Page 89 - Journal of Special Operations Medicine - Summer 2015

Clinical Guidelines for Stellate Ganglion Block to Treat Anxiety
Associated With Posttraumatic Stress Disorder

Sean W. Mulvaney, MD; James H. Lynch, MD; Russ S. Kotwal, MD, MPH

ABSTRACT
Multiple case series published in the peer-reviewed medi- including Raynaud’s disease and frostbite. Emerging indica-
1
cal literature have demonstrated the safety and efficacy of tions for SGB include hot flashes following menopause or
right-sided stellate ganglion block (SGB) for the treatment of breast cancer treatment, as well as anxiety symptoms associ-
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anxiety symptoms associated with posttraumatic stress disor- ated with PTSD. 4–12
der (PTSD). As this is a new indication for a well-established
procedure, there is relatively little information available to as- Posttraumatic stress disorder may develop after a person ex-
sist clinicians in determining the utility of SGB for their pa- periences a traumatic event, including sexual assault, com-
tients. Presented are clinical guidelines to assist the provider bat-related action, or threat of violence or imminent death.
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with patient selection, patient education, and follow-up. Also Right-sided SGB is a therapeutic modality that can be used to
described is a technique to perform SGB under ultrasound- successfully treat anxiety symptoms associated with PTSD, as
guidance. Although additional rigorous clinical research is physiologically SGB can potentially influence both the central
needed to further investigate SGB for the treatment of anxiety autonomic network (including the amygdala, insular cortex,
symptoms associated with PTSD, these guidelines can also as- and hypothalamus) as well as the cardiovascular system, which
sist clinical investigators in their participant selection, design, are central systems responsible for anxiety. Presented are clini-
and conduct of future research as it pertains to this important cal guidelines for this procedure, based on a comprehensive
topic. review of the peer-reviewed medical literature, 4-12 as well as
extensive clinical experience with the treatment of more than
Keywords: posttraumatic stress disorder; stellate ganglion 450 patients. These guidelines are intended to help individual
block; ultrasound, guided; anxiety; clinical guidelines providers determine appropriate potential candidates for this
procedure and also to provide recommendations to clinical in-
vestigators researching the safety and effectiveness of SGB for
treating PTSD.
Introduction
Primary dysfunction of the nervous system can result in pain Although the strength of recommendation for right-sided SGB
syndromes referred to as neuropathic pain. This type of pain is to treat anxiety symptoms related to PTSD is currently limited
different from nociceptive pain, which originates from injury to 2C, as based on case-series level of evidence reported on
to non–nervous system tissue. Neuropathic pain may in part more than 200 patients, our experiences have demonstrated
be maintained by the sympathetic branch of the autonomic this procedure to be safe and effective with more than 70%
nervous system as well as the somatic nervous system. Block- of patients having both clinically and statistically significant
ade of the sympathetic nervous system can thus prove useful in relief for up to 3 months after the procedure. 10
the treatment of some types of neuropathic pain. 1
Patient Evaluation and Selection
Preganglionic sympathetic nervous system fibers originate in
the thoracic and lumbar regions of the spinal cord. Sympa- To more accurately treat and analyze care provided to patients
thetic nerves exit the spinal cord and come together to form who have PTSD, the clinical or study population must first be
the sympathetic trunk. The sympathetic trunk is a paraverte- appropriately evaluated and found to have a high likelihood
bral structure that extends into the neck to form three cervical of actually having PTSD. The Clinician-Administered PTSD
ganglia, the most caudad of which is the star-shaped stellate Scale (CAPS), PTSD Checklist–Civilian Version (PCL-C), or
ganglion. PTSD Checklist–Military Version (PCL-M) are tools that can
be used to evaluate patients for PTSD. The PCL-5, which is
The SGB is an effective method for temporarily blocking aligned with the Diagnostic and Statistical Manual of Men-
sympathetic input to the central autonomic network in the tal Disorders (DSM) V, is now available. (Although we have
brain, head, face, and arm and thus has potential for treating limited clinical experience with the PCL-5, a score of 40 or
pain that occurs in the upper extremities and thorax, as well greater appears to be appropriate). A positive CAPS or PCL-
as the face and neck. Current indications for SGB include M (or PCL-C) score of 50 or more denotes a high likelihood
1,2
sympathetically maintained pain syndromes such as complex of PTSD. 14
regional pain syndrome as well as other neuropathic pain
syndromes such as limb ischemia, herpes zoster, post herpetic The CAPS is the gold standard test for PTSD. However, CAPS
neuralgia, post radiation neuritis, and pain from vasospasm is a time- and resource-intensive test that includes a 30-item

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