TORONTO ― Case reports are mounting of immediate, durable, and significant relief of severe refractory symptoms of posttraumatic stress disorder (PTSD), according to an anesthesiologist who has seen the benefits firsthand.
Stellate ganglion blockade (SGB) “seems to significantly improve PTSD symptoms as well as significantly reduce or eliminate suicidal ideation in patients with severe PTSD,” said Eugene Lipov, MD, of the Advanced Pain Center, Hoffman Estates, Illinois.
Case reports are “steadily growing,” he noted, with the total number of patients treated with SGB for PTSD in the literature now well more than 200, with success rates of “around 70%; adding clonidine pushes it into the 80% range.”
Here at the American Psychiatric (APA) Association 2015 Annual Meeting, Dr Lipov described three patients who were helped by SGB. All of them underwent a single rightsided SGB injection at the C6 level using 7 cc of local anesthetic under fluoroscopic guidance. PTSD symptoms were assessed using the PTSD Checklist–Military Version (PCL-M). Data on suicidal ideation were collected when available.
“A Changed Man”
The first patient was a soldier with severe PTSD who was severely suicidal for whom traditional therapy had failed. The patient experienced rapid and marked reduction in symptoms following SGB.
“This patient was treated with SGB and became nonsuicidal in 2 days following the procedure,” Dr Lipov said. His PCL-M score went from 71 (out of a maximum score of 85) before treatment to 54 1 day after treatment.
However, his symptoms returned 16 days later, and he received a second SGB, which has had a lasting effect. Four years later, his PCL-M was 29; he was “off all drugs, and his wife said he is a changed man,” Dr Lipov reported.
The second patient was a soldier who served in the military for 8 years as a truck driver. During two deployments to Iraq, he reported seeing burning and dismembered bodies.
He was admitted to the inpatient psychiatric ward four times for severe PTSD and suicidality. During his final stay, he scored 80 on the PCL-M. Two days following SGB, he was discharged from the ward, his PCL-M having dropped to 18 and his suicidal ideation having completely resolved, Dr Lipov noted. “He has since disappeared from the system.”
The third patient was “very interesting,” Dr Lipov said. He was blatantly suicidal but refused immediate inpatient care. An initial SGB failed. When SGB works, the clinical effect is often seen in less than 30 minutes, Dr Lipov explained. Not wanting to let the patient go for fear he would complete suicide, Dr Lipov said he opted to “switch techniques for this patient, and immediately did a C6 and C3 sequential block,” which led to “complete symptom relief.”
Rapid, Dramatic Response
Although Dr Lipov said he is encouraged by the effects he has seen, he cautioned that this is “still an unproven approach. Further work is needed to identify optimal patients for this treatment approach and to understand the mechanisms involved that can produce such a rapid, dramatic, and long-term change in psychological health for PTSD patients with suicidal ideation,” Dr Lipov told attendees.
It is hypothesized that trauma leads to an increase in nerve growth factor in the stellate ganglion. This in turn leads to a sprouting of sympathetic nerves, which increases the production of a number of neurotransmitters, including adrenaline and norepinephrine, which makes people anxious. SGB leads to a reduction in nerve growth factor and sprouting of sympathetic nerves, which helps reverse PTSD symptoms, Dr Lipov explained.
A literature review published in 2014 in the Journal of Anesthesia Clinical Research described 24 patients with severe, treatment-refractory PTSD who received SGB. Clinically meaningful improvement in symptoms of PTSD was observed in 18 of 24 patients (75%) after SGB.
However, not all the studies have been positive. Results of a randomized, controlled trial reported at the American Academy of Pain Medicine Annual Meeting in March found that SGB was not superior to sham block, as reported by Medscape Medical News at that time.
Retired Col. Elspeth Cameron Ritchie, MD, MPH, chief clinical officer, US Department of Mental Health, Government of the District of Columbia, who heard Dr Lipov’s presentation at APA 2015, said she is encouraged by the data on SGB for PTSD, but cautioned that “most of the data we have at the moment are anecdotal.”
“We don’t know who the block works for and why and how many doses it takes and all of that. But if you talk to patients who have gotten it, it’s really been lifesaving for some, so it really is something that needs to be explored further,” she commented.
The Department of Defense has earmarked $2 million for a three-center, double-blind, placebo-controlled trial of SGB in severe PTSD.
Dr Lipov and Dr Ritchie report no relevant financial relationships.
American Psychiatric Association (APA) 2015 Annual Meeting. Presented May 16, 2015.
MY COMMENT RE SHAM INJECTION
Dr. eugene lipov | Anesthesiology 6 hours ago
I believe clarification of the facts surrounding the sham / SGB study referred to above is in order . The study was done by Dr Robert McLay, He went on to say: “the most obvious explanation would be that the previously-reported benefits for PTSD were attributable to placebo effect”(1). The background for the use of SGB in treating PTSD is summarized below.
The published success rate of using SGB in treating PTSD is 75%, as reported in the literature has been, n=24, 75% (2), n=166 success rate of over 70% (3). Similar results have been show in 5 independent institutions. Walter Reed Military Hospital, Dr Mulvaney, et al (3), Tripler Army Hospital, Dr Alino et al (4), Long Beach, California Veterans Administration, Dr Alkire et al (5), Naval Medical Center San Diego, Dr Hickey A (6), Advanced Pain Centers, Dr Lipov (7).To date, over 1000 SGB have been done for PTSD with excellent safety and efficacy profile, consistent with the published results noted above. Thepatient population thatwasstudied byDr McLaymay have been sub optimalforthe study conductedsince many of the study patients are actively involved in medical board that determines their disability payments (8). In DrMcLay’s population patients had a financial incentive not to report improvement . DrMcLay’s study designmay have contributed to his conclusion, out side the population bias discussed above,that is notconsistentwith previousreports. Below is the summary of the design limitations ofDr McLay study .
1)The study did not use an active placebo , that is a compound that mimics the side effects of the active treatment (9). In this case Horner’s syndrome(ie, enophthalmos, ptosis, miosis, and heterochromia) the patient can easily tell if eye droop occurs or not . This makes blinding problematic since a patient can easily tell if the had a local anesthetic vs normal saline ( normal saline does not produce Horner’s syndrome )
2)Forty-two military service members with PTSD were randomized to receive SGB (n=27) or Sham injection (n=15). Due to a 2:1 ratio each placebo would be weighted twice as important vs SGB .( typically the study of this type is Phase 2 requiring 100 to300 participants that have the condition designed to treat ).
In conclusion, it is unfortunate, that a small study in a suboptimal population that has not gone through the peer review of a formal article( this was poster presentation ) , may prevent patients who may have a marked improvement in their PTSD symptoms from receiving SGB. Critical to note that the current PTSD therapies are succeeding at a rate below 30%, (10)The SGB efficacy should be judged by an adequately powered RCT study with a truly representative population, in fact this study is now funded and is in the process of being conducted.
1) McLay,R, Hanling, S, Drastal, CA, Adams, G, Hickey, A,(2015) “A Randomized, Double-Blind, Placebo-Controlled Trial of Stellate Ganglion Block in the Treatment of Post-Traumatic Stress Disorder “,Scientific Poster ,126, Presented at the 2015 AAPM Annual Meeting.
2) Navaie, M., Keefe, M. S., Hickey, A. H., McLay, R. N., & Ritchie, E. C. (2014). Use of Stellate Ganglion Block for Refractory Post-Traumatic Stress Disorder: A Review of Published Cases. J Anesth Clin Res, 5(403), 2.
3) Mulvaney, S. W., Lynch, J. H., Hickey, M. J., Rahman-Rawlins, T., Schroeder, M., Kane, S., & Lipov, E. (2014). Stellate Ganglion Block Used to Treat Symptoms Associated With Combat-Related Post-Traumatic Stress Disorder: A Case Series of 166 Patients. Military medicine, 179(10), 1133-1140.
4) Alino J, Kosatka D, McLean B, et al: 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: 473 -477
5). Alkire, M. T., Hollifield, M., Khoshsar, R.,et al . Prolonged Relief of Chronic Extreme PTSD and Depression Symptoms in Veterans Following a Stellate Ganglion Block. Presented at American Society of
Anesthesiology , October 11, 2014
6) Hickey A, Hanling S, Pevney E, Allen R, McLay RN. Stellate ganglion block for PTSD. Am J Psychiatry. 2012;169(7):760.
7) Lipov, Eugene G., Maryam Navaie, Peter R. Brown, Anita H. Hickey, Eric T. Stedje-Larsen, and Robert N. McLay. “Stellate ganglion block improves refractory post-traumatic stress disorder and associated memory dysfunction: a case report and systematic literature review.” Military medicine 178, no. 2 (2013): e260-e264.
8) Personal communication from a physician , the name is not disclosed due to possible career impact of this individual
9)Benedetti F. Placebo Effects , second edition, Oxford Print 2014 . Print .
10) Hoge CW . Interventions for war-related posttraumatic stress disorder: meeting veterans where they are. JAMA. 2001; 306: 549-551