Delving into the Effects of Ultrasound-Guided Dual Injection SGB

In the past year, Soft Reboot Wellness has been deeply involved in observing and analyzing the outcomes of ultrasound-guided stellate ganglion blocks (SGBs) performed in our Bay Area mental health clinic. This journey has provided us with a profound understanding of how this treatment impacts conditions like anxiety, PTSD, and Long Covid. Through this blog post, we aim to share our insights and experiences contributing to the broader dialogue and collaboration within the medical community regarding these treatments.

Understanding the Varied Responses to stellate ganglion block

Our observations have led us to identify four primary types of client reactions to stellate ganglion block:

Immediate Relief: Some individuals experience a rapid decrease in anxiety and nervous system overactivity.
Subtle Shifts: Others show gradual, sometimes barely noticeable, changes over days to weeks.
Rebound Symptoms: A significant number of individuals report a surge in PTSD symptoms, such as emotional flooding, or experience rebound anxiety. This typically begins 1 to 2 weeks post-procedure, although in some cases, it can be observed immediately or the day after the procedure.
Minimal Response: A small segment of clients show no significant response to the treatment.

Analyzing the Factors Behind Diverse Reactions

Anatomical Variations and Dual-Level Blocks

Individual anatomical differences, including variations between the two sides of the same person, play a significant role in treatment outcomes. Approximately one-third of clients respond well to a single stellate ganglion block and don’t require further treatment. However, for others, especially if PTSD symptoms re-emerge, repeating the stellate ganglion block on the contralateral side can be effective and safe.

Anatomical Variations

Our practice, influenced by Dr. Mulvaney’s June 2020 study, offers injections at the C6 level and additional injections at higher cervical levels such as C4 or C3. The ‘dual shot’ approach is designed to accommodate individual anatomical differences. This method aims to ensure more comprehensive coverage, especially considering the location variability of the stellate ganglion, predominantly around C7. These differences in the sympathetic chain’s course through the neck may explain why some patients benefit more from a two-level block.

Technique Nuances

The approach involves using potential spaces rather than directly targeting the stellate ganglion. We utilize a small volume of local anesthetic, hoping to infiltrate the region effectively. This is also why some side effects that do not relate to the sympathetic nervous system are noted, including hoarse voice, difficulty swallowing, and feeling of lump in throat.

The Importance of Follow-Up Evaluations

Post-SGB follow-up using PCL-5 surveys at one week and one month is crucial for assessing the treatment’s effectiveness.

In cases where a patient with PTSD and a high PCL-5 score shows no improvement following a right-sided stellate ganglion block (SGB), exploring a left-sided block as an alternative is advisable. However, it’s crucial to maintain a minimum gap of 12 hours between the procedures to mitigate risks such as airway obstruction. Interestingly, approximately 1-5% of patients unresponsive to a right-sided SGB may experience significant benefits from a left-sided block. Medical literature indicates that about 20% of patients, including those who only partially respond to a right-sided SGB, could see more substantial improvement with a left-sided SGB. This is often attributed to individual variations in the anatomy of their “fight or flight” response system.

Our approach involves a follow-up with clients about a week after the initial treatment to assess progress and plan the next steps in their treatment journey. We’ve observed that patients with Long Covid frequently require bilateral blocks to achieve considerable symptom relief. The interval between the first and second block appears to be flexible; most patients typically wait 2 to 3 weeks before undergoing the contralateral block and still report a noticeable improvement in their symptoms.

The IFS Perspective on SGB

From an Internal Family Systems (IFS) viewpoint, the nervous system can act as a ‘protector’, especially in cases of PTSD. The sudden easing of symptoms following SGB may be disconcerting, as clients might feel they’ve lost a familiar protective mechanism, highlighting the importance of psychological support.

Understanding “SGB Bends”: The Rapid Remission Phenomenon

Rapid Changes Post-SGB

Similar to Jessica Katzman’s concept of “Ketamine Bends”, the “SGB Bends” refer to the swift remission of PTSD and overactive nervous system symptoms after SGB, resembling emotional and physiological ‘decompression’. Rapid psychological shifts can be profoundly disorienting for individuals. These sudden changes can disrupt established coping mechanisms, challenge long-held beliefs about oneself, and create a sense of uncertainty about the future.

Psychotherapeutic support is essential in managing rapid psychological shifts, as it helps individuals adjust to new mental states, develop healthier coping strategies, and process emotions, thereby facilitating a stable, long-term integration of these changes into their lives and relationships.

Setting Realistic Expectations for SGB

It’s essential to acknowledge that despite a correct anatomical approach and technique, a certain percentage of patients may not respond to SGB. This understanding is crucial when setting realistic expectations and planning future treatments, especially for emerging applications like Long Covid and PTSD.

Emphasizing Therapy and Preparation

Considering the varied responses, it’s imperative for SGB candidates to actively engage with a therapist. This ensures alignment between therapeutic approaches and comprehensive preparation for the treatment. SGBs can provide temporary relief and are often more effective when combined with other treatments like ketamine.

Personal Insights from Dr. Sara’s SGB Experience

Dr. Sara underwent the SGB procedure herself; the process was enlightening for her. The experience, though uncomfortable, was not painful, and Dr. Sara encountered side effects like droopy eye, hoarseness, head ache, neck soreness and nasal congestion. The subtle changes she observed over a few months, coupled with a brief period of rebound anxiety, have greatly informed her approach to client care.

Conclusion: A Journey of Patience and Empathy

Embarking on this SGB journey requires patience and a deep understanding of each client’s unique experience. As Dr. Sara and Soft Reboot Wellness continue to explore and adapt in this field, Dr. Sara’s dedication to providing informed, empathetic care in the Bay Area remains unwavering.