Use of Stellate Ganglion Block to Treat Post-Traumatic Stress Disorder (PTSD)

Use of Stellate Ganglion Block

to Treat Post-Traumatic Stress

Disorder (PTSD)

Jennifer Hodge, BSN, RN, CCRN, SRNA Duke Nurse Anesthesia Program

Objectives:

• Define Post-Traumatic Stress Disorder (PTSD) and understand diagnostic criteria of this disorder.

• Understand the prevalence of PTSD in the current population.

• Discuss current pharmacological treatments for PTSD and their downfalls.

• Correctly identify the anatomy of Stellate Ganglion. • Understand the theory and mechanism of action

explaining how the stellate ganglion block can treat PTSD.

What is PTSD?

• Military Combat/War • Violent personal assault

• Physical attack, mugging, rape, robbery, kidnapping

• Terrorist attacks

• 9/11, Oklahoma bombing, World Trade Center Bombing, random public shootings

• Severe accidents • Natural disasters

• Tsunami, earthquake, hurricane

PTSD is a debilitating psychological

condition triggered by a major traumatic

event.

Some History…

PTSD Diagnosis

• Adults, adolescents, and children older than six years.

• Multiple criteria must be met to receive diagnosis

• Symptoms grouped into four different categories

Criterion A:

Stressor

The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or

threatened sexual violence, as follows: (one required)

• Direct exposure

• Witnessing (in person)

• Indirectly, by learning that a close relative or friend was exposed to trauma or death

• Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of

Criterion B:

Intrusion Symptoms

The traumatic event is persistently re-experienced in the following way(s): (one required)

• Recurrent, involuntary, and intrusive memories.

• Traumatic nightmares.

• Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to

complete loss of consciousness.

• Intense or prolonged distress after exposure to traumatic reminders.

• Marked physiologic reactivity after exposure to trauma-related stimuli.

Criterion C: Avoidance

Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required)

• Trauma-related thoughts or feelings.

• Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

Criterion D:

Negative Alterations in Cognition and Mood

began or worsened after the traumatic event: (two required)

• Inability to recall key features of the traumatic event • Persistent (and often distorted) negative beliefs and

expectations about oneself or the world

• Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences

• Persistent negative trauma-related emotions

• Markedly diminished interest in (pre-traumatic) significant activities.

• Feeling alienated from others

• Constricted affect: persistent inability to experience positive emotions.

Criterion E:

Alterations in Arousal and Reactivity

Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event:

(two required)

• Irritable or aggressive behavior

• Self-destructive or reckless behavior

• Hypervigilance

• Exaggerated startle response

• Problems in concentration

Criterion F: Duration

Persistence of symptoms (in Criteria B, C, D, and E) for more than one month.

Criterion G:

Functional Significance

Significant symptom-related distress or functional impairment (e.g., social, occupational).

Criterion H: Exclusion

Disturbance is not due to medication, substance use, or other illness.

• Hypervigilance

• Exaggerated startle response

• Fear and anxiety

• Nightmares and flashbacks, including sight, sound, and smell recollection

• Avoidance of recall situations

• Anger and irritability

• Guilt

• Depression

• Increased substance abuse

Treatments

• SSRIs- 1st _{line treatment}

• Zoloft, Paxil, Prozac, Celexa

• Seroquel- off label use • Alpha₁ antagonist • Prazosin • Alpha₂ agonist • Clonidine Downfalls • Duration of medication onset and “drop out” • Somnolence & Fatigue • Sexual Dysfunction

• Increased risk of suicide • Polypharmacy

Methylenedioxymethamphetamine

(MDMA)

Potential Complications

• Infection

• Bleeding

• Intravascular injection

• Subarachnoid injection

• Local anesthetic toxicity

• Pneumothorax

Current Uses for SGB

• Migraines

• Complex Regional Pain Syndrome (CRPS)

• Atypical face pain- Herpes Zoster

• Hot flashes

• Raynaud’s phenomenon

• Craniofacial Hyperhidrosis

• Pseudorabies virus mapping in rats (Westerhaus & Loewy, 2001) • Connections established between Stellate Ganglion and insular and

infralimbic cortical regions, hypothalmus and amygdala.

Case Study 1

• 48 year old male

• Victim of physical assault

• One week post event- prescribed three medications

• New symptoms at 23 days post event.

• Relaxation therapy started but unsuccessful.

Results

• Pt reported immediate decrease in anxiety

• Change in symptoms and medication usage one week post SGB

• Repeat of SGB with pulsed radiofrequency done at day 32 d/t return of symptoms

• Follow up three months later, pt reported 90% improved

Procedure for Case Studies 2 & 3

• Radiographic confirmation of right C6 transverse process • Skin localized and 25 ga. Quincke needle placed via anterior

paratracheal approach under fluoroscopic guidance • 2 cc radio-opaque dye injected to visualize spread.

• 7 cc of 0.5% Ropivicaine injected slowly after neg. aspirate • Pt monitored for horner’s syndrome, facial anhidrosis and

Case Study 2

• PCL score 76 out of 85

• 1 year psychiatric treatment prior to SGB • On multiple medications:

• Zoloft, Seroquel, Trazadone, Effexor, and Ambien

• Experiencing multiple side effects from current medication

• somnolence, sexual dysfunction and auto accident d/t falling asleep at wheel.

46 yr male retired military involved in close range

combat event, where he was rendered unconscious from an explosion.

Results

• Improvement 5 minutes after block placement

• Anxiety score decreased from 8 to 2

• Tapered off all medications except Ambien

• Able to sleep for 6-7 hrs per night

• Nightmares diminished in both intensity & frequency

• Remission for 3 mths, procedure repeated at 7 mths d/t return of symptoms and PCL of 67.

• 4 months after 2nd procedure- off all psychotropic meds and PCL score of 34

Case Study 3

36 yr. old active duty male involved in Battle of Fallujah during Operation Iraqi Freedom.

• PCL score of 54

• 1 year psychiatric care prior to SGB

• Medications

Results

• Immediate improvement in anxiety levels post SGB

• PCL score of 24 which remained consistent at 7 month follow up

• Discontinued all medications with resolution of adverse side effects

References

• (2010). In search of an effective treatment for combat-related post-traumatic stress disorder (ptsd): Can stellate ganglion block be the answer?. World Institute of Pain, 10(4), 265-266.

• Alleva, E., Petruzzi, S., Cirulli, F., & Aloe, L. (1996). NGF regulatory role in stress and coping of rodents and humans. Pharmacology Biochemistry and Behavior, 1(54), 65-72

• Freidman, M.J., Resick, P.A., Bryant, R.A., Brewin, C.R. (2010). Considering PTSD for DSM-5. Depression and Anxiety, 1-20. DOI 10.1002/da.20767

• Lipov, E. G., Joshi, J. R., Sanders, S., & Slavin, K. V. (2009). A unifying theory linking the prolonged

efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes and posttraumatic stress disorder (PTSD), Medical Hypotheses, 72, 657-661.

• Lipov, E., Kelzenberg, B., Rothfeld, C., & Abdi, S. (2012). Modulation of NGF by cortisol and the stellate ganglion block-is this the missing link between memory consolidation and PTSD?. Medical Hypotheses, 79, 750-753.

• Lipov, E., Kelzenberg, B., (2012). Sympathetic system modulation to treat post-traumatic stress disorder (PTSD): A review of clinical evidence and neurobiology. Journal of Affective Disorders, 1-3(142), 1-5. • Lipov, E.G., Lipov, S., Sanders, S.E., Siroko, M.K. (2008). Letter to the Editor: Cervical Symptathetic

Blockade in a Patient with Post-Traumatic Stress Disorder: A Case Report. Annals of Clinical Psychiatry, 20(4), 227-228.

• Mulvaney, S.W., McLean, B., Leeuw, J.D. (2010). The Use of Stellate Ganglion Block in the Treatment of Panic/Anxiety Symptoms with Combat-Related Post-Traumatic Stress Disorder; Preliminary Results of Long-Term Follow up: A Case Study. World Institute of Pain, 4(10), 359-365.

• Westerhaus, M.J., Loewry, A.D., (2001). Central Representation of the sympathetic nervous system in the cerebral cortex. Brain Research. 903, 117-127.