76 - Dr Robert Groysman - Stellate Ganglion Block

Episode 76 of the Long Covid Podcast is a chat with Dr Robert Groysman about the work he has been doing treating Long Covid with the Stellate Ganglion Block. We discuss what the block is and how it can be really successful in helping people. 

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(music - Brock Hewitt, Rule of Life)

Transcript

Jackie Baxter  0:00  
Hello, and welcome to this episode of the long COVID Podcast. I am delighted to welcome my guest today, Dr. Robert Groysman, who has been using the Stellate Ganglion Block to help people with long COVID. So we're going to be talking a lot about that today. So welcome to the podcast.

Robert Groysman  0:17  
Thank you so much, Jackie. It's a pleasure to be here.

Jackie Baxter  0:20  
Thank you so much. It's so exciting to be talking to you. To start with, would you mind just introducing yourself just a little and maybe just saying a little bit more about what it is that you do?

Robert Groysman  0:30  
Sure. So my name is Robert Groysman. I am a physician - that means a medical doctor, and I am dual boarded. What that means is I have diplomat status in two different boards. One is American Board of anesthesiology, and the other one is the American Board of pain medicine. I originally trained as an anesthesiologist, but right now mostly spending time working on pain management interventional, which means different kinds of injections. So I'm an expert at treating pain and other conditions by injecting specific areas of the body.

Jackie Baxter  1:07  
Wow, is that what led you into sort of looking at long COVID and the sort of pain side of it?

Robert Groysman  1:15  
So what led me to dealing with long COVID Actually, is my treatment of PTSD sufferers. So, way before long COVID was even a thing, I was treating patients for PTSD, everything from rape victims, to veterans, to people who were wrongfully convicted in jail, people who have been kidnapped to other countries. I mean, you won't believe the stories that I've heard. And based on the work of Dr. Eugene Lipov, he kind of pioneered this whole thing with stellate ganglion block for PTSD. So I started doing this roughly five years ago. And we've had immense success with it, roughly 80%. 

So I kind of fell into this long COVID thing, even before we knew what long COVID was, so back in January of the year this whole thing started. So we just happened to have a patient that had PTSD and something about loss of smell. You know, we had no connection, obviously, from COVID, and that and, you know, we did the stellate ganglion block and his smell came back. So it kind of got the gears working. And, you know, we didn't do anything for a little while. 

And then we started seeing more patients coming in with loss of smell, and then abnormal smell. So as first there was only loss of smell, and of course, you get this news that kind of came out, you know, COVID - How do you know you have COVID, you lose your smell. As soon as you lose your smell and taste, you have COVID, you know, and all the jokes came out and everything, you know, everybody thought that this was a temporary thing, and it would just go away on its own. 

And so we started seeing more and more patients with loss of smell. And then a few months later, we started seeing patients with abnormal smell, and then all the other parosmias, and all the other symptoms started coming out. So I think we probably the earliest treaters of long COVID even before long COVID became a thing, we knew where it was long hauler, long COVID, Post Acute COVID syndrome PACS. So all this stuff was unknown. So that's kind of how I got into the long COVID game, so to speak.

Jackie Baxter  3:33  
Yeah, I mean, that's amazingly interesting, isn't it? You know, I think I was probably one of the early long COVID kind of cohort. But you know, there were people who were infected prior to March 2020, which we know now - at the time we maybe didn't, but I mean, I think for me, I didn't really hear the words long COVID until maybe May - June of 2020. But, you know, it had obviously been around before that. And you know, I suppose in some ways it had been around for decades beforehand with ME/CFS you know, and I think the jury's still out on whether it's exactly the same thing. 

But yeah, maybe we should backtrack just a little bit. What is the stellate ganglion?

Robert Groysman  4:14  
So a stellate ganglion is basically a collection of nerve cells. Okay, so a ganglion is kind of like a mini brain in the nervous system. It's our autonomic nervous system. So it's that's different from the sensory system, you know, things that basically let you feel things like pressure or touch, or even pain. And it's different from the motor system, motor nervous system where these nerves control your arms and legs and basically everything else in your body that is voluntarily controlled by you. 

So this part of the nervous system controls the automatic stuff, autonomic - automatic, so things that you don't have to think about - things like pupil size, things like producing tears and saliva. That's automatic, right? Breathing. I mean, yes, you can voluntarily control it, but you don't have to really think about it, your heart rate, making your heartbeat - that's all controlled by the autonomic nervous system. Digestion is a big one. So getting the food from your throat down into your esophagus into your stomach, producing the acid, getting it into your intestines, all that's kind of controlled, you don't have to do anything, think about it. That's all autonomic nervous system. 

So the roles are split between the sympathetic nervous system and the parasympathetic nervous system. Most of the stuff that is the maintenance stuff, the immune system control, the inflammation control, the maintenance, parts of repair, all that's handled by the parasympathetic nervous system. Okay, so that system is in control of all that. And it's really meant to be in the driver's seat 99% of the time. 

Sympathetic nervous system comes along for the ride, sits shotgun. And if anything happens, that gets you excited, like, you know, being chased by an angry dog or seeing a beehive or almost get hit by a car, it pushes the parasympathetic out of the way and gets into the driver's seat. So it has a purpose, fight or flight. And this system is meant for temporary short term use. 

So this is where the stellate ganglion comes in - this little part of the brain consists of two separate plexuses. One is the inferior cervical plexus, and one is the superior thoracic Plexus. Now, these little brains are all the way from the brainstem down to the bottom of your spine. And it's kind of a way for your brain to consolidate the automatic decisions in different parts of your body without having to go through your brain to make these decisions. And as I said, it's all automatic. So the stellate ganglion is very, very important. It's one of the most important ganglia. And that's because it controls a lot of the communication between the brain and the heart and the lungs and the chest. 

So basically, all the signals from the sympathetic that originate in your brain, go through the stellate ganglion through a track. And it decides where it needs to go, if it needs to go back to the brain, if it needs to go to the heart, if it needs to go to your arm. So things like sweating is controlled by the sympathetic nervous system, the composition of sweat is controlled by the sympathetic nervous system. I don't know if you knew that - even your tears actually can have different composition, depending on what's happening. But what's important is is kind of a most important relay between the memory part of your brain which is the amygdala, it sits in your temporal region, and the rest of your body. 

So one way the stellate ganglion communicates and basically consolidates the information is - you may have fear from running from a dog, but you're going to react way faster next time, because it's stored in your amygdala. And it's automatically going to send that signal down to the sympathetic to race your heart, dilate your pupils, to make you breathe shallow, and and fast. And to make you sweat, because you're going to cool your body off because knows you're going to be using your muscles to either run or fight. So that's what it normally supposed to do. This little structure called the stellate ganglion. The problem is, is that in long COVID, it's not functioning properly. And that's kind of where we see all the problems with the symptoms.

Jackie Baxter  8:54  
Right. So it's a bit like a switchboard almost?

Robert Groysman  8:58  
Yes, exactly. It's exactly like a switchboard.

Jackie Baxter  9:01  
That's cool. And that totally explains the - You listed off a whole list of things that the autonomic nervous system kind of controls - your breathing, your heart rate, your sweating, your pupil size, your gut, there were other things. And these are all things that are associated with the symptoms of long COVID. And you know, they're all subtly different for everybody, but they're pretty common ones that you just mentioned aren't they?

Robert Groysman  9:28  
Yes. And I'll explain to you how this all falls into, I guess my theory of dysautonomia. So there's a lot of different I guess hypothesis of why long COVID happens. I mean, people can't even decide what long COVID is. I mean, if you look at the WHO definition, you look at the CDC definition, they're very different. Mostly they refer to how long after you've had COVID the symptoms develop. They can't agree on symptoms, they can't agree on a lot of the specifics. But Dysautonomia just basically means that the autonomic nervous system is not working properly. It's a dysfunction of the autonomic nervous system. Now that doesn't tell you if it's working too high or too low, it just means it's not working right. 

But I can essentially explain most of the symptoms, if not all, using the dysautonomia model. One of the comments is, is that the parasympathetic nervous system basically modulates or controls your inflammation, which comes from where - your immune system. And people don't think inflammation is immune system, but it is. Parasympathetic basically keeps it under control. So if the parasympathetic nervous system or the vagus nerve is not functioning properly, your autoimmune system is going to be a little out of control, which you start developing these autoimmune-like conditions, you start seeing things like celiac disease, you start seeing thyroiditis, you know, thyroid problems, you start seeing rheumatoid arthritis-like symptoms, lupus, sjogrens, Raynauds, all these things start coming up all of a sudden, in long COVID when the person's never had these symptoms. So I mean, yeah, you could say that, you know, there's some other mechanism causing these autoimmune conditions. But we can also explain that because the Parasympathetic is not, it's not functioning properly.

Jackie Baxter  11:25  
Yeah, so they are all completely interconnected, aren't they?

Robert Groysman  11:29  
They are 

Jackie Baxter  11:29  
all these kinds of different things that could be happening or symptoms or immune system and your autonomic system and your all your other systems. They're all connected, aren't they?

Robert Groysman  11:43  
Well, yes, because when your immune system is not functioning properly, if it's overactive, you will have some chronic inflammation, even if it's low level, that could explain some of the changes that happen in the brain. And that could explain some of the brain fog and the chronic fatigue. Also, another way to look at it is if you're in chronic sympathetic tone, your constant fight or flight, blood flow is not going to be the same in your brain and in your head as it is normally under Parasympathetic control, that can also explain some of the changes that happen with brain fog and fatigue. 

Now, you know, the whole smell and taste thing. You notice that that's very unique to long COVID. There's other causes of dysautonomia. Diabetes is a very common cause of having autonomic neuropathy or Dysautonomia - same thing - just another way of saying it, but it doesn't cause problems with taste or smell. Lyme disease does this, but doesn't cause problems with taste or smell. Lupus can cause it. But again, no issues with taste or smell. So there's something unique that COVID does, in addition to the Dysautonomia, that causes this, 

Jackie Baxter  13:07  
do you know what that is? 

Robert Groysman  13:08  
So I think it's the initial insult to those to the support cells. So there is initial damage. Okay. I mean, that's been shown, that has been shown in cadavers. But I don't think this damage is permanent. I think it's repaired within a couple of months. Because this tissue is renewed from the stem cells that's in the area. And it's repaired, but it's not rebooted. So we need to do something to kind of kickstart the process, and that's where the stellate ganglion comes in - the block.

Jackie Baxter  13:44  
Cool, so maybe that would be a good time to shift this over to talk about the stellate ganglion block. So yeah, what is it?

Robert Groysman  13:54  
so this area of the neck is kind of prime real estate. There's a lot of important structures there. So there's the nerves that come out from your spine in the cervical area that go to your arm. This is called the brachial plexus. And these are cervical nerve roots that come out and basically power your arm and shoulder and your hand. And there's also the vertebral artery, which is a very large artery that travels inside the spine structure to the brain. So it's an important blood supply to the brain. And you obviously also have the carotid artery and the jugular vein, the internal jugular vein. So these are just the vascular structures and the nerve structures. You also have your thyroid gland and your esophagus that are sitting all within about two and a half inch cube in this area where we're going, so it's an advanced block. So you need to be able to recognize every single structure and avoid anything that's bad and get to where you need to get to. 

So back to kind of where the stellate ganglion is, when we do the block, we're not technically injecting around the stellate ganglion, because it would be dangerous to do so. And the reason is, is because it's closer to the thoracic. And there's also lung in there - the top part of the lung called the cupola. And there's a chance if you go too low in the neck, or too inferior, you can get into the lungs. So we usually go on several levels up, usually this is done either at C six or C seven cervical levels, as you know, we have seven cervical vertebrae. 

So this this ganglia sits on the front side part of the neck. And you have to find it under ultrasound, and kind of what we're looking for really is that the sympathetic track and it has different positions, it's not always in the same place in every single person. This part of the anatomy is actually somewhat variable, not just where the stellate ganglion sits, or the track sets, but also where the carotid and the jugular vein sits and the shape and position of the vertebral area that we're targeting. So really, what we're looking for is there's a part of the vertebral body, which is the entire part of the vertebrae, the bony part of the spine, it's called anterior tubercle. 

Now behind this, or further back, I guess, is where these nerve roots come out - that we don't want. That's the NoNo zone, we want to be in front of that, okay. And there's a muscle called the longus colli muscle. And this track can either be on top of the muscle, or sometimes underneath the prevertebral fascia, which overlays the muscle - I know I'm getting a little technical, sorry. So it's important to be able to recognize where this track is, because if you don't put it in the right area, you're not going to get a good block. So that's number one. Number two, if you don't know where you going, you can get into trouble - I just listed you all the structures there, they're getting into any of these structures could be, you know, bad, or catastrophic. So it's really important to know where you're going. 

And like I said, it is variable, which means each person has a very unique anatomy when we look in there. So that's, I mean, the nitty gritty part of it is, is that we find the track using ultrasound, because ultrasound lets you see all these structures, it lets you see veins, arteries, nerves, muscle, soft tissue, thyroid, esophagus, all these things are visible on ultrasound, not so much under X ray or fluoroscopy. I know some doctors do this with fluoroscopy, which I don't recommend, because you can't see any of the soft structures, you see the spine, that's it. And it's just landmark based, whereas I just in every single person on the ultrasound where it goes. And basically surrounding the area with the local anesthetic, there's no steroid used or anything. 

So once you've done that, usually within 30 seconds to a minute, you'll start seeing what's called Horner's syndrome. I tell people ahead of time, so they don't get scared or worried. But it's what's supposed to happen. So everything's gonna be on the side you're doing the block. Okay, so the eye is going to be droopy, the upper lid, it's going to be droopy. And that's because the sympathetic nervous system innervates a muscle in the upper lid. So once you block that it kind of drops down a little bit, the eye becomes red, the pupil becomes small. Why? Because the sympathetic makes it large. That's what it's supposed to do. To let more light in. You'll notice that your nostril on the side that you're blocking, usually we start on the right, will be stuffy. And again, sympathetic will constrict the blood vessels making it easier to take a breath. Another one that some people get is flushing. So either half the face will turn red or be flushed or warm. Sometimes it goes into the shoulder and arm as well. 

So those are all considered part of the Horner's syndrome. It lasts as long as the local anesthetic lasts, but the effect of the block lasts longer. That's the key. One other thing that happens usually is it blocks what's called the recurrent laryngeal nerve. And this is a nerve that goes to the vocal cords. So we only do one side at a time because of this. So you develop like a little frog in your throat or hoarseness. And you do not want to block both sides at the same time for this reason, because that would create a medical emergency. So if you don't develop Horner's syndrome, you didn't do a sympathetic block. I mean, it's as simple as that. If nothing is happening up here, you didn't do a sympathetic block. I don't know what you did, you put local in there. But, you know, kind of makes sense.

Jackie Baxter  20:15  
Yeah. So these symptoms, the Horner's syndrome, you said, that's a sign that it's worked. So that's a good thing?

Robert Groysman  20:21  
Yes, I like to see at least three different signs to know that that work. If you only see one, then you're not quite sure. So I use three out of the five, to say that it's worked well. So I didn't mention this, but that's a traditional style of ganglion block, you go at C six, or C seven, mostly six. And it's tolerated well awake, you know, part of the skin, then you guide a needle to where it needs to go, and you put the local anesthetic in, and then you come out. 

Now we do something a little different, we also go to C4. Okay. And that's the secondary part. And that's technically not part of the stellate ganglion, it's part of this the same track that it's on, you know, another car of the train where the stellate ganglion comes through. But this is part of the superior cervical plexus. And it's been shown in a study that, at least with PTSD, that the results are superior by including two levels as opposed to just doing one. So that's kind of where we've seen our successes.

Jackie Baxter  21:25  
Wow. Sounds like really precision kind of thing, isn't it? And I mean, you know, I've noticed, just personally, how very different everyone's symptoms, bodies, everything - everyone's so different, but I've never really thought about how that translated into somebody like yourself, who's treating people. So you're looking at everybody, and you're thinking, not only are your symptoms and everything else different, the way your neck looks is different too?!

Robert Groysman  21:54  
Yes, yes. And let me tell you, I mean, there's so many variations, it's not even funny, with extra arteries, sometimes in the way, sometimes extra veins, so you really kind of sometimes need to do like a, almost like a slalom course, you know, weaving and bobbing around various structures, so you don't cause any damage. You kind of envision where you need to be. And then you have to plot a course. And it's not always a straight line.

Jackie Baxter  22:25  
I was just imagining the bit in Star Wars where they're heading for the whatsit in the middle of the Deathstar.

Robert Groysman  22:33  
Right. All right, the core. Yeah.

Jackie Baxter  22:36  
Yeah - the sort of maneuver to get in there! So you say that this, this is called a block? And it's the sympathetic nervous system that you're trying to block? Is that the idea?

Robert Groysman  22:48  
Yeah, so the only thing it does is it basically prevents signals from both the brain from reaching the body and vice versa, from the body reaching the brain on the sympathetic nervous system side, but it's only one side at a time. So your body still has the other side to work. If you happen to be dominant on the side we're blocking, which about roughly 80% of people are right dominant, nothing to do with hands, by the way. And you happen to block the right side and they happen to be dominant, the majority of people will see a result, the result is immediate. I mean, like, within 30 seconds of doing the block, everything changes - everything from brain fog to the taste and smell. The first thing they tell me is that alcohol, alcohol smells normal, because we're cleaning them off with alcohol. And these are people who have not smelled anything for the last two years or longer, or people have an abnormal smell. 

So yeah, I mean, I was I was really surprised myself how quickly the result is. So you know, this is not because of rewiring, okay. I mean, rewired, you know, smell system or olfactory system is not going to fix itself in 30 seconds or a minute, right? It's not going to regenerate itself in 30 seconds to a minute, and even inflammation is not going to go away within 30 seconds to a minute. I mean, even if you put steroid in there, you know it will take days before you start seeing an effect, not seconds. So something different is happening, which also kind of gives us clues as to the causes. 

So the majority of stuff I treat is going to be neurological, psychological. So things like smell and taste - so either a no taste or smell. Parosmia. Dysgeusia, abnormal taste and smell, the anxiety, insomnia that happens. They can't sleep. The fatigue that comes along with with COVID - Some people get depressed or PTSD, that treats that as well. I've had some success with tinnitus, long covid caused tinnitus. In fact, I treated a gentleman a week and a half ago, that came in specifically for the tinnitus, and I told them, Look, I don't know what the outcome is going to be. Because we just don't have many patients with tinnitus, and it worked for him, immediately. 

We're still kind of trying to figure out which symptoms works really well for and which ones are kind of hit or miss. I will tell you, people who have brain fog or fatigue, usually feel very tired after the block, sometimes for just a day, sometimes for a few days. And I think that happens, because the sympathetic is kind of keeping them wired for so long, and the body adjusts to that. And when you remove that, you're exhausted, your body just feels exhausted, you would just want to sleep and rest. 

So people who don't respond to the right side, so they could be potentially left-siders, you know, some people are a left siders and a few people fall into the no dominance, you need to do both sides to see any effect. We've seen people from each of those categories. 

So we also do vagus nerve stimulation, I don't do it in office, I basically teach people how to do it. And this is kind of the other side, we talked about the sympathetic - by blocking the sympathetic, but one possibility, and nobody really looked at this is, maybe it's not the sympathetic, maybe it's because the vagus is low, maybe the parasympathetic is low. And by stopping the sympathetic, you make the other side come up. So they're kind of linked, almost on a seesaw. So when one goes up, the other goes down. Like it's also possible and quite possible that it has nothing to do with the sympathetic, it's, we're indirectly basically improving the parasympathetic. And that's what does the work. 

And that also explains the whole Vagus Nerve Stimulation done in the ear. It's a slower process for sure, than the stellate ganglion block, it could take up to three months or longer. But it does improve taste and smell, does improve brain fog. And it does improve most of the symptoms people have. It just takes longer. And just like the stellate ganglion block, it doesn't work for every single person. And I guess the thinking there is maybe it's more stuck. They need additional work to get unstuck. Once you get unstuck, you have to keep it unstuck. And that means reducing your stress, reducing your stress, normal stress. Have you heard stories of people fluctuating - their symptoms fluctuating either during the day? Or when they go away somewhere? They're everything comes back to normal. And then when they return? It's back to the bad bad one.

Jackie Baxter  27:58  
Yeah. And we were on holiday last week. And it was amazing how much better I felt,

Robert Groysman  28:03  
right? So it's not the altitude, it's not the air. You know, the air is not fresher where you went. You're just basically reducing your stress level. And when you do that, you're letting the parasympathetic have a little bit more of a say of what happens. But I think most people in long COVID are stuck in this high sympathetic fight or flight mode, low parasympathetic vagus mode. And, unfortunately, or fortunately, I don't know how you - depends how you look at it, parasympathetic and the vagus are responsible for the healing, for the maintenance. So all the tissue repair stuff happens on the parasympathetic control. 

You know, if you're fighting for your life, your body doesn't care about fixing your cut, or fixing your nerve or fixing anything. It's focused on keeping you alive. That's what it wants to do right there. But that's why I said sympathetic, you know, should be shotgun most of the time, not in driver's seat. But what happens when it is - if it is in the driver's seat all the time, 24/7. Well your body doesn't maintain itself, it can't heal. It doesn't control your immune system. It's a little wild, it doesn't control inflammation, it's a little wild. Our digestion is abnormal. I mean, everything kind of goes to pot.

Jackie Baxter  29:26  
So it's about kind of evening them out, and that could be blocking the sympathetic or it could be stimulating the parasympathetic, or both? 

Robert Groysman  29:36  
Or both. Well, I want to make it clear though you don't you never want 100% sympathetic or 100% parasympathetic, because that also is not good. You want a balance, but you still want the parasympathetic in the driver's seat. And the sympathetic sitting next, not the other way around. You can't survive with just one, you need both. But you need them in balance, you need the parasympathetic to be in control most of the time. Because that's what our bodies need. That's how we function.

Jackie Baxter  30:09  
Yeah, yeah, I mean that totally makes sense. So I mean, you talked about seeing improvement in people that you've been working with - would you say you'd seen improvement in most people?

Robert Groysman  30:24  
it really depends on which symptoms we're talking about. And I know they're all part of the same, you know, the same constellation. But as you've seen with long COVID, there's over 100 symptoms that have been documented with long COVID - some very serious, some not too serious. But they're all, they're all important in long COVID. So because I'm mainly target, the neurologic and the psychologic. Yes, I've seen improvement in the majority of people that I've treated. Have I had non responders, sure, just like with any other treatment, or medication, or even surgery, there's going to be some people that just don't respond. 

Now, like I said, this may be just because they're so stuck that they need multiple before you start seeing an effect. But the majority of people without taste or smell respond, and timing doesn't seem to really have an impact - we've treated somebody who was 27 and a half months post COVID that recovered. With abnormal taste or smell what I'm going for, and what I consider a success is somebody who can tolerate a food or drink that they couldn't before. Or smell, it may not be normal, you know, may not be what they remember. But it's tolerable now. So that allows you to be around people and, and eat and even if orange or the chocolate doesn't taste quite like you remember it. It's something that you can tolerate and enjoy. Whereas before you couldn't. And you know, the culprits we have peanut butter, chocolate. We have coffee, we have garlic, onion. And for some people, chicken and meat. Those are the big ones. Yeah, and if you couldn't eat before, and now you can, if you couldn't be in your office because every smell and perfume drove you crazy. And now you can - I consider this a success.

Jackie Baxter  32:19  
Yeah, and I guess, you know, it's like with everything that we try. You know, some of it is stuff that we've been hacking ourselves at home, and sometimes it's with people who actually know what they're doing, like yourself. And anything that is an improvement is good. You know, it doesn't have to be 100% successful to not have been a success, I think

Robert Groysman  32:43  
For most people yes, but you know, some people are unreasonable or have very high expectations, and feel disappointed unless it's 100%. I try to be realistic with expectations and let them know, but you know what, you're doing good work, too. I mean, we're all doing this basically to help people. And, you know, unfortunately, this kind of stuff, because people are desperate, brings out a lot of charlatans and scams and stuff. So, you know, I caution people to be careful. 

And I know part of this is the fault of doctors and the medical community, because long COVID is still very much gaslighted. And that's because there's no test or a way to tell somebody - Yeah, you got long COVID It's not like a diabetes test. You could check their their sugar or their hemoglobin A1C or, or some some way like an MRI or CAT scan or blood tests that will pinpoint and say, Yes, you got this. And because of that a lot of doctors don't take it seriously. You know, they tell their patients they're imagining it or it's in their head, they send to psychiatrists, I've seen that. So, you know, it's a strange, strange world that we live in.

Jackie Baxter  34:02  
I mean, yeah, you're absolutely right. It's I think it's brought out the best and the worst and a lot of people. So yeah, you mentioned with the block that you know that there's two sides that you can do. And you mentioned that some people might need more than one. So is this something that might need to be done - I don't know if regularly is the right word - but you know, sort of more than once? Or is it a one and done? Or is it going to be different for different people?

Robert Groysman  34:29  
Yeah, that's a really loaded question. And - so I've done a lot of rescue blocks. Okay, so basically, people have done it elsewhere and come to me and it works. So the question is, am I doing something different? Or is it because we're repeating it? So I've developed a three day protocol and a five day protocol just basically daily stellate ganglion blocks. Basically stellate ganglion blocks over three and five days daily to try to get non responders to respond. And some people do get better with repeats. Some people don't respond after one or two sets on each side. So yes, there is benefit to repeating it.

Jackie Baxter  35:15  
Sure. And I guess that's just going to depend on the person?

Robert Groysman  35:19  
Yes, and how stuck they are, how resistant their autonomic nervous system is to change. And think about it this way, you know, your nervous system is set up a certain way, and your body likes homeostasis, or equilibrium, even if it's abnormal. So let's say you've had long COVID for two years, and your body is used to it, even if it's abnormal. And then you take this rubber band and you stretch it back to the normal spot. But it's under tension. And your body really, really wants it to snap back. And for some people it does, even though it's an abnormal state, it's what your body's used to. And it likes equilibrium. 

And in those cases, we do something a little different. If you just keep snapping back, we do something called a pulsed radiofrequency, which basically, is similar to a stellate ganglion block, the needle goes in the same areas. But in addition to putting the local anesthetic, you also zap it - is an electrical pulse that send in and it stuns the track. And they can stun the track anywhere from a week to three months. It's variable in different people. And during that time, you know, the signals are not normally going. So some people need a longer time to be in that state to get it to stick in the place where you wanted it to go. Not where it wants to go, where you want it to go. So there's other things we do to kind of help it along if it's being stubborn, and just wants to go back to where it was.

Jackie Baxter  36:54  
Right. So it's just Yes, different people take slightly different ways and times to sort of readjust almost

Robert Groysman  37:01  
Well, sure every stellate ganglion block, every treatment is customized. No two people are going to be alike, they're going to require different protocols. 

Jackie Baxter  37:12  
Yeah. So I guess the other thing I was going to ask, are there any downsides to doing this - is the worst that can happen is that it doesn't work?

Robert Groysman  37:23  
So complications really depend on the person driving the needle, right? The most common thing that I see, and this is from other practices, is they'll do what's called an interscalene brachial plexus block. So remember those nerves, I said, that come out of the spinal cord in the neck and they go into your shoulder and your arm? Well, they're a little bit further back. From where the Stellate Ganglion block sits. And if you don't recognize the landmarks, you put the medication a little further back. And when the local anesthetic goes around these nerves, your arm goes numb, and you can't move it for a couple hours. So this is something we do for a block, let's say if we're doing shoulder surgery, or something on your upper arm or, or even the forearm. You know, if we want to do surgery on it and make it numb and not being able to move this is the block you would do to do that. But it doesn't help with the stellate ganglion at all, not even a little bit because the medication is placed in the wrong location. 

If you put her into an artery, you get a seizure immediately, because both the carotid and vertebral artery go into the brain. So the second you put in as little as one milliliter, you're going to get a seizure and it's not going to be a good day for you or the patient. You could potentially get into the esophagus or the thyroid gland and you can numb up other nerves that you don't want to. Those are kind of the main complications. 

Other ones you know, will be like a hematoma, which is a collection of blood if you penetrated, let's say, a vein or an artery and you didn't inject. But you pull the needle out and leaks out into the area you're gonna get a little goober, you know, size of a walnut or size of an orange, you don't know, of blood. It's not going to be comfortable. As long as a person is not on blood thinners, it's most likely not dangerous, it'll resolve they just have a sore neck for a couple of weeks, like any bruise. Infection, bleeding, and nerve injury are common to any invasive procedure you do, including something like getting a shot of the flu. Okay, or B 12. Shot. These all are risks. They're very rare. But yeah, they're there. 

As far as side effects. Like I said, it makes people very tired. Especially if you have brain fog or fatigue, otherwise it doesn't. So if you have it already, it can make it worse for a couple of days, sometimes a couple hours, sometimes a couple of days. 

Now, I have been very cautious in people with PoTS, Postural Orthostatic Tachycardia Syndrome, you know, you're familiar with this. So a lot of symptoms cross with long COVID. Like with chronic fatigue syndrome, right, a lot of things cross with long COVID. If you have stable PoTS, it's stable, but I liken it to seeing an acrobat, stacking six chairs on a ladder, and then balancing on the point. So yeah, the Acrobat is stable. But you get my point here, right? Doesn't take much to knock them off, or one way or the other. So on the surface, it looks like everything's good. But if you dig underneath, you notice that it's, you know, it's hanging on by thread. 

So the stellate ganglion sometimes can destabilize this, similar to like, you know, pushing the acrobat one way or the other. And symptoms become worse for a little while. I'm very cautious about doing these people who have PoTS in general, just because of that. I'm not talking about COVID - long covid caused PoTS, I'm talking about people who have PoTS, and then develop long covid on top of it. 

So, you know, I tell people ahead of time, that this could potentially happen. Have I done people with PoTS that had normal responses? Absolutely. And I don't have no idea who's going to have a kind of a decompensated PoTS and who's not. So I mean, you know, some people when it does destabilize, I guess it would be you know, increased tiredness, dizziness, things like that, like basically making the PoTS symptoms worse, because we destabilized the system that was balancing on a head of a pin. And there's no way to know ahead of time who's going to be at risk for that or not. But anybody with PoTS I tell them, you know, do you want to take this risk or not? Because I can't tell you, I can't tell you if it's gonna happen or not. Most of the time, it doesn't. But you know, if you happen to be one of the unlucky ones, it will, you know, nothing is permanent, it's just going to be, you know, a month or two until it readjusts itself. 

But that's really it, I mean, it's a very safe block. In experienced hands, I'm gonna emphasize this - in experienced hands, this is not a watch a YouTube video and do the block, this is not a go to a weekend course and do the block. Okay? This really is an advanced block, I have worked very long and hard, perfecting the technique, modifying the protocol, changing things out to make it better and better and better each time. Decrease the risks, improve the results. So it's like a result of many years of work. 

This is not one of those, you know, see one, do one, teach one. You know, the old adage in medical school, you know, you see - we see it once, you do it while the doctor watches you. And then you teach somebody else how to do it. Not this one, not this one. So like I said, because of all the important structures there, you can really get into trouble if you don't recognize you're in the part you shouldn't be in. So, you know, luckily, we have never seen any complications or anything. Never had a seizure or anything like that. And I've done roughly 1800 stellate ganglion blocks in my career, so far.

Jackie Baxter  43:31  
Well, that's good to know that, you know, with someone who knows what they're doing, it's safe, and it's quite likely to be successful.

Robert Groysman  43:40  
Yes. And I always ask people, you know, people come to me in - I have a Facebook group, you know, where we where I do a treatment group. But basically, you know, they'll say I had a bad block. I had a block that didn't work. My first question is, did you get a Horners? Did you get the droopy eyes? Did you get the red eye? Did you get this small pupil? Did you get a stuffy nostril? Well, no. Well, what did you get? Well, my shoulder was numb, you know, my neck was numb. Okay, well, you didn't have a stellate ganglion block, you had local put into your neck. Congratulations. I mean, I'm glad you weren't hurt. But you didn't have a stellate ganglion block. So you don't know if it would have worked? Because you didn't really have it. I mean, I'm sorry. I'm sorry. You didn't have it, but you didn't. You know, so how could you know if it worked or not? Since you didn't have it? 

That's the number one reason for stellate ganglion blocks to fail. If you look on Reddit, you look and you look at the global Facebook support group for long COVID. Parosmia anosmia, the success rate is around 20 to 30%. Because they're including all these ones that weren't done properly. So, I mean, yeah, you had your neck injected, you know, great, but you didn't have a stellar ganglion block. I mean, Yeah, it's kind of like in my pain practice, you know, I had a neck injection. Okay, which one - I do 10? Well, I don't know they use the steroid. Okay, which one - I do 10. You know, it's like, just because you had it done in your neck doesn't mean you had, you know, you know that you had a good block and the block that you intended to do. So it's very precise. Yeah. And we're talking about a millimeter or two can make a huge difference.

Jackie Baxter  45:25  
Right. So yeah, it does need to be done properly. Otherwise, it's definitely not going to work.

Robert Groysman  45:31  
It's not just the needle position. But when you're injecting, you need to see where the medication is spreading. If you don't like where the medication is spreading, you stop, and you readjust the needle. You don't just keep injecting and hope it's going to correct itself because it doesn't. I make it look easy, but it's not. It really isn't. You know, some people who are watching me, they're like, Oh, this looks, you know, looks like a piece of cake. Yeah. Like, like a skater doing, you know, quadruple Axel. And, you know, it looks looks easy, but there's no way in hell I'm gonna be able to do that. No matter how easy it think it looks. 

So yeah, I mean, I'm very good at this block. You know, we have very good results because of that. And no complications, you know, thank God, I'm not gonna lie. My table here. But yeah, that's essentially kind of, you know, the stellate ganglion, in the basket. Yes. Look, a lot of people get nervous, you know, oh, my God, I'm gonna get an injection in my neck. It's scary. You know, it's right next to my face. It really is tolerated. Well, I've done it as young as 10 years old on an awake person - tolerated very well, we talk to people, we hold their hands. It doesn't really hurt that much, because it's numbed up. Like I said, it's very easy to tolerate. I don't think I've had really anybody who said stop, you know, it's too uncomfortable. I can't do it.

Jackie Baxter  46:51  
Oh, that's really good to know. Because as soon as you start talking about needles, it feels a little bit ughhhhh

Robert Groysman  46:58  
Well I'm gonna tell you something, though. A lot of times sedation requirements are a reflection of the doctor more than the patient. Some doctors don't want the patient awake while they're doing the procedure. And that maybe a confidence thing, I don't know. But I do know, some that will not do any injections on an awake patient. But it's not needed, is my point. It's really not all that uncomfortable. And it's tolerated very well.

Jackie Baxter  47:26  
Cool. Well, that's really great to know.

Robert Groysman  47:29  
So one question I would, you know, and this comes up, both from patients and doctors. So most of the time, when you do a block, you know, I do an interscalene block, let's say, because it's very similar, to numb up a shoulder and arm. And when the block wears off, everything comes back. Right? The sensation and the movement comes back. And it's very predictable. If the local anesthetic is supposed to last for four hours, you know, when the block wears off in four hours, everything comes back. 

Something's different about doing a sympathetic block or stellate ganglion block, the effects outlast the block length. So this is very different than oral medications, you know, similar to Tylenol, and Advil or these blocks where once it's out of your system, it's out of your system, you're not going to get more pain relief, you know, a week later. Because you took a pill, you know, on Monday - on Friday it's not going to still be effective, right? Something happens here is different. And there's modification of the pathways. Okay. Like I said, in some people still snaps back. But how do you explain it lasting a week after the injection, a month after the injection, or two years after the injection? 

Something changes there, that's more permanent. It resets the system in such a way that for most people anyway, it doesn't want to go back to the old way, despite the block being gone, the Horners is gone, everything is gone. There's one other medicine that does this, ketamine, it does something that lasts way beyond the effect of the drug - once it's out of the system, the effectiveness still lasts. 

So, you know, trying to explain to somebody who is used to basically doing normal blocks or you know, normal medicines, how something can outlast the effects of the drug or the effect of the block is sometimes difficult. We don't know 100% what changes to make it basically outlast, but we do know something does, there is a mechanism that changes. It's either in the immune system, with the inflammatory process or in the autonomic nervous system, that it flips a switch and that switch does not want to go back even after it's done. But it's very, very different for this, for this compared to any other block you do. 

One other thing I want to address is the spontaneous healing. Okay, I'm sure you've heard stories about this. So you've been two years out, or sometimes 17 or 18 months out, and everything sort of returns back to normal, maybe not 100%. But 95%, 98%, they're good for about a month or two, or maybe six months. And then something happens. Either they get another respiratory infection, or they have surgery or they get COVID again, and then what happens? A lot of times, everything comes back, the same as it was the first time. So my question is, is, did you heal? Did you heal when you say you recovered? At the two years? Did you heal? Are you healed? Or is something else going on? Is it a compensatory mechanism, kind of fooling your body into thinking you repaired it, but you're not, and then doesn't take much of something to kind of set it back to where it was. 

So this is kind of one of my hypotheses is that because the vagus tone in the parasympathetic tone is low, after you've had COVID, you don't heal well. Healing is very delayed, it's very slow, it's almost non-existent. Similar to why sleep is problematic. Deep sleep is when your parasympathetic is the boss. You know, it kinda takes over the reins. And when you're in deep sleep, and that's when the majority of the healing happens. And, you know, you spend about a third of your night in deep sleep normally. But I bet if we tested long covid patients, which we haven't done yet, I bet you that they're deep sleep percentage will be much lower. They sleep, but they don't sleep. 

So I think though because you're slowing down the repair process significantly, that your body can make compensations. Your system doesn't fully heal. And therefore it's very sensitive too, and unstable and fragile, kind of like that acrobat on on the ladder and the 6 chairs and top of the ladder. It's balanced, but it's not stable. So we got to get these people to heal, which is where improving the parasympathetic is important. And hopefully have some resistance to further insults later on, whether it's a cold or having sinus surgery or something like that. 

You know, all I want to do is really share kind of what I know and you know, hopefully, if I help at least one person, I've done my job and, you know, just basically saying that, you know, there's somebody who wants to listen, and this is real, you know, long COVID is real no matter what anybody says, you know, no matter what your doctor says, or it's really and you're not crazy, okay? You're not crazy. It's not in your head. It's actually happening. So there's at least one doctor that believes you Okay.

Jackie Baxter  53:07  
Well, thank you so much for joining me today. It's been absolutely fascinating. I feel like my brain is about to explode - in a good way. So thank you so much for giving up your time. And and thanks for all that you're doing. 

Robert Groysman  53:19  
You're welcome.

Transcribed by https://otter.ai