Therapy for Trauma: How the Stellate Ganglion Block Helps

Summary: As a therapy for trauma, the stellate ganglion block (SGB) helps calm down the sympathetic nervous system and reduce the circulation of hormones associated with stress.

Key Points:

• The SGB can prepare patients with a history of trauma for talk therapy.
• The SGB can reduce the likelihood of triggering traumatic memories during exposure therapy.
• Some patients report immediate relief from acute trauma symptoms after one SGB treatment
• SGB is not a standalone treatment, but rather a treatment most effective when used in combination with standard, trauma-informed care, including talk therapy and exposure therapy

What is the Stellate Ganglion?

The word stellate means star-like or star-shaped, and a ganglion is:

“…a group of neuron cell bodies in the peripheral nervous system. Ganglia can be categorized, for the most part, as either sensory ganglia or autonomic ganglia, referring to their primary functions.”

Therefore, the first thing to know is that the stellate ganglion is a star-shaped group of neurons. Here’s a definition of the stellate ganglion from the National Institutes of Health (NIH):

“The stellate ganglion is a collection of sympathetic nerves found anterior to the neck of the first rib.…the stellate ganglion forms as a result of the fusion of the inferior cervical and first thoracic sympathetic ganglions. It is present in up to 80% of the population.”

In other words, the stellate ganglion is a group of nerves located at the base of the neck/top of the torso, behind the first (top) rib, formed in most people when two ganglia fuse to from one. Neurons from the stellate ganglion project – meaning they connect to and carry information to/from – the upper neck, the arms, and the central organs, and among other functions, exert a “…regulatory effect on the autonomic nervous system, the endocrine system, and the immune system.”

In addition, its association with the sympathetic nervous system means the stellate ganglion plays a role in our fight or flight response, which triggers the following responses when a person perceives that they are in danger:

• Enhances vision
• Increases heart rate
• Relaxes airways
• Slows digestion
• Releases energy-providing molecules from the liver

Finally, the stellate ganglion, vis a vis its role in the fight or flight response, is associated with the release of neurotransmitters such as acetylcholine, epinephrine, norepinephrine, and the release of cortisol, the stress hormone. Chronic exposure to cortisol is associated with a wide range of negative physical outcomes, as well as the exacerbation and escalation of symptoms associated with trauma-related mental health disorders such as post-traumatic stress disorder.

The role the stellate ganglion plays in those various functions, and its impact on symptoms associated with elevated stress hormones like cortisol, make an intervention such as a stellate ganglion block an excellent candidate for therapy for trauma and the treatment of trauma-related mental health disorders.

Before we discuss the stellate ganglion block, we’ll take a moment to discuss the role cortisol plays in stress and stress/trauma-related disorders.

Cortisol: Upsides and Downsides

Cortisol plays an essential role in key body functions. It’s necessary for our survival. In that way, the word cortisol is functionally synonymous with the word stress. There are times when we need stress for our immediate safety or to galvanize us into taking action related to something in the future. But when we don’t need it for those reasons, and high levels of cortisol remain in our bloodstream for too long, there are negative consequences.

A well-known book published in the early 90s does an excellent job describing what happens to the human body when exposed to too much cortisol for too long. The short version:

It takes a toll on your body, brain, and emotions.

The author, Dr. Robert Sapolsky, draws on an example from the animal kingdom to explain why mammals in the wild – despite having a stress response system like humans – don’t experience chronic stress and never get stress-related illnesses like ulcers.

Dr. Sapolsky imagines an animal in the wild – a prey animal, like a deer or a rabbit – having a typical day in the woods, free of stress up to that point. Enter a predator – a wolf or a bear, for instance – and everything changes. In the prey animal, the fight or flight response – driven by cortisol and adrenaline – activates instantly. A massive release of cortisol and adrenaline boosts heart rate, enables muscles to absorb more oxygen, and prioritizes any physical systems that helps the animal either run away for fight to the death, while diverting resources away from physical systems unrelated to fighting or fleeing.

That’s how the fight or flight response works in mammals with a central nervous system like ours.

The human fight or flight system acts in much the same way. When we experience an environmental stressor, an internal chemical cascade ensues, and we’re in fight or flight mode in no time flat, just like a prey animal in the wild. What happens next, though, is completely different. In animals, when the threat is gone, the hormones clear the system quickly, in less than 20 minutes. But humans, cortisol lingers, sometimes for days, weeks, and months, which can result in significant physical, psychological, and emotional consequences, including anxiety, irritability, and negative symptoms associated with post-traumatic stress disorder (PTSD). In addition, in humans, internal stimuli, like memories, can trigger an identical chemical cascade, perpetuating and recapitulating overexposure to stress hormones.

What is the Stellate Ganglion Block?

The stellate ganglion block (SGB) is exactly what it sounds like. It’s a technique – an injection of an anesthetic –that effectively interrupts the action of and prevents the neurons in the stellate ganglion from communicating with other areas of the body and brain.

Here’s a complete, medical definition of the SGB available in the report “Stellate Ganglion Blocks” published by the National Institutes of Health (NIH), the National Library of Medicine, and the National Center for Biotechnology Information (NCBI):

“[The] stellate ganglion block (SGB) is used for the treatment of many medical conditions including complex regional pain syndrome and peripheral vascular disease. Historically, the anesthetic has been injected at the C6 or C7 vertebral level.”

For context, the C6 and C7 vertebrae are located at the base of the neck: C7 is the last vertebra of the neck, just above the first thoracic vertebra, called T1, which is the vertebra that protrudes more than those directly above and below it.

Here’s an expansion of the definition of the SGB, including its mechanism of action and a selection of its uses, including as a therapy for trauma:

“The therapeutic effects of SGB are due to the block in neural connections in its region of innervation, the improvement in the blood supply of the region, the reduction of adrenal hormones plasma concentration. SGB can be used in medical conditions like post-traumatic stress disorder or cluster headaches.”

Common uses for the SGB include:

• Complex regional pain syndrome of the head and upper limbs
• Chronic post-surgical pain
• Peripheral vascular disease
• Raynaud disease, i.e. cold fingers and toes in response to stress, may include discoloration of skin
• Scleroderma, an autoimmune disease involving overproduction of collagen
• Orofacial pain, i.e. pain in the mouth and face
• Phantom limb pain
• Atypical/recurring chest pain
• Cluster/vascular headaches
• Post-traumatic stress disorder
• Meniere syndrome, an inner ear disorder

The SGB is approved for treatment of the disorders above and approved for off-label use as a therapy for trauma and trauma-related disorders such as post-traumatic stress disorder.

Stellate Ganglion Block (SGB) as Therapy for Trauma: The Evidence

We describe how the SGB works, above: it attenuates systems involved in the release of stress hormones in the human body.

But does that really work as a therapy for trauma, and help reduce symptoms of PTSD?

First, let’s look at an early report on the impact of SGB on PTSD – i.e. as a therapy for trauma – from the initial phases of a clinical trial conducted by the U.S. Department of Veterans Affairs (VA) at the National Center for PTSD.

That study, called “Effect of Stellate Ganglion Block Treatment on Posttraumatic Stress Disorder Symptoms: A Randomized Clinical Trial” showed the following outcomes in active-duty members of the U.S. Armed Forces:

• Significantly lower scores on PTSD screens 8 weeks after treatment
• Greatest improvements observed in patients with the most severe symptoms at baseline, i.e. the start of the study

Here’s how the lead author on the study, Dr. Kristine Rae Olmstead described those results – and the patient experience of SGB – in 2019:

“Some people described the treatment as opening a door. Some felt significantly less anxious even when they thought about the trauma, so they were then able to do the talk therapy willingly and effectively.”

Those initial outcomes were promising. Now, five years later, we have new research, in the form of a meta-analysis called “Optimizing Clinical Outcomes With Stellate Ganglion Block and Trauma-Informed Care: A Review Article.”

Let’s take a look at the results of this analysis of ten studies on SGB as therapy for trauma – i.e. PTSD – that included data from close to 1,000 patients. Among adult patients with PTSD, treatment with SGB showed:

• Reduction of over 10 points in scores on a PTSD screen in 80% of patients in this study
• Decrease of almost 30 points for males and females on a PTSD screen in this study
• Reduction of an average 22 points for males and females on a PTSD screen in this study

We’ll discuss these results below.

The Advantages of Stellate Ganglion Block (SGB) as a Therapy for Trauma

While previous research questioned the overall utility and effectiveness of SGB for trauma and/or PTSD, this study confirms the data supporting SGB qualifies as Level 1B Evidence. Level 1B evidence means supporting data includes the following:

“…individual randomized controlled trials, with narrow confidence intervals, indicating a strong evidence base for effectiveness.”

That means that in trials with an experimental group and a placebo, or control group, SBG outperformed the placebo/control group, with statistical analysis showing small margins of error. That’s very good news for people with PTSD who haven’t yet responded to treatment. The significant reductions in scores we share above represent real progress in PTSD treatment and therapy for trauma.

There are several benefits to using SGB as a supportive, ancillary, or complementary treatment for PTSD. However, despite the promising outcomes in recent research, the authors of the study above caution patents new to SGB and trauma treatment overall. Here’s what they say:

• SGB is not a magic cure for PTSD: 10%-20% of patients report no symptom improvement.
• It’s essential to receive SBG therapy/injection from an experienced, licensed, and qualified physician or equivalently trained medical personnel: the injection itself is in a sensitive and requires specific training to administer safely.
• SGB should always be part of a comprehensive, holistic, trauma-informed treatment plan, not as a standalone treatment itself.

It’s important to understand that the SGB prepares the nervous system, i.e. calms it down and gets it out of chronic fight or flight mode, and enables patients to approach therapy from a psychological state that feels safe.

SGB as Therapy for Trauma and Treatment for PTSD

With the qualifications above stated clearly and understood completely, patients with complex, recurring, hard to treat PTSD and/or trauma-related disorders can find hope in the emergence of a new and effective treatment for PTSD.

Anyone considering the SBG for trauma or PTSD should also know the following:

1. Healing from PTSD requires proactive participation and commitment on the part of the patient.
2. Expecting SBG to function as a type of permanent reset for the brain and body without also engaging in therapy will likely result in disappointment
3. Therapy for trauma, including PTSD, requires patients to revise and restructure their patterns of thought and emotion, and process problematic memories in a healthy and productive manner

The new evidence we present in this article indicates that the SGB may help patients engage in talk and exposure therapy without fear of being triggered, retraumatized, or re-experiencing traumatic events in their thoughts and feelings. From this perspective, SGB may be appropriate as an initial therapy, rather than one to try after other approaches – such as a combination of talk therapy and exposure therapy – have failed.

We’ll offer this quote from the authors of the article with the views of the large-scale VA study we cite above:

“It’s best if SGB is provided in the context of deep and respectful collaboration across interdisciplinary lines. Physicians who provide the SGB treatment and the behavioral health clinicians who provide co-therapy must see each other as two parts of a powerful combinatory care approach. Clinicians must be willing to refer to physicians so that their patients can begin therapy in a physiologically supported way and physicians must understand that therapeutic interventions are equally critical for patients’ healing.”

That’s the very approach we espouse here at Crownview Medical a holistic, collaborative, interdisciplinary approach, based in respect and an understanding that health, including physical, behavioral, and mental health, means more than the absence of symptoms. It means thriving in all domains of experience, and living a fulfilling, self-directed life based on personal values and choices.