Stellate Ganglion Block (SGB) for Post Traumatic Stress Disorder (PTSD) in Seattle and Bellevue
In the Media
Click the “play” button to watch three recent broadcasts about SGB for PTSD from “60 Minutes” and “CBS This Morning” and “The Joe Rogan Experience.” These videos feature brave patients who share their stories as well as the two pioneers in the use of SGB for PTSD; Sean Mulvaney, MD and Eugene Lipov, MD.
What is PTSD?
Post-Traumatic Stress Disorder (PTSD) is a mental health condition characterized by a heightened response to a traumatic event. A alternate term for this condition is Post Traumatic Stress Injury (PTSI). This can result in feelings of persistent stress, anxiety, and fear, even when there is no immediate danger present. Those who suffer from PTSD often avoid situations that remind them of the traumatic event or place and may experience flashbacks. These flashbacks can be as real as the moment they occurred.
PTSD can develop from any type of traumatic experience, either physical or emotional. PTSD is not limited to military and law enforcement service. It is often treated with various forms of therapy, medication, and at times, stellate ganglion block (SGB) injections. SGB for PTSD has recently gained worldwide attention due to the TV program “60 Minutes.”
Symptoms of PTSD
Symptoms of intrusive memories may include:
- Recurrent, unwanted distressing memories of the traumatic event
- Reliving the traumatic event as if it were happening again (flashbacks)
- Upsetting dreams or nightmares about the traumatic event
- Severe emotional distress or physical reactions to something that reminds you of the traumatic event
Symptoms of avoidance may include:
- Trying to avoid thinking or talking about the traumatic event
- Avoiding places, activities or people that remind you of the traumatic event
Negative changes in thinking and mood
Symptoms of negative changes in thinking and mood may include:
- Negative thoughts about yourself, other people or the world
- Hopelessness about the future
- Memory problems, including not remembering important aspects of the traumatic event
- Difficulty maintaining close relationships
- Feeling detached from family and friends
- Lack of interest in activities you once enjoyed
- Difficulty experiencing positive emotions
- Feeling emotionally numb
Changes in physical and emotional reactions
Symptoms of changes in physical and emotional reactions (also called arousal symptoms) may include:
- Being easily startled or frightened
- Always being on guard for danger
- Self-destructive behavior, such as drinking too much or driving too fast
- Trouble sleeping
- Trouble concentrating
- Irritability, angry outbursts or aggressive behavior
- Overwhelming guilt or shame
For children 6 years old and younger, signs and symptoms may also include:
- Re-enacting the traumatic event or aspects of the traumatic event through play
- Frightening dreams that may or may not include aspects of the traumatic event
What is a Stellate Ganglion Block (SGB)?
The stellate ganglion is a bundle of nerves that is located deep in the lower neck. It is located within the cervical sympathetic chain. Sympathetic nerves play a strong role in our fight-or-flight response. When you have PTSD, these nerves malfunction and are constantly sending distress signals to your brain and body. Injecting local anesthetic (numbing medicine) around these nerves is called a stellate ganglion block (SGB). SGB resets these nerves that are chronically in fight-or-flight response. This is similar to rebooting your computer; after the “SGB reboot,” your nerves function normally. Stellate ganglion block (SGB) injections need to be performed under either ultrasound and/or fluoroscopic guidance as there are major blood vessels and organs nearby. The SGB injection is not new and has been used for 100 years to treat painful conditions such as chronic regional pain syndrome (CRPS) of the upper extremity. More recently, SGB is being used to treat PTSD.
The only physicians that are formally trained in the SGB procedure are Interventional Pain Management physicians (MDs and DOs). We learn how to safely perform SGB during a year-long advanced training program called a Pain Medicine fellowship. A fellowship is the highest level of training a physician can complete and is done after four years of medical school, one year of internship, and three years of residency. Even then, the SGB technique used for PTSD treatment is more complex than when used for painful conditions and in many cases requires even more refinement after fellowship. For example, SGB used for PTSD treatment is done under ultrasound at two different levels and great care is taken to ensure a proper Horner’s syndrome after the SGB procedure. This is rarely the case in a standard SGB procedure when used for pain. Stellate ganglion block is a technically demanding procedure that requires precise image guidance using an ultrasound machine and sometimes a form of x-ray called a fluoroscope. We always prefer to use ultrasound as it allows us to better visualize nerves, arteries and veins in this delicate area.
You may wonder why some physicians use ultrasound while others use fluoroscopy. The answer is fairly simple; it is much safer and accurate to use ultrasound but much more difficult to learn this method. Fluoroscopy is faster but does not allow for the visualization of delicate nerves and blood vessels in the area. The procedure is non painful, as it involves only a single needle poke in the side of the neck after numbing the skin. Typically, we will first perform SGB on the right side of your neck, as medical studies have found the right side to be most efficacious in most people. However, less than 5% of patients may require an SGB on the left side of the neck if they do not respond to a properly performed right sided SGB procedure. If you are visiting us from far away, we will typically schedule a right SGB followed by a left SGB on a subsequent day to ensure that you have the best opportunity for optimal outcomes. For safety reasons, we do not treat both sides on the same day. In our clinic, we have top of the line ultrasound machines and flouroscopy available. With rare exception, we prefer to perform this procedure under ultrasound guidance.
Be careful; you may find professionals such as naturopathic physicians (NDs) or nurse practitioners (ARNPs or DNPs) offering this procedure. They are unqualified to perform this procedure. They will do their best to hide their lack of training in interventional pain management procedures from you. These professionals complete no formal hospital-based residency nor fellowship in performing pain management procedures. It is dangerous for NDs or NPs to attempt to perform complex interventional procedures such as a stellate ganglion block. If you are looking for a professional to perform this procedure on you, be sure they are a physician (MD or DO) and have completed medical school, internship, formal hospital-based residency and especially a one year long accredited Pain Medicine fellowship. Some physicians with Sports Medicine fellowship training are also qualified to do this procedure. You can check if your physician is a board certified physician at the American Board of Medical Specialties website. Only then are they qualified to safely perform this procedure.
This video from Drs. Escolar and Amador demonstrates the anatomy and technique involved with this specialized procedure:
How Effective is the SGB?
The severity of PTSD can be measured using a psychological intake called the PCL-5. The PCL-5 is a well known and standard test used by mental health professionals such as psychiatrist and psychologists. A reduction of 10 points or more is considered a meaningful change in the mental health profession; meaning if your mental health professional sees a 10 point drop in your score, a treatment can be considered successful. Using the two level SGB technique in which the injection is performed at both C6 and C4, SGB is successful in approximately 85% of patients who see an average of 50% reduction in their symptoms. This is a mean reduction in the PCL-5 score of over 30 points (Dr. Mulvaney, et. al.). Consider that an SGB procedure takes only around 30 minutes to complete, and compare this to months or years of conventional therapy and medications.
Several studies have been performed in the past, analyzing the effectiveness of stellate ganglion block (SGB) for the treatment of PTSD. Although results were favorable, the level of research was not ideal. Very recently, however, the first multi-site, randomized control trial was published by the Journal of the American Medical Association (JAMA). The results show that two stellate ganglion blocks two weeks apart help reduce symptoms related to PTSD. You may read the study here:
A 2022 study was published by Drs. Lipov et. al. This study tracked 327 patients who had received a stellate ganglion block for PTSD. This showed that patients benefited from an average reduction in the PCL score (PTSD severity score) of 29 points. A reduction of 10 points is considered clinically significant in the medical field. It also showed that virtually all causes of PTSD responded to the Stellate Ganglion Block procedure equally well (for example, sexual assault, physical violence and combat trauma survivors all had similar improvements; the cause of PTSD does not effect the outcome of a SGB procedure).
Drs. Lynch & Mulvaney et. al. surveyed multiple mental health clinicians including psychiatrists and psychologists. They found of those behavioral health clinicians with personal experience incorporating SGB into their trauma- focused psychotherapy, 95% of respondents would recommend SGB to a colleague as a useful tool for the treatment of trauma-related disorders. SGB was rated at least as useful as the most valuable interventions listed in the American Psychological Association Clinical Practice Guideline for the Treatment of Post-traumatic Stress Disorder with 100% of respondents characterizing SGB as ’Very Beneficial’ or ’Somewhat Beneficial:
Our SGB Experience
Dr. Attaman has performed SGB procedures for over 12 years, initially for painful conditions and then for PTSD. He has performed hundreds of SGBs specifically to treat PTSD. He is a Seattle Met “Top Doc” in Pain Medicine for 2015-2021 and Seattle Magazine “Top Doc” in Pain Medicine for 2019.
Take Home Message
PTSD is a life altering problem for anyone who has suffered a major traumatic event in their lives. PTSD is not limited to military trauma. Stellate ganglion blocks have shown promising results in recent studies and those who suffer from PTSD are encouraged to discuss the SGB procedure with a qualified physician. If you have PTSD and feel that you are stuck, or that you have worked very hard in therapy but have reached a plateau that you cannot pass, or feel the physical symptoms of PTSD such as tension, difficulty taking a deep breath, or racing heart will not improve, SGB may be a very good option for you. It is also important to know these injections are just one component of the treatment regimen and that continued therapy under the direction of a mental health care professional is beneficial as well.