Ganglion Impar block technique

1. Ganglion impar block
Dr Minhaj Akhter
MBBS, MD (PMR), PDF, FIPM, CCEPC
Assistant Consultant
Pain and Palliative Care, BMCHRC

2. • Ganglion Impar / Ganglion Of Walther /
Sacrococcygeal Ganglion
• Pelvic, Retroperitoneal just anterior to
the SC junction
• Originally – Sympathetic nerve-mediated
cancer pain
• Now for both malignant and non-
malignant

3. • Afferent nerves approach ganglion impar from the distal rectum,
anus, distal urethra, distal vagina, and perineum
• Sympathetic and nociceptive fibers also run from the GI to pelvic
viscera.
• Given its supply of nociceptive and sympathetic innervation to these
sacral and perineal structures, the GI is a nidus for relaying
information related to pain in these structures from the periphery to
the central nervous system
• Thus, the GI is a target for neuronal block or ablation in order to
reduce pain symptoms to these aforementioned regions.
PATHOPHYSIOLOGY

4. INDICATION

5. • Single ganglion, is converged by the caudal ends of the two
sympathetic trunks.
• Location - Anterior to the sacrococcygeal joint, Coccyx , Tip of the
coccyx
• Oh et al.- study of topographic anatomy
• Shape of the ganglion was classified as
• Oval In 26%
• Irregular In 20%
• Triangular In 14%
• Elongated In 10%
• Rectangular In 8%
• U-shaped In 8%
• 14% of the samples- connection of two caudal ends of the sympathetic trunks
without forming a recognizable ganglionic shape
Anatomy

6. Figure 37.1 illustrates the locations of the ganglion
impar, in terms of relative index

7. • Average distances of the midpoint of the sacrococcygeal joint and the
tip of the coccyx to the ganglion impar to be 8.6 mm and 25.0 mm
respectively.
• Sympathetic chain Anterolateral aspect of the vertebral column
Continue caudad Sacral sympathetic ganglia Merge
Ganglion impar, ganglion of Walther, or the sacrococcygeal ganglion

8. There are number of essential structures to identify both through manual palpation and
with the assistance of fluoroscopy
or ultrasound in order to successfully complete this block and avoid complications for the
patient

9. Illustration of the ganglion impar. (a) Anteroposterior illustration of
lumbosacral spine. (b) Lateral illustration of sacrum

10. • 3.5-inch 22-gauge spinal needle is bent at an angle and introduced through
the anococcygeal ligament in the midline
• Directed cephalad and posterior and is kept close to the coccyx
• Guided to the anterior portion of the sacrococcygeal junction
• Finger of the nondominant hand is kept in the rectum throughout the
procedure to avoid the needle entering the rectum.
Original Technique (Plancarte et al.)//Lateral
Technique

11. LIMITATIONS
• Difficult to guide due to the bend, hard to remove the stylet
• Quincke-type needle - unwanted tissue damage which leads to bleeding.
• Keeping the finger in the rectum - injury to the practitioner

12. • Prepare the patient before the procedure
• History, physical examination, and radiological studies
• All complications and detail should be explained
• Valid written consent should be obtained
• Prothrombin time, Partial thromboplastin time, bleeding time, CRP,
and urine analysis
• Intravenous fentanyl, midazolam, and/or propofol may be used for
the patient ’s comfort.
• If RF - patient needs to be awake to respond to the stimulation test.

13. Equipment and drugs for ganglion impar block
• 5ml syringe for local anesthetic solution
• 1½ inch, 25 gauge needle for skin infi ltration.
• 22 gauge, 3 ½ inch needle for ganglion impar block.
• 5ml syringe for contrast material, iohexol.
• 5ml syringe for the ganglion impar block.
• 5ml of 1% lidocaine for skin infiltration.
• 5ml contrast solution, e.g. iohexol.
• 5ml of 0.5% bupivacaine combined with depomedrol.
• 6% phenol/ in saline for neurolytic block (only for cancer patients).

14. • Patient is placed in the lateral decubitus
position with the hips flexed toward the
abdomen
• Local anesthesia is injected at the level of the
anococcygeal ligament, which is situated in the
midway between the anus and the tip of the
coccyx

15. • A 22-gauge spinal needle that has been previously bent according to
the curvature of the coccyx is introduced
• Maintain the tip of the needle in the midline and outside the
posterior rectal wall
• Inserting the index finger in the rectum facilitates placement of the
needle's tip at the level of the sacrococcygeal junction
• Technique can be quite uncomfortable in the patient with rectal
pathology and also make it difficult to maintain sterility during the
procedure
• Confirm the position of the needle
• Inject 2 ml contrast solution
• A smooth line image should be viewed in this position.

19. Drug
• Inject 5 ml of 1% lidocaine or 0.5% bupivacaine together with
deposteroid solution
• In cancer patients, inject 4 –5ml of 6% phenol in saline

20. • Curved needle technique described by Nebab and Florence
• Make it easier to guide the needle in the manner of a “suture” needle

22. • In this approach needle is placed directly in the
retroperitoneal space, in the midline at the level of
sacrococcygeal junction in the prone position
• Advantage - physician does not have to insert a
finger in the rectum
• This approach may be challenging in patients with
arthritis in the bones and calcification of the
ligaments of the sacrum and coccyx
Prone Technique / trans-discal/ transsacrococcygeal

23. • Palpate the sacrococcygeal junction
• Place the C -arm in a posteroanterior position
• Mark the sacrococcygeal junction after palpation

24. • Rotate the C -arm in a lateral position
• Infiltrate the skin with 1% lidocaine solution on the sacrococcygeal
junction

30. • Double-bend needle has also been used in a case report published by
McAllister et al. via a paramedian approach

32. • Modified Needle-Inside-Needle Technique (Munir et al.)

35. • The resulting curvature of the
coccyx is decreased, allowing
access to the ganglion impar with a
straight needle easy
• However, placement of a finger in
the rectum and fluoroscopy
guidance are needed
Lithotomy Technique

36. • Reig et al.
• Prone position
• First needle, the transcoccygeal needle, is introduced through the
sacrococcygeal ligament.
• The next needle, the transdiscal needle, is then placed through a
coccygeal disc
Thermocoagulation: A Modified Approach
• 15-cm radiofrequency needle with
a 5-mm active tip is introduced
• Subsequently, lidocaine is injected
through each needle, followed by
several minutes later with
radiofrequency lesioning at 80 °C
for 80 s

39. Postprocedure care
• Should be observed hypotension
• In the case of hypotension-intravenous electrolyte
• The recovery and observation time depends on the sedation and
analgesia used
• The patient should be provided with all instructions including whom
to call or where to go for any postprocedure urgent/emergency care
• The patient should be discharged accompanied by a responsible adult

42. References
1. P. Prithvi Raj, Serdar Erdine. Pain-Relieving Procedures. John Wiley & Sons; 2012.
2. P. Prithvi Raj, Lou L, Serdar Erdine, Staats PS, Waldman SD, Racz G, et al. Interventional
Pain Management: Image-Guided Procedures. Elsevier Health Sciences; 2008.
3. Essentials Of Interventional Techniques In Managing Chronic Pain. S.L.: Springer
International Pu; 2019.
4. Munir MA, Zhang J, Ahmad M. Une technique modifiée pour le bloc du ganglion
coccygien: une aiguille dans une aiguille. Canadian Journal of Anesthesia. 2004
Nov;51:915-7.
5. Nebab EG, Florence IM. An alternative needle geometry for interruption of the
ganglion impar. The Journal of the American Society of Anesthesiologists. 1997 May
1;86(5):1213-4.
6. Scott-Warren JT, Hill V, Rajasekaran A. Ganglion impar blockade: a review. Current pain
and headache reports. 2013 Jan;17:1-6.

43. Thanks