SGB procedure holds potential promise for PTSD treatment

Walter Reed Army Medical Center in Bethesda, MD, has published case reports detailing the successful treatment of combat-related post-traumatic stress disorder with a stellate ganglion block.

SGB is a 10-minute procedure during which local anesthesia is injected next to the stellate ganglion, a collection of nerves in the neck. SGB has been used safely to treat chronic pain and other ailments since 1925, but Dr. Eugene Lipov, a Chicago-area anesthesiologist and researcher, has pioneered this approach for the treatment of PTSD.

In duplicating Dr. Lipov's work, the Walter Reed team, led by Lieutenant Colonel Sean W. Mulvaney, M.D., found that, "unlike conventional treatments for PTSD, SGB appears to provide results almost immediately. Both patients experienced immediate, significant and durable relief."

One of the patients in the Reed case reports is a 36-year-old white male on active military duty whose symptoms began after the battle of Fallujah. The other patient is a 46-year-old Hispanic male retired from military service whose symptoms began 18 years ago in the first Gulf War. For over a year, both patients had been receiving pharmacologic treatment, which was ineffective in treating their symptoms; both suffered adverse effects from their medications, including depression, somnolence and erectile dysfunction.

The Walter Reed case reports, published in the May 2010 issue of Pain Practice 10.3, concluded that "selective blockade of the right stellate ganglion at C6 level is a safe and minimally invasive procedure which may provide durable relief from PTSD symptoms, allowing the safe discontinuation of psychiatric medications."

Dr. Lipov was invited to provide his expert opinion on the results in a guest editorial, which noted that Dr. Mulvaney's case reports were not the first to describe the psychiatric effects of the SGB. As he wrote, "[Other reports have] described the successful treatment of mental depression by bilateral stellate ganglion block, unexpected improvement in schizophrenia following SGB, and improvement of despair in rats by a superior cervical sympathetic ganglion block."

Dr. Lipov has published papers in several medical journals, providing a theoretical model of the biological brain changes that reverse PTSD following the procedure. "Using functional MRIs to show the part of the brain that is active during fear and other traumatic emotions, we can see and measure the physiologic changes that occur during trauma," he explains. "These MRIs are telling us that the cause of PTSD is physical in nature, and not simply a 'psychological condition.'"

In a paper published in 2009, he proposed a mechanism, based on solid experimental data, that trauma leads to an increase in nerve growth factor. "That leads to sprouting of the sympathetic nerves, which leads to increased production of norepinphrine - adrenaline - and that makes people anxious," he says. A block placed next to the stellate ganglion leads to a decrease in nerve growth factor and a reversal of PTSD symptoms.

The coming tsunami of PTSD cases. The Department of Veterans Affairs is seeing an increasing number of soldiers returning from Iraq and Afghanistan with a mental disorder such as major depression or PTSD. As deployments lengthen, those numbers are expected to grow.

About 25 percent of homeless Americans are veterans—131,000 according to VA statistics—and more than 75 percent have a mental disorder, often PTSD. The National Coalition for Homeless Veterans has noted that Iraq veterans are already beginning to show up in that population.

"If we could use the stellate ganglion block to treat these patients, we might be able to turn back the tide and stop the surge of PTSD," says Dr. Lipov. "Multiple attempts were undertaken to secure funding for randomized, controlled trials to quantify the efficacy of SGB, but the primary obstacle to funding has been the lack of a theoretical model to explain how SGB relieves PTSD and its simplicity.

"We are hoping that Dr. Mulvaney's confirmation of our results will open the door to further research so that PTSD sufferers all over the country - ultimately, all over the world - will be relieved of this debilitating disorder."