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Ganglion Impar Blockade

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Essentials of Interventional Techniques in Managing Chronic Pain

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Abstract

The ganglion impar, also known as the ganglion of Walther or sacrococcygeal ganglion, is a structure found in the pelvic retroperitoneum anterior to the sacrococcygeal junction. Given its supply of nociceptive and sympathetic innervation to a number of pelvic and perineal structures, it is a central point for relaying pain information in this region. As such, the ganglion impar is an excellent candidate for neuronal block or ablation in order to greatly reduce or eliminate pain symptoms to these aforementioned structures. The literature provides adequate evidence suggesting that ganglion impar blocks provide both immediate and long-term amelioration of pelvic and perineal pain states. These blocks have also been found beneficial for malignant and nonmalignant pain sources alike. In this chapter, we review the indications for a ganglion impar block, as well as relevant anatomy, complications, and precautions for the procedure. A myriad of techniques are used for this block in the field of interventional pain. We review the most common and safest approaches to this block, including appropriate strategies for the use of fluoroscopic and/or ultrasound image guidance.

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References

  1. Patel V, Manchikanti L. Ganglion impar block. In: Interventional techniques in chronic non-spinal pain. Paducah: ASIPP Publishing; 2009. p. 185–98.

    Google Scholar 

  2. Scott-Warren JT, Hill V, Rajasekaran A. Ganglion impar blockade: a review. Curr Pain Headache Rep. 2013;17:306.

    Article  PubMed  Google Scholar 

  3. Plancarte R, Amescua C, Patt R. Presacral blockade of the ganglion of Walther (ganglion Impar). Anesthesiology. 1990;73:A751.

    Google Scholar 

  4. Toshniwal G, Dureja G, Prashanth S. Transsacrococcygeal approach to ganglion impar block for management of chronic perineal pain: a prospective observational study. Pain Physician. 2007;10:661–6.

    PubMed  Google Scholar 

  5. Nebab E, Florence I. An alternative needle geometry for interruption of the ganglion impar. Anesthesiology. 1997;85:1213–4.

    Article  Google Scholar 

  6. Russo MA. Letter to the editor regarding Reig et al. Thermocoagulation of the ganglion impar of Walther: description of a modified approach. Preliminary results in chronic, nononcological pain. Pain Pract 2005;5:103–110. Pain Pract 2005;5:.367; author reply 367–368.

    Google Scholar 

  7. CS O, Chung IH, Ji HJ, et al. Clinical implication of topographic anatomy on the ganglion impar. Anesthesiology. 2004;101:249–50.

    Article  Google Scholar 

  8. Agarwal-Kozlowski K, Lorke DE, Habermann CR, et al. CT-guided blocks and neuroablation of the ganglion impar (Walther) in perineal pain: anatomy, technique, safety, and efficacy. Clin J Pain. 2009;25:570–6.

    Article  PubMed  Google Scholar 

  9. Datir A, Connell D. CT-guided injection for ganglion impar blockade: a radiological approach to the management of coccydynia. Clin Radiol. 2010;65:21–5.

    Article  CAS  PubMed  Google Scholar 

  10. Karaman H, Tüfek A, Kavak GO, et al. Would pulsed radiofrequency applied to different anatomical regions have effective results for chronic pain treatment? J Pak Med Assoc. 2011;61:879–85.

    PubMed  Google Scholar 

  11. Demircay E, Kabatas S, Cansever T, et al. Radiofrequency thermocoagulation of ganglion impar in the management of coccydynia: preliminary results. Turk Neurosurg. 2010;20:328–33.

    PubMed  Google Scholar 

  12. Eker HE, Cok OY, Kocum A, et al. Transsacrococcygeal approach to ganglion impar for pelvic cancer pain: a report of 3 cases. Reg Anesth Pain Med. 2008;33:381–2.

    Google Scholar 

  13. Vichinsky EP, Johnson R, Lubin BH. Multidisciplinary approach to pain management in sickle cell disease. Am J Pediatr Hematol Oncol. 1982;4:328–33.

    CAS  PubMed  Google Scholar 

  14. Green IC, Cohen SL, Finkenzeller D, et al. Interventional therapies for controlling pelvic pain: what is the evidence? Curr Pain Headache Rep. 2010;14:22–32.

    Article  PubMed  Google Scholar 

  15. Reig E, Abejón D, del Pozo C, et al. Thermocoagulation of the ganglion impar or ganglion of Walther: description of a modified approach. Preliminary results in chronic, nononcological pain. Pain Pract. 2005;5:103–10.

    Article  PubMed  Google Scholar 

  16. Gautam SKS, Agarwal A, Das PK. Ganglion impar block for sympathetically mediated pain in a patient with a rectourethral fistula. Pain Physician. 2014;17:E107.

    PubMed  Google Scholar 

  17. Sağır O, Ozaslan S, Köroğlu A. Application of ganglion impar block in patient with coccyx dislocation. Agri. 2011;23:129–33.

    Article  PubMed  Google Scholar 

  18. Malec-Milewska M, Horosz B, Kolęda I, et al. Neurolytic block of ganglion of Walther for the management of chronic pelvic pain. Wideochir Inne Tech Malo Inwazyjne. 2014;9:458–62.

    PubMed  PubMed Central  Google Scholar 

  19. Johnston PJ, Michálek P. Blockade of the ganglion impar (walther), using ultrasound and a loss of resistance technique. Prague Med Rep. 2012;113:53–7.

    Article  CAS  PubMed  Google Scholar 

  20. Lim SJ, Park HJ, Lee SH, et al. Ganglion impar block with botulinum toxin type a for chronic perineal pain -a case report. Korean J Pain. 2010;23:65–9.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Wemm K Jr, Saberski L. Modified approach to the ganglion impar (Ganglion of Walther). Reg Anesthesiol. 1995;20:544–5.

    Google Scholar 

  22. Loev MA, Varklet VL, Wilsey BL, et al. Cryoablation: a novel approach to neurolysis of the ganglion impar. Anesthesiology. 1998;88:1391–3.

    Article  CAS  PubMed  Google Scholar 

  23. Yeo SN, Chong JL. A case report on the treatment of intractable anal pain from metastatic carcinoma of the cervix. Ann Acad Med Singap. 2001;30:632–5.

    CAS  PubMed  Google Scholar 

  24. Romanes GJ. The peripheral nervous system. In: Romanes GJ, editor. Cunningham’s textbook of anatomy. 12th ed. Oxford: Oxford University Press; 1981. p. 739–827.

    Google Scholar 

  25. Leonhardt H. In: Innere Organe, Leonhardt H, Tillmann B, et al., editors. Anatomie des Menschen. New York: Georg Thieme Verlag Stuttgart; 1987. p. 444.

    Google Scholar 

  26. Berry MM, Standring SM, Bannister LH. Nervous system. In: Williams PL, Bannister LH, et al., editors. Gray’s anatomy. 38th ed. New York: Churchill Livingstone; 1995. p. 901–1397.

    Google Scholar 

  27. Moore KL, Dalley AF. Clinically oriented anatomy. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 1999. p. 350.

    Google Scholar 

  28. Rosse C, Gaddum-Rosse P. Hollinshead’s textbook of anatomy. 5th ed. Philadelphia: Lippincott- Raven; 1997. p. 652–3.

    Google Scholar 

  29. Chang-Seok O. Clinical implications of topographic anatomy on ganglion impar. Anesthesiology. 2004;101:249–50.

    Article  Google Scholar 

  30. Fritz J, Chhabra A, Wang KC, et al. Magnetic resonance neurography-guided nerve blocks for the diagnosis and treatment of chronic pelvic pain syndrome. Neuroimaging Clin N Am. 2014;24:211–34.

    Article  PubMed  Google Scholar 

  31. Munir M, Zhang H, Mahmood A. A modified needle-inside-needle technique for the ganglion impar block. Can J Anesthesiol. 2004;51:915–7.

    Article  Google Scholar 

  32. Basagan Mogol E, Turker G, Kelebek Girgin N, et al. Blockade of ganglion impar through sacrococcygeal junction for cancer-related pelvic pain. Agri. 2004;16:48–53.

    PubMed  Google Scholar 

  33. Raj PP, Lou L, Erdine S, et al. Ganglion of impar block. In: Raj PP, editor. Radiographic imaging for regional anesthesia and pain management. Philadelphia: Churchill Livingstone; 2003. p. 238–41.

    Google Scholar 

  34. Waldman SD. Hypogastric plexus block and ganglion impar block. In: Waldman SD, editor. Pain Management. Philadelphia: Saunders; 2007. p. 1350–7.

    Chapter  Google Scholar 

  35. Plancarte R, Velazquez R, Patt RB. Neurolytic blocks of sympathetic axis. In: Patt R, editor. Cancer pain. Philadelphia: JB Lippincott Publishers; 1993. p. 417–20.

    Google Scholar 

  36. McAllister RK, Carpentier BW, Malkuch G. Sacral postherpetic neuralgia and successful treatment using a paramedial approach to the ganglion impar. Anesthesiology. 2004;101:1472–4.

    Article  PubMed  Google Scholar 

  37. Foye PM. New approaches to ganglion impar blocks via coccygeal joints. Reg Anesth Pain Med. 2007;32:269.

    Article  PubMed  Google Scholar 

  38. Huang JJ. Another modified approach to the ganglion of Walther block (ganglion of impar). J Clin Anesth. 2003;15:282–3.

    Article  PubMed  Google Scholar 

  39. Day M. Sympathetic blocks: the evidence. Pain Pract. 2008;8:98–109.

    Article  PubMed  Google Scholar 

  40. McAllister RK. Paramedial approach to the ganglion impar. Reg Anesth Pain Med. 2007;32:367.

    Article  PubMed  Google Scholar 

  41. Foye PM, Patel SI. Paracoccygeal corkscrew approach to ganglion impar injections for tailbone pain. Pain Pract. 2009;9:317–21.

    Article  PubMed  Google Scholar 

  42. Foye PM, Buttaci CJ, Stitik TP, et al. Successful injection for coccyx pain. Am J Phys Med Rehabil. 2006;85:783–4.

    Article  PubMed  Google Scholar 

  43. Hong J, Jang H. Block of the ganglion impar using a coccygeal joint approach. Reg Anesth Pain Med. 2006;31:583–4.

    Article  PubMed  Google Scholar 

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Acknowledgments

This book chapter is modified and updated from a previous book chapter, “Ganglion Impar Block” by Vikram Patel, MD, and Laxmaiah Manchikanti, MD, in Interventional Techniques in Chronic Non-Spinal Pain published by ASIPP Publishing. The permission has been obtained from ASIPP Publishing.

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Authors and Affiliations

  1. Department of Anesthesiology/Pain Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA

    Karina Gritsenko

  2. Department of Anesthesiology, University of California San Francisco Medical Center, San Franciso, CA, USA

    Michael Lubrano

  3. ACMI Pain Care, Algonquin, IL, USA

    Vikram B. Patel

Authors
  1. Karina Gritsenko
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  2. Michael Lubrano
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  3. Vikram B. Patel
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Corresponding author

Correspondence to Karina Gritsenko .

Editor information

Editors and Affiliations

  1. Pain Management Center of Paducah, Paducah, Kentucky

    Laxmaiah Manchikanti

  2. Department of Anesthesia, LSU Health Science Center, New Orleans, Louisiana, USA

    Alan D. Kaye

  3. Mid Atlantic Spine and Pain Physicians, Newark, Delaware

    Frank J.E. Falco

  4. Service Line Chief of Interventional Radiology, Director of Interventional Neuroradiology, Chief of NeuroInterventional Spine Service, Massachusetts General Hospital, Boston, Massachusetts, USA

    Joshua A. Hirsch

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Gritsenko, K., Lubrano, M., Patel, V.B. (2018). Ganglion Impar Blockade. In: Manchikanti, L., Kaye, A., Falco, F., Hirsch, J. (eds) Essentials of Interventional Techniques in Managing Chronic Pain. Springer, Cham. https://doi.org/10.1007/978-3-319-60361-2_37

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  • DOI: https://doi.org/10.1007/978-3-319-60361-2_37

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-60359-9

  • Online ISBN: 978-3-319-60361-2

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