Stellate Ganglion Block: Treatment for Long Covid
What is a Stellate Ganglion?
The stellate ganglion is a collection or cluster of nerves, known as the stellate ganglion, that lives on the front of our spines in our neck. It is responsible for some of the automatic or autonomic responses that your body does such as the fight or flight response, dilating your pupils, increasing your heart rate, and so on. They relay the signal from your spinal cord to your brain and from your brain to your spinal cord.
Dr Groysman explains treating long covid symptoms with a stellate ganglion block (SGB)
Call or book an appointment online today to find out how SGB For Long Covid could help you.
Does the SGB work?
What is a stellate ganglion block?
The Stellate Ganglion Block (SGB) is an advanced medical procedure and must be performed by someone with medical expertise in doing these type of blocks. One way to reduce the sympathetic tone of the head, face, and neck, and chest areas is to block this bundle of nerves is with a local anesthetic. We often block the stellate ganglion at C6. We also perform a similar injection at C4 to block the sympathetic cervical chain. Live ultrasound guidance provides a safe passage to our intended target. We do not recommend fluoroscopic or x-ray guidance as any extra blood vessels that occur will not be seen and can potentially be injured.
Numbing this area with a local anesthetic often causes Horner’s syndrome. This is a temporary (3-4 hours) and harmless set of signs that we use to confirm a good sympathetic blockade. This is a collection of symptoms including a bloodshot red eye, upper lid partially closed, and a smaller pupil compared to the unaffected side. Additionally, on the side blocked, the nose will become stuffy, part of the face can become flushed or warm as can the arm. Lastly, because some of the local anesthetic can travel, it can block the recurrent laryngeal nerve and make you hoarse or feel a lump in your throat. Some of the local anesthetic can fall on part of the brachial plexus causing a tingling sensation in the shoulder, arm, or fingers. The arm should not be completely numb or weak, this would not be a sign of a successful stellate ganglion block (SGB).
For people who get a great response and recovery of symptoms, but the recovery doesn’t last, we have another option.
What can the SGB do for Long Covid?
These findings are from my own personal observations and have not been peer reviewed. Stellate ganglion block or SGB can correct a lot of the neurological and psychological problems associated with long covid. Please note that its actually correcting the problems with the dysautonomia as opposed to just going after symptoms of long covid. It can help with:
- parosmia/dysgeusia
- anosmia/ageusia/ +/- hyposmia
- brain fog
- chronic fatigue
- exercise intolerance
- chest pain
- neuropathies in arms/hands/shoulders
- anxiety associated with PTSD or long covid
- PTSD
- insomnia
While I have observed that it can help with some of the other long covid symptoms, its not consistent. For instance, I have observed improvement of tinnitus in some as well as neuropathic pain in the legs.
Recovery can be permanent or may not last depending how stuck and resistant your sympathetic nervous system is. It sometimes snaps back to where you were despite it being in an abnormal state, because the body likes equilibrium. Stress or another illness can also cause long covid to show its head again.
86% of participants saw some improvement of their symptoms.
|
Symptom
|
Total reports
|
% relief
|
|---|---|---|
|
Shortness of breath
|
17
|
88
|
|
Cough
|
10
|
80
|
|
Fatigue
|
35
|
77
|
|
Chest pain
|
10
|
80
|
|
Joint pain
|
16
|
94
|
|
Tachycardia/palpitations
|
9
|
78
|
|
Symptoms worsen
|
27
|
27
|
|
Pins and needles
|
9
|
100
|
|
Diarrhea
|
8
|
88
|
|
Changes in taste/smell
|
18
|
56
|
|
Fever
|
1
|
100
|
|
Dizziness
|
17
|
77
|
|
Difficulty sleeping
|
14
|
71
|
|
Rash
|
2
|
100
|
|
Mood changes
|
21
|
21
|
|
Headache
|
16
|
81
|
|
Changes in menstrual cycle
|
5
|
80
|
|
Brain fog
|
33
|
79
|
Numerous research studies have demonstrated the effects of SGB in the modulation of the immune system and hyperinflammation.
How does the SGB work?
- natural killer cell activity reduction
- decrease in levels of inflammatory cytokines such as IL-1, IL-4, IL-6, IL-8, and TNF-α
- increase of anti-inflammatory cytokine IL-10 and calcitonin gene-related peptide (CGRP)
- regulate endothelial dysfunction
- regulate microcirculation
- regulate coagulopathy
- reduction of neurogenic pulmonary edema
- pulmonary arterial hypertension
- reduction of pathological positive feedback loops
After SGB treatment, when your sense of smell (anosmia) and taste (dysgeusia) get better, it’s because the treatment restores the balance between two parts of your nervous system. This happens by blocking the overactive sympathetic part in your neck, which is responsible for head and neck functions. It’s possible that when this sympathetic part is too active, it disrupts important cranial nerves like the ones for smelling, facial movement, and taste perception, causing these issues.
Timing is crucial when using a treatment called SGB for long COVID-19 syndrome. If we wait too long, the body’s adjustment to the condition may make SGB less effective. It’s like dealing with a stubborn door. The longer you wait, the harder it is to keep it open. We’ve noticed that when SGB is delayed in people with other long-lasting post-viral conditions like Lyme disease or chronic fatigue syndrome, it doesn’t work as well compared to those with long COVID-19. They only see a small improvement, about 10-20%, with each injection.
Subtypes of Long Covid
| Incidence | Subtype | Group Specifics |
|---|---|---|
| 34% | Kidney, heart, circulation; Anemia
Heart failure Cardiac dysrhythmias/tachycardia, palpitations, Abnormalities on heartbeat, acute renal failure; fluid and electrolyte disorders; Nausea/vomiting | Median 65 years 1:1 male:female Covid hospitalization 61% More preexisting conditions |
| 33% | Respiratory & sleep, anxiety, fear related, headache, nonspecific chest pain , breathing abnormalities (shortness of breath, cough) and throat/chest pain | Female 63%
Median age 51 years From later waves of covid COPD/asthma |
| 23% | Musculoskeletal and nervous system, arthritis/joint pain, digestive; headaches, malaise, fatigue, cognitive problems/brain fog, smell and taste problems, neuropathies, sleep problems, skin rashes | Female > 60% |
| 10% | Digestive and respiratory; GERD, gastritis, nausea/vomiting, diarrhea, abdominal or pelvic pain; lower respiratory disease, throat pain, chest pain; | Female >60% |
SGB was effective for the red symptoms.
Questions to ask your provider before an SGB
I get asked a lot of questions about what to ask a doctor who will do the SGB?
- How many SGB’s have you done in the last month?
- Do you do the SGB with fluoroscopy or ultrasound? Ultrasound is technically safer as arteries, veins, nerves are seen and can be avoided.
- Do you do one level or 2 per side (C4 and C6)? Dual level has been shown to increase recoveries.
- Do you do C6 or C7?
- What local anesthetic do you use?
- Do you use a steroid?
- What do you do if I don’t develop a good Horner’s syndrome (red eye, droopy eye, small pupil, stuffy nostril, flushing of face)?
- Can I have it done awake, or do you sedate patients for this procedure?
- Have you had any complications from the SGB in the last year?
- What kind of success have you had doing SGB’s for parosmia/anosmia/brain fog/anxiety?
How does a Stellate Ganglion Block (SGB) work?
By temporarily blocking these nerves, it can reset and correct the dysregulation that occurs in your ANS, specifically the sympathetic nervous system. Based on the current available evidence and the dramatic and almost instant resolution of these symptoms after an SGB, it appears to be a functional problem rather than a structural damage of the nerves. Because it may be functional, it often only requires one set of injections per side for lasting relief of the symptoms. We provide this long covid treatment right here in our in office procedure suite.
What does getting an SGB feel like?
You will feel the pressure on your neck from the ultrasound probe. You will feel a short pinch and a burn for a few seconds and then it will be numb. Next you may notice some pressure and a popping sensation. It is tolerated very well awake. We typically don’t sedate patients because it makes it more difficult to assess the results. The entire procedure takes less than 10 minutes to complete.
What Does the Procedure Look Like?
There are really only a few contraindications to this procedure. If you are taking a blood thinner, it would be best to stop a few days before the procedure if you are able. There is nothing really special that needs to be done beforehand. You do not need to fast. Purchasing a vagus nerve stimulator is helpful after the procedure.
What Dr. Groysman performs is very different from a standard SGB that is covered by insurance for pain conditions. A standard SGB is one level at C6 or C7 and usually with a steroid. His technique is one of a kind unique procedure. This is why he sees such high % of success. First, it is ultrasound guided. Second, it is done at 2 different levels: C6 and C4. Lastly, he ensures that the right tissues separate from the sympathetic nerves. Vagus nerve is also freed.
Ultrasound allows for live needle guidance, eliminates all radiation, and soft tissues such as arteries, veins, nerves, thyroid gland, and bone are all visible. Dr. Groysman prefers to see these structures while doing this procedure.
It is a way to interrupt the signals going in and out from the stellate ganglion by numbing the ganglion with a local anesthetic such as lidocaine, ropivacaine, or bupivacaine. This is performed under live ultrasound guidance at least in practice, but it can also be performed with fluoroscopy or live x-ray guidance. This procedure is an injection but it is tolerated very well even awake. We also block the C3 or C4 area which contains the superior cervical plexus and the sympathetic tract or road to the brain. This is not technically part of the actual SGB, but has been shown to improve results by Dr. Eugene Lipov, MD.
Absolutely not. Aside from smell and taste, it has been shown to help with brain fog, fatigue, anxiety, aches and pains, neuropathies, and even tinnitus in some.
It is a group of nerves located on each side of your cervical-thoracic vertebrae (the bones in your neck and chest part of your spine). Signals from the brain stop there before going to the rest of your body. Information for this ganglion is also relayed to the rest of the body including the face, brain, head, neck, arms, and chest. You have one of these on each side of your neck.
It helps to maintain your heart rate and breathing rate even if it’s not in control. It controls your blood pressure. Its main purpose is to protect you from harm and stress, the so-called fight or flight. Best examples are if you almost got run over by a car or being chased by angry bees or dog, perhaps even during and after a heated argument. Its function is to create the best possible conditions to either fight or run. These could include dilating your pupils to allow light to enter the eye, increasing your heart rate and force of heart pumping, dilatating your airways to allow for harder and faster breathing, and supplying more blood flow to muscles of your arms and legs. What does the SNS sacrifice to do all of this? It shunts blood away from your digestive tract so that you won’t be digesting anything. You won’t secrete anything: tears or saliva. You will sweat though.
Your body is meant to have the PNS in the driver seat most of the time. PNS allows your body to heal and take care of maintenance. SNS is like a wrecking ball to our inside, or better yet, a bull in a China shop (although, I can’t think of any time I would want that). It’s great for short term when needed but not 24/7. You are being exposed to epinephrine (adrenaline) and cortisol all day long. You will not only be on edge and have anxiety, but you will also have a difficult time shutting down to go to sleep.
Initially this happens because of direct damage from the covid-19 virus to the supporting cells of the nerves of your nose and tongue, however this tends to heal within a few weeks after recovering from the virus. The smell and taste problems may spontaneously resolve after a few weeks, or they may turn into a lasting effect. The abnormality is fueled by stress and illnesses because both increase sympathetic drive.
There have been many different treatments proposed, but the ones that appear to be most successful and reliably reproduced are the stellate ganglion block and the external ear vagus nerve stimulation. There are many other treatments for other symptoms of long covid.
It is shaped with points similar to a star so it was called a stellate. It is similar to the word stellar.
No of course not. It corrects an abnormal feedback in the autonomic nervous system. It also stops and reduces the inflammation caused by chronic immune activation.
Yes, but not directly. Regular nerve conduction and muscle testing (NCV/EMG) will not show anything about autonomic nervous system (ANS). There are several indirect ways to test the the ANS. Looking at effects on heart rate, blood pressure and sweating is often helpful. Tilt table. Heart Rate Variability (HRV). QSART.
We typically start with a right sided SGB block because most people appear to be right dominant when it comes to which tract is used more frequently. Both blocks can be safely done on the same day.
If you look at closed claim studies, the risks are bleeding, infection, nerve injury, spinal cord injury, seizures, pneumothorax, thyroid gland injury, and esophagus injury however in over 4000 procedures I have not seen one of these in my clinic.
Assuming the SGB was safely performed by an experienced provider such as the ones we perform in our clinic, we expect and want to see the Horner’s syndrome. This is a constellation of signs that show up almost immediately after the block is completed. You may also feel a lump in your throat, hoarseness, loss of voice, or difficulty swallowing for the duration of the effects of the block. This is not caused by the SGB, but by the inadvertent numbing of one of the vocal cord nerves called the recurrent laryngeal nerve. This is not dangerous as long as both sides of your neck are numbed at the same time.
This syndrome is temporary and results from the decreased output of the sympathetic nervous system to your brain, face, head, neck, arms, and chest. It causes a slight droopiness of the eye, redness in the white of the eye, a smaller pupil compared to the unblocked side, a stuffy nose on one side, and flushing of the eye, face, neck, ear, shoulder or arm. The skin in these areas increases in temperature around 1 degree Celsius and appears flushed or red. It is not necessary to see all of these, but I prefer to see at least 3 different signs to indicate that we did a good and solid sympathetic block.
Assuming it was not from lack of technique, it could be because your symptoms are NOT from dysautonomia. There are several other causes of long covid including gut dysbiosis and mitochondrial dysfunction.
No. It is not dangerous and it is temporary when associated with an SGB. We need to see this to verify that you actually received a good SGB and a sympathetic nervous system block. You are not having a stroke or anything like that.
Some smooth muscles that we can’t control voluntarily are controlled by both the parasympathetic and sympathetic nervous system. Others only have one or the other. The droopy upper eyelid or ptosis is caused because we stop the functioning of one of such smooth muscle in your upper lid. The pupil size becomes small under predominantly parasympathetic control when we take away the sympathetic nervous system influence. Similarly, the nostril on the side of the blood becomes engorged and swells without the sympathetic nervous system influence.
The heart rate and blood pressure can temporarily increase for 30-60 minutes after a block. Most often symptoms of anxiety, smell and taste tend to respond immediately or within minutes after the block. The other symptoms often take longer to reduce or eliminate and are usually realized by the next day.
Continue the vagus nerve stimulation after the SGB. Try to avoid stressful situations if possible. Try to avoid getting sick or surgery if possible. It takes time for the new state to stabilize and be accepted by your body after being in a heightened sympathetic nervous system state.
We don’t target the symptoms but the actual source of the problem, the dysautonomia. What we have seen respond best to the SGB is smell and taste abnormalities including anosmia (no smell), parosmia (abnormal, and hyposmia, but not phantosmia), brain fog, anxiety, depression, and chronic fatigue.
Some providers talk about the SGB as a reset. What exactly is reset? It is a nerve block. During the duration of the block, the sympathetic nervous system is off on one side. During this time, the parasympathetic tone is elevated and there are regional blood flow changes in your brain, head, neck, and chest. The combination of these things persist after the block wears off.
Because the sympathetic and parasympathetic are on opposite ends of a see-saw, when sympathetic tone decreases, the vagus nerve tone increases.
Aside from the SGB, many of the maneuvers that help improve your vagus nerve tone also calm down your sympathetic response.
While the block duration is only for a few hours, the changes it causes can be very long lasting. Most people will experience long term effectiveness. Occasionally, some people can revert back to their original symptoms after a few days or weeks. This is more likely with life stresses, getting sick again, or after surgery.
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