22nd Annual Pain Medicine Meeting 2023

Stellate Ganglion Block for PTSD & Chronic Low Back Pain

•Stellate ganglion blocks (SGB) have effectively been utilized in treatment-resistant post-traumatic stress disorder (PTSD), refractory chronic pain, and complex regional pain syndrome (CRPS).

•The overlapping pathophysiology of these syndromes may contribute to the success of the SGB in alleviating seemingly distinct indications.

•Precision medicine includes the utilization of therapies that can maximize benefit based on individual patient factors.

•Due to the co-occurrence of chronic pain and PTSD, it is important to investigate therapies that may be able to simultaneously address both issues.

The authors present the first novel case of the successful use of a SGB in the treatment of PTSD, chronic myofascial pain, and chronic low back pain in a single patient.

•40-year-old female veteran, with a past medical history of treatment-resistant PTSD

•Evaluated for chronic myofascial pain; Low back pain and bilateral, non-radiating, neck and posterior arm pain

•Cervical and lumbar MRIs revealed multilevel degenerative discogenic disease and neural foramina narrowing

• The patient failed both conservative and non-conservative interventional pain treatment options, including duloxetine, gabapentin, hydrocodone, epidural steroid injection, radiofrequency ablation, and peripheral nerve stimulation.

•The patient also failed multiple medication trials for PTSD, including numerous SSRI’s and prazosin, as well as topiramate and gabapentin for associated anxiety and mood stabilization.

•An SGB was recommended to control PTSD symptoms and to possibly address her upper extremity pain (Fig.1).

The patient’s chronic low back pain, myofascial pain, and PTSD symptoms were assessed prior to the procedure, and then after 1 day, 1 week, and 6 weeks post procedure. PTSD symptoms were evaluated using the CAPS-5 and pain symptoms were assessed on a scale of 1-10. Table 1 shows the patient experienced both an improvement in pain scores and an improvement in PTSD symptoms following the Stellate Ganglion Block.

•The Stellate Ganglion (SG) is a sympathetic ganglion consisting of the 6th and 7th cervical vertebrae and first thoracic sympathetic ganglia, and its block allows for a broad sympathetic blockade1,2

•The underlying mechanisms of PTSD and conditions such as Chronic Low Back pain and CRPS can be linked under the umbrella of Central Sensitization

•Central Sensitization is a term that covers a wide range of clinical disorders (Fig.2), all related to amplification of pain reception by the CNS3

•The SGB has been widely used, particularly in Military settings, for the use of PTSD in veterans due to its ability to blunt the increased noradrenergic activity seen in PTSD patients.4

•One study proposed a mechanism for the underlying efficacy for SGBs in CRPS and PTSD, which involved the increased release of Nerve Growth Factor in pathological states, leading to an increase in Norepinephrine and sympathetic hyperactivity.5

•The successful results of the SGB in the treatment of both PTSD and chronic myofascial pain reinforces an association between the two pathologies

•While SGBs have been used for the treatment of CRPS, the true novelty of this particularcase series lies in the improvement of thelow back pain.

•Pressure algometry studies have shown patients suffering from LBP have significantly lowered pressure pain thresholds and hyperalgesia both in their back and peripheral sites.6

•Study conclusions have shown individuals with LBP have decreased pain thresholds, increased pain responses, and prolonged duration of pain after heat, chemical, pressure, and electrical stimuli, all consistent with features of central sensitization.6

•While much research has been done on SGB for PTSD and chronic pain (specifically CRPS), there have been no case reports in its use for chronic low back pain and for its use of both PTSD and pain in a single patient.

•The SGB was used for PTSD and chronic low back pain in an additional 2 patients. While both were eventually lost to follow up, both patients showed marked improvement of LBP immediately after the procedure (>70% decrease). One patient improved from a preprocedural score of 10, to 6 on 1-day post procedure, and to 0 on 1-week post procedure. Additionally, PTSD symptomsimproved from severe/markedly elevated to moderate/threshold.

•SGB may be an appropriate therapy for concomitant PTSD and overlapping pain syndromes, including low back pain, related to central sensitization (Fig.2).

22nd Annual Pain Medicine Meeting 2023

STELLATE GANGLION BLOCK FOR PTSD & CHRONIC PAIN

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