Page 104 - JSOM Winter 2024

Updated Findings on the Efficacy of Combined Subanesthetic

Ketamine Infusion and Cervical Sympathetic Blockade as a
Symptomatic Treatment of PTSD/TBI in a
Special Forces Patient with a 2-year Follow-up

A Case Report

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Eugene Lipov, MD *; Zubin Sethi, OMS-IV ; Hunter Rolain, OMS-IV 3

ABSTRACT
Posttraumatic stress disorder (PTSD)/blast traumatic brain in- seems to have a synergistic effect on the symptoms of bTBI and
jury (bTBI) in a Special Operations Forces (SOF) cohort has PTSD in the SOF cohort.
been shown to be successfully treated using a cervical sym-
pathetic blockade (CSB)/ketamine infusion (KI) combination, Methods
termed the SOF method. In a prior case report, the patient was
followed for 1 year. This report followed the same patient for a Cervical Sympathetic Block
total of 720 days and found prolonged and sustained benefits Detailed informed consent was obtained prior to all proce-
with respect to PTSD and bTBI symptoms with further appli- dures for CSB. The patient first received a right-sided CSB
cation of the SOF method. with the following protocol. The patient was placed in the
supine position with the head rotated slightly to the left, with
Keywords: SOF; PTSD; ketamine infusion; cervical sympathetic monitoring per clinic protocol. The skin of the neck was
blockade; bTBI; TBI cleaned with chlorhexidine-isopropyl alcohol preparation
and 2g of sterile ultrasound gel was applied. The neck was
scanned using a broadband linear transducer (8–13 MHz
from the level of the 6th to the 4th cervical vertebrae in trans-
Introduction
verse view) using Mindray MX7. The skin at the injection
Special Operations Forces (SOF) represent the most elite mem- site on the lateral neck was anesthetized with 1.5mL of 1%
bers in the U.S. Military. SOF personnel are known to develop lidocaine. Using an in-plane approach under real-time ultra-
higher incidences of blast traumatic brain injury (bTBI) and sound guidance, a 22-gauge echogenic needle was placed just
posttraumatic stress disorder (PTSD), likely due to train- dorsal to the ventral fascia of the longus coli, medial to the
ing and/or the intensity of combat. They develop comorbid longus capitus. After aspiration, negative for CSF or blood,
neuropsychological disorders, including anxiety, depression, 0.5mL of 0.5% bupivacaine was injected, while monitoring
cognitive impairment, and suicidality. Current treatments the patient. After observing the patient for 30 seconds, a sec-
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demonstrate limited efficacy in addressing the unique neuro- ond 4-mL aliquot was injected. The patient was monitored
psychiatric symptoms in SOF members and veterans. Firstline for an additional 30 seconds. After the patient verbally con-
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PTSD treatments have focused on psychotherapy or medica- firmed absence of any concerning symptoms, an additional
tion, with drop-out rates of 30%–40% in randomized clinical 4mL of 0.5% bupivacaine was slowly injected over 1 minute
trials (RCTs). In those who have completed treatment, 60%– for a total injection volume of 8mL for a single-level block.
80% have recovered, with intention-to-treat analyses report- This was repeated at the 4th cervical level, with a total of 4mL
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ing recovery rates as low as a 40%. of bupivacaine. Left-sided CSB was performed the following
day due to safety considerations following the same injection
bTBI and PTSD present with many overlapping neuropsychi- protocol as above.
atric symptoms, including anxiety, irritability, insomnia, per-
sonality changes, and memory problems, which complicates Ketamine Infusion
diagnostic differentiation. The patient received 5 KI and SGB Detailed informed consent was obtained prior to all infusions
to the left and right sides over a 5-day period (Table 1). Ac- following a consultation. The initial infusion of racemic ket-
cordingly, SOF personnel would benefit from simultaneous amine hydrochloride (0.5mg/kg) was administered over 45
treatment for PTSD and TBI. Ketamine infusion (KI) com- minutes. Premedication with ondansetron (4-mg intravenous
bined with cervical sympathetic block (CSB), the SOF method, push) was used for all sessions, and an anesthesiologist was
*Correspondence to Eugene Lipov, Stella Center, 1 Oak Hill Dr, Unit 100, Westmont, IL 60559 or hope4ptsi@gmail.com
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1 Dr. Eugene Lipov is Chief Medical Officer at Stella Center, Westmont, IL. Zubin Sethi and Lt Hunter Rolain are affiliated with Midwestern
University Chicago College of Osteopathic Medicine, Downers Grove, IL.
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