For decades, thousands of active-duty service members have sought treatment for trauma exposure. Stellate ganglion block (SGB) is a fast-acting nerve block documented in medical literature for nearly a century that has shown promise as a potentially life-altering treatment for post-traumatic stress (PTS).
OBJECTIVE:
This review aims to answer the practical questions of those who support individuals suffering from trauma: (1) SGB’s safety profile (2) efficacy data (3) potential advantages and limitations, (4) a cross-cultural application example, (5) and the use of SGB in combination with talk therapy to optimize clinical outcomes.
METHODS:
The current body of literature, to include several large case series, meta-analyses, and a sufficiently powered randomized controlled trial, were reviewed, and presented to describe the history of SGB for emotional trauma symptoms and address the objectives of this review.
RESULTS:
Critical consideration is given to the safety and efficacy data on SGB and the evolution in safety-related technologies. Advantages such as decreased barriers to care, rapid onset, and decreased dropout and limitations such as treatment non-response, potential adverse effects, and misconceptions about the treatment are then described. Finally, the cross-cultural application of SGB is explored based on the deployment of SGB in Israel.
CONCLUSION:
SGB is associated with level 1B evidence and a reassuring safety profile. Evolving the model of care through the combined use of effective biological treatments like SGB with trauma informed talk therapy offers a hopeful path forward for supporting those who suffer from post-traumatic stress.
Aleanakian,R., Chung,B. Y., Feldmann,R. E.Jr., Benrath,J. (2020). Effectiveness, safety, and predictive potential in ultrasound-guided stellate ganglion blockades for the treatment of sympathetically maintained pain. Pain practice: The Official Journal of World Institute of Pain, 20(6), 626–638.
3.
Alino,J., Kosatka,D., McLean,B., Hirsch,K. (2013). Efficacy of stellate ganglion block in the treatment of anxiety symptoms from combat-related post-traumatic stress disorder: A case series. Military Medicine, 178(4), e473–e476.
Alkire,M. T., Hollifield,M., Khoshsar,R., Nguyen,L., Alley,S. R., Reist,C. (2015). Neuroimaging suggests that stellate ganglion block improves post-traumatic stress disorder (PTSD) through an amygdala mediated mechanism. Presented at the Anesthesiology Annual Meeting.
6.
Bouskill,K. E., Farmer,C. M., Cabreros,I., Cantor,J. H., Ernecoff,N., Hu,L., Fischer,S. H., Kofner,A., Meredith,L. S., Mizel,M. L., Motala,A., Piquado,T., Predmore,Z., Ramchand,R. (2022). Improving Care for Veterans with Traumatic Brain Injury Across the Lifespan. Santa Monica, CA: RAND Corporation.
Cheney,A. M., Koenig,C. J., Miller,C. J., Zamora,K., Wright,P., Stanley,R., Fortney,J., Burgess,J. F., Pyne,J. M. (2018). Veteran-centered barriers to VA mental healthcare services use. BMC Health Serv Res, 18(1), 591.
9.
Dantzer,R., O’Connor,J. C., Freund,G. G., Johnson,R. W., Kelley,K. W. (2008). From inflammation to sickness and depression: When the immune system subjugates the brain. Nature reviews. Neuroscience, 9(1), 46–56. https://doi.org/10.1038/nrn2297
Dworkin,R. H., O’Connor,A. B., Audette,J. (2010). Recommendations for the pharmacological management of neuropathic pain: An overview and literature update. Mayo Clinic Proceedings, 85(3, suppl), S3–S14.
12.
Ferguson,J. M. (2001). SSRI antidepressant medications: Adverse effects and tolerability. Primary Care Companion to the Journal of Clinical Psychiatry, 3(1), 22–27.
13.
GAO (Government Accountability Office). (2022). Behavioral Health: Available Workforce Information and Federal Actions to Help Recruit and Retain Providers (GAO-23-105250). Published: Oct 27, 2022. Accessed 8/23/23 online: https://www.gao.gov/products/gao-23-105250
14.
Ghai,A., Kaushik,T., Kundu,Z. S., Wadhera,S., Wadhera,R. (2016). Evaluation of new approach to ultrasound guided stellate ganglion block. Saudi Journal of Anaesthesia, 10(2), 161–167.
Hanling,S. R., Hickey,A., Lesnik,I., Hackworth,R. J., Stedje-Larsen,E., Drastal,C. A., McLay,R. N. (2016). Stellate ganglion block for the treatment of posttraumatic stress disorder: A randomized, double-blind, controlled trial. Reg Anesth Pain Med, 41(4), 494–500.
17.
Held,P. (2022). Enhancing Cognitive Processing Therapy for Posttraumatic Stress Disorder Via Stellate Ganglion Block Treatment: A Pilot Trial (SGB). Identifier NCT05534126. https://classic.clinicaltrials.gov/ct2/show/NCT05534126
18.
Institute of Medicine. (2008). Treatment of PTSD: An Assessment of the Evidence (Report Brief). Washington, DC: The National Academies Press.
19.
Karnosh,L. J., Gardner,W. J. (1947). The effects of bilateral stellate ganglion block on mental depression; report of 3 cases. Cleveland Clinic Quarterly, 14(3), 133–138.
20.
Kerzner,J., Liu,H., Demchenko,I., Sussman,D., Wijeysundera,D. N., Kennedy,S. H., Ladha,K. S., Bhat,V. (2021). Stellate ganglion block for psychiatric disorders: A systematic review of the clinical research landscape. Chronic Stress(Thousand Oaks, CA).
21.
Kharadi,D., Patel,K., Rana,D., Patel,V. (2015). Off-label drug use in Psychiatry Outpatient Department: A prospective study at a Tertiary Care Teaching Hospital. Journal of Basic and Clinical Pharmacy, 6(2), 45–49.
22.
Kirkpatrick,K., Khan,M. H., Deng,Y., Shah,K. B. (2023). A review of stellate ganglion block as an adjunctive treatment modality. Cureus, 15(2), e35174.
23.
Kopacz,D. J., Emanuelsson,B. M., Thompson,G. E., Carpenter,R. L., Stephenson,C. A. (1994). Pharmacokinetics of ropivacaine and bupivacaine for bilateral intercostal blockade in healthy male volunteers. Anesthesiology, 81(5), 1139–1148.
24.
Lambert,M. J., Hansen,N. B., Finch,A. E. (2001). Patient-focused research: Using patient outcome data to enhance treatment effects. Journal of Consulting and Clinical Psychology, 69, 1590–172.
25.
Lebovits,A. H., Yarmush,J., Lefkowitz,M. (1990). Reflex sympathetic dystrophy and posttraumatic stress disorder. Multidisciplinary evaluation and treatment. The Clinical Journal of Pain, 6(2), 153–157.
26.
Lipov,E. (2023). Survey Reveals That Renaming Post-Traumatic Stress ‘Disorder’ to ‘Injury’ Would Reduce Stigma. Cureus.
27.
Lipov,E. G., Jacobs,R., Springer,S., Candido,K. D., Knezevic,N. N. (2022). Utility of cervical sympathetic block in treating post-traumatic stress disorder in multiple cohorts: A retrospective analysis. Pain Physician, 25(1), 77–85.
28.
Lipov,E. G., Joshi,J. R., Lipov,S., Sanders,S. E., Siroko,M. K. (2008). Cervical sympathetic blockade in a patient with post-traumatic stress disorder: A case report. Annals of Clinical Psychiatry, 20(4), 227–228.
29.
Lipov,E. G., Navaie,M., Brown,P. R., Hickey,A. H., Stedje-Larsen,E. T., McLay,R. N. (2013). Stellate ganglion block improves refractory post-traumatic stress disorder and associated memory dysfunction: A case report and systematic literature review. Military Medicine, 178(2), e260–e264.
30.
Liu,L. D., Duricka,D. L. (2022). Stellate ganglion block reduces symptoms of Long COVID: A case series. Journal of Neuroimmunology, 362, 577784.
31.
Lynch,J. H., Muench,P. D., Okiishi,J. C., Means,G. E., Mulvaney,S. W. (2021). Behavioral health clinicians endorse stellate ganglion block as a valuable intervention in the treatment of trauma-related disorders. Journal of Investigative Medicine: The Official Publication of the American Federation for Clinical Research, 69(5), 989–993.
32.
Lynch,J. H., Mulvaney,S. W., Bryan,C. J., Hernandez,D. (2023). Stellate ganglion block reduces anxiety symptoms by half: A case series of 285 patients. Journal of Personalized Medicine, 13(6), 958.
33.
LynchJ. H. (2020). Stellate ganglion block treats posttraumatic stress: An example of precision mental health. Brain and Behavior, 10(11), e01807.
34.
Lynch,J. H., Mulvaney,S. W., Kim,E. H., de Leeuw,J. B., Schroeder,M. J., KaneS. F. (2016). Effect of stellate ganglion block on specific symptom clusters for treatment of post-traumatic stress disorder. Mil Med, 181(9), 1135–1141.
35.
McLean,B. (2015). Safety and patient acceptability of stellate ganglion blockade as a treatment adjunct for combat-related post-traumatic stress disorder: A quality assurance initiative. Cureus, 7(9), e320.
36.
Mott,J. M., Mondragon,S., Hundt,N. E., Beason-Smith,M., Grady,R. H., Teng,E. J. (2014). Characteristics of U.S. veterans who begin and complete prolonged exposure and cognitive processing therapy for PTSD. J Trauma Stress, 27, 265–273.
37.
Mott,J. M., Hundt,N. E., Sansgiry,S., Mignogna,J., Cully,J. A. (2014). Changes in psychotherapy utilization among veterans with depression, anxiety, and PTSD. Psy Serv, 65, 106–112.
38.
Mulvaney,S. W., Curtis,K. E., Ibrahim,T. S. (2020). Comparison of C6 stellate ganglion versus C6 and C4 cervical sympathetic chain blocks for treatment of posttraumatic stress disorder (PTSD): Analysis of 147 patients. Journal of Neurological Disorders and Stroke, 7(3), 1–4.
39.
Mulvaney,S. W., Lynch,J. H., Curtis,K. E., Ibrahim,T. S. (2022). The successful use of left-sided stellate ganglion block in patients that fail to respond to right-sided stellate ganglion block for the treatment of post-traumatic stress disorder symptoms: A retrospective analysis of 205 patients. Military Medicine, 187(7-8), e826–e829.
40.
Mulvaney,S. W., Lynch,J. H., Hickey,M. J., Rahman-Rawlins,T., Schroeder,M., Kane,S., Lipov,E. (2014). Stellate ganglion block used to treat symptoms associated with combat-related post-traumatic stress disorder: A case series of 166 patients. Military Medicine, 179(10), 1133–1140.
41.
Najavits,L. M. (2015). The problem of dropout from “gold standard” PTSD therapies. F1000prime Reports, 7, 43.
42.
Navaie,M., Keefe,M. S., Hickey,A. H., McLay,R. N., Ritchie,E. C., Abdi,S. (2014). Use of stellate ganglion block for refractory post-traumatic stress disorder: A review of published cases. Journal of Anesthesia and Clinical Research, 5(4).
43.
Patterson,B. K., Guevara-Coto,J., Yogendra,R., Francisco,E. B., Long,E., Pise,A., Rodrigues,H., Parikh,P., Mora,J., Mora-Rodríguez,R. A. (2021). Immune-based prediction of COVID-19 severity and chronicity decoded using machine learning. Frontiers in Immunology, 12, 700782.
44.
Pearson,L., Maina,A., Thompson,L., Harden,S., Aaroe,A., Compratt,T. (2023). Stellate ganglion block to treat long COVID-19 Syndrome: A 41 patient retrospective cohort study. Preprint Accessed Online on 8/17/23: medRxiv. 2023.08.10.23290338.
45.
Peterson,A. L., Straud,C. L., Young-McCaughan,S., McCallin,J. P., Hoch,M., Roux,N. P.3rd, Koch,L., Lara-Ruiz,J., Roache,J. D., Hein,J. M., Blount,T. H., STRONG STAR Consortium (2022). Combining a stellate ganglion block with prolonged exposure therapy for posttraumatic stress disorder: A nonrandomized clinical trial. Journal of Traumatic Stress, 35(6), 1801–1809.
46.
Peterson,K., Bourne,D., Anderson,J., Mackay,K., Helfand,M. (2017). Evidence Brief: Effectiveness of Stellate Ganglion Block for Treatment of Posttraumatic Stress Disorder (PTSD) [Internet]. Washington (DC): Department of Veterans Affairs (US). Available from: https://www.ncbi.nlm.nih.gov/books/NBK442253/
47.
Pizer,S. D., Prentice,J. C. (2011). What are the consequences of waiting for health care in the veteran population?J Gen Intern Med, 26(Suppl 2(Suppl 2)), 676–682.
48.
Rae-Olmsted,K. L. R., Bartoszek,M., Mulvaney,S., McLean,B., Turabi,A., Young,R., Kim,E., Vandermaas-Peeler,R., Morgan,J. K., Constantinescu,O., Kane,S., Nguyen,C., Hirsch,S., Munoz,B., Wallace,D., Croxford,J., Lynch,J. H., White,R., Walters,B. B. (2020). Effect of Stellate Ganglion Block Treatment on Posttraumatic Stress Disorder Symptoms: A randomized clinical trial. JAMA Psychiatry, 77(2), 130–138.
49.
Rauch,S., Foa,E. (2006). Emotional processing theory (EPT) and exposure therapy for PTSD. Journal of Contemporary Psychotherapy, 36, 61–65.
50.
Schnurr,P. P., Friedman,M. J., Engel,C. C., Foa,E. B., Shea,M. T., Chow,B. K., Resick,P. A., Thurston,V., Orsillo,S. M., Haug,R., Turner,C., Bernardy,N. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized controlled trial. Journal of the American Medical Association, 297, 820–830.
Stone,K. J., Viera,A. J., Parman,C. L. (2003). Off-label applications for SSRIs. American Family Physician, 68(3), 498–504.
54.
Summers,M. R., Nevin,R. L. (2017). Stellate ganglion block in the treatment of post-traumatic stress disorder: A review of historical and recent literature. Pain Practice: The Official Journal of World Institute of Pain, 17(4), 546–553.
55.
Surya,S., McCall,W. V., Iltis,A. S., Rosenquist,P. B., Hogan,E. (2015). The practice of electroconvulsive therapy in US correctional facilities: A nationwide survey. The Journal of ECT, 31(3), 150–154.
56.
Sussman,D., Tassone,V. K., Gholamali Nezhad,F., Wu,M., Adamsahib,F., Mattina,G. F., Pazmino-Canizares,J., Demchenko,I., Jung,H., Lou,W., Ladha,K. S., Bhat,V. (2023). Local injection for treating mood disorders (LIFT-MOOD): A pilot feasibility RCT of stellate ganglion block for treatment-resistant depression. Chronic Stress (Thousand Oaks, Calif.), 7, 24705470231160315.
57.
Telaranta,T. (1998). Treatment of social phobia by endoscopic thoracic sympathectomy. European Journal of Surgery, 164(1), 27–32.
Verrills,P., Lipov,E., Wright,R., SethiZ. (2023). Efficacy of right-sided cervical sympathetic block in treating post-traumatic stress disorder in Australian cohorts: A retrospective analysis. Res Pract Anesthesiol Open J, 7(1), 15–20.
61.
Watts,B. V., Shiner,B., Zubkoff,L., Carpenter-Song,E., Ronconi,J. M., Coldwell,C.M. (2014). Implementation of evidence-based psychotherapies for posttraumatic stress disorder in VA specialty clinics. Psychiatric Services, 65, 648–653.
62.
Wulf,H., Maier,C. (1992). Komplikation und nebenwirkungen bei blockaden des ganglion stellatum. Ergebnisse einer Fragebogenerhebung [Complications and side effects of stellate ganglion blockade. Results of a questionnaire survey]. Der Anaesthesist, 41(3), 146–151.
Zhang,J., Nie,Y., Pang,Q., Zhang,X., Wang,Q., Tang,J. (2021). Effects of stellate ganglion block on early brain injury in patients with subarachnoid hemorrhage: A randomised control trial. BMC Anesthesiology, 21(1), 23.
