Page 94 - Journal of Special Operations Medicine - Summer 2015

understand what happened with a successful SGB. Let them Discussion
know that the relaxed feeling after SGB is similar to the light
feeling that occurs after taking off a heavy backpack. There When reading the medical literature pertaining to SGB for
is nothing in a backpack that makes one feel light, it is the PTSD, consider if the study cohort is like the patient population
absence of the backpack that makes one feel light. Similarly, being assessed for treatment and whether the study conclu-
there is nothing in local anesthetic that makes one feel relaxed, sions can be generalized to your patient population. Most of
what they are experiencing is the absence of their chronically the patients we treated and reported in the medical literature
activated “fight or flight” response. It appears that SGB “re- were active duty military personnel who wanted to remain on
sets” this chronic inappropriate sympathetic tone for a long active duty and were not seeking any form of discharge or dis-
time. This explanation has proven useful for describing how ability benefit.
9
SGB works, although the exact mechanism is not known at
this time. Record the results of the initial PTSD evaluation At the 2015 American Academy of Pain Medicine Annual
(CAPS or PCL), procedure note with quantitative score of the Meeting, McLay et al presented their findings from a random-
resultant Horner’s syndrome, and additional examination and ized controlled trial of 42 patients that compared SGB to a
20
findings in the patient’s medical record. Re-emphasize appro- sham injection for the treatment of PTSD symptoms. Their
priate precautions to the patient before discharge. study results showed PTSD symptoms improved significantly
for both groups following treatment; however, there was no
statistical difference between SGB and sham. Variations in
Patient Follow-up procedure technique and dosing, as well as variations in study
Quantitative follow-up after SGB is critical, and should be participant motivation and characteristics, may have had some
conducted at 1 week, 1 month, and 3 months. The natural degree of influence on their results; thus, additional study of
history is that many cases of PTSD will significantly resolve by SGB is still warranted.
1 year without treatment. Therefore, studies with long-term
follow-up (i.e., more than 3 months after SGB) will require It has been a challenge to get some behavioral health providers
significantly larger numbers to show an effect, as long-term to accept SGB therapy. This may be overcome with consistent
follow-up will mask an effect in smaller studies. In our opin- emphasis that SGB is used only to reduce chronic inappropri-
ion, showing significant benefit out to 3 months is sufficient ate sympathetic tone, thereby potentiating other behavioral
to justify the procedure. The patient’s response to SGB deter- health therapies for PTSD. Our message has always been that
mines possible future therapy with SGB. SGB is not a cure for PTSD; it is only one part of an effective
treatment plan for PTSD.
Input from family, close friends, or work colleagues on any
change in the patient’s condition can prove invaluable. This Subjectively, SGB therapy is highly accepted by our patients,
may be difficult to formally obtain in study populations. In and they may not want other forms of treatment even if they
our experience, spouses, friends, and colleagues have noted could benefit from them; this is a choice of the patient. Mili-
significant improvements in the patient that the patient is not tary patients are concerned with any treatment, especially
aware of. A potential option is to request study subjects to ask pharmaceutical, that may result in a decrease in physical or
their family or trusted friends if they have noticed any changes mental performance or potential decrease in battlefield surviv-
prior to the subjects completing follow-up monitoring. Con- ability. Our recent case series documents no degraded perfor-
sider using a formal instrument given to spouses before and 1 mance in reaction time, motor quickness, vigilance, memory,
month after SGB. or concentration after SGB, and actually showed an improve-
ment in these measures. Our ongoing studies include a large-
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SGB is not a “cure” for PTSD, and symptoms may return with scale, multicenter, randomized controlled trial to further assess
an incidental trigger. If the patient has a documented positive safety and efficacy.
response from SGB, they have a high likelihood of receiving
benefit from retreatment. For SGB nonresponders who had a Eliminating the stigma some individuals associate with PTSD
10
documented dense Horner’s syndrome after SGB, wait at least 2 remains an important part of treating the military community.
weeks after the initial right-sided SGB before further treatment. Military leaders and healthcare providers must convey a clear
Additionally, reconsider the diagnosis of PTSD and the suitabil- and consistent message to the patient that having PTSD does
ity of the patient for SGB, as discussed earlier in this article. not convey failure or weakness. Their PTSD was a result of
their service to their country under extreme circumstances or a
Consider treating the patient with additional SGBs if the patient traumatic event they had no control over. These patients need
has had a documented and significant improvement from SGB to understand that this diagnosis alone will not negatively af-
lasting at least 1 month. Additionally, consider using the policy fect their security clearance or future service in the Department
of “no follow-up documentation, no second treatment.” Explain of Defense.
this policy to the patient to help get patient buy-in for appropriate
follow-up monitoring. Explain that although the risks involved Conclusion
with an SGB are very low, there is still some risk of a significant
complication and that documentation of even transient improve- Based on comprehensive review of the medical literature and
ment is needed to justify the small risk involved with a repeated extensive first-hand experience with this procedure, we present
treatment. Follow-up by electronic transmission of the PCL-M these clinical guidelines to assist providers with determining
(or PCL-5) form can be done if the patient is deployed. the suitability of SGB for PTSD in their patient populations.

84 Journal of Special Operations Medicine Volume 15, Edition 2/Summer 2015