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Ganglion Impar Block

Evidence for a useful block for chronic pain

kritikadoshi
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Ganglion Impar Block

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  1. GANGLION IMPAR BLOCK Dr KritikaDoshi MD, DA, FIPP, ISSP (Pain fellowship) Consultant In Chronic Pain: Doshi pain Relief Centre, Bethany Hospital, Jupiter Hospital www.painreliefcentre.in

  2. Ganglion Impar Block • The ganglion impar is the terminal ganglion of the sympathetic chain. • It is a single ganglion and although the anatomy is variable, it is usually found just caudal of the sacrococcygeal junction. • It is also referred to as “Walther’s Ganglion.” • Plancarte et al first described the technique of ganglion impar block in 1990Plancarte R, Velazquez R, Patt R. Neurolytic blocks of the sympathetic axis. In: Patt RB, ed. Cancer Pain. Philadelphia, PA: JB Lippincott; 1993:417–420.

  3. Anatomy • Sympathetic trunk in pelvis- on anterior sacral surface, ganglia lie medial to sacral foramina • Contains visceral afferents from the perineum, distal rectum, anus, distal urethra, vulva and distal 1/3 of vagina • Single ganglion due to fusion of both • Lies anterior to saccrococcygeal joint

  4. Position for Procedure • Lateral • Prone • Lithotomy • But, presence of local tumor, infection etc may make all these painful for patient

  5. Trans-sacrococcygeal • 22G, 3.5” needle, Fluro guided • Passed through sacro-coccygeal junction into retroperitoneal space • Dye spread confirmed • Neurolysis 4-6ml, 6-10% Phenol

  6. CT guidance- better needle placement • Ozyalcin S, Tunaci A, Acunas B et al: Three dimensional spiral-CT guided ganglion impar block: Case report. Pain Digest 7:204-207, 1997 • Waldman Sd: Atlas of Interventional Pain Management, 2nd ed. Philadelphia, Saunders, 2004

  7. CT-Guided, Lateral View of Dye

  8. complications • Rectal injury • Injection of neurolytic onto nerve roots, rectal cavity • Cauda equina

  9. A literature search produced 5 articles. One article was purely a technique article and was not included. • The remaining articles consisted of 3 case reports and 1 prospective case series

  10. All received a grade of 1C, ie, strong recommendation, low-quality evidence. • The strong recommendation is secondary to the indications for the block: vulvar cancer pain, chronic perineal pain, and sacral postherpetic neuralgia. • Low quality of evidence was assigned as all were case reports or case series

  11. Basagan Mogol E, Turker G, Kelebek Girgin N et al: Blockade of ganglion Impar through sacrococcygeal junction for cancer related pelvic pain. Agri 16:48-53, 2004 - 9 patients with malignancy related perineal pain

  12. Conclusion • Sympathetic blocks are very useful in persistent SMP refractory to medical Mx • Correct Patient selection important • Safe imaging and adhering to protocol can give good results with the procedures selected • This is invaluable for CRPS and vascular pains

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