Guided Anesthetic Injection May Help Patients With PTSD

According to the National Center for PTSD, posttraumatic stress disorder (PTSD) affects about 5% of U.S. adults in any given year. While behavioral interventions (such as prolonged exposure therapy) are highly effective, finding a therapist trained to deliver the therapy can be challenging. Medications for PTSD—including sertraline (for stress and anxiety) and prazosin (for nightmares)—may be more accessible, but fail to address the trauma underlying the condition.

“When it comes to this debilitating psychiatric disorder, what we have been doing hasn’t been working,” said Kristine Rae Olmsted, M.S.P.H., a psychiatric epidemiologist at RTI International, a nonprofit research organization. “We need new treatment modalities to help these people who are hurting.”

The stellate ganglion block—which has been used for nearly 100 years to treat pain—may offer an alternative option for patients with PTSD. The procedure has been used as an off-label PTSD treatment for nearly two decades, but currently there are only a few peer-reviewed clinical trials assessing the technique.

Targeting Sympathetic Nervous System

A stellate ganglion block involves an injection of anesthetic (typically Ropivacaine or Bupivacaine) next to a bundle of nerves near the base of the neck known as the stellate ganglion. These nerves are a key conduit of the sympathetic nervous system, which regulates blood pressure, sweating, and pain perception. Activation of the sympathetic nervous system also triggers the “flight-or-fight” response, which can be dysregulated in people with PTSD.

Eugene Lipov, M.D., a trained anesthesiologist and pain physician, was introduced to stellate ganglion block therapy in the 1980s when treating patients with neuropathic pain (such as burn pain or shingles). He believed that by adjusting the position of the stellate ganglion block he could temporarily block communication to the brain circuits controlling the flight-or-fight response, resetting the system and reducing symptoms of PTSD.

He began treating people with PTSD, including military and survivors of abuse, in 2006. In 2012, he modified his approach by delivering two ultrasound-guided anesthetic injections to the stellate ganglion region, first at vertebrae C6 and then higher up at C3/C4. Lipov said that the two injections ensure a thorough blockade. He called the new approach dual sympathetic reset.

Lipov is now the chief medical officer at the Stella Center, which offers advanced stellate ganglion block therapy, among other options, for patients paying out of pocket.

In 2022, Lipov published a report in the journal Pain Physician. This retrospective analysis of over 300 patients who came to his clinic for more than 20 types of trauma between 2016 and 2020 found that 81% reported noticeable improvements (at least a 10-point change on the PTSD checklist) at a follow-up assessment seven to 30 days after their procedure.

In the report, Lipov and colleagues wrote: “[T]he advancement of psychological trauma care may require a paradigm shift based on the understanding that trauma is a biological injury with associated psychological changes. … The combination of medical innovation with best practice talk therapy treatment may lead to a new standard of care for individuals suffering psychological trauma.”

In a separate study by Rae Olmsted, 113 active-duty service members with elevated PTSD symptoms (81% of enrollees met the DSM-5 criteria for PTSD) were randomized to receive either two stellate ganglion block injections or two sham injections, spaced two weeks apart, in combination with their regular PTSD treatments.

Eight weeks after the first injection, those who received stellate ganglion blocks reported significantly lower symptoms of PTSD than those receiving sham therapy, as measured by the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). CAPS-5 scores fell on average 12.6 for the group receiving stellate ganglion blocks and 6.1 points in those receiving the sham treatment.

“Beyond the statistics, these results were clinically significant,” Rae Olmsted said, noting that a 10-point change on the CAPS-5 is often considered a benchmark reflecting a noticeable difference. “People’s lives were getting better.”

(Co-authors on the study with Rae Olmsted include Sean Mulvaney, M.D., of the Uniformed Services University of the Health Sciences and James H. Lynch, M.D., of the U.S. Army Special Operations Command. In 2021, Mulvaney and Lynch co-founded the Stellate Institute, another private center that provides stellate ganglion block.)

Questions Remain

Rae Olmsted said that countless questions remain regarding the benefits and risks of stellate ganglion block in patients with PTSD. One of these questions involves the durability of treatment; one case series of military patients suggests the effects of a stellate ganglion block diminish after one month, while a subsequent larger analysis reported they may last at least three months.

Rae Olmsted is currently leading a prospective cohort study that will monitor about 300 service members and veterans for 12 months following a stellate ganglion block. In addition to tracking the participants’ PTSD and other behavioral symptoms, the study will also periodically assess neurocognitive functioning.

“One of the biggest questions prospective participants asked in our trial was whether they could fire their weapon if they needed to,” she said. “They were concerned that numbing part of their fight-or-flight response would prevent them from being able to react quickly.” According to Rae Olmsted, the numbing effects of the procedure wear off within six to eight hours and anecdotal reports suggest that cognition improves following the procedure, but getting reliable data will be critical.

Charles Marmar, M.D., the Peter H. Schub Professor and chair of psychiatry at NYU Grossman School of Medicine, also believes stellate ganglion block needs more rigorous testing. “There is a rationale for why the procedure might work, but most of the positive reports are subjective, and there are a lot of biological details we still don’t know,” he said.

With any spinal injection, there are risks, Marmar continued. For example, anesthetic injection can trigger allergic reactions, eye drooping, or even brief convulsions.

Lipov said the rate of adverse events is very rare with his protocol (about 1 in 1,000). In the study by Rae Olmsted and colleagues of 113 participants, there were six adverse events reported—ranging from pain and redness at the injection site to low blood pressure.

If a patient has severe PTSD that has not responded to multiple treatments, then a stellate ganglion block might be considered, Marmar said. He thinks emerging approaches such as neurofeedback or reconsolidation therapy—in which traumatic memories are reshaped as neutral memories under appropriate medication—offer more promise. “But, I have been wrong before,” he noted.

Lipov, whose own father struggled with PTSD, has been passionate about encouraging mental health professionals to learn more about stellate ganglion block and include it in their toolbox for PTSD care alongside medications and behavioral therapy.

Rae Olmsted said she hopes that more psychiatrists familiarize themselves with the research and explore potential locations where they could refer patients for this treatment.

“There are many civilian pain clinics that offer [stellate ganglion block], but find out if potential referrals are reputable,” she said. One key question is whether the clinic uses ultrasound for the injection, as that is the gold standard.

The randomized trial by Rae Olmsted and colleagues was funded by a grant from the U.S. Army’s Defense Medical Research and Development Program. Lipov’s retrospective study involved no external funding. ■