Dr Tim GriceHJH,M

DR TIM GRICE

INFORMATION SHEET AND CONSENT FOR INJECTION TO THE STELLATE GANGLION (IN THE NECK) WITH OR WITHOUT SEDATION

STELLATE GANGLION ANATOMY

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Dr Tim GriceTHE STELLATE GANGLION  (or cervicothoracic ganglion) is a sympathetic ganglion formed by the fusion of the inferior cervical ganglion and the first thoracic ganglion, which exists in 80% of cases. The Stellate ganglion is located at the level of C7 (7th cervical vertebrae), anterior to the transverse process of C7, superior to the neck of the first rib, and just below the subclavian artery.

CLINICAL INDICATIONSThe clinical significance of these ganglia is that they may be blocked in order to decrease the symptoms exhibited by 

1. Raynaud's phenomenon -whitening of the hands due to constricted circulation causing pain2. Hyperhydrosis (extreme sweating) of the hands.3. Sympathetically mediated pain such as complex regional pain syndrome type I (reflex

sympathetic dystrophy). 4. Post Traumatic Stress Disorder (PTSD). 5. Blunt needling of the stellate ganglion with an acupuncture needle is used in Traditional

Chinese Medicine to decrease sympathetically mediated symptoms as well.6. Block of the stellate ganglion has also been explored in coronary artery bypass surgery. 7. Has potential as a means of reducing the number of hot flashes and night awakenings

suffered by breast cancer survivors and women experiencing extreme menopause

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Dr Tim Grice

Evidence for Treatment of Post Traumatic Stress Disorder (PTSD) with Stellate Ganglion Nerve Block (SGNB)There were initial reports of good responses for patients after undergoing a Stellate Ganglion Nerve Block for PTSD. These were initially performed on mainly ex-military/military personnel after suffering from the effects of PTSD for some time.

Initially 75% of case study patients had a benefit from the procedure. Some patients noticed return of their symptoms after 4 months. These patients underwent a second Stellate Ganglion Nerve block and many had a protracted benefit lasting a number of years.

There has been a small placebo controlled trial (i.e. half patients get the SGNB and the other half just get an injection of saline) published recently. It found that whether or not the patient was treated with a placebo of with a SGNB they had an improvement in there symptoms, It also found that if the patient had a second SGNB then they had extra benefit. The conclusion was that the SGNB was only as good as placebo (Shame injection) in the treatment of PTSD.

March 19, 2015FOR IMMEDIATE RELEASE

8735 W. Higgins Road, Suite 300 Chicago, IL 60631-2738 847-375-4731 Phone info@painmed.org www.painmed.org

Contact Information Email: info@painmed.org Attn: Director of Communications American Academy of Pain Medicine Phone: 847-375-4731

Stellate Ganglion Block Showed No Significant Benefit for Post-Traumatic 3

Dr Tim Grice

Stress Disorder in Controlled Trial

March 19, 2015, NATIONAL HARBOR, Md. – A sympathetic nerve block that has shown promise for treatment of post-traumatic stress disorder (PTSD) performed no better than sham treatment in a randomized controlled trial, new research shows. However, patients who received a repeat treatment saw greater improvement, the investigators reported today in a scientific poster at the

31st

Annual Meeting of the American Academy of Pain Medicine.

“We were disappointed to find that, under more controlled conditions, we could not reproduce the positive findings that had been reported in case series and in the popular press,” said Robert McLay, M.D., Ph.D., lead author and part of the collaborative team of researchers from the University of California–San Diego, the Naval Medical Center–San Diego and the Naval Hospital of Okinawa, Japan.

Of 42 military service members with PTSD, 27 were randomized to receive SGB and 15 to receive a sham injection. An independent assessor measured PTSD severity at one week after the procedure and again at one month in a double-blind study design. Patients who still met PTSD criteria could receive a second SGB or crossover from sham to active treatment. The investigators also measured pain, depression, anxiety, cognitive function and disability.

Results showed PTSD symptoms improved significantly for both groups after treatment; however, there was no statistical difference between SGB and sham. Greater improvements were seen after a second SGB treatment than after the first, the research team reported.

“The most obvious explanation would be that the previously-reported benefits for PTSD were attributable to placebo effect,” McLay said. “Alternatively, it is possible that only particular people with PTSD respond well to the SGB treatment, or that small variations in how the technique is performed result in different outcomes for PTSD.”

Although the current results do not support SGB for PTSD, given that the treatment does have some risks, the avenue of research will continue. McLay voiced the wish to work with others who experienced or observed more positive results.

If it does work, SGB is almost the ideal treatment, he said, because it is fast, easy to perform and lacks any stigma that may still cling to psychotherapy or psychiatric medications.

“It is important to remember that whether SGB works for PTSD or not, there are other options available,” McLay emphasized. “Those who suffer from PTSD symptoms should seek treatment.”

Summary: Patients generally benefit but it may be a Placebo effect and not necessarily form the Stellate Ganglion Nerve Block

INJECTION METHODThe injection is often given near the Chassaignac's Tubercle (anterior tubercle of transverse process of C6) due to this being an important landmark lateral to the cricoid cartilage.

It is thought that anaesthetic is spread along the paravertebral muscles to the stellate ganglion.

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Dr Tim Grice

XRAY OF THE INJECTION BEING PERFORMED (LEFT NEEDLE PLACEMENT AND RIGHT WITH RADIO-OPEAQUE CONTRAST TO CONFIRM CORRECT NEEDLE PLACEMENT)

WHEN BOOKING THE PROCEDURE

On the day of booking your procedure, please advise staff if you are – Taking blood thinners (especially warfarin and clopidogrel) Diabetic Pregnant, or any chance of being pregnant Allergic to:

o Shellfisho Steroids

o Local anaestheticso Iodine

o Betadineo Chlorhexidine

Unwell or have an infection

DAY OF THE PROCEDURE

DO NOT eat or drink (for 6 hours before your procedure), TAKE your usual medications with a small amount of water (apart from those mentioned

previously), and ARRANGE for someone to accompany you home.

DURING THE PROCEDURE

After arriving you will need to complete the necessary paperwork. Then – You will change into a hospital gown, A small drip will be inserted into one of your veins, You may be given a mild sedative,

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Dr Tim Grice Your heart rate and blood pressure will be monitored throughout the procedure, You will lie face down on an x-ray table, then the skin over the area to be injectedwill be

cleaned with an antiseptic solution, A sterile barrier will be created, A local anaesthetic will be injected to numb the area, You will be asked to map out your pain distribution, An x-ray machine will be used to guide a small needle towards the nerve, You may experience some discomfort, however this usually subsides and can be treated

with icepacks and medication.

AFTER THE PROCEDURE

You will be monitored in a recovery area until you are ready to go home. This usually takes between 60 – 120 minutes.

You will be given a pain relief chart to fill out. SHOW this to your doctor at your next consultation.

Preferably, someone will take you home and stay with you for the next 24 hours. Pain may return when the anaesthetic wears off. Some people experience an initial

increase in pain and stiffness, which may continue for several days. If necessary you may apply an ice pack to the area for 20 minutes at a time, for 1-2 days following the procedure.

You may take simple pain-killers such as Paracetamol to ease any discomfort. Remove any dressing the day after your procedure. Avoid a rapid increase in your activities. Gradually increase your daily activities as

tolerated. Discuss this with your doctor. If steroids were injected, it may take several days for the benefits to be noticed.

Additionally, you may feel flushed in the face and/or notice a change in your mood for a few days. Diabetic patients may notice a rise in blood sugar levels.

If you have received sedation during your procedure, the effects may last up to 24 hours. Due to the effects, you may not remember some of the information given to you during the procedure. For the next 24 hours, you SHOULD NOT –

o Drive a vehicle, o Drink alcohol, o Operate machinery,

o Make important decisions, o Sign legal documents, or o Travel unaccompanied.

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Dr Tim Grice

COMPLICATIONS

This procedure is usually safe and uneventful. However, as with any procedure there is always a small degree of risk.Complications associated with a stellate ganglion block include Horner's syndrome,

Common Complications Horner’s Syndrome (this should always be present if the injection has worked correctly (see

above picture) it only lasts for approximately 1 day and can give mildly blurred vision in the affected eye for that period

Continuing PTSD (if this was the reason for the injection) ie injection failure Minor bleeding in the area injected Bruising in the area injected Temporary weakness or numbness from the local anaesthetic Side effects from the steroid (if injected) Brief increased pain that may fluctuate Short term high/low Blood Pressure

More Serious but much Rarer Side Effects Intra-arterial or intravenous injection of local anaesthetic causing difficulty swallowing, vocal

cord paralysis, epidural spread of local anaesthetic, seizure pneumothorax. Permanent nerve injury to the including weakness, Allergy to the anaesthetic or steroid used in the sedation or as part of the procedure Increase of any pre-existing medical condition such as cardiac conditions Brief mild to moderate increase in pain that involves a burning sensation (this is easily

treated with a simple pain relief) Damage to the blood vessels around the injection on rare occasions Infection Bruising around the area from needle trauma

Please discuss with your doctor any other questions you may have about this procedure or this information sheet. If you agree to have the procedure, you will be asked to sign a consent form.

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Dr Tim GriceIf you notice –

Any swelling from the site, Any bleeding from the site, or Have any other concerns, Difficulty breathing

please contact your General Practitioner, Queensland Pain Doctor, or the Emergency Department of your local hospital.

CONTACT DETAILS

Dr Tim GriceSpecialist Pain Medicine PhysicianQueensland Pain DoctorSuite 4, Level 4123 Nerang StSouthport, QLD 4215Phone: 07 5532 0468Fax: 07 5528 3850Email: admin@qpdr.com.au

PTSD ReferencesMil Med. 2013 Feb;178(2):e260-4. doi: 10.7205/MILMED-D-12-00290.

Stellate ganglion block improves refractory post-traumatic stress disorder and associated memory dysfunction: a case report and systematic literature review.Lipov EG1, Navaie M, Brown PR, Hickey AH, Stedje-Larsen ET, McLay RN.

CONSENT

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Dr Tim GriceI have had time to read and I understand the information and instructions provided to me regarding the Injection of the Stellate Ganglion and post-procedural care. The common risks are:- Horner’s Syndrome (this should always be present if the injection has worked correctly (see above picture) it only lasts for approximately 1 day and can give mildly blurred vision in the affected eye for that period, Continuing PTSD (if this was the reason for the injection) ie injection failure, Minor bleeding in the area injected Bruising in the area injected, Temporary weakness or numbness from the local anaesthetic, Side effects from the sedation, Brief increased pain that may fluctuate, Delayed response to the steroid for a few days (if injected), Short term high/low Blood PressureThe more serious but rare risks are:- Intra-arterial or intravenous injection of local anaesthetic causing difficulty swallowing, vocal cord paralysis, epidural spread of local anaesthetic, seizure, pneumothorax. (collapsed lung), Permanent nerve injury to the including weakness, Allergy to the anaesthetic drug used in the sedation or as part of the procedure, Increase of any pre-existing medical condition such as cardiac conditions , Brief mild to moderate increase in pain that involves a burning sensation (this is easily treated with a simple pain relief), Damage to the blood vessels around the injection on rare occasions, Infection, Bruising around the area from needle trauma Serious anaesthetic / procedural complications and very rarely death, Increased lifetime risk of cancer due to X-rays exposure, Very rare risk of surgery due too injuries from the procedure

I understand that this procedure is not permanent but can be repeated a number of times if necessaryI understand that there have only been case reports of patients benefiting form Stellate Ganglion Nerve block. In the only small placebo controlled trial there was the same benefit whether a placebo or a Stellate Ganglion Nerve Block was performed with no statistical significant difference in outcomeI understand that this procedure is only part of my treatment and that Rehabilitation and ongoing psychological support may be required will also be required to maximize my benefit.I understand that I have the right at any stage to change my mind even after I have signed this document.I have had time to ask any questions and raise any concerns I have regarding this procedure and its risks with Dr Tim Grice.I understand that there are alternatives to this procedure including; no –treatment, medication and psychological support.I believe that all my questions have been discussed and answered to my satisfaction. I understand that if there were any immediate life threatening Incidents happen during the procedure that they will be treated as part of the procedure. I understand and agree that a sample of my blood can be taken and tested should a member of staff have exposure to my bodily fluids as part of the procedure.I believe that all my questions have been discussed and answered to my satisfactionI I understand that I may need further procedures to get a longer lasting benefit should the injections prove to be beneficialI consent to a Stellate Ganglion Injection with / without sedation (delete one option)

Patient Name: ___________________________________ Date: _________

Patient Signature: ________________________________

Doctor Name: ___________________________________

Doctor Signature: ________________________________CONTACT DETAILSDr Tim Grice Specialist Pain Medicine Physician Queensland Pain DoctorSuite 4, Level 4, 123 Nerang St, Southport, QLD 4215Phone: 07 5532 0468 Fax: 07 5528 3850 Email: admin@qpdr.com.au

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