What is Post-traumatic stress disorder (PTSD)?

PTSD is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, combat, or rape or who have been threatened with death, sexual violence or serious injury. Some propose using the term Post-traumatic stress injury (PTSI) to de-stigmatize the term “disorder” and to indicate the biologic nature of the traumatic injury sustained which can be healed with proper treatment, such as stellate ganglion block.

Many people who are exposed to a traumatic event experience symptoms such as:

  • Being irritable or easily startled, having angry outbursts or problems concentrating or sleeping

  • Distressing dreams or repeated, involuntary memories

  • Avoiding activities and situations that may trigger distressing memories

  • Feeling detached or estranged from others or difficulty experiencing positive emotions

For a person to be diagnosed with PTSD, these symptoms must last for more than a month and must cause significant distress or problems in the individual’s daily functioning. Symptoms may appear years after the trauma and often persist for months and sometimes years. PTSD often occurs with other related conditions, such as depression, substance use, memory problems and other physical and mental health problems.

PTSD affects approximately 3.5 percent of U.S. adults every year, and an estimated one in 11 people will be diagnosed with PTSD in their lifetime.

What are the risks of an SGB procedure?

The overall risks of having a significant adverse event are very small (much less than 1 in 1000) when done by a skilled provider with ultrasound guidance. There is a very small risk of a seizure from inadvertently injecting the local anesthetic into a blood vessel. There is an extremely small risk of forming a dangerous hematoma (collection of blood from a bleeding vessel). This risk is very small in people not taking blood thinning medications. SGB should not be done in people currently on blood thinning medications. About 20 percent of the time after a block, some patients get a hoarse voice or feel like there is something in the back of their throat. This occurs when the anesthetic spreads to another nerve near the larynx. This is not a mistake, it just happens sometimes. The hoarse voice or feeling in your throat, if it occurs, will wear off in 3-6 hours.

At what cervical vertebral level does Dr. Mulvaney and Dr. Lynch perform the SGB?

The doctors routinely performs the SGB at the 6th cervical vertebral level (C6). After the June 2020 publication by Dr. Mulvaney, which shows that two level blocks may be more beneficial, clinical practice changed so patients will also be offered an additional injection at higher cervical levels such as C4 or C3. Although there are over 20 peer-reviewed medical publications showing efficacy and safety when the SGB is done at the C6 level, Dr. Mulvaney’s June 2020 publication was the first study showing that two level blocks may be more beneficial. There are well-referenced anatomical differences in how a person’s sympathetic chain courses through their neck which may explain the additional benefits of a two level block in some patients. There is no additional fee if additional levels are performed.

Why is an ultrasound-guided SGB more effective?

Ultrasound allows the needle to be safely guided around the nerves and blood vessels in the neck as it is placed next to the stellate ganglion. Under x-ray (fluoroscopic) guidance, only bones are visible, so nerves are not visible at all and their position can only be approximated. Using ultrasound guidance to safely perform an SGB takes special training and considerable skill, which many pain medicine trained physicians do not have. Although during his fellowship in anesthesia/pain medicine at Walter Reed National Military Medical Center, Dr Mulvaney learned to do SGBs with fluoroscopic-guidance, he rejected this method as being more painful, less efficacious and unnecessarily risky as it exposes patients to contrast dye and ionizing radiation from the x-ray. Doesn’t it just make sense that you should be able to actually see your target as well as avoiding major blood vessels and nerves?

How do Dr. Mulvaney and Dr. Lynch evaluate if the SGB was successfully performed?

Dr Mulvaney was the first person to publish a grading scale to evaluate and measure Horner’s syndrome which is expected after a successful SGB. Horner’s syndrome is a series of temporary changes that happens on the side of the body that was blocked only once the “fight-or-flight” nervous system has been successfully turned off. Some of the changes are easily visible and includes ptosis (the eyelid will droop), miosis (the pupil will get smaller) and scleral icterus (the white part of the eye become red). After performing an SGB for a patient, Dr Mulvaney asks another staff person to grade and assign the resulting Horner’s syndrome a score (to reduce bias). Although this is uncommon, if for some reason the Horner’s score is not adequate by 5 minutes after the SGB, Dr Mulvaney will then repeat the procedure on the same side. (below is a picture of a typical Horner’s response).

What should I do if the initial SGB provided on the right side C6 does not provide the results that I had hoped for?

Although SGB has been demonstrated in the medical literature to provide durable relief of anxiety symptoms associated with PTSD, no therapy is 100% effective for all patients. A patient may have other medical conditions affecting their anxiety symptoms which may not respond to treatment with SGB. However, if they are a good candidate for this therapy, (PTSD diagnosis with an elevated PCL-5 score) and they fail to respond to a right-sided SGB, then the patient should consider a left-sided. This must be done at least one day later for safety reasons. (NEVER have a block on both sides of the neck within a 24-hour period; in theory this could result in a fatal blockage of the airway). Although the exact figure is not known at this time, about 1-5% of patients will not respond to a right-sided SGB but will respond profoundly to a left-sided SGB. Also, new unpublished data suggests that some people, perhaps as high as 20% of people, even if they partially respond to a right sided SGB, may have a more profound response to a left-sided SGB. This appears to be the case because some people have anatomic differences in how their “fight or flight” system is wired. If they fail to respond to a properly performed SGB with a good resulting Horner’s on the right or left side, then SGB is not an effective therapy for this patient and further SGBs should not be attempted.

What is the percentage of success?

We carefully screen our potential patients to select those that have the best chance of having success with the SGB. In a properly selected patient, we have a published success rate of over 85% (defined by significant improvements in the PCL-5 score).

How many treatments does it usually take?

About one third of patients are successfully treated with a single SGB and do not need another SGB. Some people may be exposed to conditions that “re-trigger” their PTSD symptoms and need another treatment in the future. It can be safely repeated if it was helpful the first time.Completing follow up PCL-5 surveys at one week and one month after your SGB is performed is very important so we can document whether this was a good therapy for you.

How many of these blocks has Dr. Mulvaney and Dr. Lynch done?

Over a 10-year period, Dr. Mulvaney has completed over 2000 ultrasound-guided SGBs and is the most experienced physician in the world at this technique. He has been an invited speaker on nationally broadcast television, including the CBS show 60 Minutes.

He is an academic physician and has published 8 studies and papers on this topic and routinely is an invited lecturer on this topic in major national and international stages. He has taught hundreds of physicians neck sonographic anatomy and SGB technique. As a fellowship-trained and board-certified interventional pain physician, he is also proficient in fluoroscopically (x-ray) guided SGBs, but he strongly feels that the fluoroscope method is more painful, less accurate and unnecessarily exposes patients to ionizing radiation.

Do I need to be sedated?

No. Sedation actually significantly increases the risk of this procedure. I have performed over 2000 SGBs and not used sedation on a patient. This procedure is NOT painful. Most patients describe it as a 1/10 for pain. The environment in my clinic is calm, and I will talk you through everything. Even people who don’t like needles will do fine.

Are you treated in the same appointment as the screening?

Everyone is screened prior to being scheduled. No additional appointment is needed for screening.

Can I drive after the procedure?

The accepted medical practice is that you cannot drive for 8 hours after this procedure. Please plan to have a driver with you or use a driving service like Uber.

How does SGB work to help PTSD symptoms?

The Stellate Ganglion is part of the cervical sympathetic chain, a key part of the sympathetic nervous system, which is the “fight or flight” nervous system. In PTSD and some other anxiety conditions, the “fight or flight” nervous system gets stuck in the “ON” position. By precisely placing long-acting local anesthetic (ropivacaine) around the stellate ganglion, the unproductive and chronic “fight or flight” response is turned off for several hours. Dr Mulvaney and other researchers believe this allows the brain and the body to “reset” back to a non-anxiety state. The brain has a quality called “neuroplasticity”, which means it can actually have durable change in response to treatments like an SGB. What we do know and can measure is this “resetting” results in long-term relief of anxiety symptoms.

Where is the closest airport?

Our office is located at 116 Defense Hwy Suite 203, Annapolis, Maryland 21401. Baltimore Washington International Airport (BWI) is the closest airport and is 25 minutes to the North. Reagan International airport is 50 minutes away, and involves traveling on the 495 Beltway, which may have heavy rush hour traffic. Dulles International Airport is approx 1.5 hours away and also subject to heavy traffic. There are many lodging options in the greater Annapolis area. Ask our front desk for more information. We have a travel guided posted on our website and on the link below.

What symptons does SGB treat?

In our clinical practice and research, I have mostly used and published on using SGB to successfully treat the anxiety symptoms associated with PTSD. I have also used it successfully to treat some anxiety conditions which have overlapping symptoms with PTSD, but the evidence for anxiety conditions other than PTSD is only anecdotal, or based on what we see in clinical practice.

What does SGB NOT treat?

SGB is not a treatment for Depression, Bipolar disorder, Schizophrenia or any variants of Schizophrenia, Personality Disorders or Seizure disorders. Traumatic Brain Injury (TBI) and PTSD symptoms can overlap. I have not found SGB to be specifically helpful for treatment of TBI. It can help the PTSD symptoms that may also be present.