al, 1 a question was raised as to why the results are so different
between the retrospective study by Mulvaney et al 9 in which 166
patients had marked improvement and the study conducted at

American Society of Regional Anesthesia and Pain Medicine
2017



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