American Society of Regional Anesthesia and Pain Medicine November 2017 - 57

the Naval Medical Center San Diego that did not do better than
placebo. One large difference is the population group that Hanling
et al 2,8 studied. The patients undergoing SGBs may have been
inappropriate for the study because most were in the process of
undergoing a disability evaluation and may have had secondary
financial incentives to resist treatment. 2,8 Marked improvement
in PTSD symptoms has been shown at five independent medical
institutions: Mulvaney et al 9 at Walter Reed Medical Center;
Alino et al 10 at Tripler Army Hospital; Alkire et al 5 at Long Beach,
California, Veterans Administration; Hicky et al 11 at the Naval
Medical Center San Diego; and Lipov et al 3,4 at the Advanced Pain
Centers. To date, more than 2,500 military personnel have been
treated with SGB with good to very good success (unpublished).
Hanling et al 1 went on to discuss potential rare but "catastrophic
risk" of SGB as one of the reasons SGB should not be used to
treat PTSD. Wulf and Maier 12 conducted a single, large study
of SGB risks in 1992 (pre ultrasound or fluoroscopic-guidance
era) in which 45,000 SGBs were performed. The incidence of
severe complications was 1.7 in 1,000 blockades. No fatalities
were reported. Most complications were related to the central
nervous system toxicity from rapid local anesthetic absorption
(ie, convulsions). 12 A high subarachnoid block was reported in
six cases, high epidural blockade in three, pneumothorax in
nine, and allergic reactions in two patients. 12 It is likely that in
the current ultrasound and/or fluoroscopic guidance era, where
imaging is widely accepted as being a standard of care, further
reductions will occur in reported complications. Given the known
suicide risk associated with PTSD of 22 per day, 13 a possible
complication rate of 1.7 out of 1,000 pales by comparison
(0.17%). Furthermore, PTSD symptoms are positively correlated
with suicide risk. 14 Finally, SGB has been reported to impact
suicidal ideation. 10,15
In summary, I believe that the randomized controlled trial by
Hanling et al 2 should not prevent practitioners from offering
SGB as a valued and safe treatment for PTSD. A well-powered
study is being conducted in three sites at Womack Army Medical
Center, with disability evaluation patients excluded for reasons
associated with secondary gain issues. One of the limitations
of the current study is the lack of fMRI response monitoring.
Veterans Administration evidence-based synthesis program
recommends an fMRI evaluation in a study where SGB is used to
treat PTSD symptoms. 8

REFERENCES
1.

Hanling S, Fowler I, Hackworth R. Stellate ganglion block for posttraumatic
stress disorder: a call for clinical caution and continued research. ASRA News.
May 2017;10-14.

2.

Hanling SR, Hickey A, Lesnik I, et al. Stellate ganglion block for the treatment of
posttraumatic stress disorder: a randomized, double-blind, controlled trial. Reg
Anesth Pain Med 2016;41(4):494-500. doi: 10.1097/AAP.0000000000000402.

3.

Lipov EG, Joshi JR, Lipov, Sanders SE, Siroko MK. Cervical sympathetic
blockade in a patient with post-traumatic stress disorder: a case report. Ann
Clin Psychiatry 2008;20(4):227-228. doi: 10.1080/10401230802435518.

4.

Lipov E. Successful use of stellate ganglion block and pulsed radiofrequency
in the treatment of posttraumatic stress disorder: a case report. Pain Res Treat
2010;2010:963948. doi: 10.1155/2010/963948.

5.

Alkire MT, Hollifield M, Khoshsar R, Nguyen L, Alley S, Reis, C. Neuroimaging
suggests that stellate ganglion block improves post-traumatic stress disorder
(PTSD) through an amygdala mediated mechanism. Paper presented at:
Anesthesiology 2015 Annual Meeting; October 24, 2015; San Diego, CA.
Available at: http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;js
essionid=0CAC170518A556F620F2245A983B8314?year=2015&index=5&absn
um=3003. Accessed September 3, 2017.

6.

Telaranta T. Treatment of social phobia by endoscopic thoracic sympathectomy.
Eur J Surg 1998;164(S1):27-32.

7.

Lipov E, Kelzenberg B. Sympathetic system modulation to treat post-traumatic
stress disorder (PTSD): a review of clinical evidence and neurobiology. J Affect
Disord 2012;142(1-3):1-5. doi: 10.1016/j.jad.2012.04.011.

8.

Center C, Peterson K, Bourne D, Anderson J, Mackey K, Helfan, M. Evidence
Brief: Effectiveness of Stellate Ganglion Block for Treatment of Posttraumatic
Stress Disorder (PTSD). Washington, DC: Department of Veterans Affairs; 2017.

9.

Mulvaney SW, Lynch JH, et al. Stellate ganglion block used to treat symptoms
associated with combat-related post-traumatic stress disorder: a case
series of 166 patients. Mil Med 2014;179(10):1133-1140. doi: 10.7205/
MILMED-D-14-00151.

10. Alino J, Kosatka D, McLean B, Hirsch K. Efficacy of stellate ganglion block
in the treatment of anxiety symptoms from combat-related post-traumatic
stress disorder: a case series. Mil Med 2013;178(4):e473-e476. doi: 10.7205/
MILMED-D-12-00386.
11. Hicky A, Hanling, S, Pevney E, Allen R, McLay RN. Stellate ganglion block for
PTSD. Am J Psychiatry 2012;169(7):760. doi: 10.1176/appi.ajp.2012.1111172.
12. Wulf H, Maier C. Complications and side effects of stellate ganglion blockade:
results of a questionnaire survey. Anaesthesist 1992;41(3):146-151.
13. Kemp J, Bossarte R. Suicide Data Report: 2012. Washington, DC: Department of
Veterans Affairs, Mental Health Services, Suicide Prevention Program; 2013.
14. McKinney JM, Hirsch JK, Britton PC. PTSD symptoms and suicide risk in
veterans: serial indirect effects via depression and anger. J Affect Disord
2017;214:100-107. doi: 10.1016/j.jad.2017.03.008.
15. Lipov E. Marked impact on suicidal ideation and suicidology in a military
populations following a cervical sympathetic blockade. In: Guide to the 2015
Annual Meeting: Integrating Body and Mind, Heart and Soul; May 14, 2015;
Toronto, Canada. Abstract 802.

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