Efficacy of cervical sympathetic blockade in the treatment of primary and secondary PTSD symptoms: A case series.

Background: Post-traumatic stress disorder (PTSD) can develop in individuals following exposure to an overwhelmingly traumatic event. Secondary PTSD is defined as occurring after exposure to a person with primary PTSD, such as an intimate partner. Successful treatment of PTSD symptoms by the use of cervical sympathetic blockade (CSB) has been previously reported to help with symptoms irrespective of PTSD cause. Objective: To describe the efficacy of CSB in treating symptoms of primary and secondary PTSD in two couples, and visualize CSB impact through neuroimaging. Methods: Four patients received CSB at C6 and C4 with ultrasound guidance on the right side followed by the left side a day later. PTSD symptoms were evaluated in all patients using the PTSD Checklist (PCL-5) before and after the procedure. Patients underwent SPECT scans acquired using a high resolution Picker (Philips) Prism XP 3000 triple-headed gamma camera, with low-energy high-resolution fan beam collimators, one day before and one week after the procedures. Results: CSB showed acute benefit for symptoms of primary and secondary PTSD, offering a clinically significant reduction in PTSD symptoms in all four patients. The PCL-5 scores of patients with primary PTSD were reduced from 41 to 7 and from 44 to 6 on the 80-point scale. The PCL-5 scores of patients with secondary PTSD were reduced from 40 to 17 and from 43 to 7 on the 80-point scale. Furthermore, SPECT imaging showed stark increases in activity in the prefrontal pole and thalamus in all patients, and increases in activity in the inferior orbital prefrontal cortex in three of four cases. Modulation of activity in the temporal lobes, orbital prefrontal cortex and basal ganglia was also noted after the procedure. Conclusion: CSB is a minimally invasive procedure with an excellent safety profile, providing relief of primary and secondary PTSD symptoms. The increase in prefrontal pole, thalamus and inferior orbital activity correlates with the improved symptomatology.

Survey Reveals That Renaming Post-Traumatic Stress 'Disorder' to 'Injury' Would Reduce Stigma.

Background Self-stigmatization has an estimated prevalence of 41.2% among adults with post-traumatic stress disorder (PTSD). Since the name PTSD was introduced, arguments have been made that the term "disorder" may discourage patients from revealing their condition and seeking care. We hypothesize that renaming PTSD to post-traumatic stress injury (PTSI) would reduce the stigma associated with PTSD and improve patients' likelihood of seeking medical help. Methods An anonymous online survey was distributed by the Stella Center (Chicago, IL) between August 2021 and August 2022 to 3000 adult participants, of which 1500 were clinic patients and visitors. Another 1500 invitations were sent out to the Stella Center's website visitors. Results A total of 1025 subjects responded to the survey. The respondents were 50.4% female (51.6% had been diagnosed with PTSD) and 49.6% male (48.4% had been diagnosed with PTSD). Over two-thirds of the respondents agreed that a name change to PTSI would reduce the stigma associated with the term PTSD. Over half of the respondents agreed that it would increase their hope of finding a solution and their likelihood of seeking medical help. The cohort diagnosed with PTSD was most likely to believe in the impact of a name change. Conclusion This study provides significant insight into the potential impact of renaming PTSD to PTSI. The biggest effect is likely to be the reduction or elimination of stigma, followed by an increase in the hope of finding successful medical treatment for PTSD. The above changes will likely improve access to care and reduce suicidal ideation in a complex cohort.

Efficacy of combined subanesthetic ketamine infusion and cervical sympathetic blockade as a symptomatic treatment of PTSD/TBI in a special forces patient with a 1-year follow-up: A case report.

Co-occurrence of posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) symptoms are particularly prevalent in the special operations forces' community, along with other related conditions (e.g., endocrine dysregulation, sleep disorders, chronic pain). Ketamine infusion (KI) has been shown to increase neuroplasticity as well as memory improvement and cervical sympathetic block (CSB) has been shown to improve cognitive function, reduce sympathetic overactivity, and improve other symptoms of PTSD. We want to report the efficacious use of a single intervention consisting of bilateral CSB technique with subanesthetic KI X5 in a Special Operations Forces patient, diagnosed with PTSD with comorbid TBI, evaluated during treatment and at 1-year follow-up. We postulated KI and CSB would have a synergistic effect. Our patient received KI starting at 0.5 mg/kg, which was escalated daily. KI was combined with right-sided ultrasound-guided CSB (C6 and C4 levels). This was followed the next day by left-sided CSB and KI. Patient's PTSD symptoms were evaluated using the Posttraumatic Stress Disorder Checklist (PCL-5), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), suicidal ideation and other related factors by Concise Health Risk Tracking Self Report (CHRTSR). All measures were assessed prior to treatment, during treatment, and 394 days after. KI combined with CSB showed immediate and prolonged benefits 394 days later regarding the symptoms of PTSD, anxiety, depression, suicidal ideation, and cognitive deterioration (patient report). KI combined with CSB can markedly reduce symptoms of PTSD, psychiatric comorbidities, and cognitive dysfunction.

Utility of Cervical Sympathetic Block in Treating Post-Traumatic Stress Disorder in Multiple Cohorts: A Retrospective Analysis.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a prevalent and debilitating condition in the United States. Success rates for evidence-based therapies are inconsistent, and many suffer in silence due to the stigmata associated with seeking traditional mental health care. This has led clinicians to explore new therapeutic options, with cervical sympathetic blockade (CSB), performed at the stellate and/or superior cervical ganglion levels, recently emerging as a promising treatment option. Rapid therapeutic onset, improved compliance, and high clinical efficacy rates have made this an attractive approach for both providers and patients. However, to date, CSB as a treatment of PTSD has primarily been used in male patients with military-related trauma. OBJECTIVE: To evaluate the efficacy of CSB as a treatment option for PTSD in both genders and multiple etiologies of psychological trauma. STUDY DESIGN: Retrospective cohort study. SETTING: An established anesthesia pain clinic in Chicago, IL, USA. METHODS: Following retroactive IRB approval, 484 consecutive cases of patients diagnosed with PTSD and treated with CSB, performed by a single provider (December 2016 - February 2020) were analyzed. The primary outcome measurement was the PTSD Checklist Score version DSM IV (PCL-4). Patient demographic and clinical information collected included age, gender, type of trauma leading to PTSD, history of suicidal attempts, and psychiatric medication use. RESULTS: After exclusion of cases due to missing data points, 327 patients were included in the final statistical analysis, having completed both PCL-4 pre and post CSB, between 7- and 30-days post-intervention. The patient population included military men (n = 97), civilian men (n = 85), military women (n = 13) and civilian women (n = 132). We identified 21 types of self-reported trauma leading to PTSD. Average decrease in PCL score for men and women was 28.59 and 29.2, respectively. Statistical analysis of the male population with a military background showed a significantly greater change in corresponding PCL scores than civilians (PCL-M change = -31.83 vs PCL-C change = -24.89). Likewise, women who had a military background had a significantly greater reduction in PCL score than civilians (39.15 vs 28.23). Statistically significant improvements in PTSD symptoms were noted independent of the causative trauma type, gender, age greater than 20, previous suicide attempts, or use of prescription medications for PTSD. Among the 21 types of reported trauma, 19 types reached statistical significance. LIMITATIONS: Limitations include the limited scope of observation giving exclusive focus on pre- and post-PCL data, the limited duration of observation, the self-reported nature of the patient-provided data, and the provision of treatment by a single physician. CONCLUSION: CSB seems to be an effective treatment for PTSD symptoms irrespective of gender, trauma type, PTSD-related drug use, suicide attempt, or age.

How does stellate ganglion block alleviate immunologically-linked disorders?

BACKGROUND: The stellate ganglion is an autonomic nervous ganglion, formed by the fusion of the inferior cervical sympathetic ganglion and the first thoracic sympathetic ganglion, which is present in about 80% of people. It is anterior to the neck of the first rib and contains neurons that supply sympathetic innervation to the head and neck. Injection of local anesthetics near the stellate ganglion (stellate ganglion block; SGB) has been used for multiple clinical indications including sympathetic-mediated pain and vascular insufficiency syndromes of the upper extremity. In addition, reports on SGB having significant impact on conditions linked to immune dysfunction have been published for a century, but the mechanisms of SGB action have been poorly understood. HYPOTHESIS: SGB hinders the sympathetic innervation of the immune organs, thus modulating the immune system activity and leading to the alleviation of the disease. EVIDENCE: All primary (thymus and bone marrow) and secondary immune organs (spleen, lymph nodes, mucosa-associated lymphoid tissue) receive a substantial sympathetic innervation, with norepinephrine (NE), as the main neurotransmitter. Complementarily, T and B lymphocytes express ß2-adrenergic receptors, while innate immune cells express both α- and ß-adrenergic receptors. The consequences of adrenergic receptor signaling can be summarized as immuno-modulatory. Activation of adrenergic receptors leads to decreased levels of pro-inflammatory cytokines (e.g. IL-1ß, IL-6, TNF-α) and increased levels of anti-inflammatory cytokines, like IL-10 or TGF-ß. Cellular changes include increase in the number of regulatory T cells and shift of the Th1/Th2 balance towards the Th2 response. Since the changes in immune response are global, the explanation has to include generalization of the SGB effect. A likely explanation includes centripetal neuronal pathways between the stellate ganglion and deep brain regions such as insula, amygdala, and hippocampus. Those, in turn, have reciprocal innervation with locus ceruleus, a brain-stem structure involved in the control of the autonomous nervous system. CONCLUSION: Various pathologic conditions have been shown to be SGB responsive, where the symptoms have been reduced or eliminated. Many of those clinical improvements have been mirrored by measurable immunologic changes. A plausible explanation, consistent with the evidence available so far, is that SGB exerts its effects by regulating the immune system, through a central, reflex-like pathway. Our hypothesis provides a theoretical framework for understanding the effects of SGB and could, thus lead to wider usage of the technique in immune-linked disorders such as ulcerative colitis.

Efficacy and safety of stellate ganglion block in chronic ulcerative colitis.

Sympathetic system modulation by stellate ganglion blockade may modulate immune dysfunction and significantly improve symptoms of chronic ulcerative colitis.

Possible Reversal of PTSD-Related DNA Methylation by Sympathetic Blockade.

Studies have shown that brain-derived neurotrophic factor (BDNF) level increase is associated with post-traumatic stress disorder (PTSD) risk. BDNF may be a "missing-link" that mediates the interaction between genetics, environment, and the sympathetic system. Trauma has been shown to induce DNA methylation that in turn can increase BDNF concentration due to increased gene expression. Therapies that focus on the reduction of beta-NGF (BNGF) levels may impact PTSD symptoms. The focus of this paper is to discuss possible effect of stellate ganglion block (SGB) on epigenetic changes noted with PTSD mediated by BDNF and NGF. Stellate ganglion block has recently shown significant therapeutic efficacy for treatment of PTSD symptoms. Previously reported theoretical mechanisms of SGB impact on PTSD have focused on likely reduction of NGF, leading to eventual loss of extraneous sympathetic nerve growth, eventually leading to reduction of secondary norepinephrine level, which in turn is hypothesized to reduce PTSD symptoms. We used PUBMED to obtain available data following a search for the following: DNA, neurotrophic factors, post-traumatic stress disorder, and demethylation following local anesthetic application. A number of articles meeting criteria were found and reviewed. Based on the evidence summarized, trauma can lead to DNA methylation, as well as BNGF/NGF level increase, which in turn starts a cascade of sympathetic sprouting, leading to increased brain norepinephrine, and finally symptomatic PTSD. Cascade reversal may occur in part by demethylation of DNA caused by application of local anesthetic to the stellate ganglion.

A review of the use of stellate ganglion block in the treatment of PTSD.

Current treatments for PTSD are often not effective or acceptable to the patient. There are a number of emerging new treatments. One promising new one is stellate ganglion block, an anesthetic treatment for pain which relieves symptoms of severe and chronic PTSD in some patients. The focus of this chapter is to summarize clinical evidence available for the effectiveness of cervical sympathetic ganglion injection called stellate ganglion block (SGB), as well as demonstrate possible clinical applications of its use. Cervical sympathetic blockade involves injecting a local anesthetic next to a group of nerves (ganglion) in the neck. The technique has been used clinically since 1925 with very few side effects. Finally, the neurobiology of SGB is discussed. Challenges to the use of SGB include the lack of randomized clinical trials and practitioners familiar with the use of SGB for PTSD.

Stellate ganglion block used to treat symptoms associated with combat-related post-traumatic stress disorder: a case series of 166 patients.

OBJECTIVE: Report the successful use of stellate ganglion blocks (SGBs) in 166 active duty service members with multiple combat deployments experiencing anxiety symptoms associated with post-traumatic stress disorder (PTSD). BACKGROUND: Successful treatment of PTSD symptoms with SGB has been reported previously. This is the largest published case series evaluating SGB with a minimum of 3 months follow-up. METHODS: Following clinical interview including administration of the PTSD Checklist (PCL), 166 service members with symptoms of PTSD elected to receive a SGB. All patients received a SGB on the right side at the level of the sixth cervical vertebrae (C6). The PCL was administered the day before treatment to establish a baseline, repeated 1 week later, and then monthly out to 3 months. A positive response was considered to be an improvement in the PCL score by 10 or greater points. Follow-up PCL scores from 3 to 6 months were obtained and analyzed for 166 patients. RESULTS: In a military population with multiple combat deployments, over 70% of the patients treated had a clinically significant improvement in their PCL score which persisted beyond 3 to 6 months postprocedure. CONCLUSION: Selective blockade of the right cervical sympathetic chain at the C6 level is a safe and minimally invasive procedure that may provide durable relief from anxiety symptoms associated with PTSD.

Stellate ganglion block improves refractory post-traumatic stress disorder and associated memory dysfunction: a case report and systematic literature review.

The prevalence of post-traumatic stress disorder (PTSD) has reached epidemic proportions among U.S. veterans, many of whom also have concurrent alcohol use disorder. This case report describes improvements in PTSD symptom severity and memory dysfunction in a combat-exposed veteran with persistent PTSD and alcohol use disorder following two treatments of stellate ganglion block (SGB). PTSD severity was measured using the PTSD Checklist, Military Version. Memory function was evaluated using the Rey Auditory Verbal Learning Test. One month after the first SGB, a 43.6% reduction in PTSD severity was observed along with increases in immediate memory (50%), recent memory (28%), and recognition memory (25%). Following a second SGB, PTSD severity decreased by 57.7% and memory function substantially improved, with pronounced changes in immediate memory (50%), recent memory (58%), and recognition memory (36%). One year after SGB treatments, the patient has stopped drinking alcohol, continues to have sustained relief from PTSD, has improved memory function, and has become gainfully employed. Future studies that employ robust epidemiologic methodologies are needed to generate confirmatory evidence that would substantiate SGB's clinical utility as an adjunctive treatment option for PTSD.

Peripheral nerve field stimulation for the management of localized chronic intractable back pain: results from a randomized controlled study.

OBJECTIVES: Improved device technology has caused a renewed interest in peripheral nerve field stimulation (PNfS). This study sought to obtain preliminary estimates of the safety and efficacy of PNfS in patients with localized chronic intractable pain of the back. MATERIALS AND METHODS: This Institutional Review Board-approved, prospective, randomized, controlled, crossover study consisted of two phases. During phase I, patients rotated through four stimulation groups (minimal, subthreshold, low frequency, and standard stimulation). If a 50% reduction in pain was achieved during any of the three active stimulation groups (responder), the patient proceeded to phase II, which began with implant of the permanent system and lasted 52 weeks. The primary endpoint was a reduction in pain, assessed by the visual analog scale (VAS). Analysis of variance, including the effects of patient, treatment, and study period, was used for phase I results. Phase II results were analyzed by paired t-tests. RESULTS: A total of 44 patients were enrolled at five sites. Of these patients, 32 were implanted with a trial system and 30 completed phase I. During phase I, there were significant differences in mean VAS scores between minimal stimulation and subthreshold stimulation (p = 0.003), low frequency stimulation (p < 0.001), and standard stimulation (p < 0.001). Twenty-four patients were classified as responders to the therapy, and 23 patients received permanent system placement. Significant differences in VAS scores were observed between baseline and all follow-up visits during phase II (p < 0.001) CONCLUSIONS: The results provide evidence to support safety and effectiveness of PNfS as an aid in the management of chronic, localized back pain.