Stellate Ganglion Block: Revolutionizing Relief for PTSD, Long COVID, and Chronic Pain

Stellic ganglion blocks have been recently a return in popularity mainly because of the preponderance of long COVID symptoms. And a lot of patients who have PTS who have failed conservative treatment and antidepressants, they are seeking out practitioners that can do a stelic ganglion block in search of amelioration of their condition.

But today's episode is different. Today we're talking about one specific procedure with a story so surprising it deserves its own episode: the stellate ganglion block. It's a small injection into a cluster of nerves in the neck. It's been used in medicine for roughly 100 years, and in recent years, it's shown remarkable results for conditions most people would never associate with a pain clinic. PTSD, long COVID smell and taste loss, anxiety, and complex pain conditions like CRPS. So if you or someone you love is living with trauma that just won't loosen its grip or senses that never came back after COVID, this episode may change everything that you thought was possible. Let's continue. Dr. Nyer, let's start with the basics. Um, what is the stelic ganglion and what role does it play in the body?

The stelate ganglion block, it is, as you mentioned, it's a fairly simple injection that's done usually in the right or the left side of the neck. In order to understand what a stellate ganglion block is, one needs to understand what is the stellate ganglion? How does it form, or um what type of nerves are in the stellate ganglion? In order to have a better understanding of that, we need to first understand that human beings have something known as a central nervous system, the peripheral nervous system, and the autonomic nervous system. We've talked about the central nervous system that consists of the brain and the spinal cord. And then we've also talked about the peripheral nervous system, which would include all the peripheral nerves. Our last episode, we talked about stimulating these peripheral nerves when there is a chronic pain condition. Now, there's also another nervous system called the autonomic nervous system. This consists of the sympathetic nervous system and the parasympathetic nervous system. The sympathetic nervous system, we all know about the fight and flight response. We also know about the parasympathetic nervous system, which is the part of the nervous system that controls mood, our sleep, our behavior sometimes, and uh different hormones control or are in charge of these separate nervous systems. It's also important to understand that the autonomic nervous system is probably a much more primitive nervous system in human beings. In fact, one can go back into the history of evolution when we think about single cells, such as uh algae, these are single cells with a nucleus. Initially, the question is how would these one-celled organisms know where to go to to get food? Well, they were able to sense the difference in the concentration in the fluid, meaning the ocean or the rivers and seas where these organisms lived. And due to the difference in the osmotic pressure, they were able to guide the cell towards the source of food. And once it reached that source, it would diffuse the food across into the cell membrane and get assimilated by the cell. As this cell started becoming more complex, it developed things like a flagella or a small little whip-like appendage on the cell itself to allow it to propel itself towards food. Then, of course, other adaptations occurred, and over the centuries, excuse me, over the centuries, the organism became more complex. The cells grouped together as tissues, and then tissues grouped together as organs, and then we evolved from a water-based organism to an organism that could live both on land and sea, and we evolved into human beings. One can attribute this evolution primarily in the autonomic nervous system. Because in humans, most of the organs that are controlled by the autonomic nervous system are things like the heart and the lungs. So, as I was saying, the autonomic nervous system in humans, the organs that are mainly innervated by the autonomic nervous system are organs like the heart and the heartbeat, the breathing and the rate at which we breathe. There are many other functions, like the function of the gut. How does the gut know when to produce gastric acid to digest food? Or when does it know to tell each of the different organs that are involved in the process of digestion? It is not under our conscious control, it is autonomic. So, how did this autonomic system evolve through the centuries? And I believe the autonomic nervous system that we have, which is a combination of the sympathetic and the parasympathetic, evolved in this way. So, therefore, the fight and flight response: if we see a tiger just walk into the room, our initial instinct would be to run away. Running away involves adrenaline. Adrenaline will selectively divert blood flow to our legs so that we have the ability to run. When we get stressed or anxious, again, adrenaline is released. So the autonomic nervous system controls things like heart rate, blood flow, and there is a part of the autonomic nervous system that also contain or controls pain. So sometimes patients can have fairly trivial injuries or even surgeries that can trigger a medical condition called chronic sympathetic dystrophy or CRPS, which essentially involves a derangement of the autonomic nervous system, in particular the sympathetic nervous system. So for a long, long time, stellate ganglion blocks were used to treat complex regional pain syndrome, CRPS. So I think it would be important for us to first define the stellate ganglion block, and what are we blocking? So the name stellate ganglion block, stellate means star-shaped. Ganglion is a collection of nerves. And of course, the block would mean putting a local anesthetic to disrupt transmission of nervous impulses. The stely-ganglion block is also called the inferior cervical sympathetic chain. And it is in this vicinity of this bunch of nerves where we place numbing medicine to disrupt neurotransmission. And disrupting this neurotransmission will, in a way, negate the sympathetic outflow. So, in effect, what we will see when a sympathetic block is done is that there will be increased blood flow to the limb. Let's say we're doing a sympathetic block on the right side of the neck, there will be increased blood flow going down to the right side of the upper limb. Now, in the case of complex regional pain syndrome, why do we want an increased blood flow? Because the causes of the chronic pain in a limb is due to accumulation of certain chemicals that upregulate or amplify pain. So by performing a stellate ganglion block, we're able to increase the blood flow to the limb, thereby washing away some of these neurochemicals that are sensitizing or amplifying pain. So that is how stellate ganglion blocks have been useful in treating painful conditions of the upper extremity or even the lower extremity. Now, I actually had a patient while the Gulf War was going on. This patient had accidentally had a gunshot wound in her hand. And when we talked to the patient, we were able to establish that the patient developed this hypersensitivity to pain, even though she was about six or seven months post-incident. The scar or the the the wound had already healed. But she had this extremely sensitive, painful limb. After I evaluated the patient, we did we determined that a stellic ganglion block would be the best treatment option for the patient. But interesting enough, she also then told me a story about a very bad experience that she had on the battlefield. And without going into the details, essentially she had to see things that were quite horrific for regular people, let alone uh military folks. And as a result of that, she had also developed post-traumatic stress. So, and this was about, as I was saying, it was during the Second Gulf War, so it's nearly about 15 years plus ago. Uh, we were able to talk to her insurance company uh about getting um this approved. But prior to doing the injection, I also uh did something known as a PTS checklist. It is essentially a questionnaire that is discussed with a patient, and the and the patient's symptoms for PTS is scored. And she scored 82 out of 100, which was very, very high. So after doing this uh PTS checklist, we performed a stellate ganglion block on the right side, and 30 days later, we performed another stellate ganglion block because that is part of the protocol in the treatment for chronic regional pain syndrome. We then evaluated the patient 60 days later. She definitely had improvement in her pain in the upper limb. We also did the PTS checklist again. And I know this is extremely bizarre, but now her score came down to 42. You know, I had talked to the local uh VA hospital about this, but unfortunately they told me that this is not a recognized procedure, so we wouldn't be able to endorse it. But nevertheless, I told the patient that we will do this injection for her and any other military folks who has PTS. I mean, we do it pro bono because we see the benefit of it. Now, fast forward 15 to 16 years later, we now see more and more medical papers regarding the treatment of PTS with stellate gangliene blocks. However, even despite these medical papers, most insurance companies will not cover this treatment for PTS. You can also treat patients with obsessive compulsive disorder with stellate gangliene blocks. Now, we'll get into the more scientific reasons for that in just a second, because post-COVID there were multitude of patients who started complaining about very bizarre symptoms. Now, what came to my notice in particular was abnormal smells and abnormal tastes, which really didn't have any anatomical correlation. And most of these patients would say that these symptoms started right after they had a bout of COVID. Many patients that I interviewed would say to me that they would have very putrid smells, they would they would smell things like burnt hair. And they would say that their taste would change and that a lot of things would taste like metal, or some people even said that their taste was so awful that they couldn't eat. So there were some medical papers that came out of Germany saying that a stellate ganglion block on the right side would actually help reduce these symptoms. Now, then comes the reason as to why would a stellate ganglion block, which is an injection using a local anesthetic to a cluster of nerves in the neck, how would that help reduce these bizarre symptoms like parosmia, which is abnormal smell, and dysgousia, which means abnormal taste. In order to understand that, it would be imperative for us to connect the dots. The innervation for taste and for smell does have contributions from the stellate ganglion. There is a portion of our smell and taste that is mediated or controlled by the sympathetic and parasympathetic nervous system. To give you some clarity to what I'm saying, you must have heard of the Pavlovian theory of when you show a dog food, it would start salivating. You do that with an association of a bell, you ring a bell while you give the dog food, you will find out that when there's no food, but you still ring the bell, the dog will still salivate. This has to do with the autonomic nervous system. So it would go to reason that when patients have abnormal smell and abnormal taste, that there is a dysfunction in the autonomic nervous system. Therefore, if we put local anesthetics in the region of the stellate ganglion block, this the anesthetic aging will last for about five hours. That would be enough time for the sympathetic nervous system to be rebooted. And when it starts again, as the local anesthetic wears out, the patient now will have reduced parosmia and dyscousia. And slowly they will come back to a status quo to where they were before having COVID and these long COVID symptoms. Now, with regards to post-traumatic stress, one of the things that researchers have found is that in these patients there is a substance called nerve growth factor, nerve growth factor, which is elevated. And the finger is pointed to that growth factor being responsible for these abnormal symptoms. Now, mind you, long COVID symptoms are not just limited to abnormal smell and abnormal taste. Patients have had headaches, a feeling of lethargy, exacerbation of conditions like chronic fatigue syndrome, joint pain, problems with digestion, bloating, problems with urination, problems with going to the bathroom, defecation. And patients would swear that it is after they developed COVID that these symptoms have appeared and has gotten worse. Now, researchers have also found that after receiving a stellate ganglion block, they are seeing that the nerve growth factor reduces substantially. Of course, there are more studies that are going to be required to be able to show definitively that nerve growth factor is responsible for both PTS, OCD, long COVID symptoms. But as far as I'm concerned, because I've trained to do stellate ganglion blocks safely, and I have seen patients that have had PTS, long COVID symptoms, chronic uh uh CRPS and other conditions improve with stellate ganglion blocks, that I am more than ready to help patients who come with these symptoms to treat them. How is the stellate ganglion block perform? I perform these procedures under x-ray guidance, where I can see the anatomy very well. It's a very, very thin needle. The patient, the patient's skin is anesthetized, and I'm able to see exactly where the needle needs to be placed with x-ray guidance. So I know precisely where the stellate ganglion is. We numb the skin, place the needle, and we also inject a dye to make sure that we're not in any other uh tissue or blood vessel. Um, and the dye will tell me definitively that I'm where the nerve complex is located. And then I inject the medicine and I'm done. I'm usually done within five to ten seconds. The patient comes to the recovery room, they recover for about 30 minutes, and of course, before the injection is done, I also will give the patient. A general idea as to what to expect after the block. So remember, we're doing a stellate ganglion block. So the structures that are innervated by the stellate ganglion will get blocked. And so there are certain symptoms that are associated with blocking. And these constellations of symptoms are called Horner syndrome. Horner syndrome, I know it sounds ominous, but it's just certain changes that you will notice. For instance, you will notice that the white of the eye becomes a little bit red. And then you will feel like a stuffy sensation in your nose, like you have a little bit of a cold. You might feel hoarse in your voice. And the right side of your face, which is the side that we're injecting, will become a little bit warm, and so will the right side of your upper arm. All of this is part of the stellate ganglion block, which all those symptoms will wear off in about five hours. But once you see those symptoms, you know that the block is in the right place, and that relief, symptomatic relief, is on its way. I would say that there are very, very few risks with this procedure, especially when it's done under x-ray guidance or under ultrasound guidance. In fact, there was a recent study that came out that they did performed a cellate ganglion block using x-ray guidance in 275 patients, and none of them had any complications. So it is a safe procedure, and to put it bluntly, you are getting a great bang for your buck. So I think in a nutshell, this is what a stellate ganglion block is, and I would implore any patients who are listening to this broadcast who have symptoms of chronic intractable pain, chronic fatigue syndrome, long COVID symptoms, PTS, OCD, even problems with their sleep rhythm. The stellate ganglion block is something that's worth considering because we've seen a plethora of patients who have done well.

Yeah, speaking of patients who have done well, this procedure has been around for about a hundred years, Dr. Nyer. But you know, most people and even many physicians have not heard of it. So tell us what it was originally used for and why is it suddenly getting so much attention right now?

Well, again, originally it was for complex regional pain syndrome, where the patient will have exacerbation of pain due to disruption of the sympathetic nervous system. You can also use a stellate ganglion block when a patient develops frostbite up their hands, for instance. And as I explained to you earlier on, when a stellate ganglion block is performed, the blood flow to that limb is increased. So as you know, frostbite is when there's so much of uh cold or or ice that the blood flow is reduced in the digits, and that causes gangrene or necrosis of the digits. So you could increase the blood flow to allow the crossbite to get better faster. So, and it's also can be used for a condition called Raynaud syndrome. Ray Nod syndrome is also a connective tissue disorder where very similar phenomena will occur. When the Raynaud's phenomenon is triggered, it reduces the diameter of the arteries in the hands, and that can cause severe pain. So a stellate ganglion block will actually help blood flow open up again. Now, stelly ganglion blocks have been recently it has made a uh you know a return in popularity mainly because of the preponderance of long COVID symptoms, and a lot of patients who who have PTS who have failed you know conservative treatment and antidepressants, they are seeking out practitioners that can do a stellate gangoline block in search of uh amelioration of their condition.

Um, I have heard of Reynolds uh disease before. It's not something that cures it, but it's something that helps manages it. Is that correct?

That is correct. It's absolutely correct. It doesn't occur all the time, but there are certain triggers that will cause a Raynaud's phenomenon to come into effect, and a stelly ganglion block would be the best answer for it.

Yes. Um, so I've not sure, I think you know this, Dr. Narr, but I used to work in a med spot where we did a lot of cool sculpting, and we couldn't do it on patients who had Raynaud's disease and um the so on and so forth. So I'm curious if that would be uh helpful because that was something that was never discussed. Interesting.

Right. I I think that uh the whole concept of how the sympathetic nervous system evolved and how stelly ganglion blocks help is amazing. In fact, there are researchers that say that when patients experience traumatic events, the body goes into a hyper-inflammatory state, and it also affects certain centers in the brain, like the limbic center, which consists of the amygdala, the insula, and these areas control the emotional state. So now there's a connection between emotions, trauma, pain, and that is most likely the reason why the inflammatory system kicks in and the nerve growth factor increases in the body, which then is the ideal cocktail to cause PTS, long COVID symptoms. And there are connections with uh things like Ellers-Danlow syndrome syndrome and Potts syndrome, which share many similar signs and symptoms. And I've also treated a patient with Ellers Danlow's with stely ganglion blocks, and they have been successful in reducing some of their symptoms.

So interesting. Um, you know, you just mentioned that this was used for PTSD, especially for, you know, for example, veterans and first responders. So, how can a physical injection in the neck help with what most people consider as a psychological condition?

Well, as I was saying, the psychological aspect of the trauma activates the emotional centers in the brain, namely the amygdala, the insula, and the hippocampus. And these are the areas that will associate sadness with a traumatic event. And it becomes a vicious cycle, which the stellate ganglion tends to break because now you are putting an anesthetic agent to disrupt that innervation or the or the nerve pathways that keep recycling. And once you're able to reboot that system with the sympathetic block, they tend to get back to normalcy. That would be the best explanation, in addition to the reduction of the nerve growth factor in the body. So I believe that's the connection, that's where we are able to connect the dots with PTS, emotional uh uh trauma, and how stellate ganglion block can break that cycle.

So you mentioned long COVID. Long COVID has uh left many people with, like you spoke about earlier, that distorted taste and smell, and like the coffee that smells like garbage and food that tastes like metal and chemicals. So tell us a little bit more about um how the stellate ganglion block helps those patients and what are the results that you're seeing? Is it something where they just need uh one treatment, or what does the protocol look like?

Well, I can tell you a few patients that I treated in the last three months. They had come to me with maybe 18 or 20 months of having uh abnormal smell and taste. And they said they tried various different medications and a number of physicians who did try certain treatments, but none of them actually helped. And so they read about stellate ganglion blocks and they came to see me. And of course, we did an extensive evaluation of how long they've had these symptoms, what are these symptoms consisting of? Um, how has that changed their diet, their weight? And after getting a very thorough understanding of what's going on with these patients, I performed a stellate ganglion block. And what I've noticed is after one stellate ganglion block, usually about 30% of their symptoms start improving. And they can they know that their symptoms are improving because they're able to eat more things, they're able to actually gain some more weight. And usually after the second stellate block, and I usually space them with 30 days between injections, and I only do one side at a time because it is not uh prudent medicine to do a stellate gangrene block on both sides, because there are certain risks to the procedure, and uh you don't want to do it on both sides at the same time. So I usually focus on the right side because that's the side that I've seen the most response. So within 60 days, about 60 to 80 percent of their abnormal symptoms have resolved. So much so that they don't require any further injections.

That's incredible. So, in a way, it's it's permanent or semi-permanent. It is. But that's fantastic. So now walk us through the procedure itself. What does the patient actually experience from the moment they come in till when they go home? You mentioned it was quick, but walk us through what that actually looks like.

Sure. So as I was saying, when the patient comes in, we kind of evaluate what the cause of these symptoms are. And most often you can trace it back to COVID. We talk about the patient's understanding of what a stellate ganglion block is, why does COVID, uh, long COVID symptoms occur. And in general, we educate the patient about the why and how. And then we talk about the injection itself. We reassure the patient that you know this procedure is done under X-ray guidance. So we know where that needle is at all times. We emphasize that it's a short procedure, it's a safe procedure, and uh we tell the patient that uh because x-ray guidance is used, we're able to quickly get into the area where the stalate gangrene is, inject the medicine, and we also explain to them all the safeguards that we take. For instance, as I mentioned earlier, we do inject a dye to make sure that the needle is in the correct position. And only once we've ascertained that, we inject the medicine and remove the needle. And it I usually tell them that the numbing part feels like a small little bee sting that lasts for maybe a split second. And usually I have patients and patient support staff that are in the room that reassure the patient, hold their hands, and you know, make sure that they know that there's somebody else other than me that's in the room uh to walk them through it. And as I said earlier, it is a very quick procedure. I'm usually done within about 10 to 15 seconds. And then after that, the patient comes to the recovery room, they recover, we talk about the Horner syndrome, what they expect, and we reassure them that these symptoms will resolve in about five hours.

How do you know if someone's a good candidate for the stelic ganglion block? And um, how quickly do patients typically know whether it's working or not? How quickly do they see results?

I usually tell patients to expect a difference within two weeks. Because it does take around two weeks for those established pathways to be terminated because of that stellate ganglion block. So most patients, you know, when I interview them about 30 days later, they tell me, you know, at least a third or maybe two-thirds of their symptoms have resolved.

So are there any other conditions where this block uh is making a difference that might surprise our listeners?

Well, as I was saying, long COVID is not necessarily just abnormal smell and taste. You can have severe joint pain, you can have palpitations, abnormal sleep rhythm, bowel and bladder dysfunction, um Potts syndrome, where patients can for no good reason start having heart fluttering. Um we talked about post-traumatic stress, OCD, um Rhinoz phenomenon, um we talked about complex regional pain syndrome. There are a number of other conditions other than long COVID, as I've just mentioned.

So for the Kentuckians that are listening right now who have been told perhaps even by a physician that their trauma, their smell, uh, or taste loss or their pain is just something that they have to live with and deal with and kind of get over. Um what do you want them to know?

I think that, again, as I always say, all that you have to lose is your pain or these abnormal symptoms. The injection is simple, it's safe, and I think patients should not give up and they don't have to live with these symptoms that they have, especially when they can trace it back to COVID.

Yeah, absolutely. And that evaluation, like you mentioned, is the first step and really important. Um yeah, and that you know, if you're in Kentucky, these options you don't have to go to New York, you don't have to go to, you know, Massachusetts or California or somewhere. You have it right in your backyard, these like top-of-the-line options.

That's correct.

Fantastic. Well, thank you, Dr. Nyer, and thank you all for joining us for episode nine of the Kentucky Pain Reversal Show. Today's biggest takeaway, some of the most stubborn conditions, trauma, long COVID, pain that doesn't follow the rules, are not character flaws or mysteries. They're just signs of a nervous system stuck in fight or flight. And there is a procedure that can reach it. Next episode, we're looking at where this entire field is headed: peripheral nerve stimulators, and what Dr. Nyer believes is the wave of the future for many pain conditions. Lower the pills, lower the surgeries, stop the pain. We'll see you back in episode 10