For years now, stellate ganglion blocks have been found to help anxiety and PTSD. Some are spectacular and some not. Most have been right sided stellate blocks only. Now a case with BILATERAL stellate blocks has been done with initial significant (>75%) results, and repeated 2 month later with bilateral (botulinum 50 u one side two weeks apart) of each other lead to immense improvement. Swallowing issues for 6 weeks is annoying. Radiofrequency to ganglions prolonged effect and Ketamine addition improved results.
Kuo, Jonathann, and Megan Nicklay.
Botox-Enhanced Stellate Ganglion Blockade for the Treatment of Post-traumatic Stress Disorder.
Cureus 15.4 (2023).
https://www.cureus.com/articles/145220-botox-enhanced-stellate-ganglion-blockade-for-the-treatment-of-post-traumatic-stress-disorder.pdf
Procedure:
Local:
Injected 7 mL of 0.5% bupivacaine into and around the sympathetic ganglion
at the right C6 anterior tubercle level and 3 mL of 0.5% bupivacaine at the right C4 anterior tubercle level.
One week later do other side.
Botulinum:
injected 1 mL of 0.5% bupivacaine and 50 units of BOTOX® (onabotulinumtoxinA) into and around the sympathetic ganglion at the level of the right C6 anterior tubercle.
Do other side 2 weeks later.
Results:
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Pulsed radiofrequency to bilateral stellate ganglion repeatedly can give long lasting effects
Block, Tabitha, Jonathann Kuo, and Marcel Green.
Pulsed Radiofrequency-Enhanced Dual Sympathetic Block for the Treatment of Post-Traumatic Stress Disorder.
Cureus 15.7 (2023).
- bilateral DSB procedures at the C6 and C4 level over consecutive days – first shots
- “ultrasonography with an in-plane technique, placing it in the anterior lateral position,
which was also confirmed by fluoroscopy. 7 cc (mL) of bupivacaine 0.5% was injected into and around the sympathetic ganglion at the level of the right C6 anterior tubercle. This methodology was repeated at the fourth cervical vertebra level (C4), with the
exception of injecting 3 ccs (mL) of bupivacaine 0.5% into and around the sympathetic ganglion at the level of the right C4 anterior tubercle” - bilateral pulsed radiofrequency-enhanced dual sympathetic blocks
One article combined it with ketamine:
- inject 4th and 6th levels bilaterally (one day apart for sides)
- “0.5 mL of 0.5% bupivacaine was injected, and after observing the patient for 30 s, a second 4 mL aliquot was injected. The patient was monitored for an additional 30 s. After the patient verbally confirmed an absence of any concerning symptoms, an
additional 4 mL of 0.5% bupivacaine was slowly injected over 1 min for a total injection volume of 8 mL for a single-level block.”
Ketamine:
- initial infusion of racemic ketamine hydrochloride (0.5 mg/kg) was administered over 45 min. For my IM shoulder injections,this would be 40 mg for the 80 kg person which would be like 15 mg IM shoulder every 15 minutes
- dosage could be up to double to induce to induce mild to moderate dissociation.
- 5 infusions given
Results: “combined KI (ketamine) and CSB (cervical sympathetic blocks) appear to have a profound and long lasting (over 1 year) impact onthe symptoms of TBI and PTSD. Although the mechanisms of the effect are not fully elucidated, it provide a very effective new treatment for this unique and complex population.”
Comment – Injections in this area are fraught with concerns about IV penetration. Came across article finding this could be obviated by very slow infusion with ultrasound. One of those that did unilateral injections admitted some only responded when a repeat injection was done on opposite (left) side. So bilateral – one day apart might become the standard.
I stand by repeated IM ketamine at shoulder as a simple format that could be transferred to his family doctor’s office once tolerance to side effects occurs. I was very nervous when starting ketamine in office only to find an oxymeter interfered with the finger on iphone and any random overmedication was tolerated and patients requested full treatment.