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|Issue 124||March 2017|
The report is a product of the VA/HSR&D Evidence Synthesis Program.
Effectiveness of Stellate Ganglion Block for Treatment of PTSD
Post-traumatic stress disorder (PTSD) is the third most common psychiatric diagnosis among Veterans treated within the VA healthcare system. Experts estimate that up to 20% of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) Veterans, up to 12% of Gulf War Veterans, and up to 30% of Vietnam War Veterans have experienced PTSD. Consequently, the need for PTSD treatment may increase within the Veteran population in the coming years. Conventional treatments for PTSD include psychotherapy, pharmacotherapy, or their combination; however, several challenges have been identified in their effectiveness and reach. Stellate ganglion block (SGB) has been promoted as an add-on therapy for individuals with PTSD who have not fully responded to conventional treatments.
The stellate ganglion is a cluster of nerve cell bodies located between the C6 and C7 vertebrae. Injection of local anesthetic to the stellate ganglion, a procedure known as stellate ganglion block (SGB), inhibits sympathetic nerve impulses to the head, neck, and upper extremities, and has been used to treat various disorders (i.e., migraines, facial pain, hot flashes). The specific mechanisms of action by which SGB may mitigate PTSD symptoms remains incompletely understood, but some suggest that SGB may suppress amygdala over-activity and nerve growth factor – and consequent perivascular norepinephrine increases and induces a sedative effect. Some of the proposed benefits of SGB for PTSD may include:
This Evidence Brief discusses to what extent SGB provides clinically relevant benefits, any potential harms, and identifies those Veterans who might be most likely to benefit from this treatment. Investigators with VA's Evidence-based Synthesis Program Coordinating Center located in Portland, OR searched multiple data sources (i.e., MEDLINE®, CINAHL, Cochrane Register of Controlled Trials, etc.) for relevant articles through February 7, 2017. After reviewing 174 records, including some identified via reference lists and hand-searching, they identified only 1 comparative study. An overview of initial findings from uncontrolled case series also was provided.
Summary of Findings
Due to the high risk of bias of case series, the pattern of their finding very encouraging results, followed by a negative RCT, is quite common. It suggests that while it is possible that some patients benefit, the response rates seen in case series will not hold up in actual practice. Substantial uncertainty remains about the potential harms of SGB as well. The randomized controlled trial, as well as RCTs of SGB for complex regional pain syndrome, were inadequately powered to support or refute findings from the frequently cited, but methodologically weak, 1992 German questionnaire survey of 45,000 SGBs that found 1.7 instances of severe complications per every 1,000 individuals.
Evidence also was insufficient to determine which Veterans are most likely to benefit from SGB for PTSD. Clinical factors that could be used to select patients include failure to respond to – or high risk of non-compliance with conventional therapies, low risk of bleeding and other complications, patient preference, and availability of SGB.
Moreover, outcome assessment and data analysis should be conducted by research or quality improvement personnel who do not have strong prior views of the effectiveness of SGB.
For additional related evidence review work, investigators further recommend that a review of the state-of-the-science of PTSD outcome assessment methods, such as has been done in the field of chronic pain outcome assessment, could be useful in informing the direction of future research for PTSD as a whole.
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ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.
This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.
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