Stellate Ganglion Block (SGB) Therapy for Post Traumatic Stress Disorder (PTSD)

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 Stellate Ganglion Block (SGB) Procedure for Post Traumatic Stress Disorder (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.

Frequently Asked Questions on SGB Treatment for PTSD

Is SGB painful?

It is not painful. Most patients rate it 0-2 on the pain scale for a few seconds. First, we numb your skin with local anesthetic using a needle the thickness of an acupuncture needle. Then, we precisely guide a very thin needle using an ultrasound machine to the target, which is not very deep in your neck. While this procedure is technically complicated to perform for your physician, is is very easy to tolerate as a patient.

Is stellate ganglion block covered by health insurance?

Your initial consultation and follow-up exams are covered by most insurances. However, the SGB procedure itself is not covered by insurance when used to treat PTSD.

What are the risks of SGB?

SGB has been performed for almost one hundred years (really!) to treat various conditions. Therefore we have a large set of data to evaluate safety. SGB is very safe if performed by a fellowship-trained and board-certified Pain Medicine subspecialist physician such as Dr. Attaman. There is a less than 1 in 1000 chance of any serious negative side effects. Although extremely rare, such side effects can include allergic reaction, temporary or permanent nerve damage, paralysis, internal bleeding, hematoma formation, infection/abscess formation, puncture of the spinal cord or its surrounding layers, spinal fluid leakage with possible headache, stroke, seizure, respiratory distress, pneumothorax, hoarse voice, palpitations, heart attack, difficulty swallowing, local anesthetic toxicity with neurologic and cardiac defects, and procedure failure. Please note, if this procedure is performed by a Naturopathic Physician (ND), Nurse Practitioner (ARNP or DNP) or Physician’s Assistant (PA), it should be considered unsafe as these professionals cannot obtain the advanced training required to safely perform this procedure.

How long does it take to complete an SGB injection?

Once we have you in our procedure room and have cleaned your skin with special soap, the procedure takes about 10-20 minutes to complete. Most of this time is spent scanning your neck with our ultrasound machine to find the ideal target location. The actual time our needle is in your neck is a few minutes.

How long will stellate ganglion block help with PTSD?

While SGB is not effective for everybody, if it works for you it can last many weeks to years and in many cases can be permanent. SGB can be repeated as needed, if needed, in the future. There is no limit to how many you can have. If you have had positive benefit from an SGB in the past, but you feel your PTSD symptoms returning, it is better to repeat the SGB sooner rather than later when the symptoms may become stronger.

Will SGB interfere with my psychological therapy?

Absolutely not! SGB helps to remove the physical symptoms you experience from PTSD such as a racing heart, sweating, hypervigilance, and generalized body tension. Once these physical symptoms are reduced by SGB, you may find you and your psychologist or counselor can make great progress with therapy.

What are the normal side effects of the SGB procedure?

A successful SGB block will cause your face to look a little strange for a few hours, and cause you to have some interesting symptoms. You will have a droopy eyelid, your eye will become blood-shot. Your voice may be hoarse. Your arm on the treated side may become warm and flushed with more blood flow than usual. You may have a runny nose. All these are NORMAL and not reason for concern. These side effects will go away later in the day or over night. You may also have a headache similar to a migraine, or feel like you cannot take a deep breath with your belly muscles on the treated side. These are not dangerous and will resolve.

Do I have a medical problem that will prevent me from having an SGB?

If you have allergy to our medications, acute or chronic lung disease, active infection in the area, have had extensive surgery in the front of your neck, or are on blood thinners that you cannot safely stop, you may not be a candidate. We will fully evaluate all of these issues with you in person during a consultation in our clinic. Please do NOT stop your blood thinners without consulting with your prescribing physician first to discuss the risks.

Can I repeat the SGB procedure?

Yes! As long as it helped you initially, you may repeat it as often as you need. There is no limit. We may also try a left sided SGB if you’ve had good but suboptimal relief from a right sided SGB.

How do you monitor the success of the SGB procedure for PTSD?

We follow a protocol to measure the strength of the SGB block developed by Dr. Mulvaney; 1. Immediately after the procedure, we will grade the success of your SGB procedure by assessing the amount of eyelid drooping, the degree of your bloodshot eye, and how much your pupil contraction has changed. If it appears the SGB was not successful in producing a strong result, we will usually repeat the procedure the same day to ensure a good sympathetic block. 2. We ask that you continue to see your mental health professional during and after the SGB procedures. 3. We will administer a psychological screening test called a PCL-5 after your SGB procedure to see if your symptoms have improved in a measurable way.