CRNA fixes parosmia with Stellate block!?!

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Ligament said:
SGB is a 100 year old procedure (seriously).

It is has been done this way for the vast majority of that time.
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...until US and XRAY showed up on scene and dramatically improved both morbidity and efficacy.
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MitchLevi said:
I agree with all of this.

He clearly missed and had to keep trying.

Doing these with US alone isn't as reliable as combined US + XRAY (the way I do it).

I have on several occasions injected contrast under US and checked with fluoro. Despite what looks like meticulous US technique, the contrast isn't always great.

You may be perfectly placed at C6, but you've still got to anesthetize C7 and T1 for it to truly work. That requires a certain dispersal pattern and just bc you're seemingly great at C6 doesn't mean it will do what you want and neatly cover C7 and T1. The proximal thoracic ganglia needs to be anesthetized.

I would encourage each of you to do the following for the next 5 stellates you do and see if I'm correct:

Have XRAY get an AP shot and mark C6 on the skin. XRAY then pulls out about 2 feet to get out of the way. Put the US probe on your skin mark and ensure you're at C6.

Do your US-guided stellate, but inject contrast 2cc instead. Have XRAY come back and shoot a pic.

You'll find very often you're not deep enough and your contrast is a little more lateral than you'd perhaps like to see.

This guy in the video simply missed and kept trying. I wouldn't. If I screwed that up you'd have to come back another day.

Seems the stellate is the ESI of the 80s and 90s - Just shoot the medicine in there and it will fix everything.
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You don’t need to have it go below the rib for SGB for that’s to get the lower stuff around first rib; for PTSD you don’t need to have the spread go as inferior; Mulvaney mentioned this in one of his studies I think
 
soccrwz said:
You don’t need to have it go below the rib for SGB for that’s to get the lower stuff around first rib; for PTSD you don’t need to have the spread go as inferior; Mulvaney mentioned this in one of his studies I think
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For what 90% of us are treating you sure do (CRPS).

What I understand about SGB for PTSD you need the superior cervical ganglion correct? At like C3?
 
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Used to do under rib ct guided to get the kuntz fibers. Like someone else mentioned I’m not really excited to do sgb anymore based on reimbursement plus don’t see a lot of crps in my current practice (on purpose)
 
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Ducttape said:
interesting but i would really be circumspect about quoting a rate of 1%. those are kind of tenuous grounds to determine 1% risk of a sentinel event.

the article you posted was a case study, and they had significant safety measures in place. they waited an hour between blocks, and that seems much more reasonable because of how bupivacaine works.

im still unclear of mechanism of action for a mechanism that is centrally acting. the use of stellates for intractable arrhythmias was previously discussed (by me) on this forum. i can understand that mechanism as you are blocking sympathetics downstream (in the heart).
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Statistics are fun things to hide behind. It can't be a sentinel event though as it's an anticipated complication that you should have a plan for, whether you're in the clinic or on the ward.

I remember when deep cervical plexus blocks used to be done and you'd be intubating people right after because of the bilateral RLN/phrenic blockade. Sucky times. Acute respiratory failure after deep cervical plexus block for carotid endarterectomy as a result of bilateral recurrent laryngeal nerve paralysis - PubMed

We've gotten better at things though and there's a need for options for a lot of weird things that seem to respond to SGBs.

Another example
www.ncbi.nlm.nih.gov

Bilateral stellate ganglion block for migraine: A case report

Migraine is a recurrent, disabling neurovascular headache disorder. The patient's quality of life can be severely impaired by migraine attacks. Stellate ganglion block (SGB) can be used to relieve pain in the head, neck, and upper extremities. In the ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Bilateral for migraines in 2 patients, multiple times.
 
MitchLevi said:
For what 90% of us are treating you sure do (CRPS).

What I understand about SGB for PTSD you need the superior cervical ganglion correct? At like C3?
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As I said for PTSD you don't need to as much inferior spread, this thread isn't about CRPS, you need inferior spread for UE CRPS no one is debating that
 
SGB for PTSD, CRPS, depression, parosmia, Raynaud's, vtach, phantom limb, postherpetic neuralgia.

What's next on the list for this wondrous procedure?
 
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Ligament said:
:) I'm not advocating for the blind approach believe me.
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I dunno, I can feel my own Chassaignac’s tubercle easily, and it’s shallow enough I could reach it with a very small needle - couldn’t be that hard. (I use combined fluoro/US approach similar to what others described though, for the few I do - belt and suspenders approach)
 
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soccrwz said:
As I said for PTSD you don't need to as much inferior spread, this thread isn't about CRPS, you need inferior spread for UE CRPS no one is debating that
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Indeed, this thread is not about CPRS, cardiac disease, gangrene, or whatever other tangent has been thrown out there. This thread is about parosmia.
 
ragnathor said:
SGB for PTSD, CRPS, depression, parosmia, Raynaud's, vtach, phantom limb, postherpetic neuralgia.

What's next on the list for this wondrous procedure?
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Gluten sensitivity
 
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soccrwz said:
As I said for PTSD you don't need to as much inferior spread, this thread isn't about CRPS, you need inferior spread for UE CRPS no one is debating that
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Which is why I asked what cervical chain ganglia are we targeting...The only one that makes sense to me is superior at C3 but I'm not seeing ppl advocate for low volume, higher level injections.

Of course, parosmia makes zero sense to me with a stellate, but since we're talking about it I'd like to know how this is supposed to work.

I predict another 17 random Dx will be thrown around for SGB over the next 4 yrs. The wilder the world gets, the more stellates we'll see on LinkedIn.

Maybe Putin needs a stellate.

Perhaps democracy exists at Chassaignac's tubercle.
 
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MitchLevi said:
Of course, parosmia makes zero sense to me with a stellate, but since we're talking about it I'd like to know how this is supposed to work.
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pubmed.ncbi.nlm.nih.gov

How does stellate ganglion block alleviate immunologically-linked disorders? - PubMed

Various pathologic conditions have been shown to be SGB responsive, where the symptoms have been reduced or eliminated. Many of those clinical improvements have been mirrored by measurable immunologic changes. A plausible explanation, consistent with the evidence available so far, is that SGB...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

If you want to read conjecture on various MOAs for some of these things

I suspect though when we do it with 6-10 mL we are getting combined vagal and sympathetic blockade but I haven't seen solid data for that.
 
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soccrwz said:
You don’t need to have it go below the rib for SGB for that’s to get the lower stuff around first rib; for PTSD you don’t need to have the spread go as inferior; Mulvaney mentioned this in one of his studies I think
Click to expand...
If you're not, it's not a stellate block. Stellate ganglion lives down there.

Sounds to me like "stellate" blocks for PTSD/etc is really a cervical ganglion block then.
 
Ferrismonk said:
If you're not, it's not a stellate block. Stellate ganglion lives down there.

Sounds to me like "stellate" blocks for PTSD/etc is really a cervical ganglion block then.
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This is my belief.
 
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Ferrismonk said:
If you're not, it's not a stellate block. Stellate ganglion lives down there.

Sounds to me like "stellate" blocks for PTSD/etc is really a cervical ganglion block then.
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It appears the cervical sympathetic chain, middle and superior sympathetic ganglia are heavily involved in PTSD. But again, we are discussing Parasomias in this thread.
 
Contrast injected at the C6 level has consistently reached the C7-T1 interspace, which is the commonly accepted location of the stellate ganglion. The first rib is at T1, the interspace is above that, the rib below
 
hyperalgesia said:
This is a tangent but I saw an ophthalmologist for a routine visit and was planning on seeing him regularly. Suddenly he pawns me off to his optometrist to help build other aspects of the practice (passive income). Very annoying but this is what docs do to themselves by empowering midlevels.
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IDK, sounds to me like an ortho surgeon having you follow up with the office PMR guy.
 
nvrsumr said:
Im PMR but learned in my gas fellowship that volume fixes almost anything. Fun to do under anothers license.

Did hanging drop CESIs in VA exam rooms with crash cart god knows where... Hey turn Vet turn ur seat around and lay your forehead on the counter. This wont hurt a bit.
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Why u hating on hanging drop
 
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painfree23 said:
Why u hating on hanging drop
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5. Do not use the hanging drop technique to determine epidural needle placement, since this is not a reliable means of identifying the epidural space. I am aware of 2 malpractice claims in which spinal cord injury was associated with failure of the hanging drop technique to indicate epidural needle entry.

www.apsf.org

Avoiding Catastrophic Complications from Epidural Steroid Injections

Epidural steroid injections are frequently performed for patients with lumbar and cervical radiculopathy, the accepted indications. A review of Medicare
www.apsf.org www.apsf.org
 
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Blind CESI using hanging drop or LOR with a bad outcome should result in loss of license and attempted murder charges.

There's no excuse for that in 2022. I don't care what ppl did back in the day.

If someone did a C3-4 TFESI with 80mg Depo and the pt had a stroke or died you'd want that doctor prosecuted.

No one in this forum would consent to that as a patient, nor would anyone allow that to be done to their mother.
 
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Ligament said:
This thread has gone WAY off topic. This is not the CESI technique thread.
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Dude, this is an example of virtue signaling in the field of pain. We just want everyone to know we're on the good team and of high ethics!
 
I have zero doubt cesi with lor is done all the time today. I think it was useful for me to learn. I agree not std of care in general.

Fellow year ahead of me tickled the cord and the attending still wasn’t over it.
 
powermd said:
Holy schitt, I didn't notice that.

Do they even carry MP insurance?
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I don't know, but that is somewhat irrelevant as they cannot have any training in this procedure in any legitimate way. Meaning, they should not be doing this procedure or even thinking about it.
 
powermd said:
Holy schitt, I didn't notice that.

Do they even carry MP insurance?
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Isn’t a naturopath malpractice insurance just a few tinctures of charcoal or Fleets enema?
 
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Hydrodissection of the vagus? Amazingly beneficial if you use Sprite as your injectate. Can get away with Orangina or Ginger Ale, but Sprite is generally superior.
 
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MitchLevi said:
Hydrodissection of the vagus? Amazingly beneficial if you use Sprite as your injectate. Can get away with Orangina or Ginger Ale, but Sprite is generally superior.
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No ultrasound or fluoro of course, because image is nothing, thirst is everything.
 
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Ligament said:
I don't know, but that is somewhat irrelevant as they cannot have any training in this procedure in any legitimate way. Meaning, they should not be doing this procedure or even thinking about it.
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This ND has been doing fluoro-guided biologics for over ten years: Docere Clinics - Meet The Doctors

Loosely-worded state practice acts generally boil down to: “if you can train in it, it’s within your scope.” Only a manner of time before NPs, CRNAs, NDs, and DCs are all hospital-credentialed to do these procedures.
 
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chibadriver said:
This ND has been doing fluoro-guided biologics for over ten years: Docere Clinics - Meet The Doctors

Loosely-worded state practice acts generally boil down to: “if you can train in it, it’s within your scope.” Only a manner of time before NPs, CRNAs, NDs, and DCs are hospital-credentialed to do these procedures.
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“Dr. Adelson… …has performed more than 6,000 stem cell procedures and has injected stem cells into more than 1,600 intervertebral discs, placing him solidly among those most experienced in the world with use of stem cells for the treatment of pain.” And recently “…launched his flagship product, the Full Body Stem Cell Makeover”
 
chibadriver said:
“Dr. Adelson… …has performed more than 6,000 stem cell procedures and has injected stem cells into more than 1,600 intervertebral discs, placing him solidly among those most experienced in the world with use of stem cells for the treatment of pain.” And recently “…launched his flagship product, the Full Body Stem Cell Makeover”
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Makes sense if you don’t think about it.
 
lobelsteve said:
What's wrong with you folks? Free country. Stupid people deserve to be plucked. And his partner, Dr. Killen? That's the real story.
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You wouldn't last 6 weeks of conversations with that...Nope. Don't give you 6 weeks of "inflammation" and "toxins."
 
chibadriver said:
“Dr. Adelson… …has performed more than 6,000 stem cell procedures and has injected stem cells into more than 1,600 intervertebral discs, placing him solidly among those most experienced in the world with use of stem cells for the treatment of pain.” And recently “…launched his flagship product, the Full Body Stem Cell Makeover”
Click to expand...
They have a video of the Full Body on Instagram. It's wild. Looks like fat and tons of BMAC is harvested, then injected EVERYWHERE, including...
Screenshot_20220328-181242.png
 
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Ligament said:
Followup on this issue. I am posting for the sake of public safety.

His name is David Gaskin, CRNA. He is in Texas.

Here is his web page:

Republic Pain Specialists - Pain Management Bryan, College Station & Madisonville, Texas > About > Our Team

One of his patients, a 30 y/o female seeking treatment for parosmia, video recorded her SGB procedure with him on March 4th. This is done to treat parosmia. She records him doing the following, all on the same day, in this sequence:
  1. Right SGB
  2. Right SGB
  3. LEFT SGB
  4. Right SGB
She has very evident Horner's syndrome's on each side.

For those of you unaware, bilateral SGB on the same day can block the bilateral recurrent laryngeal nerves and create a surgical airway emergency.

She also reports in her video that:
  1. He will perform the SGB on pregnant patients "If your are past your first trimester"
  2. Children "as long as they are able to sit still"
Here is her youtube video showing David Gaskin doing the procedure bilaterally on the same day. Time/date stamps can be seen on the ultrasound unit to confirm this is all the same day.



This patient seems to be a very kind and sincere person trying to get relief from parosmia, and help others with it. Of course, do not direct any negative comments toward her or her youtube channel.

In case it is taken down, I have downloaded it, and encourage you to do the same if you see the need.




​

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so... is sterile technique, mask, gloves, etc over-rated? why are you being so careful when this goes on every single day...
 
Could those of y'all doing the T1/first rib block describe the volume and approach?
 
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I think getting the recurrent laryngeal nerve is more common than described.

Tell me, doesn't the patient sound a little more horse after the block (in Ligament's video)? That is from an incomplete block of the RLN. I find that many of my patients get a little horse after.

Regarding Long Covid and Parosmia - she nails it on the head at the end of the video. These weird symptoms are likely NOT an anatomical issue or nerve tissue damage. It is likely more in line with fibromyalgia or chronic fatigue, or other syndrome that involves a complex nature of emotion and cognition.

Please review this article if you think you should be doing this routinely for someone who feels a little off (that being anxiety, decreased smell, not getting along with their sister, etc.)

I do them for PTSD. Anecdotally, they do seem to work and patients sure love them. And just a reminder, I am listed on the RCT that showed they DIDN'T work.
 

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