An Interventional Injection for the Treatment of Post-Traumatic Stress Disorder (PTSD)

Transcription

1 An Interventional Injection for the Treatment of Post-Traumatic Stress Disorder (PTSD) Jason G. Anderson, D.O. ABPMR board certified in PM&R subspecialty board certified in Pain Medicine and Sports Medicine Spinal Diagnostics Tualatin, Oregon October 28, 2014

2 Patient #1 Will you do a stellate ganglion block for my PTSD?

3 Objectives» Define PTSD» Discuss the Epidemiology of PTSD» Briefly discuss current accepted treatments for PTSD» Stellate Ganglion Block and why it may help» Discuss current literature results» Discuss results in my practice

4 PTSD Is a debilitating psychological condition triggered by experiencing or perceiving a traumatic event In WWII, was called "shell shock"

5 PTSD diagnosis (DSM-V) Age greater than 6 years old History of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters Symptom duration greater than 1 month Impaired Functioning (e.g. - vocational, social) Symptoms not attributable to another condition

6 Summary of PTSD Symptoms Flashbacks/Blackouts Traumatic Nightmares/Trouble Sleeping Avoidance of situations that recall the trauma Irritability and Anger Impending Sense of Doom or Guilt Inability to enjoy life (Numb) Detached from others Hypervigilence 6

7 PTSD Almost 1 in 5 (18.3%) women have been sexually attacked In these women, greater than 50% lifetime prevalence. Lipov E, Kelzenberg B, Rothfeld C, Abdi S. Modulation of NGF by cortisol and the Stellate Ganglion Block - is this the missing link between memory consolidation and PTSD? Med Hypotheses Dec;79(6):750-3.

8 PTSD Prevalence in Military 14%-35% of approximately 23 million US veterans of combat duty Only 6.8% of non-combat duty veterans Lipov E, Kelzenberg B, Rothfeld C, Abdi S. Modulation of NGF by cortisol and the Stellate Ganglion Block - is this the missing link between memory consolidation and PTSD? Med Hypotheses Dec;79(6):750-3.

9 PTSD In military between 2005 and 2008 PTSD incidence increased from 7% to 11% Attempted suicide rate increased from 1% to 2% Alino J, Kosatka D, McLean B, Hirsch K. Efficacy of stellate ganglion block in the treatment of anxiety symptoms from combat-related post-traumatic stress disorder: a case series. Mil Med Apr;178(4):e473-6.

10 Veterans with PTSD 40% to 84% have concurrent alcohol or substance use disorder mortality is twice as high as those with only PTSD Lipov EG, Navaie M, Brown PR, Hickey AH, Stedje-Larsen ET, McLay RN. Stellate ganglion block improves refractory posttraumatic stress disorder and associated memory dysfunction: a case report and systematic literature review. Mil Med Feb;178(2):e260-4.

11 Veterans with PTSD Alcohol + PTSD 80% have disturbance in memory function and concentration Lipov EG, Navaie M, Brown PR, Hickey AH, Stedje-Larsen ET, McLay RN. Stellate ganglion block improves refractory posttraumatic stress disorder and associated memory dysfunction: a case report and systematic literature review. Mil Med Feb;178(2):e260-4.

12 Consequences of PTSD» The Patient» Relationships/Marriages» Children» Grandchildren 12

13 Traditional Treatment Medications SSRIs SNRIs Prazosin Nightmares - Decreased Risperidone No better than placebo Counseling Cognitive Behavioral Therapy Eye Movement Desensitization & Reprocessing Stress Management Meditation Yoga

14 Traditional Treatment: The Problem In military veterans and active duty with combat exposure 30% success rate of all treatments Mulvaney SW, Lynch JH, Hickey MJ, Rahman-Rawlins T, Schroeder M, Kane S, Lipov E. Stellate ganglion block used to treat symptoms associated with combat-related post-traumatic stress disorder: a case series of 166 patients. Mil Med Oct;179(10):

15 The Stellate Ganglion Stellate Ganglion present in 70-80% of individuals fusion of the inferior cervical ganglion and the first thoracic ganglion provides sympathetic innervation to the head, neck and upper limb Elias M. Cervical sympathetic and stellate ganglion blocks. Pain Physician Jul;3(3):

16 Stellate Ganglion Mapping Westerhaus and Loewy in 2001 used pseudorabies virus injections to identify connections of the stellate ganglion Lipov EG, Joshi JR, Sanders S, Slavin KV. A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD). Med Hypotheses Jun;72(6):

17 Stellate Ganglion Block Procedure Fluoroscopic guided and US guided are most common today Involves local anesthetic injection of bupivacaine or ropivacaine at the level of C6/C7 vertebra Right-sided SGB is necessary to affect right hemisphere structures responsible for autonomic responses to emotional stimuli and links to unconscious emotional memories Content Source: Dr. Lipov Lipov E. Successful use of stellate ganglion block and pulsed radiofrequency in the treatment of posttraumatic stress disorder: a case report. Pain Res Treat. 2010;2010: Illustration: Fox, K. W., & Furman, M. B. (2012). Stellate Ganglion Block. Atlas of Image-Guided Spinal Procedures,

18 Hickey AH, Navaie M, Stedje-Larsen ET, Lipov EG, McLay RN. Stellate Ganglion Block for the Treatment of Posttraumatic Stress Disorder. Psychiatric Annals, 2013 Feb;43(2),

19 Narouze S, Vydyanathan A, Patel N. Ultrasound-guided stellate ganglion block successfully prevented esophageal puncture. Pain Phy

20 Fox, K. W., & Furman, M. B. (2012). Stellate Ganglion Block. Atlas of Image-Guided Spinal Procedures,

21 Horner's Syndrome Ptosis (droopy eyelid) Miosis (small pupil) Anhydrosis (no sweating on ipsilateral face) Enophthalmos Also expect 1.5 degree temp increase on ipsilateral side Fox, K. W., & Furman, M. B. (2012). Stellate Ganglion Block. Atlas of Image-Guided Spinal Procedures,

22 Potential Complications of SGB pneumothorax bleeding infection allergic reaction intravascular injection and its consequences phrenic nerve or recurrent laryngeal nerve palsy hypotension injury to adjacent vascular structures (particularly the vertebral artery) bradycardia

23 Current Indications for SGB CRPS I & II Migraines/Headaches Hyperhydrosis in face and neck Peripheral neuropathy Vascular ischemic pain Raynaud's Herpes Zoster of the upper limb

24 Lipov EG, Joshi JR, Sanders S, Slavin KV. A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD). Med Hypotheses Jun;72(6):

25 Lipov EG, Joshi JR, Sanders S, Slavin KV. A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD). Med Hypotheses Jun;72(6):

26 Lipov EG, Joshi JR, Sanders S, Slavin KV. A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD). Med Hypotheses Jun;72(6):

27 PTSD and Cortisol Urine cortisol levels lower in individuals that go on to develop PTSD NGF after trauma is decreased if given cortisol 25 patients 1/2 saline 1/2 hydrocortisone 60% reduction in developing PTSD in hydrocortisone group Lipov E, Kelzenberg B, Rothfeld C, Abdi S. Modulation of NGF by cortisol and the Stellate Ganglion Block - is this the missing link between memory consolidation and PTSD? Med Hypotheses Dec;79(6):750-3.

28 Slide courtesy of Dr. Eugene Lipov SGB for PTSD

29 PTSD Checklist (PCL) 3 versions - military (PCL-M), civilian (PCL-C), and stressor (PCL-S) DSM-IV version: 17 questions Self reported score of 1 to 5 (17 to 85 points) Quick Assessment A change of 5 to 10 points is reliable (better than chance) A change greater than 10 points is threshold for clinically meaningful change DSM-V version (PCL-5): 20 questions Self reported score of 1 to 4 (20 to 80 points) "Using the PTSD Checklist for DSM-IV (PCL)" by National Center for PTSD; on 10/18/2014

30 Stellate Ganglion Block for PTSD at Tripler Army Medical Center (2013) Sample & Methods 4 cases Right C6 cervical sympathetic blockade using 7mL of 0.5% ropivacaine with Fluoro guidance PCL-M used to measure pre- and post-treament symptom severity Results Case 1 PCL score 64 to 22 after first SGB PCL score 35 to 29 after second SGB 1 month later Case 2 PCL score from 80/85 to 18 Case 3 PCL score from 69 to 34 Case 4 PCL score from 76 to 24 Conclusion: Stellate Ganglion Block Appears to be safe and efficacious treatment for PTSD May be beneficial for nonresponders of other treatments for PTSD Alino J, Kosatka D, McLean B, Hirsch K. Efficacy of stellate ganglion block in the treatment of anxiety symptoms from combat-related post-traumatic stress disorder: a case series. Mil Med Apr;178(4):e Special Thanks to Dr. Lipov

31 SGB for PTSD in 166 Service Members with Combat Exposure (2014) Sample & Methods 166 service members with multiple combat deployments 89% had direct close combat action of which 81% had been in at least 5 deployments Only 5 had been on medication Right C6 cervical sympathetic chain ganglion with 6 ml of 0.5% ropivacaine with US guidance PCL-M used to measure pre- and postscores with a minimum 3 months follow-up in 75 patients over 75% of these patients continued to deploy to combat zones and were exposed to combat after treatment Considered a "responder" if PCL score dropped by at least 10 points Mulvaney SW, Lynch JH, Hickey MJ, Rahman-Rawlins T, Schroeder M, Kane S, Lipov E. Stellate ganglion block used to treat symptoms associated with combat-related post-traumatic stress disorder: a case series of 166 patients. Mil Med Oct;179(10):

32 SGB for PTSD in 166 Service Members with Combat Exposure (2014) Mulvaney SW, Lynch JH, Hickey MJ, Rahman-Rawlins T, Schroeder M, Kane S, Lipov E. Stellate ganglion block used to treat symptoms associated with combat-related post-traumatic stress disorder: a case series of 166 patients. Mil Med Oct;179(10):

33 SGB for PTSD in 166 Service Members with Combat Exposure (2014) Mulvaney SW, Lynch JH, Hickey MJ, Rahman-Rawlins T, Schroeder M, Kane S, Lipov E. Stellate ganglion block used to treat symptoms associated with combat-related post-traumatic stress disorder: a case series of 166 patients. Mil Med Oct;179(10):

34 SGB for PTSD in 166 Service Members with Combat Exposure (2014) Results Responders (ave. 22 point drop in PCL) At 1 week, 78.6% At 1 to 2 months, 81.8% At 3 to 6 months, 73.5% Conclusion Selective blockade of the right cervical sympathetic chain at the C6 level is a safe and minimally invasive procedure that may provide at least 3 months of relief from symptoms associated with combat-related PTSD. Mulvaney SW, Lynch JH, Hickey MJ, Rahman-Rawlins T, Schroeder M, Kane S, Lipov E. Stellate ganglion block used to treat symptoms associated with combat-related post-traumatic stress disorder: a case series of 166 patients. Mil Med Oct;179(10):

35 SGB for PTSD in 166 Service Members with Combat Exposure (2014) Results Responders (ave. 22 point drop in PCL) At 1 week, 78.6% At 1 to 2 months, 81.8% At 3 to 6 months, 73.5% Conclusion Selective blockade of the right cervical sympathetic chain at the C6 level is a safe and minimally invasive procedure that may provide at least 3 months of relief from symptoms associated with combat-related PTSD. Mulvaney SW, Lynch JH, Hickey MJ, Rahman-Rawlins T, Schroeder M, Kane S, Lipov E. Stellate ganglion block used to treat symptoms associated with combat-related post-traumatic stress disorder: a case series of 166 patients. Mil Med Oct;179(10):

36 » 5 patients My personal experience» 3 males - veterans of combat experience now retired» 1 special forces» 2 air force pilots» 2 females» 1 with history of close friend being murdered» 1 with history of childhood sexual abuse

37 My personal experience Required: Active treatment with a mental health professional A PCL-C at every visit A diagnosis of PTSD A 1 to 2 week follow-up after the procedure A 6 week follow-up Technique: Stellate Ganglion Block utilizing 7.0 ml of 0.5% ropivacaine performed on the right side at the C6 level using fluoroscopy

38 My experience with PTSD/SGB Results: Case 1 PCL score 57 to 37 (1 week) to 25 (5 weeks) Case 2 PCL score 61 to 31 (1 week) to 42 (8 weeks) Case 3 PCL score 76 to 58 (2 weeks) to 60 (8 weeks) Case 4 PCL score 70 to 60 (2 weeks) Case 5 PCL score 57 to 22 (2 weeks) I can sleep for the first time in years. I don t have nightmares any more. My migraine headaches are gone. I feel like I want to dance. When I smile I mean it. Things that triggered me before don t trigger me anymore. I don t go from trigger to rage anymore. My spouse has noticed I am calmer. I can watch all the way through Lone Survivor without [flying off the handle.] I don t have blackouts any more. I don t have road rage when driving any more.

39 Conclusions Stellate Ganglion Block for PTSD Stellate Ganglion Block works within 30 minutes 100% Compliance 2-3 Blocks needed for full recovery (?) Over 70 % efficacy compared to current standard of care Studies suggest (but further studies needed) May improve memory function in those with PTSD/alcohol use May eliminate alcohol dependency May help eliminate suicidal ideation in PTSD patients May help for other psychologic conditions Question still to be answered Is is durable and repeatable over time?

40 Special Thanks Patient #1 The PTSD patients discussed Dr. Eugene Lipov Dr. Sean Mulvaney

41 References Mulvaney SW, Lynch JH, Hickey MJ, Rahman-Rawlins T, Schroeder M, Kane S, Lipov E. Stellate ganglion block used to treat symptoms associated with combat-related post-traumatic stress disorder: a case series of 166 patients. Mil Med Oct;179(10): Lipov EG, Slavin KV. More evidence supporting unified theory of stellate ganglion block. Med Hypotheses Jul;81(1):146. Alino J, Kosatka D, McLean B, Hirsch K. Efficacy of stellate ganglion block in the treatment of anxiety symptoms from combat-related post-traumatic stress disorder: a case series. Mil Med Apr;178(4):e Hickey AH, Navaie M, Stedje-Larsen ET, Lipov EG, McLay RN. Stellate Ganglion Block for the Treatment of Posttraumatic Stress Disorder. Psychiatric Annals, 2013 Feb;43(2), Lipov EG, Navaie M, Brown PR, Hickey AH, Stedje-Larsen ET, McLay RN. Stellate ganglion block improves refractory post-traumatic stress disorder and associated memory dysfunction: a case report and systematic literature review. Mil Med Feb;178(2):e Lipov E, Kelzenberg B. Sympathetic system modulation to treat post-traumatic stress disorder (PTSD): a review of clinical evidence and neurobiology. J Affect Disord Dec 15;142(1-3):1-5. Lipov E, Kelzenberg B, Rothfeld C, Abdi S. Modulation of NGF by cortisol and the Stellate Ganglion Block - is this the missing link between memory consolidation and PTSD? Med Hypotheses Dec;79(6): Hickey A, Hanling S, Pevney E, Allen R, McLay RN. Stellate ganglion block for PTSD. Am J Psychiatry Jul 1;169(7):760. Lipov EG, Navaie M, Stedje-Larsen ET, Burkhardt K, Smith JC, Sharghi LH, Hickey AH. A novel application of stellate ganglion block: preliminary observations for the treatment of post-traumatic stress disorder. Mil Med Feb;177(2): Fox, K. W., & Furman, M. B. (2012). Stellate Ganglion Block. Atlas of Image-Guided Spinal Procedures, Alino J. Misleading conclusion from the unifying theory of the stellate ganglion block for the treatment of posttraumatic stress disorder. Med Hypotheses Sep;77(3):465. Mulvaney SW, McLean B, de Leeuw J. The use of stellate ganglion block in the treatment of panic/anxiety symptoms with combat-related post-traumatic stress disorder; preliminary results of long-term follow-up: a case series. Pain Pract Jul-Aug;10(4):

42 References (continued) Lipov E. In search of an effective treatment for combat-related post-traumatic stress disorder (PTSD): can the stellate ganglion block be the answer? Pain Pract Jul-Aug;10(4): Lipov E. Successful use of stellate ganglion block and pulsed radiofrequency in the treatment of posttraumatic stress disorder: a case report. Pain Res Treat. 2010;2010: Lipov EG, Joshi JR, Sanders S, Slavin KV. A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD). Med Hypotheses Jun;72(6): Lipov EG, Joshi JR, Lipov S, Sanders SE, Siroko MK. Cervical sympathetic blockade in a patient with post-traumatic stress disorder: a case report. Ann Clin Psychiatry Oct-Dec;20(4): Khalsa SS, Shahabi L, Ajijola OA, Bystritsky A, Naliboff BD, Shivkumar K. Synergistic application of cardiac sympathetic decentralization and comprehensive psychiatric treatment in the management of anxiety and electrical storm. Front Integr Neurosci Jan 2;7:98. Narouze S, Vydyanathan A, Patel N. Ultrasound-guided stellate ganglion block successfully prevented esophageal puncture. Pain Physician Nov;10(6): Abdi S, Zhou Y, Patel N, Saini B, Nelson J. A new and easy technique to block the stellate ganglion. Pain Physician Jul;7(3): Westerhaus MJ, Loewy AD. Central representation of the sympathetic nervous system in the central cortex. Brain Res 2001;903: Elias M. Cervical sympathetic and stellate ganglion blocks. Pain Physician Jul;3(3): Lebovits AH, Yarmush J, Lefkowitz M. Reflex sympathetic dystrophy and posttraumatic stress disorder. Multidisciplinary evaluation and treatment. Clin J Pain Jun;6(2): "Stellate Ganglion Block for PTSD: Patient Success Stories" by LTC Sean Mulvaney, M.D. on 10/18/2014 "Using the PTSD Checklist for DSM-IV (PCL)" by National Center for PTSD on 10/18/2014

43 Questions? Recommend watch Stellate Ganglion Block for PTSD: Patient Success Stories - a YouTube video by Dr. Sean Mulvaney

44 44

45 Criterion A: Stressor (DSM-V) The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required) Direct exposure. Witnessing, in person. Indirectly, by learning that a close relative or close friend was exposed to trauma. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties. Does not include being exposed to media of an event.

46 Criterion B: Intrusion symptoms The traumatic event is persistently re-experienced in the following way(s): (one required) Recurrent, involuntary, and intrusive memories. Traumatic nightmares. Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Intense or prolonged distress after exposure to traumatic reminders. Marked physiologic reactivity after exposure to traumarelated stimuli.

47 Criterion C: Avoidance Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required) Trauma-related thoughts or feelings. Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

48 Criterion D: Negative Alterations in Cognition & Mood Negative alterations in cognitions and mood that began or worsened after the traumatic event: (two required) Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs). Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous"). Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences. Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame). Markedly diminished interest in (pre-traumatic) significant activities. Feeling alienated from others (e.g., detachment or estrangement). Constricted affect: persistent inability to experience positive emotions.

49 Criterion E: Alterations in Arousal and Reactivity Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required) Irritable or aggressive behavior Self-destructive or reckless behavior Hypervigilance Exaggerated startle response Problems in concentration Sleep disturbance

50 Criterion F, G, and H Criterion F: Duration of Symptoms Persistence of symptoms (in Criteria B, C, D, and E) for more than one month. Criterion G: Functional Significance Significant symptom-related distress or functional impairment (e.g., social, occupational). Criterion H: Exclusion Disturbance is not due to medication, substance use, or other illness.

51 PTSD Theory on Memory Dysfunction Lipov E, Kelzenberg B, Rothfeld C, Abdi S. Modulation of NGF by cortisol and the Stellate Ganglion Block - is this the missing link between memory consolidation and PTSD? Med Hypotheses Dec;79(6):750-3.

52 SGB Effect on PTSD Lipov E, Kelzenberg B, Rothfeld C, Abdi S. Modulation of NGF by cortisol and the Stellate Ganglion Block - is this the missing link between memory consolidation and PTSD? Med Hypotheses Dec;79(6):750-3.