Impar Ganglion Blockade

The most caudal ganglion of the sympathetic chain, the impar ganglion is located anterior to the sacrum and posterior to the rectum (Figure 12.5). It marks the end of the sympathetic chain. It receives innervation from the low pelvis and perineum.

Indications

Indications for impar ganglion blockade include the following:

Intractable low pelvic pain and perineal pain as a result of rectal cancer, uterine cancer, or prostate cancer

Endometriosis causing lower pelvic and perineal pain

Rectal Cancer Tailbone

Figure 12.7. Lateral view of the sacrococcygeal region. A needle, bent to produce a back-looking curve (arrows), is introduced fluoroscopically inferior to the coccyx. It is directed superiorly and posteriorly to position the tip at the anterior face of the lower sacrum near the sacrococcygeal junction. Because the rectum lies immediately anterior to the sacrum locally, radiographic contrast material is introduced to ensure that the needle tip is not inside the bowel.

Figure 12.7. Lateral view of the sacrococcygeal region. A needle, bent to produce a back-looking curve (arrows), is introduced fluoroscopically inferior to the coccyx. It is directed superiorly and posteriorly to position the tip at the anterior face of the lower sacrum near the sacrococcygeal junction. Because the rectum lies immediately anterior to the sacrum locally, radiographic contrast material is introduced to ensure that the needle tip is not inside the bowel.

The technique for impar ganglion blockade involves placement of needle such that the tip is located just anterior to the surface of the sacrum.2,6 This may require a double curved needle to be angled superiorly and posteriorly such that the needle tip will lie along the anterior face of the sacrum (Figure 12.7). Alternatively, the needle may be passed through the sacrococcygeal junction. Radiographic contrast should be injected to confirm optimal needle tip location and to exclude a position within the rectum or a vascular structure.

For temporary relief, 8 to 10 mL of bupivacaine 0.25% is administered. For permanent relief, 6 to 10 mL of absolute alcohol or 6% phenol can be administered (with the patient under general anesthesia).

Complications include puncture or injury of the rectum and nerve root injury during neurolysis.

References

1. Erickson SJ, Hogan QH. CT guided injection of the stellate ganglion: description of the technique and efficacy of sympathetic blockade. Radiology 188:707-709, 1993.

2. Waldman SD. In: Atlas of Interventional Pain Management. Philadelphia: WB Saunders; 1996:269-271.

3. Gangi A, Dietemann JL, Schultz A, et al. Interventional procedures with CT guidance: cancer pain management. Radiographics 16:1289-1304, 1996.

4. Yarzebski JL, Wilkinson H. T2 and T3 sympathetic ganglia in the adult human: a cadaver and clinical-radiographic study and its clinical application. Neurosurgery 21:339-342, 1987.

5. Gimenez A, Martinez-Noguerro A, Donoso L, et al. Percutaneous neuroly-sis of the celiac plexus via anterior approach with sonographic guidance. AJR Am J Roentgenol 161:1061-1063, 1993.

6. Wong W. Management of back pain using image guidance. J Women's Imaging 2:88-97, 2000.

7. Gangi A, Dietemann JL, Mortazavi R, et al. CT-guided interventional procedures for pain management in the lumbosacral spine. Radiographics 18:621-633, 1999.

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