Efficacy of cervical sympathetic blockade in the treatment of primary and secondary PTSD symptoms: A case series.

Background: Post-traumatic stress disorder (PTSD) can develop in individuals following exposure to an overwhelmingly traumatic event. Secondary PTSD is defined as occurring after exposure to a person with primary PTSD, such as an intimate partner. Successful treatment of PTSD symptoms by the use of cervical sympathetic blockade (CSB) has been previously reported to help with symptoms irrespective of PTSD cause. Objective: To describe the efficacy of CSB in treating symptoms of primary and secondary PTSD in two couples, and visualize CSB impact through neuroimaging. Methods: Four patients received CSB at C6 and C4 with ultrasound guidance on the right side followed by the left side a day later. PTSD symptoms were evaluated in all patients using the PTSD Checklist (PCL-5) before and after the procedure. Patients underwent SPECT scans acquired using a high resolution Picker (Philips) Prism XP 3000 triple-headed gamma camera, with low-energy high-resolution fan beam collimators, one day before and one week after the procedures. Results: CSB showed acute benefit for symptoms of primary and secondary PTSD, offering a clinically significant reduction in PTSD symptoms in all four patients. The PCL-5 scores of patients with primary PTSD were reduced from 41 to 7 and from 44 to 6 on the 80-point scale. The PCL-5 scores of patients with secondary PTSD were reduced from 40 to 17 and from 43 to 7 on the 80-point scale. Furthermore, SPECT imaging showed stark increases in activity in the prefrontal pole and thalamus in all patients, and increases in activity in the inferior orbital prefrontal cortex in three of four cases. Modulation of activity in the temporal lobes, orbital prefrontal cortex and basal ganglia was also noted after the procedure. Conclusion: CSB is a minimally invasive procedure with an excellent safety profile, providing relief of primary and secondary PTSD symptoms. The increase in prefrontal pole, thalamus and inferior orbital activity correlates with the improved symptomatology.

Utility of Cervical Sympathetic Block in Treating Post-Traumatic Stress Disorder in Multiple Cohorts: A Retrospective Analysis.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a prevalent and debilitating condition in the United States. Success rates for evidence-based therapies are inconsistent, and many suffer in silence due to the stigmata associated with seeking traditional mental health care. This has led clinicians to explore new therapeutic options, with cervical sympathetic blockade (CSB), performed at the stellate and/or superior cervical ganglion levels, recently emerging as a promising treatment option. Rapid therapeutic onset, improved compliance, and high clinical efficacy rates have made this an attractive approach for both providers and patients. However, to date, CSB as a treatment of PTSD has primarily been used in male patients with military-related trauma. OBJECTIVE: To evaluate the efficacy of CSB as a treatment option for PTSD in both genders and multiple etiologies of psychological trauma. STUDY DESIGN: Retrospective cohort study. SETTING: An established anesthesia pain clinic in Chicago, IL, USA. METHODS: Following retroactive IRB approval, 484 consecutive cases of patients diagnosed with PTSD and treated with CSB, performed by a single provider (December 2016 - February 2020) were analyzed. The primary outcome measurement was the PTSD Checklist Score version DSM IV (PCL-4). Patient demographic and clinical information collected included age, gender, type of trauma leading to PTSD, history of suicidal attempts, and psychiatric medication use. RESULTS: After exclusion of cases due to missing data points, 327 patients were included in the final statistical analysis, having completed both PCL-4 pre and post CSB, between 7- and 30-days post-intervention. The patient population included military men (n = 97), civilian men (n = 85), military women (n = 13) and civilian women (n = 132). We identified 21 types of self-reported trauma leading to PTSD. Average decrease in PCL score for men and women was 28.59 and 29.2, respectively. Statistical analysis of the male population with a military background showed a significantly greater change in corresponding PCL scores than civilians (PCL-M change = -31.83 vs PCL-C change = -24.89). Likewise, women who had a military background had a significantly greater reduction in PCL score than civilians (39.15 vs 28.23). Statistically significant improvements in PTSD symptoms were noted independent of the causative trauma type, gender, age greater than 20, previous suicide attempts, or use of prescription medications for PTSD. Among the 21 types of reported trauma, 19 types reached statistical significance. LIMITATIONS: Limitations include the limited scope of observation giving exclusive focus on pre- and post-PCL data, the limited duration of observation, the self-reported nature of the patient-provided data, and the provision of treatment by a single physician. CONCLUSION: CSB seems to be an effective treatment for PTSD symptoms irrespective of gender, trauma type, PTSD-related drug use, suicide attempt, or age.

Possible Reversal of PTSD-Related DNA Methylation by Sympathetic Blockade.

Studies have shown that brain-derived neurotrophic factor (BDNF) level increase is associated with post-traumatic stress disorder (PTSD) risk. BDNF may be a "missing-link" that mediates the interaction between genetics, environment, and the sympathetic system. Trauma has been shown to induce DNA methylation that in turn can increase BDNF concentration due to increased gene expression. Therapies that focus on the reduction of beta-NGF (BNGF) levels may impact PTSD symptoms. The focus of this paper is to discuss possible effect of stellate ganglion block (SGB) on epigenetic changes noted with PTSD mediated by BDNF and NGF. Stellate ganglion block has recently shown significant therapeutic efficacy for treatment of PTSD symptoms. Previously reported theoretical mechanisms of SGB impact on PTSD have focused on likely reduction of NGF, leading to eventual loss of extraneous sympathetic nerve growth, eventually leading to reduction of secondary norepinephrine level, which in turn is hypothesized to reduce PTSD symptoms. We used PUBMED to obtain available data following a search for the following: DNA, neurotrophic factors, post-traumatic stress disorder, and demethylation following local anesthetic application. A number of articles meeting criteria were found and reviewed. Based on the evidence summarized, trauma can lead to DNA methylation, as well as BNGF/NGF level increase, which in turn starts a cascade of sympathetic sprouting, leading to increased brain norepinephrine, and finally symptomatic PTSD. Cascade reversal may occur in part by demethylation of DNA caused by application of local anesthetic to the stellate ganglion.

Stellate ganglion block improves refractory post-traumatic stress disorder and associated memory dysfunction: a case report and systematic literature review.

The prevalence of post-traumatic stress disorder (PTSD) has reached epidemic proportions among U.S. veterans, many of whom also have concurrent alcohol use disorder. This case report describes improvements in PTSD symptom severity and memory dysfunction in a combat-exposed veteran with persistent PTSD and alcohol use disorder following two treatments of stellate ganglion block (SGB). PTSD severity was measured using the PTSD Checklist, Military Version. Memory function was evaluated using the Rey Auditory Verbal Learning Test. One month after the first SGB, a 43.6% reduction in PTSD severity was observed along with increases in immediate memory (50%), recent memory (28%), and recognition memory (25%). Following a second SGB, PTSD severity decreased by 57.7% and memory function substantially improved, with pronounced changes in immediate memory (50%), recent memory (58%), and recognition memory (36%). One year after SGB treatments, the patient has stopped drinking alcohol, continues to have sustained relief from PTSD, has improved memory function, and has become gainfully employed. Future studies that employ robust epidemiologic methodologies are needed to generate confirmatory evidence that would substantiate SGB's clinical utility as an adjunctive treatment option for PTSD.

'Hybrid neurostimulator': simultaneous use of spinal cord and peripheral nerve field stimulation to treat low back and leg pain.

Treatment of chronic back and leg pain in patients with failed back surgery syndrome (FBSS) remains problematic as none of the currently available approaches are universally successful in achieving lasting pain control. Spinal cord stimulation (SCS) is very effective for controlling radicular pain but rarely provides adequate control of pain in the lower back. Recently, a technique of peripheral nerve stimulation (PNS) was introduced to control pain in a group of patients for whom back pain dominated the clinical picture. Because PNS does not control neuropathic pain due to lumbosacral radiculopathy involving the lower extremities, we developed a hybrid technique of SCS and PNS that offers potential control of both axial pain in the lumbar area and radicular pain to the lower extremities. This chapter presents our results and the possible mechanisms of action.

A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD).

The mechanism of action of the stellate ganglion block (SGB) is still uncertain; however it has been used successfully in treatment of chronic regional pain syndrome (CRPS) for many years. Our new insights in to the mechanism of action of the stellate ganglion block were first reported in 2007 in our publication detailing the control of hot flashes with the use of stellate ganglion blockade. We have demonstrated very significant results in the treatment of hot flashes and our most recent application of this block has been for the treatment of posttraumatic stress disorder (PTSD). Stellate ganglion has been demonstrated to have second and third order neurons connections with the central nervous system nuclei that modulate body temperature, neuropathic pain, the manifestations of PTSD, and many other areas. We believe that the commonality between the CRPS, HF and PTSD is the trigger of increased nerve growth factor (NGF) leading to the increase in brain norepinephrine (NR), which in turn is affected by the SGB leading to a prolonged reduction of NGF and eventually a decrease in NR. This, in turn, leads to a reduction or elimination of many of the symptoms of CRPS, Hot flashes, and PTSD.

Use of peripheral subcutaneous field stimulation for the treatment of axial neck pain: a case report.

Objective. To present a novel technique of neuromodulation for the treatment of axial neck pain. Materials and Methods. A case of a patient with history of long-standing axial neck pain with previous cervical spine operation and confirmed discogenic pain is presented. Traditional treatment measures did not provide adequate pain relief. A trial of peripheral subcutaneous field stimulation (PSFS) was performed. Following an excellent response during a week-long trial, a permanent PSFS system was implanted. The patient was followed for nine months after internalization. Results. Seven-day trial of PSFS resulted in complete relief of the patient's pain. This 100% relief of pain continued after the implantation of permanent PSFS system consisting of two quadripolar electrodes, one placed over the paraspinal muscles parallel to midline, and the other positioned horizontally over the ipsilateral trapezius muscle. The patient was gradually weaned off of all opioid medications and continues to report 100% reduction in pain intensity at the nine-month follow-up. Conclusion. PSFS represents a new and promising modality in treatment of axial neck pain. Exact mechanism of the pain relief remains unclear.

Effects of stellate-ganglion block on hot flushes and night awakenings in survivors of breast cancer: a pilot study.

BACKGROUND: Debilitating hot flushes and sleep dysfunction often affect survivors of breast cancer, most notably in those taking anti-oestrogen medications. Conventional treatments have been only partially effective in diminishing these issues, and some have serious risks. We did a pilot study to investigate our hypothesis that stellate-ganglion block can be a safe and effective treatment for hot flushes and sleep dysfunction in this patient population. METHODS: 13 survivors of breast cancer (in remission) with severe hot flushes and night awakenings were treated with stellate-ganglion block at the anterolateral aspect of the C6 vertebra on the right side under fluoroscopy. Patients recorded hot flushes in a daily diary by use of the Hot-Flash Score, devised by Sloan and colleagues, and night awakenings by use of the Pittsburgh Sleep Quality Index. Both instruments were used 1 week before the procedure [A40] and then weekly after the procedure for 12 weeks. We used the generalised-estimating-equations method to analyse the longitudinal measurements of the number of hot flushes and night awakenings over time. This method is a popular approach to analysing datasets that have repeated measures from the same person, and is robust because it does not need the complete distribution of the outcomes to be specified. This trial is registered on the International Standard Randomised Controlled Trial Number register (ISRCTN14318565). FINDINGS: There were no adverse events resulting from the stellate-ganglion block, although patients had temporary Horner's syndrome indicating the effectiveness of the block. Five patients had only one stellate-ganglion block and eight had two stellate-ganglion blocks. The total number of hot flushes decreased from a mean of 79.4 (SD 37.4) per week before the procedure to a mean of 49.9 (SD 39.9) per week during the first 2 weeks after the procedure (p=0.0002). The total number of hot flushes continued to decrease over the remaining follow-up period (weeks 3-12), and stabilised at a mean of 8.1 (SD 5.6) per week (p<0.0001). The number of very severe hot flushes was decreased to near zero by the end of the follow-up period (week 12; p<0.0001). Night awakenings decreased from a mean of 19.5 (SD 14.8) per week before the procedure to a mean of 7.3 (SD 7.1) per week during the first 2 weeks after the procedure (p<0.0001). The total number of night awakenings continued to decrease over the remaining follow-up period (weeks 3-12) and stabilised at a mean of 1.4 (SD 1.2) per week (p<0.0001). INTERPRETATION: The findings of this study suggest that stellate-ganglion block can provide survivors of breast cancer with relief from hot flushes and sleep dysfunction with few or no side-effects. Long-term relief of symptoms has the potential to improve overall quality of life and increase compliance with anti-oestrogen medications for breast cancer.