Ganglion Impar Injection: Difference between revisions
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Injection treatment of the ganglion impar with local anaesthetic with or without corticosteroid is a procedureto treat [[Coccydynia]]. Needle placement is generally done by piercing through the sacrococcygeal disc space. Radiofrequency treatments such as pulsed radiofrequency is a newer technique and may provide better results than blockade.{{#pmid:31652036|sir}} | |||
==Anatomy== | ==Anatomy== | ||
The ganglion impair is a midline sympathetic ganglion anterior to the upper coccyx, formed by the caudal termination of paired sympathetic chains. The ganglion provides both sympathetic and visceral innervation to the coccyx, perineum, and anal regions. The size and location can vary, and in some people the ventral ramus of the sacral nerve roots run close by. It is classically at the level of the sacrococcygeal junction. | |||
==Indications== | ==Indications== | ||
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==Technique== | ==Technique== | ||
The optimum technique uses a combination of ultrasound and fluoroscopy. Ultrasound alone cannot accurately assess needle depth, while fluroscopy alone cannot accurately identify the sacrococcygeal junction nor its angulation due to bowel gas. | The optimum technique uses a combination of ultrasound and fluoroscopy. Ultrasound alone cannot accurately assess needle depth, while fluroscopy alone cannot accurately identify the sacrococcygeal junction nor its angulation due to bowel gas. In the combined technique the needle is first inserted under ultrasound guidance, and then the depth verified by fluoroscopy. This provides optimum accuracy and safety.<ref>{{#pmid:20447308}}</ref> | ||
===Ultrasound Guided=== | ===Ultrasound Guided=== | ||
[[File:US sacral hiatus and SCJ.jpg]] | |||
Ultrasound guided techniques have been described such as by Ghai et Al<ref>{{#pmid:31007658}}</ref> | Ultrasound guided techniques have been described such as by Ghai et Al<ref>{{#pmid:31007658}}</ref> | ||
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===Fluoroscopic Guidance=== | ===Fluoroscopic Guidance=== | ||
[[File:Ganglion impar fluoroscopy.PNG|thumb|left|200px|Fluoroscopic lateral view of ganglion impar block. Courtesy of Sir et al<ref name="sir"/>]] | |||
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===Non-ultrasound Guided=== | ===Non-ultrasound Guided=== | ||
Revision as of 17:42, 26 July 2020
| Ganglion Impar Injection | |
|---|---|
| Indication | |
Injection treatment of the ganglion impar with local anaesthetic with or without corticosteroid is a procedureto treat Coccydynia. Needle placement is generally done by piercing through the sacrococcygeal disc space. Radiofrequency treatments such as pulsed radiofrequency is a newer technique and may provide better results than blockade.[1]
Anatomy
The ganglion impair is a midline sympathetic ganglion anterior to the upper coccyx, formed by the caudal termination of paired sympathetic chains. The ganglion provides both sympathetic and visceral innervation to the coccyx, perineum, and anal regions. The size and location can vary, and in some people the ventral ramus of the sacral nerve roots run close by. It is classically at the level of the sacrococcygeal junction.
Indications
Contraindications
Technique
The optimum technique uses a combination of ultrasound and fluoroscopy. Ultrasound alone cannot accurately assess needle depth, while fluroscopy alone cannot accurately identify the sacrococcygeal junction nor its angulation due to bowel gas. In the combined technique the needle is first inserted under ultrasound guidance, and then the depth verified by fluoroscopy. This provides optimum accuracy and safety.[2]
Ultrasound Guided
Ultrasound guided techniques have been described such as by Ghai et Al[3]
- Position: prone, lower limbs internally rotated, toes pointing to the opposite foot. This helps to separate the buttocks and provides a flatter sacral hiatus site.
- Place the transducer in the transverse position and visualise the sacral hiatus, the two sacral cornuae, and the sacrococcygeal ligament which traverses the sacral hiatus above the epidural space
- Obtain a longitudinal position of the sacral hiatus, the proximal portion of the transducer resting between the two cranial sacral cornuae. The first cleft caudal to the sacral hiatus is the sacrococcygeal junction.
- Confirm the location of the sacrococcygeal junction by pressing with a long forceps under sonographic monitoring.
- Anaesthetised the overlying skin
- Advance a 23 gauge needle through the sacrococcygeal junction using an out of plane technique.
- Advance the needle until a loss of resistance is felt, which indicates that the needle tip is ventral to the sacrococcygeal ligament. Note that this is not always felt, hence the ideal use of combined imaging with fluoroscopy to confirm needle depth. Ultrasound cannot visualise the ventral coccyx
- Inject 3-5mL of 1% lidocaine or 10mL of 0.25% bupivicaine and 40mg of methylprednisolone.
Fluoroscopic Guidance
Non-ultrasound Guided
This is not recommended
Complications
Aftercare
Videos
See Also
External Links
References
- ↑ 1.0 1.1 Sir & Eksert. Comparison of block and pulsed radiofrequency of the ganglion impar in coccygodynia. Turkish journal of medical sciences 2019. 49:1555-1559. PMID: 31652036. DOI. Full Text.
- ↑ Lin et al.. Ultrasound-guided ganglion impar block: a technical report. Pain medicine (Malden, Mass.) 2010. 11:390-4. PMID: 20447308. DOI.
- ↑ Ghai et al.. A prospective study to evaluate the efficacy of ultrasound-guided ganglion impar block in patients with chronic perineal pain. Saudi journal of anaesthesia 2019. 13:126-130. PMID: 31007658. DOI. Full Text.
