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A751 Presacral Blockade of the Ganglion of Walther (Ganglion Impar)
... Ganglion impar block is an acceptable treatment modality among injection treatments, with proven efficacy. This technique, first described by Plancarte for the treatment of cancer cases with pelvic metastases, has evolved and has been performed in several variants (14). Today, ganglion impar block is used in the treatment of many different types of pain and perianal hyperhidrosis (15), except for oncological pain and coccydynia (16). ...
... The drugs used during the injection are essentially local anesthetics, corticosteroids, or neurolytic agents (14). ...
... Although the technique can be performed under fluoroscopy, USG (17) and CT-guided (18) blocks have also recently been described. In many of the techniques described, the trajectory of the needle may also differ: through the anococcygeal ligament (14), sacrococcygeal joint (19), intercoccygeal joint (20), bone segment (21), and paracoccygeal (20). ...
Background/Aims: Coxadini is a painful disease of the vertebral apex whose most common aetiological cause is direct-indirect trauma. While in acute cases cure is usually achieved with conservative treatment, in persistent cases interventional treatment methods come to the fore. Injections are often used when there is no response to conservative treatment. Injections can be given either directly into the posterior coccygeal region under fluoroscopic guidance or into the precoccygeal region. The most commonly favoured precoccygeal block is the impar ganglion block. In our study, we aimed to analyse the pain and sleep quality of patients who had undergone ganglion impar blockade at the end of the one-year follow-up. Material and Methods: Patients who presented with coxadinia between October 2019 and April 2021 were retrospectively analysed. Patients who did not respond to conservative treatment, were over 18 years of age at the time of the procedure, had symptoms that persisted for more than 6 months and agreed to participate in the study were included in the study. The VAS, SF-36 and Pittsburg Sleep Quality Index measurements recorded at the first examination of the patients were analysed. All patients were called in for a final follow-up 12 months after the injection and the VAS, SF-36 and Pittsburg Sleep Quality Index assessments were repeated. Results: 20 patients (17F / 3M) were included in our study. The mean age of my patients at the time of intervention was 41.05 ± 11.27. The mean time from symptom onset to intervention was 22.25 ± 17.06 weeks. There was a significant decrease in VAS scores, and significant improvement in SF-36 subcategories and Pittsburgh Sleep Quality Index scores. (p < 0.001) Conclusion: Ganglion impar injection is a treatment method that can help relieve pain, improve sleep quality and daily-life functions in cases that do not respond to medical treatment and lifestyle changes
... Additional techniques have been described in a 2013 review on the ganglion impar block [126]. The anococcygeal approach uses fluoroscopy to guide a 22-gauge needle through the anococcygeal ligament to locate the tip retroperitoneally at the sacrococcygeal junction [127]. The transverse coccygeal approach uses a needle to cross the coccyx through one of the inferior joint spaces in between the coccygeal segments [128,129]. ...
... Ganglion impar neurolysis was first described in 1990 for patients experiencing pain secondary to perineal cancer [127]. Additional indications for pain included other malignancies including cervical, colonic, bladder, rectal, and endometrial carcinomas. ...
... SHPBs have found an increasing role in the management of pelvic pain associated with cancer of pelvic visceral organs [147]. The presence of nociceptive afferent fibers that innervate pelvic organs alongside corresponding sympathetic nerves facilitates inhibition by neurolytic agents [127,151]. Neurolytic SHPB has been described in patients with extensive gynecologic, colorectal, and genitourinary cancer with incapacitating pelvic pain. In a group of 26 patients, 18 reported more than 50% reductions in visual analog pain scores (VAPS) within two blocks in addition to reductions in oral opioid therapy [152]. ...
Purpose of Review
Pain is a prevalent symptom in the lives of patients with cancer. In light of the ongoing opioid epidemic and increasing awareness of the potential for opioid abuse and addiction, clinicians are progressively turning to interventional therapies. This article reviews the interventional techniques available to mitigate the debilitating effects that untreated or poorly treated pain have in this population.
Recent Findings
A range of interventional therapies and technical approaches are available for the treatment of cancer-related pain. Many of the techniques described may offer effective analgesia with less systemic toxicity and dependency than first- and second-line oral and parenteral agents. Neuromodulatory techniques including dorsal root ganglion stimulation and peripheral nerve stimulation are increasingly finding roles in the management of oncologic pain.
Summary
The goal of this pragmatic narrative review is to discuss interventional approaches to cancer-related pain and the potential of such therapies to improve the quality of life of cancer patients.
... It usually lies in midline; however, it may lie paramedian to the sacrococcygeal joint (SCJ) or coccyx. Ganglion impar provides sympathetic and nociceptive innervation to the perineum, coccyx, anus, distal rectum, urethra, vulva, urethra, and vagina. 1 Since its first description by Plancarte et al. in 1990, GI block (GIB) has been employed for management of intractable coccydynia, chronic perineal pain (CPP), chronic prostatitis, chronic proctitis, and chronic pelvic pain of both malignant and nonmalignant etiologies. [2][3][4][5][6][7][8] Successful GIB has also been reported for management of postradiation enteritis pain, rectourethral fistula, pain in rectal area due to cramps, perineal sweating disorders, radiation-induced cystitis, and vulvodynia. ...
... Ganglion impar provides sympathetic and nociceptive innervation to the perineum, coccyx, anus, distal rectum, urethra, vulva, urethra, and vagina. 1 Since its first description by Plancarte et al. in 1990, GI block (GIB) has been employed for management of intractable coccydynia, chronic perineal pain (CPP), chronic prostatitis, chronic proctitis, and chronic pelvic pain of both malignant and nonmalignant etiologies. [2][3][4][5][6][7][8] Successful GIB has also been reported for management of postradiation enteritis pain, rectourethral fistula, pain in rectal area due to cramps, perineal sweating disorders, radiation-induced cystitis, and vulvodynia. [9][10][11] The GIB approaches described in the literature include "anococcygeal," "transdiscal sacrococcygeal," "paramedian sacrococcygeal," "transcoccygeal/intercoccygeal," "paracoccygeal cork screw," and their modifications. ...
... [9][10][11] The GIB approaches described in the literature include "anococcygeal," "transdiscal sacrococcygeal," "paramedian sacrococcygeal," "transcoccygeal/intercoccygeal," "paracoccygeal cork screw," and their modifications. [1][2][3][4][5][6][7][8][9][10][11] Currently, the intercoccygeal approach is considered the most preferred owing to both technical feasibility as well as anatomic location of GI (closer to Co1-Co2 joint). 7,12,13 Interventional procedures targeting GI can be classified into diagnostic (local anesthetic), therapeutic (local anesthetic with corticosteroids, Botulinum Toxin Type A [BoNT A]), neurolytic (chemical neurolysis, cryoablation, or radiofrequency thermocoagulation), or neuromodulation (pulsed radiofrequency). ...
Aim: This article aims to review the currently available evidence on the ganglion impar block (GIB) and neurolysis for management of chronic pain of malignant or nonmalignant etiology. Introduction: Ganglion impar (GI) represents the fused termination of bilateral thoracolumbar sympathetic chains. It is a retroperitoneal structure, lying behind the rectum and ventral to the sacrococcygeal junction (SCJ) or coccyx. Ganglion impar provides sympathetic and nociceptive innervation to the perineum, coccyx, anus and distal urethra, rectum, vagina, and vulva. In this review, the indications, approaches, effectiveness and, complications of GIB are discussed based on the data from the current literature. Results: We screened 18 full-text studies based on our search. Out of them, 2 were randomized controlled trials (1 each on GIB for chronic intractable coccydynia and phantom rectum pain), 15 were observational (prospective or retrospective) studies, and 1 was anatomic cadaveric study. These studies included were from 2004 to till date. Our review results inferred that (1) GIB appears to be a safe and effective technique for management of pain in patients with chronic coccydynia, chronic perineal and pelvic pain, not responding to the conservative measures; (2) both anatomic location of GI and technical feasibility favor the transcoccygeal approach (Co1–Co2) as the most suitable approach followed by the transsacrococcygeal approach. Conclusion: Ganglion impar block improves pain and the quality of life in patients suffering from chronic intractable coccydynia, chronic perineal and pelvic pain of both malignant and nonmalignant etiology. Keywords: Chronic pelvic pain, Chronic perineal pain, Coccydynia, Ganglion impar, Ganglion impar block, Neurolysis.
... ology [14]. Favourable results of combined neurolysis of the ganglion impar and superior hypogastric plexus in the reduction of pelvic oncological pain are also reported, since the latter includes neural afferent fibres of pelvic viscera [9,15]. ...
... Its neural network is formed by several neurological fibres but it is not yet fully understood: it is believed to include not only the nociceptive and sympathetic fibres of the perineum, distal portion of the rectum, anus, distal urethra, lower third of the vagina, and vulva/scrotum [1,2], but also sympathetic branches innervating the pelvic organs [7,8]. Ganglion impar neurolysis was first described in 1990 by Plancarte et al. [9] for the treatment of pain related to perineal cancer. The neurolysis can be performed according to four techniques: anococcygeal, coccygeus-transverse, intercoccygeal and trans-sacrococcygeal, the latter being the most common. ...
... Plancarte et al. [9]described reduction of more than 60% of the intensity of perineal pain in half of the patients. Several studies have reported cases of patients with pelvic tumours with baseline pain relief of 50% or more after the procedure, with reduction of baseline visual analogue scale scores of 9-10 to mild pain levels that persist after more than 2 months of follow-up and with a significant reduction of opioid use [10][11][12]. ...
Cancer-related pain is a very prevalent problem in all stages, with 10% of patients requiring invasive techniques for adequate pain management. Ganglion impar neurolysis has been used in the treatment of pelvic-perineal pain with efficacy and rare complications, but only a few case or series reports in cancer patients have been published. We report the case of a patient presenting with an ovarian carcinoma (FIGO stage IIIC), who had several disease relapses at the colorectal transition and need for palliative colic prosthesis. She presented later with anorectal pain associated with a rectovaginal fistula, which had an important impact on the activities of her daily life. She was submitted to two ganglion impar neurolyses, which resulted in improved pain control for a total of 5 months, an important improvement in her quality of life, and reduction of opioid consumption. The authors aim to alert to the importance of pain control and to address the fourth step of the WHO analgesic ladder as an option for cancer patients, including palliative patients.
... Ganglion impar block was first described by Plancarte and has been a safe and effective method applied for the last two decades in patients with coccydynia. [10][11][12] This study presents a new fluoroscopy-controlled approach in patients with chronic traumatic coccydynia by applying ganglion impar block using the needle-inside-needle technique from the intercoccygeal region without the administration of contrast material. With this approach, the cost and possible side effects of using contrast material can be prevented. ...
... The ganglion impar block was first defined by Plancarte and was performed using 22-gauge pre-bent spinal needles with fluoroscopy and entering through the anococcygeal ligament and palpating the rectum and coccyx with the index finger of the other hand. [10] However, it was observed that this method could cause needle breakage and rectal and vascular injuries, and some authors had 30% failure in their experience. [17] Based on these experiences, Wemm [18] and his colleagues described a transcoccygeal approach that is easier and safer to implement. ...
Background:
This study presents a new fluoroscopy-controlled approach in patients with chronic traumatic coccydynia by applying ganglion impar block using the needle-inside-needle technique from the intercoccygeal region without the administration of contrast material. With this approach, the cost and possible side effects of using contrast material can be prevented. In addition, we examined the long-term effect of this method.
Methods:
The study was designed retrospectively. The marked area was entered with a 21-gauge needle syringe, and 3 cc of 2% lidocaine was administered subcutaneously by local infiltration. A 25-gauge 90 mm spinal needle was inserted into the guide 21-gauge 50 mm needle tip. The location of the needle tip was controlled under fluoroscopy, and 2 mL of 0.5% bupivacaine and 1 mL of be-tamethasone acetate were mixed and administered.
Results:
A total of 26 patients with chronic traumatic coccydinia participated in the study between 2018 and 2020. The average procedure time was approximately 3.19 min. The mean time of pain relief of more than 50% was 1.25±1.22 (1st min-72 h) min. The mean Numerical pain rating scale scores were 2.38±2.26 at 1 h, 2.50±2.30 at 6 h, 2.50±2.21 at 24 h, 3.73±2.20 at 1 month, 4.46±2.14 at 6 months 1 and 5.23±2.52 at 1 year.
Conclusion:
Our study shows that as an alternative in patients with chronic traumatic coccydynia, the long-term results of the needle-inside-needle method from the intercoccygeal region without contrast material are safe and feasible.
... 4 However, ganglion impar is a small unpaired sympathetic ganglion where two pelvic sympathetic chains converge anterior to the coccyx and was initially described as the target to manage the malignant pelvic pain of visceral origin. 6 An update understanding of the innervation of the sacrococcygeal and intercoccygeal joints revealed that these structures are innervated by coccygeal plexus, which is formed by the ventral rami of S4, S5 and first coccygeal nerve or Co1 (figure 1). 7 In addition to the sacrococcygeal and intercoccygeal joints, this coccygeal plexus also innervates the levator ani, external anal sphincter, and the skin between the anus and coccyx. ...
... It was originally described by Ricardo Plancarte in 1990 for the treatment of perianal cancer pain of visceral origin. 6 Woon and colleagues reviewed the innervation of the coccygeal area and performed their own dissection which showed that the innervation of the coccyx is composed mostly of the coccygeal nerves and the lower sacral spinal nerves, which originate from the lower sacral nerve roots. 7 10 The coccygeal plexus primarily innervates the anterior part of the coccyx. ...
Introduction
Coccydynia is a multifactorial complex clinical challenge. A multimodal approach with both conservative measures and procedural interventions is often recommended. We described a novel approach of radiofrequency (RF) ablation for the management of coccydynia.
Methods
Three patients with known history of coccydynia refractory to conservative therapy were referred to our clinic. All received different types of RF ablation before: one with anterior bipolar lesion with no analgesia benefit, one with posterior stripped lesion with good benefit but only after 8 weeks of pain flare and one received anterior monopolar lesion with 50% pain reduction for 2–3 months. All subjects underwent a novel RF ablation to the anterior surface of the sacrococcygeal and intercoccygeal joints with two bipolar lesions using multi-tined needles under fluoroscopy guidance. One bipolar lesion was between two needles: one in the sacrococcygeal and another in the intercoccygeal (between first and second coccyx) joints. Another bipolar lesion was between needles on both side of the sacrococcygeal joint.
Results
All experienced at least 65% pain relief for 6 months. The sitting endurance increased from less than 5 min to an average of 70 min. No adverse effect was observed in two and in the patient who used to have pain flare after lesioning, the pain flare lasted only for 2 weeks.
Discussion
The configuration of the two bipolar lesions with multi-tined needles in this case series stimulates the thinking of new approach for the ablation technique for pain from coccyx. Further prospective large case cohort study is needed.
... Блокады более эффективно проводить под контролем рентгенологического исследования [42] с контрастированием зоны расположения симпатического ганглия [48]. Блокады рекомендуется проводить под контролем лучевой визуализации -рентгенологической или УЗИ [29,32,48]. ...
... При безуспешности консервативного лечения блокада нервного ганглия Вальтера (имперганглия) тазовой части симпатического ствола, расположенного по средней линии перед крестцово-копчиковым соединением, является во многих случаях методом выбора. Инъекцию проводят в область крестцово-копчикового угла или вокруг крестцово-копчиковых связок [32,42]. Kodumuri P. et al. (2018) и рядом других авторов рекомендовано проводить блокаду в область крестцово-копчикового соединения при трансректальном сгибании и разгибании копчика под рентгенологическим контролем с использованием местной анестезии (или под наркозом). ...
There are no clear clinical recommendations for the diagnosis and treatment of patients with coccygodynia, and there are still debates about the choice of the best method of diagnosis, the effectiveness of blockades, the indications for surgical treatment and the most appropriate method of surgical treatment, and the need for antibiotics. The aim of the study is to evaluate the current state of the problem of diagnosis, conservative and surgical treatment of patients with post-traumatic coccygodynia based on the analysis of scientific publications. Materials and methods. A review of the literature data published on the problem of diagnosis and treatment of patients with post-traumatic coccigodenia is presented. The features of the anatomical structure of the coccyx are considered. Radiation methods for the diagnosis of coccygodynia, publication materials on the evaluation of the effectiveness of conservative and surgical treatment, and methods of surgical treatment of patients with coccygodynia are presented. The indications for surgical treatment and the results of surgical treatment of patients with coccygodenia are considered. Results. In coccygodynia, surgical treatment is indicated only in patients in whom comprehensive conservative treatment, the combined repeated blockades or radiofrequency ablation of the unpaired sympathetic ganglion are ineffective. Surgical treatment should only be carried out after the diagnosis has been precisely established, including the use of modern radiological diagnostic methods such as CT, MRI. The best method of coccyx resection is subperiosteal total proximal coccygectomy according to Key, with antibiotic therapy. The effectiveness of surgical treatment in patients with idiopathic coccygodynia is lower than in post-traumatic coccygodynia. Conclusion. Complex conservative treatment of patients with coccygodynia in most cases leads to recovery. Steroid blockades or radiofrequency ablation of the impair ganglion prove to be effective. Surgical treatment of post-traumatic coccygodynia is indicated only in cases of resistance to complex conservative treatment and ineffectiveness of blockades. The most optimal method of surgical treatment is subperiosteal proximal complete resection of the coccyx against the background of antibiotics.
... The ganglion impar block was first introduced in 1990 by Plancarte et al. [1] Since then, several modified versions have been reported by Wemm and Saberski, [2] Nebab and Florence, [3] and Foye. [4] They tried to reduce pain effectively by considering the anatomy of the ganglion impar and coccyx. ...
... [5] Second, Huang's and our technique are common in bending the needle to facilitate reaching the target ganglion. Third, the needle insertion point is laterally away from the midline, which is different from the existing methods of Plancarte et al [1] or Nebab and Florence. [3] It was expected to reduce the likelihood of infection. ...
... [2,4] Patients with persisting pain require interventional pain management procedures like ganglion impar block. [5][6][7] Ganglion impar or ganglion of Walther is a retroperitoneal structure that is formed by the fused terminal ends of both right and left paravertebral sympathetic chains. It is generally located just below the midpoint of line joining sacrococcygeal joint and tip of coccyx. ...
... Therefore, modern study designs focus on fluoroscopically guided ganglion impar blocks. [5,6,27] Ultrasound-guided [9] and CT-guided [2] ganglion impar blocks have been performed. Ultrasound does not replace fluoroscopy, because lateral fluoroscopy is still required to establish safe depth and correct site of injection. ...
Background and Aims: Coccygodynia or Coccydynia is pain in the area of coccyx and ganglion impar block is commonly used technique for treatment of coccygodynia.
Material and Methods: Forty patients of either sex in the age group of 20-70 years suffering from coccygodynia, who failed to respond to six weeks of conservative treatment were enrolled in the study. All patients were subjected to detailed clinical history, examination in the Pain Management Centre (Pain Clinic) of our Institute and imaging studies were reviewed. The patients were randomly divided into two groups of 20 each by a computer generated randomization number table: Group-TS (n = 20): Patients were administered ganglion Impar block by trans-sacrococcygeal approach Group-TC (n = 20): Patients were administered ganglion Impar block by trans-coccygeal approach with 8 ml of 0.5% bupivacaine plus 2 ml of 40mg/ml methylprednisolone acetate under fluoroscopic guidance.
Results: Both the techniques of ganglion Impar block were effective and provided good pain relief to the patients with coccygodynia. There was a statistically and clinically significant improvement in pain score after ganglion Impar block in both the groups at all time intervals during the study period. (p < 0.05). The mean pain score after ganglion Impar block was
... Neurolysis is a percutaneous procedure that involves destruction of the plexus through the injection of neurolytic agents at various concentrations within the plexus network, providing prolonged analgesia (23). It causes protein denaturation in nerve fiber membranes and permanent nerve destruction, as well as disruption of neural pathways 13 The most commonly used neurolytic agents are alcohol, phenol, glycerol, and ammonium compounds. However, phenol and alcohol are the most frequently used in clinical practice due to their availability (18). ...
Objective: To determine the effectiveness of phenol-based lytic inhibition of the splanchnic nerves at two levels versus one level, guided by fluoroscopy, in patients with upper hemi-abdominal visceral cancer pain. Materials and Methods: A retrospective, observational, descriptive, cross-sectional study was conducted on patients with upper hemi-abdominal visceral cancer pain treated at the Pain Clinic of the National Cancer Institute, Mexico. Statistical analysis was performed using SPSS V25.0. Results: Pain reduction was evaluated in 85 patients who underwent INE (65 at one level and 20 at two levels). Most patients experienced a short-term reduction in pain intensity (2 hours and 1 week) assessed using the ENA scale, with a decrease of 1 to 3 points in one-level INE and 2 to 3 points in two-level INE. In the long term, some patients maintained analgesia, with an average reduction of 4 points at one month and 3 points at three months in both groups. Opioid consumption (MED) decreased post-procedure in both groups, with an average reduction of 11.02 mg/day in the one-level INE group and 24.7 mg/day in the two-level INE group. Additionally, patients reported high levels of satisfaction (Likert Scale 4/5 or 5/5). Conclusions: The procedure is equally effective for patients undergoing one-level or two-level lytic INE. Pain control was greater in the group of patients treated with a two-level approach, as reflected in post-procedure MED, which showed a greater reduction in patients undergoing two-level INE. The satisfaction level was classified as satisfied or very satisfied, indicating that performing this procedure at either one or two levels is useful for controlling visceral cancer pain. Keywords: Cancer pain, lytic inhibition, splanchnic nerves
... Plancarte 27 first described GIB, in which the needle tip is advanced through the anococcygeal ligament and up to the anterior surface of the sacrococcygeal ligament. However, it is crucial to note that this approach carries a significant risk of inadvertent rectal perforation. ...
Aim: To assess the influence of contrast material distribution patterns on treatment
success in patients with chronic coccygodynia undergoing ganglion impar block
(GIB).
Methods: An evaluation was conducted on 58 patients who underwent GIB
from August 2021 to August 2023 at a university hospital's interventional pain
management center. Numeric rating scale (NRS) scores were recorded before the
procedure and at 1-month post-procedure. The patients were categorized into two
groups based on treatment success, defined as at least a 50% reduction in the NRS
score at 1 month.
Results: There were no significant differences between the two groups regarding
age, gender, BMI, symptom duration, comorbidities, coccyx curvature type,
presence of anterior/posterior subluxation, presence of posterior spicule, type of
approach, contrast distribution direction, and contrast dye level. Patients with
coccygodynia experienced statistically significant benefits from GIB treatment at
the 1-month follow-up (p < 0.001).
Conclusion: Although the use of contrast material in fluoroscopic procedures is
the gold standard to prevent possible complications, the distribution pattern of
contrast does not significantly affect the success of GIB treatment in patients with
coccygodynia. Further prospective and long-term follow-up studies are required to
validate these findings.
K EYWOR DS
coccygodynia, contrast material distribution pattern, ganglion impar, ganglion impar block, treatment success
... Палець поміщали в пряму кишку, щоб виявити неправильно розташовану голку. У цій серії випадків отримано добрі результати щодо зниження інтенсивності болю, про що повідомили пацієнти [13,14]. ...
Chronic pelvic pain (CPP) is usually treated conservatively, but in patients who do not respond to treatment, ganglion impar (GI) interventions are used as an alternative way to reduce pain. Objective ‒ to study the course of pain syndrome and functional status in patients with coccygodynia (CD) and CPP during the application of minimally invasive interventions on GI. Materials and methods. The analysis of the results of 56 interventions on GI in 50 patients was performed. Inclusion criteria were patients with coccyx pain for ≥3 months aged 23 to 71 years (mean age 47.9±14.8years) who did not respond to conservative treatment methods. 15 (35.7%) of the study participants were male and 27 (64.3%) were female. Interventions were performed on the patients according to five different methods, which were divided into two groups: the first group (n=34) ‒ GI block (GIB) with a local anesthetic and a steroid (patients with CD in whom medical conservative methods of treatment were not effective). The second group (n=14) consisted of persons with recurrent pain syndrome, resistant forms of CD and CPP, including after previously performed steroid injections: n=2 – neurolysis of GI with ethyl alcohol; n=2 – neurolysis of GI by phenol; n=3 – radio frequency modulation of GI; n=7 – radiofrequency ablation of GI. Results. 14.0% of all study participants had post-traumatic CD (history of falling on the coccyx), the vast majority of 86.0% ‒ idiopathic CD. Pain intensity was significantly lower post-intervention compared to baseline VAS mean of 7.6±1.5 cm: 2.5±0.9 cm one-week post-procedure, 1.5±1.9 cm one month, 1.3±1.5 cm three months, 2.1±1.2 cm six months. The average score according to the Karnovsky Scale (KS) before and after the procedure was 73.3±6.3% and 83.9±4.9%, respectively. Conclusions. Interventions on ganglion impar are an effective method of treating patients with coccygodynia of various etiology, which significantly reduce pain according to the VAS scale (p<0.001) and improve the quality of life according to the KS (p<0.001) in dynamics after 1, 3, 6 months. Minimally invasive interventions on ganglion impar make it possible to reduce tissue trauma, to quickly recover for patients after the procedure, and to minimize any complications. In the first and second groups of the study, there was a decrease in the pain on the VAS from 8.0 cm to 2.0 cm (p<0.0001) and from 7.0 cm to 2,7 cm (p<0.001) before and after the procedure, respectively. In the first and second groups of the study, there was an improvement in the indicator of functional status according to the KS from 70% (95% сonfidence interval (CI) 60‒90%) to 90% (95% CI 70‒100%, p<0.0001) and from 70% (95% CI 70‒90%) to 90% (95% CI 80‒100%, p=0.001) before and after the procedure, respectively.
... Sus abordajes vistos con técnica fluoroscópica son [31], [32]: -Anococcígeo. ...
... If a good analgesic response is elicited, then the ganglion impar is later neurolysed with dehydrated alcohol or phenol. Another technique using the anococcygeal approach achieves the same final needle position by going under the most distal part of the coccyx (89). ...
Background:
Pain is the most prevalent symptom in cancer patients. To improve pain care, World Health Organization (WHO) Pain ladder was introduced in 1986 as a template for choosing pain medications in oncological settings. Since then, advancements in oncological treatments have improved the survival of cancer patients, requiring prolonged analgesia in various treatment stages. Additionally, there have been newer challenges in pain management with opioid epidemic and associated opioid use disorders. This has shifted the focus from WHO Pain Ladder and brought new importance to the rapidly evolving realm of interventional pain modalities for cancer pain management. This article reviews such interventional pain and minimally invasive neurosurgical options for pain management in cancer patients.
Methods:
Systemic literature search in PubMed, Cochrane, and Embase. This included review articles, randomized controlled trials, non-randomized clinical trials (RCTs), and case series.
Results:
A large array of interventional pain modalities are available for oncological pain management. These modalities carry relatively lower risk and provide effective analgesia while reducing concerns related to opioid use disorder. They target various areas in the anatomical and physiological pain pathways and provide more focused options for pain management at various stages of cancer and survivorship. Additionally, with improved sterile techniques, better imaging modalities, and growing technical and clinical expertise, interventional pain modalities offer a safe and often more efficacious method of pain management nowadays. Procedural modalities like intrathecal (IT) pumps, neuromodulation, kyphoplasty, and newer more targeted ablative techniques are now increasingly finding more roles and indications in cancer population.
Conclusions:
Interventional pain techniques are rapidly evolving and have become an integral part of cancer pain management. They can provide an additional option for cancer pain management, and can help reduce opioid consumption, and associated opioid side effects. With improvement in imaging modalities, procedural techniques, hardware, and infection control, they have a good safety profile and provide a rapid and efficacious approach for cancer pain management. This review articles aims to provide a basic understanding of various interventional pain modalities, their indications, efficacy, safety data, and associated complications.
... These procedures can be applied as local repetitive per coccygeal injections or as ganglion impar block [3] . The ganglion impar block was first applied by Plankarte et al., and it continues to be applied with different techniques today [13] . Today, the ganglion impar block maintains its current position with the help of radiofrequency. ...
... 5 Ganglion impar blockade has become a valuable option for coccygeal pain treatment since its first description by Plancarte in patients with malignancy. 24 In the present study, the changes in pain level after RFT application to the ganglion impar was examined in patients with coccydynia. Treatment success was defined as demonstration of ≥50% decrease in pain score. ...
... Caudal epidural steroid injections are frequently used in the treatment of coccydynia, although there is insufficient evidence. Plancarte et al. [15] recommended the application of epidural infiltration of steroids via the peridural caudal route together with GIB block in patients who did not respond adequately to the first GIB. Sáenz et al. [6] obtained a successful response in 13 of 21 patients with coccydynia who applied GIB. ...
... Although there are different techniques for GIB, the fluoroscopy-guided transsacrococcygeal approach is often preferred because it is faster, more effective, simple, and well-tolerated by patients (Gonnade et al. 2017). In the technique of Plancart et al. by inserting a bent spinal needle through the anococcygeal ligament, the risk of rectal perforation and needle sticking in the practitioner's finger is relatively higher (Plancarte et al. 1990;Scott-Warren et al. 2013). Although it is well known that GIB provides short-term pain relief in patients with chronic coccygodynia, there are insufficient data on long-term treatment outcomes and possible factors affecting these outcomes (Gonnade et al. 2017;Elkhashab and Ng 2018;Malhotra et al. 2021). ...
Introduction
Although it is well known that ganglion impar block (GIB) reduces pain in the short term in patients with chronic coccygodynia, there are insufficient data on long-term treatment outcomes. The aim of this study was to examine the long-term outcomes of patients who underwent GIB for chronic coccygodynia and possible factors that might affect these outcomes.
Methods
The pre-treatment, 1st-hour, and 3rd-week numeric rating scale (NRS) scores of patients who underwent GIB 36-119 (min-max) months ago (between November 2011 and October 2018) due to coccygodynia were obtained from the medical records. Final NRS scores and presence of factors that may affect success such as accompanying low back pain (LBP) were questioned via telephone interviews. Treatment success was defined as a 50% or more reduction in final NRS scores compared with pre-treatment NRS scores.
Results
Telephone interviews were made with 70 patients. Treatment success was achieved in 55.7% of the patients. The patients were divided into two groups as those who achieved treatment success (group A) and those who could not (group B) and were compared. The NRS scores at the 3rd week and the number of patients with LBP in the group B were significantly higher than the group A. No serious complications developed in any patients.
Conclusion
In patients with chronic coccygodynia, GIB is an effective and safe treatment option for pain reduction in the long term. Accompanying LBP and high pain scores in the 3rd week after injection should be considered as parameters that negatively affect long-term treatment success.
Keywords: Coccygodyniaganglion imparganglion impar blocklong-term outcomeslong-term follow-up
... There are various injection techniques for ganglion impar blockade. [1,[4][5][6][7] Plancarte et al. [12] were first to report the anococcygeal approach where the tip of the needle reaches the sacrococcygeal junction retroperitoneally by inserting a bent spinal needle through the anococcygeal ligament with the guidance of fluoroscopy. Due to the risk of rectal perforation in this technique, it is often recommended that the practitioner insert the second finger of the nondominant hand into the rectum while advancing the needle. ...
Although it has been reported that caution should be exercised in terms of rectal perforation, as the ganglion impar is located just behind the rectum in the presacral space, the authors could not find any case or images of rectal perforation occurring during ganglion impar blockade in the literature. In this report, the case of a 38-year-old female with rectal perforation that developed during ganglion impar blockade, performed by the transsacrococcygeal approach under fluoroscopy guidance, is presented. Wrong needle selection and the structurally short presacral space of the patient may have influenced the development of rectal perforation in the patient. This study presents the first case and images of rectal perforation in the literature that developed during the application of ganglion impar blockade using the transsacrococcygeal technique. In ganglion impar block applications, technically appropriate needles should be used, and care should be taken in terms of rectal perforation.
... Ganglion Impar block have been described in the literature and used for the first time by Plancarte et al., 4 mainly for management of intractable coccydynia, chronic pelvic pain/ prostatic and pain of malignant etiologies . This block can be given to diagnose and locate the ganglionic fibres and has also been used for therapeautic purposes. ...
The present study was done to compare the Satisfaction level using Likert Scale among patients of chronic pelvic pain in pulsed radiofrequency ablation versus thermal radiofrequency ablation of Ganglion Impar. Material and Methods: The present study was prospective, randomized, single blinded study and was based on series of 30 patients presenting with chronic pelvic pain , having already failed conservative medical management, presenting in Pain clinic if IGMC Shimla. The patients were divided into 2 groups of 15 patients. Patients in Group A(n=15) were given thermal radiofrequency ablation where as patients in Group B were given pulsed radiofrequency ablation.Results: Mean age (in years) in group A and B was found to be 47.60± 6.833 and 42.67±7.807 years respectively. The p value was calculated to be 0.76 which was found to be statistically non significant. According to Post 24 Hours Likert scale, in Group A, 2(13.3%) patients were satisfied and 13(86.7%) were very satisfied while in Group B, 1(6.7%) patient was neutral , 10(66.7%) were satisfied and 4(26.7%) patients were very satisfied. (P= 0.004). According to Post 1 week Likert scale, in Group A, 2(13.3%) patients were satisfied and 13(86.7%) were very satisfied while in Group B, 1(6.7%) patient was neutral , 9(60.0%) were satisfied and 5(33.3%) patients were very satisfied.(p=0.011) Similarly 100% of the patients of group A were satisfied with the procedure as compared to patients of group B 3 weeks after the procedure.( p =0.011). Conclusion: Present study showed that mean Post Procedural satisfaction level using Likert Scale (24 Hours, 1,2 AND 3 week) was significantly more in group A as compared to group B. we can conclude that thermal radiofrequency ablation of ganglion impar for chronic pelvic pain produces better satisfaction level in the patients as compared to patients who were treated with pulsed radio frequency ablation.
... Blocking the Ganglion Impar attenuates this sympathetically mediated recalcitrant chronic pelvic pain, leading to reduction of opioids consumption, less side effects and an improvement in the patients' quality of life. [3][4][5] A radiofrequency ablation is a minimally invasive procedure that destroys the nerve fibers carrying pain signals to the brain. Radiofrequency ablation (RFA) of Ganglion Impar is a well-established, drug-free treatment that has been clinically proven to provide safe, effective, lasting relief from chronic pain. ...
The present study was done to compare the Post Procedural medication requirement and side effects among the patients of chronic pelvic pain in pulsed radiofrequency ablation versus thermal radiofrequency ablation of Ganglion Impar. Material andMethods: The present study was prospective, randomized, single blinded study and was based on series of 30 patients presenting with chronic pelvic pain , having already failed conservative medical management, presenting in Pain clinic if IGMC Shimla. The patients were divided into 2 groups of 15 patients. Patients in Group A(n=15) were given thermal radiofrequency ablation where as patients in Group B were given pulsed radiofrequency ablation.Results: Mean age (in years) in group A and B was found to be 47.60± 6.833 and 42.67±7.807 years respectively. The p value was calculated to be 0.76 which was found to be statistically non significant. In Group A, 13(86.7%) patients didn’t need any Medication to be started Post Procedure and 2(13.3 %) need medication post procedural while in Group B, 6(40.0%) patients didn’t need any Medication to be started Post Procedure and 9(60.0 %) need medication post procedural. The P value was 0.021 which was statistically significant. In both Group A and B None of the patients had any side effects post procedural. Conclusion: Present study showed that Post Procedural medication requirement was significantly less in group A as compared to group B and none of the patients had any side effects post procedural in both Groups.
... GIB was first described by Plancarte et al. 25 In this technique, the needle tip is advanced through the anococcygeal ligament to the anterior surface of the sacrococcygeal ligament, but has significant risk of rectal perforation. 26 Paramedian double bentneedle approach has also been used for GIB in the past, but now it's not chosen because of its technical difficulty. ...
Background:
This study aimed to determine the predictive factors affecting the success of ganglion impar block applied in chronic coccygodynia.
Methods:
Patients who received ganglion impar block to treat coccygodynia between January 1, 2018 and January 1, 2021 were retrospectively screened. Of the 195 patients, 102 met the final analysis criteria and were included in the study. Demographic data, coccygodynia etiology, coccygodynia symptom duration, history of coccyx fracture, regular opioid use, and presence of other musculoskeletal chronic pain conditions accompanying coccygodynia were obtained from patient records. In addition, coccyx radiography was examined, and coccyx curvature type, permanent subluxation, and posterior spicule presence were evaluated. The criterion for treatment success was set as ≥50% reduction in Numerical Rating Scale pain scores in the third month after treatment.
Results:
Treatment was successful of the patients in 69.6% (95% CI 60.4% to 78.7%). A significant cut-off value (24.5 months) was determined for coccygodynia symptom duration using receiver operating characteristic analysis. Symptom duration above the cut-off value was defined as prolonged symptom duration. Multivariable logistic regression analysis was performed to determine the predictive factors affecting treatment success in the third month after injection. In the final model, the presence of permanent subluxation (yes vs no), and the prolonged symptom duration (yes vs no) were found to have significant effects on treatment success (OR 9.56, 95% CI 1.44 to 63.40, p=0.02; OR 137.00, 95% CI 19.59 to 958.03, p<0.001).
Conclusion:
Treatment success of ganglion impar block for coccygodynia is high. However, longer preprocedure symptom duration and the presence of permanent subluxation were associated with a decrease likelihood of treatment success.
... Plancarte et al. used bent needle through the anococcygeal ligament. 24 The author placed the non-dominant hand index finger in the rectum to avoid an accidental breach. Wemm and Saberski suggested inserting a needle through the sacrococcygeal ligament via the trans sacrococcygeal approach directly into the retroperitoneal space. ...
Resumo
Quase 90% dos casos de coccigodínia podem ser tratados por meio de tratamento clínico conservador; os 10% restantes precisam de outras modalidades invasivas para o alívio da dor, como o bloqueio do gânglio ímpar (BGI) ou ablação por radiofrequência (ARF) do gânglio ímpar. Com o objetivo de avaliar a eficácia do BGI e ARF do gânglio ímpar no controle da dor em pacientes com coccigodínia, foi realizada uma pesquisa sistemática no PubMed, MEDLINE e Google Scholar, a fim de identificar estudos que relatam o alívio da dor, em termos de Escala Visual Analógica (EVA) ou dos seus homólogos, após o BGI ou ARF em pacientes com coccigodínia por 2 autores diferentes, de acordo com as diretrizes PRISMA. Foram definidos sete estudos com um total de 189 pacientes (104 no grupo BGI e 85 no grupo ARF). No grupo BGI, a média da pontuação EVA melhorou de 7,83 no início do estudo para 3,11 no acompanhamento de curto prazo, 3,55 no acompanhamento de médio prazo e 4,71 no acompanhamento de longo prazo. No grupo ARF, a média da pontuação EVA melhorou de 6,92 no início do estudo, 4,25 no acompanhamento de curto prazo e 4,04 no acompanhamento de longo prazo. No grupo BGI foram relatadas 13,92% de falhas (11/79) e complicações de 2,88% (3/104), enquanto que no grupo ARF foram relatadas 14,08% de falhas (10/71) e nenhuma complicação (0%). A taxa total de êxito foi >85% em qualquer uma das modalidades. O BGI e ARF do gânglio ímpar fornecem um método confiável e provavelmente excelente no controle da dor, em pacientes com coccigodínia que não respondem ao tratamento médico conservador. No entanto, deve ser estabelecido um limite entre os que responderam, os que não responderam e aqueles não respondedores tardios, sendo necessários estudos mais amplos com acompanhamento mais longo (>1 ano).
... Later Nebab and Florence modified Plancarte's technique by bending the needle to create a bow or an arc. [27,28] In 1995, Wemm and Saberski further simplified the technique by piercing the sacrococcygeal space, with an advantage of being less traumatic to the tissues and had high success rate as compared to older techniques [ Figure 1]. [29] Drug or ablative material, i n j e c t e d i n r e t r o p e r i t o n e a l s p a c e a t sacrococcygeal region has propensity to migrate cephalad, away from the ganglion. ...
... Image-guided neurolysis of the ganglion impar appears to be a generally safe and effective procedure. [58][59][60] Intrathecal drug delivery systems infuse analgesics directly into the spinal fluid at the appropriate spinal level via a subcutaneous catheter connected to an implanted, refillable drug pump. This method of analgesia can be very effective but is expensive, requires specialized equipment and well-trained staff members, and should not be initiated during an infection. ...
The essential package of palliative care for cervical cancer (EPPCCC), described elsewhere, is designed to be safe and effective for preventing and relieving most suffering associated with cervical cancer and universally accessible. However, it appears that women with cervical cancer, more frequently than patients with other cancers, experience various types of suffering that are refractory to basic palliative care such as what can be provided with the EPPCCC. In particular, relief of refractory pain, vomiting because of bowel obstruction, bleeding, and psychosocial suffering may require additional expertise, medicines, or equipment. Therefore, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an augmented package of palliative care for cervical cancer with which even suffering refractory to the EPPCCC often can be relieved. The package consists of medicines, radiotherapy, surgical procedures, and psycho-oncologic therapies that require advanced or specialized training. Each item in this package should be made accessible whenever the necessary resources and expertise are available.
... After failing conservative management, ganglion impar block was the reasonable next approach. This block was initially described by Plancarte et al (9) using a spinal needle introduced through the anococcygeal ligament and directed under fluoroscopic guidance to lie with its tip retroperitoneally at the sacrococcygeal junction. With our patient, we used the Foye technique, which is done through inserting a spinal needle through the sacrococcygeal junction so that the tip of the needle reaches just anterior to the junction (7). ...
... There are various approaches to performing a GIB. The first approach was described in 1990 by Plancarte et al. [9] as a needle insertion through the anococcygeal ligament until reaching anteriorly to the sacrococcygeal joint. Later on, transsacrococcygeal approach, other intercoccygeal joint approaches and paracoccygeal approaches were described [8,10]. ...
Ganglion impar block (GIB) is a well-recognised treatment for chronic coccydynia. Several side effects have previously been described with this procedure, including transient motor dysfunction, bowel, bladder, and sexual dysfunction, neuritis, rectal perforation, impingement of the sciatic nerve, cauda equina syndrome, and infection.
We describe the first report of imaging-documented conus infarction after an unguided-GIB performed in theatre using particulate steroids for a 17-year-old patient with coccydynia. Immediately post-GIB, patient developed transient neurological deficits in her lower limbs of inability to mobilise her legs that lasted for 24 h. These include back and leg pain, decreased power and movement, increased tone, brisk reflexes, reduced light touch sensation and proprioception of legs up to the T10 level. Urgent MRI spine showed intramedullary hyperintense signal within the conus and mild restricted diffusion on the distal cord and conus, suggestive of an acute conus infarction. On follow-up, the GIB did not result in symptom improvement of coccydynia and there was persistent altered sensation of her legs.
Various approaches of ganglion impar block have been described and performed in the past with different imaging techniques and injectants. A few cases of unusual neurological complications have been reported with the use of epidural steroid injections and ganglion impar block. Clinicians should be aware of the possible neurological complications following ganglion impar blocks and the risk of inadvertent intravascular injection of particulate steroids can potentially to be minimised by using imaging guidance.
... A review of the literature reveals very limited information on the usefulness of blockade of the ganglion impar for pain other than that of neoplastic origin. The original technique for blockade of the ganglion impar described by Plancarte et al. [9] involves a midline Res, Vol 12, Issue 2, 2019, 15-16 Parthasarathy and Batcha approach through the anococcygeal ligament with advancement of the needle tip cephalad to the anterior surface of the sacrococcygeal ligament. This technique involves placing one or two bends near the tip of the needle to more easily approximate the location of the ganglion. ...
Postherpetic neuralgia (PHN) is one of the most common and important complications of severe varicella-zoster infection, especially occurring in 20% of the elderly patients. A 59-year-old female presented with pain in the right sacral region for the past 3 months. The pain was preceded by herpes zoster. She was diagnosed as a case of Sacral PHN. We administered paramedian approach of ganglion impar block with 10 ml of 0.25% bupivacaine with 8 mg dexamethasone which resulted in immediate adequate pain relief. On follow-up after 8 weeks, the pain score continued to be less with 3/10. No complications were encountered. There was no sensory loss. We conclude that ganglion impar block with a combination of local anesthetic and steroid is a viable treatment option for sacral PHN.
... Sencan, et al significant amount of decrease in pain. Although ganglion impar blockade, first defined by Plancarte et al. [6], has evolved over time, a fluoroscopy guided transsacrococcygeal approach is often preferred in our day. Local anesthetics or a corticosteroid in addition to local anesthetics are used for the purpose of the blockade. ...
Background/Importance
Chronic coccydynia is a challenging condition to manage. Conflicting evidence exists regarding the role of the ganglion impar in coccygeal nociception. When conservative treatments fail, minimally invasive interventions at the ganglion impar may be effective in providing relief.
Objectives
To evaluate the effectiveness and safety of ganglion impar blocks (GIBs) for the management of chronic coccydynia.
Evidence review
A systematic review and meta-analysis was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies were identified through a comprehensive literature search of PubMed, Embase Classic+ Embase, CINAHL and the Web of Science in February 2024. Data on patient characteristics, intervention details, pain outcomes (measured by Visual Analog Scale and Numerical Pain Rating Scale) and adverse events were extracted. Meta-analysis was performed using standardized mean differences (SMDs) on scale of 0 to 10.
Findings
Seventeen studies described 625 coccydynia patients treated with GIB. All studies reported some level of improvement of pain after GIB. The meta-analysis included 11 studies totaling 391 patients with a baseline pain score of 7.93 (7.81 to 8.04 95% CI). GIBs were effective in reducing coccygeal pain at short-term (up to 3 months), intermediate-term (3–6 months) and long-term (greater than 6 months) follow-up. SMDs were −2.73 (95% CI −3.45 to −2.01), −3.22 (95% CI −2.82 to −1.45), −1.86 (95% CI −2.58 to −1.15) at 3 months, 3–6 months and >6 months, respectively. No serious adverse events were noted. Grading of Recommendations Assessment, Development and Evaluation assessment indicated ‘very low’ certainty of evidence across all outcomes.
Conclusions
Non-neurodestructive GIB may be a safe and potentially effective treatment option for patients with chronic, refractory coccydynia.
PROSPERO registration number
CRD42024506056.
The fascia, a continuous structure around the whole body across various anatomical locations, remains underexplored in regional anesthesia. The pelvic fascia is a particularly controversial and complicated anatomical structure. It holds significant relevance not only for surgeons but also in the realms of regional anesthesia and pain management. Many regional nerve blocking techniques in the pelvis are closely related to fascial anatomy, such as fascia iliaca compartment block, circum-psoas block, inferior hypogastric plexus block, and ganglion impar block. The continuity of fascia and interfascial spaces profoundly influences both the efficacy of blockades and the incidence of complications. A thorough understanding of pelvic fascia anatomy is crucial for understanding the potential pathways and barriers for spread of local anesthetics, enhancing analgesia, and minimizing side effects. Currently, a systematic discussion of pelvic fascia from the perspective of regional anesthesia and pain therapy is notably absent. This narrative review aims to consolidate knowledge on the anatomy of pelvic fascia pertinent to regional anesthesia and pain management, detailing relevant pelvic nerves, and associated peripheral nerve blocking techniques.
Chronic pelvic pain can be broadly defined pain in the pelvis but can include groin, lumbosacral back, buttock, perineal, and hip areas (Peng and Tumber. Pain Physician 11:215–224, 2008). There are multiple causes of pelvic pain—visceral, musculoskeletal, neurologic, and primary or secondary psychologic causes. Pelvic pain is often difficult to address and, therefore, treat, and is usually relegated to the gynecologist (or psychologist). There are several nerve pathologies that, if accurately identified, may be effectively treated, including anterior cutaneous nerve entrapment (ACNE), as well as pudendal, ilioinguinal, genitofemoral, obturator, posterior femoral cutaneous, and inferior cluneal nerves.
A ganglion impar block is a nerve block used to target sympathetic and nociceptive pain of the pelvic structures and perineum. This block has broadened its use since its inception to be utilized for both malignant and nonmalignant causes. Literature has further suggested this block can provide between 50% and 100% improvement in pain symptoms, with success being reliant on the anatomic location of the ganglion impar in relation to the sacrococcygeal junction (SCJ). There are several approaches and techniques to do this block, both safely and successfully. The trans-sacrococcygeal approach is frequently used as it provides direct access to the ganglion, and a needle-inside-needle approach further provides control and avoids needle fractures. In recent years, ganglion impar blocks (GIBs) have been completed using both fluoroscopy and ultrasound with similar effectiveness.
Perineal pain is a complex clinical condition causing significant functional impairment and frustration to the patient. The diversity of presentation and etiologies poses a challenge to the treating physician. Ganglion Impar is a solitary retroperitoneal structure in front of sacrococcygeal junction behind the rectum. It provides nociceptive and sympathetic supply to the perineal structures. Interventional pain management in the form of fluoroscopy guided Ganglion Impar block has been shown to benefit in patients with perineal pain. Here we describe a case series of Ganglion Impar block in four patients with various etiologies analysing its safety and efficacy. In this case series, four patients visiting the pain clinic in a tertiary care hospital with complaints of perineal pain of various etiologies were included. All the patients were given Ganglion Impar block under fluoroscopy guidance. NRS was assessed before the block, immediately after the block, and at time intervals of three months, six months, and one year post block. Any complications during the procedure and the follow up period were noted. All four patients had very good pain relief after block. The mean NRS value before the block was 8 ± 0.701. Ten minutes after the procedure, mean NRS value was 2.75 ± 0.95. NRS scores at three months, six months and one year follow-up intervals were 1.5 ± 1.29, 1.25 ± 1.25, and 1 ± 1.41 which is statistically significant. There were no complications. Fluoroscopy guided Ganglion Impar Block is a safe and effective intervention in the management of acute and chronic perineal pain of various etiologies providing good pain relief.
Chronic pelvic pain is defined as pain in the perineal region that can be somatic or visceral in origin which persists for more than 6 months duration and is unresponsive to analgesic therapy. Its diagnosis is made on the basis of patient’s history, detailed physical examination and radiological studies. One of the important, rare and mostly missed cause of this pain is coccydynia either traumatic or atraumatic. The treatment of coccydynia includes supportive care, analgesic therapy as well as ganglion impar neurolysis. Here, we report a case of a 42-year-old female suffering from severe chronic pelvic pain for past 15 years for which she had taken multiple analgesics including opiates and underwent multiple surgeries without any relief. She was a misdiagnosed case of coccygeal fracture which was causing chronic pelvic pain for the past 15 years which when treated with ganglion impar neurolysis gave her complete pain relief. After 1 month of the intervention, on follow up in the pain clinic the patient was absolutely pain free with NRS 1/10.Coccydynia must be considered in differential diagnosis of chronic pelvic pain especially in females of child bearing age.
Interventional oncology has emerged as an important specialty within cancer care, providing targeted therapy and palliative benefits without the side effects of chemotherapy, surgery and radiation. Covering the principles of current and emerging interventional oncology techniques and detailed diagnosis, staging and treatment algorithms, this book outlines the ways in which these image-guided therapies can inform cancer management strategies. Access to the most current information is vital in this rapidly growing and evolving area of practice. This new edition reflects the most recent clinical data on interventional oncology procedures. Chapters on image guidance and targeting, tumor ablation, embolotherapy, and response assessment have been updated to reflect major technological advances, and new material on microwave ablation and irreversible electroporation has been added. This invaluable resource for interventional radiologists provides essential education and guidance on the full range of minimally invasive image-guided procedures and their integration into comprehensive cancer care.
The Ganglion Impar was recognized as a key mediator to the sympathetic system and the block carries low morbidity and risk. The technique was initially described using a 22G spinal needle through the anococcygeal ligament. Ganglion Impar blockade is indicated for visceral perineal pain that is sympathetically maintained in both cancer and non‐cancer patients. The techniques involved in the block include transsacrococcygeal ligament technique, sacrococcygeal transdiscal approach, needle‐inside‐needle approach, paramedial approach, ultrasound‐guided technique and chemical neurolysis. Neurolytic techniques have long been used in the treatment of pain. The underlying principle for neurolytic blocks is prolonged relief of intractable pain, most often in patients with malignancies. The radiofrequency cannula can be damaged while advancing through the sacrococcygeal joint. Conventional radiofrequency is commonly associated with pain during the procedure. Complications of the technique include perforation of the rectum, epidural injection, intraperiosteal or intravascular injection and reflux of the injected substance through sacral foramina.
The superior hypogastric plexus is located on the surface of L5 and S1 vertebrae, inferior to the bifurcation of the aorta, and carries visceral afferent fibers. The plexus can be blocked for pelvic pains with malignant origin or when treatment related side effects, such as radiation and scar tissue formation, result in reproduction of pain in the pelvis. The best percutaneous approach for blocking the ganglion is dorsal to the vertebral body and under fluoroscopic guidance. The ganglion can be blocked with local anesthetics and steroids. Neurolysis is achieved by ethyl alcohol or phenol. The procedure may result in complications such as pelvic organ damage, bleeding, or nerve injury. The ganglion of impar is the most caudal ganglion of the sympathetic chain. This ganglion supplies sympathetic and visceral innervation to the lower third of the rectum, vagina, vulva, urethra, and coccyx. The ganglion of impar can be targeted for relieving visceral pain caused by neoplasms of the lower pelvic structures or surgical or radiation induced pain in the area. Coccydynia, or other benign processes that cause pain in the perineal area, can also be treated with this procedure. The procedure is relatively safe with minimal complications. Possible complications include rectal perforation, discitis, and sacral nerve root blockade. Fluoroscopic or CT image-guided blockade is used to minimize these complications.
Chronic coccygodynia is a disorder characterized by intractable pain in the coccygeal region and is difficult to diagnose and treat. The etiologies of coccygodynia are varied, however in most patients, it is usually idiopathic or followed by external or internal trauma. The traumatic events related directly with coccygodynia are direct injuries, fall on back, obstructed labour, etc. Non traumatic coccygodynia can result from degenerative joint or disc disease, hypermobility or hypomobility of the sacrococcygeal joint, obesity, infectious etiology, variants of coccygeal morphology, and cancers of the pelvis and anorectal region. Many treatment options are available for this painful condition conservative treatment such as non-steroidal anti-inflammatory drugs (NSAIDs), local analgesics, hot or cold application, transcutaneous electrical nerve stimulation (TENS), modified wedge-shaped cushions, circular cushions (donut cushions) and levator ani relaxation exercises are available. However, in nonresponsive patients who fall under the category of chronic coccygodynia, direct injections around the coccyx, ganglion impar blocks, neurolysis and coccygectomy can be done for pain relief. The current study was conducted at IMS&SUM Hospital, Bhubaneswar, Siksha 'O' Anusandhan (Deemed to be University) to estimate the effectiveness of the Ganglion Impar block for the management of chronic refractory Coccygodynia patients who had failed to respond conservative management.
Radiofrequency ablation (RFA) is a procedure in which radio waves are used to destroy abnormal or dysfunctional tissue. It has been an increasingly utilized treatment option for a variety of medical conditions, such as chronic pain, wherein sensory nerves are targeted and ablated, eliminating their ability to transmit pain signals to the brain. There is a lack of clarity regarding the indications, technique, and efficacy of RFA for chronic pelvic pain. This article reviews recent literature and discusses these topics, including adverse events for different pelvic ablation and pulsed radiofrequency treatment of chronic pelvic pain.
Purpose of Review
To provide an overview of current interventional treatment options for women with chronic pelvic pain (CPP).
Recent Findings
Accessibility of CT imaging, ultrasound, and fluoroscopy has assisted the development of novel interventional techniques. Similarly, neuromodulation techniques have improved with the development of novel stimulation patterns and device implants.
Summary
Numerous small-scale studies report high success rates with injection intervention therapies in CPP, but there are limited well-designed large-scale studies that demonstrate the superiority of treatment. Female pelvic pain is difficult to diagnose due to the multifactorial etiology and the variable presentation causing delay in accurate diagnosis and lack of response to conventional medical and initial interventional therapies. Despite the shortfalls of current studies, collectively, our understanding of chronic pain conditions and helpful injection interventions are improving. Undoubtedly, the breadth of current research will provide a rich foundation for future large-scale well-designed studies involving multiple disciplines with more uniform methods and criteria to produce reliable and reproducible results.
Cancer‐related pain affects millions of people worldwide, causing fear and diminishing the quality of life in patients suffering from cancer. Despite increasing information on analgesics and interventional techniques, it is estimated that as many as 90% of patients with advance cancer still suffer from debilitating pain. Comprehensive management of pain is an integral part of treating patients with cancer. The World Health Organization analgesic ladder recommends a sequential approach to administering analgesics based on pain severity, initially with non‐opioids for mild pain, progressing to mild, and strong opioids for more severe pain. The most common non‐opioid agents used to treat cancer pain include: acetaminophen; anti‐inflammatory agents such as nonsteroidal anti‐inflammatories and cyclooxygenase‐2 inhibitors; corticosteroids; anti‐ neuropathic agents; and bisphosphonates. These agents have demonstrated their usefulness in the management of a wide variety of acute and chronic painful conditions and, in some cases, have contributed to reducing opioid requirements.
ResearchGate has not been able to resolve any references for this publication.