Article Item

The Authors Respond

Jul 19, 2018

Ian M. Fowler, MD; Robert J. Hackworth; Steven Hanling
military medicine PTSD stellate ganglion

We would like to thank Dr Lipov for his interest in our work. The goal of the ASRA News article was to review (1) the status quo of research on the use of stellate ganglion block (SGB) for the treatment of posttraumatic stress disorder (PTSD), (2) its implication on current clinical practice, and (3) to encourage continued research while taking reasonable steps to ensure patient safety.

Without addressing each of Dr Lipov's statements point by point, we will leave it to the reader to study all sources of information and come to reasonable conclusions based on available evidence. The ASRA News article can serve as a guide to the literature even if your assessment of the literature differs from ours.

We would, however, like to respond to a few specific items. Dr Lipov commented on how the characteristics of the study population may have affected the results of our study.

The potential impact of the study population and the methodology has been consistently discussed by each of the authors at live meetings, within our previously published article, and in the recent ASRA News article. The conclusion of our study and the abstract presented at the American Academy of Pain Medicine 2015 annual meeting[1] was as follows:

  • “We cannot demonstrate any advantage of SGB over sham injection for the treatment of PTSD.
  • It is possible that SGB was underdosed, or that there are subpopulations that benefit.
  • SGB for PTSD is supported by evidence from case series, but this RCT did not support those findings.”

The letter also mentioned the previous positive trials. These positive trials were noted in the ASRA News article and include our own previous publication of a small case series showing success of SGB for PTSD at Naval Medical Center San Diego noted in the letter as reference 13. It was this very success that led us to want to perform further research.

As for the comment concerning SGB-related complications, we agree that catastrophic or severe complications are rare but do occur as noted by Dr Wulf's article (reference 12 in the letter), which reported on a survey of 76 departments in West Germany with a response rate of 51%. Therefore, the results are subject to responder bias and potential underreporting of catastrophic outcomes because of legal concerns or market forces. Regardless of whether such bias exists, our point on risk was meant to alert all clinicians who perform the procedure to study the literature and available information for side effects and harm that can result from this intervention. As mentioned in our letter, although rare, catastrophic events can and do happen and performing this intervention should not be taken lightly. Care and caution should always be used with SGBs.

Dr Lipov also wrote, “To date, more than 2,500 military personnel have been treated with SGB with good to very good success (unpublished data).”

The authors are unable to comment on the safety and efficacy results of unpublished data.

References

  1. Medina-Torne S, Hanling S, Lesnik I, et al. US Navy's First Functional Restoration Pain Program: improving readiness, restoring function, and relieving pain. Paper presented at: 2015 American Academy of Pain Medicine Annual Meeting; March 19–22, 2015; Washington, DC. Available at: http://www.painmed. org/2015posters/abstract-172/. October 5, 2017.
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