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sgb injection to treat ptsd

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The Stellate Ganglion Block for ptsd

What is PTSD?

Post-Traumatic Stress Disorder, also known as ‘Post-Traumatic Stress Injury’ (PTSI) is a psychological and emotional stress disorder/injury caused by a traumatic event.

The diagnosis of PTSD/PTSI is not limited to those who have bravely served in our military, and/or police or fire departments. PTSD can develop in anyone who has suffered any type of mental, physical, and/or emotional trauma. Also, an individual does not need to be formally diagnosed with PTSD in order to suffer from PTSD and there does not need to be a memory of the traumatic event for PTSD to develop.

Many of the symptoms accompanying PTSD demonstrate increased activation of the “fight or flight” response. There is a large overlap of symptoms among individuals with PTSD and depression/anxiety. The following are some of the common signs of PTSD:

  • Avoidance of places, people, and/or situations
  • Feelings of detachment
  • Irritability
  • Increased startle response
  • Sleep disturbances in the form of nightmares and flashbacks of the causative event(s).
  • Articulation difficulties
  • Memory/concentration difficulties
  • Decreased relaxation
  • Inappropriate stimulation
  • Visual and/or auditory hallucinations
  • Emotional distance in relationships

References: (Mulvaney et al, 2014) (Alino et al, 2013) (APA, DSM-IV, 2000) (Moore & Puri, 2012).

The Sympathetic Nervous System and PTSD:

The fight or flight system aka ‘sympathetic nervous system’ is mediated by a neurotransmitter that is a special form of adrenaline. Individuals with PTSD have demonstrated increased levels of this neurotransmitter in the cerebral spinal fluid (CSF) (Geracioti et al, 2001). Nerve growth factor (NGF), a protein involved in the creation and maintenance of nerve fibers, increases adrenaline(Isaacson & Billieu, 1996). These nerve fibers promote the process of PTSD. Fortunately, the SGB decreases NGF which subsequently decreases NE and relieves symptoms of PTSD (Lipov et al, 2009) (Takatori et al, 2006).

Certain brain structures are heavily involved in the development and treatment of PTSD. From the stellate ganglion, the signal travels to the brain’s right-sided hippocampus and amygdala, among several other structures. The hippocampus is responsible for factual memory formation. The right amygdala is responsible for producing emotional memories and subsequent responses in an unconscious fashion (Gainotti et al, 2006). It is postulated that the right-sided amygdala and hippocampus are over-active in PTSD, and this activity is reduced after a SGB (Alkire et al. 2015).

Stellate Ganglion Block (SGB):

The stellate ganglion block (SGB) has been in existence for a century, and mainly utilized for upper extremity pain. Several years ago, a patient who had both right upper extremity pain and PTSD was treated with the SGB. Both the upper extremity pain and symptoms of PTSD disappeared (Lipov et al, 2008). This monumental case set the stage for the use of the SGB to treat individuals with PTSD.

The SGB transforms the brain back to a pre-traumatic state. Results occur within 30 minutes of the injection (Hickey et al, 2013). Prolonged improvement of PTSD symptoms are seen after the SGB.

Patients with the following conditions may benefit from the stellate ganglion block:

  •  PTSD/PTSI
  • Anxiety
  • Depression
  • Lymphedema
  • Nicotine dependence
  • Complex regional pain syndrome
  • Post-herpetic neuralgia
  • Hot flashes (Lipov et al, 2009)
  • Hyperhidrosis (Karnosh & Gardner, 1947).

Secondary improvements seen include decreased alcohol use, improved memory, and reduction of hallucinations in schizophrenia (Lipov et al, 2013) (Takano et al, 2002).

Stellate Ganglion Block (SGB) for PTSD Treatment:

The success rate for the SGB is approximately 70-80%, whereas conventional treatment only has a 20-30% success rate (Mulvaney et al, 2014) (Hodge et al, 2011). The results of the SGB typically occur within 30 minutes of the injection and the results are usually long lasting (Hickey et al, 2013).

An Evidence-Based Treatment for PTSD

The success rate for the SGB is approximately 70-80%, whereas conventional treatment only has a 20-30% success rate (Mulvaney et al, 2014) (Hodge et al, 2011). The results of the SGB typically occur within 30 minutes of the injection and the results are usually long lasting (Hickey et al, 2013).

Long-Lasting and Life-Changing Benefits of SGB:

The SGB takes less than five minutes to perform versus years of cognitive behavioral therapies and medications that ultimately may not work. Many people do not wish to continuously meet with a medical professional to talk about their feelings or rely on PTSD treatment medications. The stellate ganglion block may increase the ability of the recipient to better function, gain employment, sleep better, have healthier relationships, and reap many other life-changing benefits.

There is an increased risk of suicide in patients with PTSD (Ferrada-Noli et al, 1998). Unfortunately, if antidepressants do work, it takes a long time, usually weeks to months. This time is critical when dealing with a potentially suicidal individual.  

The stellate ganglion block may help when PTSD medications for anxiety, depression, and anti-psychotics do not. As previously stated, the SGB works by decreasing adrenaline. Unfortunately, none of the following medications work via this mechanism: antidepressants typically raise serotonin and adrenaline levels, while benzodiazepines increase GABA levels, and anti-psychotics decrease dopamine levels. Additionally, all of these medications carry potentially serious side effects.

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Recent Health Articles

Alino J., Kosatka D., McLean B., Hirsch K. Efficacy of stellate ganglion block in the treatment of anxiety symptoms from combat-related posttraumatic stress disorder: a case series. Mil Med 2013; 178: e473–6.

 

Alkire, M. T., Hollifield, M., Khoshsar, R., Nguyen, L., Alley, S. R., & Reist, C. (2015). Neuroimaging suggests that stellate ganglion block improves post-traumatic stress disorder (PTSD) through an amygdala mediated mechanism. In American Society of Anesthesiology annual meeting.

 

American Psychiatric Association: The Diagnostic and Statistical Manual of Mental Disorders, Ed 4, Text Revision. Washington, DC, American Psychiatric Association, 2000.

 

Ferrada‐Noli M., Asberg M., Ormstad K., Lundin T., & Sundbom E. (1998). Suicidal behavior after severe trauma. Part 1: PTSD diagnoses, psychiatric comorbidity, and assessments of suicidal behavior. Journal of Traumatic Stress: Official Publication of The International Society for Traumatic Stress Studies, 11(1), 103-112.

 

Geracioti T.D. Jr, Baker D.G., Ekhatur N.N., et al: CSF norepinephrine concentrations in posttraumatic stress disorder. Am J Psychiatry 2001; 158: 1227–30.

 

Hanling S. R., Hickey A., Lesnik I., Hackworth R. J., Stedje-Larsen E., Drastal C. A., & McLay R. N. (2016). Stellate ganglion block for the treatment of posttraumatic stress disorder: A randomized, double-blind, controlled trial. Regional anesthesia and pain medicine, 41(4), 494-500.

 

Hickey A. H., Navaie M., Stedje-Larsen E. T., Lipov E. G., & McLay R. N. (2013). Stellate ganglion block for the treatment of posttraumatic stress disorder. Psychiatric Annals, 43(2), 87-92.
Isaacson L.G., Billieu S.C. Increased perivascular norepinephrine following intracerebroventricular infusion of NGF into adult rats. Exp Neurol 1996; 139(1): 54–60.

 

Karnosh L.J., Gardner W.J. (1947) The effects of bilateral stellate ganglion block on mental depression; report of 3 cases. Cleve Clin Q 14: 133-138.
 
Lipov E. G., Joshi J. R., Lipov S., Sanders S. E., & Siroko M. K. (2008). Cervical sympathetic blockade in a patient with post-traumatic stress disorder: a case report. Annals of Clinical Psychiatry, 20(4), 227-228.

 

Lipov E. G., Navaie M., Brown P. R., Hickey A. H., Stedje-Larsen E. T., & McLay R. N. (2013). Stellate ganglion block improves refractory post-traumatic stress disorder and associated memory dysfunction: a case report and systematic literature review. Military medicine, 178(2), e260-e264.

 

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(6), 657-661.
Moore D. P., & Puri B. K. (2012). Textbook of Clinical Neuropsychiatry and Behavioral Neuroscience 3E. CRC Press.

 

Mulvaney S.W., Lynch J.H., Hickey M.J., 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):1133–40. This is the largest publication so far on the use of SGB in military PTSD.

 

Takano M., Takano Y., Sato I. (2002) Unexpected beneficial effect of stellate ganglion block in a schizophrenic patient. Can J Anaesth 49: 758-759.

 

Takatori M., Kuroda Y., & Hirose M. (2006). Local anesthetics suppress nerve growth factor-mediated neurite outgrowth by inhibition of tyrosine kinase activity of TrkA. Anesthesia & Analgesia, 102(2), 462-467.

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