The Stellate Ganglion Block: An Alternate Look at PTSD
Because it seems to change our personality, most folks assume that Post Traumatic Stress Disorder is solely a mental health problem. PTSD sits on the same list with schizophrenia and bipolar disorder. Since it’s classified as a mental disorder, it’s treated like one — with therapy and prescription medications. First-year treatments alone, for veterans returning from Iraq and Afghanistan, cost the VA over 2 billion dollars. This comes out to about $8300 per veteran. The treatments have about a 33% success rate.
Dr. Sean Mulvaney, on the other hand, doesn’t believe that PTSD is the mental disorder we’ve made it out to be. He thinks it’s actually more of a physical injury to the sympathetic nervous system. He treats soldiers with a simple procedure called a Stellate Ganglion Block. It cost about $900. His success rate is 85%.
Dr. Mulvaney was a Navy seal for six years. He’s been a physician for the last twenty two. When I finally got him on the phone, I braced myself for the “I'm a doctor with lots to do” vibe. But as we got to talking about how PTSD rewires the sympathetic nervous system, I suddenly felt like I was tagging along with a seven-year-old who had just hooked into his first big fish. He apologized twice for getting so fired up. He says it all starts with the sympathetic nervous system.
The sympathetic nervous system is what gets your body ready for action. If you stumbled into a dark cave and found yourself nose to nose with a grizzly bear, your sympathetic nervous system would instantly release an avalanche of hormones like epinephrine and adrenaline to prepare your body to either fight for your life or make a run for it — the fight or flight response. When this response is triggered over and over again, especially in extreme situations like combat or physical abuse, the nervous system starts to reprogram itself. It’s like it short-circuits the response sequence.
When your average person gets cut off in traffic, they’ll probably get annoyed. When it happens a second time, they’ll probably get frustrated. A third time and they’re angry. There’s a progression.
When someone with PTSD gets cut off in traffic, their pupils can instantly dilate to take in more information, they may feel clammy as blood drops from their skin and rushes to their muscles, and their heart can thump while their breathing skyrockets. It’s like they’re nose to nose with a grizzly. This kind of hyper-reactivity can help keep you alive when your life is in imminent danger. But it can be hell at the breakfast table.
PTSD as a diagnosis originated in 1980. In recent years evidence has been showing that when someone endures traumatic stress, physical changes actually take place in the brain. Studies like this one out of Australia demonstrate that when a patient diagnosed with PTSD is presented with a picture of a face showing a negative emotion, they have heightened activity in their amygdala— the part of the brain that regulates the fight or flight response. Studies like this one, done with combat veterans from Iraq and Afghanistan, demonstrate that the brain also has a heightened reaction when exposed to norepinephrine—the chemical that is released to initiate the fight or flight response.
Studies like these are significant because they demonstrate that traumatic stress has literally changed the inner workings of the sympathetic nervous system—and that change looks like an injury.
For years people have been pushing to change the term PTSD to PTSI (post traumatic stress injury) because they feel it would reduce the negative stigma around PTSD. Dr. Mulvaney wants to make the change because he believes it’s more accurate.
Dr. Mulvaney says his classic patient will walk into his office overcome with guilt, telling stories about how he screamed at his three year old for spilling her cereal. “They feel guilty for how they're treating other people, and guilty that they can’t regulate their own reactions,” he says.
"If you came in here screaming at everyone because you had a broken femur, would you feel guilty about getting that fixed?" This is when it usually clicks, he says. They have a biological injury.
In order to heal the sympathetic nervous system, Mulvaney treats the Stellate Ganglion. The Stellate Ganglion is a bundle of nerves that runs along the neck on either side of the voice box. These nerves interface with the brain about pain located in the neck, arm, and chest. They’re also crucial to the regulation of the fight or flight response.
A Stellate Ganglion Block (SGB) is a simple injection of a numbing agent into these nerves on one side of the neck, typically the right side. The procedure takes about 15 minutes and patients can see results within 30 minutes. Patients walk out of the clinic the same day.
SGBs have been used since 1925 to provide relief from chronic pain. It wasn't until 2007 that Dr. Eugene Lupov, a Chicago based chronic pain physician, began to think bigger. Realizing that this same bundle of nerves he was treating for pain also regulated the fight or flight response, he decided to try it for PTSD. The results were profound. In 2008 he published his first of several studies showing promising results. Feeling the gravity of how helpful an SGB could be for treating veterans, Dr. Mulvaney jumped in and started launching his own studies to help propel the treatment forward.
But how does it work? Well, we're just beginning to understand that. We know that the bundle of nerves (Stellate Ganglion) along either side of the neck are a key piece of hardware that regulates the sympathetic nervous system. And we know that this system never really turns off. Even when sleeping, your sympathetic nervous system is surprisingly active. But when the Stellate Ganglion is injected with a numbing agent, “It seems to completely shut down, allowing it to actually reset,”says Mulvaney. “When it boots back up again, it tends to operate more like it did before the stress injuries.”
Within 30 minutes of a procedure patients often report feeling an immense sense of relief. “I feel like a ton of bricks was just lifted off my chest,” is a common phrase. Patients often start sleeping better right away, too.
The day after, if a patient gets cut off in traffic, their response might go something like this: “Hey, that guy cut me off... I used to get raging mad about this... what should I do now?”
Their sympathetic nervous system is still intact, it’s just not hyperactive anymore. Now that their brain is no longer hardwired to go straight to the fight or flight response, they are freed up to make a decision about how they will act next. It puts them back in control.
Some people call the Stellate Ganglion Block a miracle. Others call it the “God Shot.” But Dr. Lupov and Dr. Mulvaney are quick to point out that it’s not the magic bullet. The danger is for someone to think an SGB can “fix everything.” Really, it’s more like it can take that broken femur that’s been ransacking you with pain and put it in a cast. You’re on your way, but there’s going to be a whole lot of work to do before you can stand up and go for a stroll.
Whether or not PTSD is a physical injury, the symptoms are still mental. What an SGB does is prime your nervous system to accept the mental side of treatment.
The few weeks following a procedure is a critical time frame for patients to heal. It’s a “therapeutic window,” says Dr. Mulvaney. Since patients’ brains are no longer programmed to go straight to the fight or flight response, they literally need to rebuild how they are going to react to different levels of stress. This is where behavioral therapy can be a huge help. Behavioral therapy focuses on replacing unwanted behaviors with constructive ones and seems to suit SGB patients well. This is different from traditional PTSD therapies which tend to involve revisiting the trauma.
Following an SGB procedure, Dr. Mulvaney strongly cautions against doing any kind of therapy that involves revisiting trauma: “Reliving trauma after an SGB can take the nervous system right back to where it was. A patient should be well established in their new habits before they consider anything like that.”
Beyond the nervous system, it’s also important to think about what’s happening in a patient’s life. Soldiers often receive stress injuries when they’re on a mission and making a clear contribution to their team. They often receive PTSD treatment when they’re back home and struggling to make it through the day, much less contribute to society. "I usually see the sharpest turnaround when patients are freed up enough to start helping other people,” Dr. Mulvaney said. “As soon as they're able to start giving back, their recovery tends to take off."
Of course, any new treatment faces challenges. Most good candidates for an SGB are currently receiving other treatments. The two treatments of choice for veterans diagnosed with PTSD are cognitive processing therapy, where you focus on reframing unhelpful thoughts about the trauma, and prolonged exposure therapy, where you repeatedly expose yourself to memories and feelings about the trauma in order to become more comfortable with it. In 2015, a massive study reviewed 36 randomized control trials over a 35-year span. The study concluded that while up to 70% of the men and women who received these treatments did experience some improvement to their symptoms, the overall success rate was about 33%. Placebo treatment usually produces roughly the same results.
Dr. Lupov reported a 90% success rate in his last 200 cases. Dr. Mulvaney reports his 85% success rate after treating over 1500 patients. When I asked Dr. Mulvaney about the other 10-15%, he said it's tricky. Most of these patients had other complicating issues. For example, if someone also has bipolar disorder and that’s the root cause of their symptoms, an SGB will not help. It’s important to remember that even though the procedure has been around for a long time we’re still just beginning to understand how it works. For example, Dr. Mulvaney recently learned that approximately 1 out of 20 patients need an SGB in the left side of the neck instead of the right side.
The risks are well-known. Since SGBs have been used for pain for almost a 100 years, there is loads of data showing this is a very low risk procedure. General risks include bruising or soreness at the injection site. If the doctor puts the needle in the wrong spot, which is extremely uncommon, there is risk of infection, bleeding, nerve damage, or a punctured lung.
What are the critics saying? Not much — yet. But if Lupov and Mulvaney are truly getting an 85 - 90% effective rate, what would that mean for the companies that are receiving billions of dollars of VA funding for treatments that are much less effective? If the SGB procedure becomes more prominent, these companies would be incentivised to discredit SGB research and reinforce their position as the go-to treatment option.
When I asked Dr. Mulvaney why a Stellate Ganglion Block isn’t a mainstream procedure yet, he said he didn’t really know. Once a patient is diagnosed with PTSD, it’s second nature for most providers to send them off to see a therapist and maybe pick up a prescription. In order for someone to receive an SGB, a provider needs to send their patient off to get an injection in their neck. They’re not used to doing that.
As of right now, most patients learn about SGBs by word of mouth. If someone believes they are a good fit for an SGB, they may need to help educate their doctor about the options. The military has been funding SGB studies for years and they recently produced some encouraging results. There is also a growing number of VA hospitals that will perform the procedure.
After Dr. Mulvaney apologized the second time for getting so fired up, I asked him if there were any patients that stood out. He said Dakota Meyer immediately came to mind. Dakota received the Medal of Honor for repeatedly charging through enemy fire to save his teammates. But less than a year after the President of the United States looped the medal around his neck, he found everyday life to be too much and tried to kill himself. A lot more struggling followed. It wasn’t until about nine years after he attempted suicied that he received a Stellate Ganglion Block from Dr. Mulvaney.
“I went from feeling like I was stuck in New York City traffic and fifteen minutes late to a meeting that my life depended on,” Meyer said, “then, instantly I was on a quiet country road with nowhere to be. I started crying because I hadn't felt that much relief in my entire life.”
November 16, 2020