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.

What is a stellate ganglion block?

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.

86% of participants saw some improvement of their symptoms.

Total reports
% relief
Shortness of breath
Chest pain
Joint pain
Symptoms worsen
Pins and needles
Changes in taste/smell
Difficulty sleeping
Mood changes
Changes in menstrual cycle
Brain fog

Numerous research studies have demonstrated the effects of SGB in the modulation of the immune system and hyperinflammation.

How does the SGB work?

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

IncidenceSubtypeGroup Specifics
34%Kidney, heart, circulation; Anemia Heart failure
Cardiac dysrhythmias/tachycardia, palpitations,
Abnormalities on heartbeat, acute renal failure; fluid and electrolyte disorders;
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
23%Musculoskeletal and nervous system, arthritis/joint pain, digestive; headaches, malaise, fatigue, cognitive problems/brain fog, smell and taste problems, neuropathies, sleep problems, skin rashesFemale > 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 what to ask a doctor who will do the SGB?

  1. How many SGB’s have you done in the last month?
  2. Do you do the SGB with fluoroscopy or ultrasound?  Ultrasound is technically safer as arteries, veins, nerves are seen and can be avoided.
  3. Do you do one level or 2 per side (C4 and C6)?  Dual level has been shown to increase recoveries.
  4. Do you do C6 or C7?
  5. What local anesthetic do you use?
  6. Do you use a steroid?
  7. 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)?8.
  8. Can I have it done awake, or do you sedate patients for this procedure?
  9. Have you had any complications from the SGB in the last year?
  10. 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?

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 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 is shaped with points similar to a star so it was called a stellate.  It is similar to the word stellar.

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.

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.

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.

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. 

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. 

The 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.

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