Ganglion impar block in patients with chronic coccydynia

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Abstract

Introduction:

Coccydynia refers to pain in the terminal segment of the spinecaused by abnormal sitting and standing posture. Coccydynia is usually managed conservatively, however in nonresponsive patients, ganglion impar block is used as a good alternate modality for pain relief. This article studies the effect of ganglion impar block in coccydynia patients who were not relieved by conservative management.

Materials and Methods:

The study was carried out at the pain clinic in the departments of Physical Medicine and Rehabilitation and Radiology in a tertiary centre in India. It was a prospective hospital-based study, in which 35 patients with coccydynia were considered for fluoroscopy-guided trans-sacro-coccygeal ganglion impar block. The outcome assessment was done using Numerical Rating Scale (NRS) and Oswestry Disability Index (ODI) scores for a follow-up period of 6 months. Of the 35 patients, 4 were lost to follow-up. Analysis was done usingthe data from the remaining 31 patients.

Results:

The mean age of the patients suffering from chronic coccydynia was 42.9 ± 8.39 years, and patients' age range was 28–57 years. The mean score of NRS and ODI before the procedure was 7.90 ± 0.16 and 48.97 ± 1.05, respectively. The interquartile range (IQR) of NRS score remained almost unchanged during pre and postprocedure, however, IQR of ODI varied during the pre and post procedural events. The NRS and ODI scores immediately after the procedure decreased drastically showing significant pain relief in patients, and the difference of scores till the end of study was statistically significant.

Conclusion:

This study recommends the trans-sacro-coccygeal “needle inside needle” technique for local anesthetic block of the ganglion impar for pain relief in patients with coccydynia. This should be integrated with rehabilitative measures including ergonomical modification for prolonging pain free period.

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Most cited references 13

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Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain.

Lesley Smallwood Lirette, Gassan Chaiban, Reda Tolba … (2014)

Despite its small size, the coccyx has several important functions. Along with being the insertion site for multiple muscles, ligaments, and tendons, it also serves as one leg of the tripod-along with the ischial tuberosities-that provides weight-bearing support to a person in the seated position. The incidence of coccydynia (pain in the region of the coccyx) has not been reported, but factors associated with increased risk of developing coccydynia include obesity and female gender.

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Causes and mechanisms of common coccydynia: role of body mass index and coccygeal trauma.

J Maigne, L Doursounian, G Chatellier (2000)

A total of 208 consecutive coccydynia patients were examined with the same clinical and radiologic protocol. To study radiographic coccygeal lesions in the sitting position, to elucidate the influence of body mass index on the different lesions, and to establish the effect of coccygeal trauma. A protocol comparing standing radiographs and radiographs subsequently taken in the painful sitting position in coccydynia patients and in controls has shown two culprit lesions: posterior luxation and hypermobility. Obesity and a history of trauma have been identified as risk factors for luxation. Dynamic radiographs were obtained. The body mass index was compared with the coccygeal angle of incidence, sagittal rotation of the pelvis when sitting down, and the presence and time of previous trauma. The patients with the newly described lesions were examined after an anesthetic block under fluoroscopic guidance. Two new coccygeal lesions are described (anterior luxation and spicules). Obesity was found to be a risk factor. The body mass index determines the way a subject sits down, and lesion patterns were different in obese, normal-weight, and thin patients (posterior luxation: 51%, 15.2%, 3.7%; hypermobility: 26.5%, 30.3%, 14.8%; spicules: 2%, 15.9%, 29.6%; normal: 16.3%, 32.6%, 48.1%, respectively; P < 0.0001). Trauma affected the type of lesion only if it was recent (<1 month before the onset of coccydynia), in which case the instability rate increased from 55.6% to 77.1%. Backward-moving coccyges were at greatest risk of trauma. This protocol allows identification of the culprit lesion in 69.2% of cases. The body mass index determines the causative lesion, as does trauma sustained within the month preceding the onset of the pain.

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Transsacrococcygeal approach to ganglion impar block for management of chronic perineal pain: a prospective observational study.

R Toshniwal, N. S. Prashanth, G Dureja (2007)

The ganglion impar or ganglion of Walther is a solitary retroperitoneal structure at the level of sacrococcygeal junction. It provides the nociceptive and sympathetic supply to the perineal structures. Chronic Perineal Pain (CPP) has been effectively managed by ganglion impar block. In this study we analyze the feasibility, safety, and efficacy of ganglion impar block by transsacrococcygeal approach. An observational report. In this prospective study, 16 consecutive patients who required ganglion impar block for CPP were followed for two months. After informed and written consent, the ganglion impar was blocked under aseptic precautions, using a transsacrococcygeal approach. The Visual Analogue Scale for pain (VAS) at presentation time required for the pain to reduce by 50% to be considered effective and VAS was recorded at different time points during 2-month follow-up, and time required to perform the procedure, number of attempts, and any complications were also noted. All the blocks were effective with a mean duration of 12+/-3 minutes for 50% reduction in VAS. The mean duration required to perform the procedure in neurolytic block patients was 7.8+/-2 minutes and 5.7+/-1 minutes in therapeutic block patients. There were no adverse events. All the patients had significant pain relief during 2 month follow-up (p <0.05 compared to baseline). The mean VAS at 2 months was about 2. Statistical analysis was done by using paired "t"/Wilcoxon signed rank test. A transsacrococcygeal approach for a ganglion impar block is a technically feasible and safe technique. We recommend this technique for neurolysis or radiofrequency ablation of the ganglion impar and for diagnostic blocks, especially when the diagnosis and further plan of management is dependent on the response of the diagnostic block.

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Author and article information

Journal

Journal ID (nlm-ta): Indian J Radiol Imaging

Journal ID (iso-abbrev): Indian J Radiol Imaging

Journal ID (publisher-id): IJRI

Title: The Indian Journal of Radiology & Imaging

Publisher: Medknow Publications & Media Pvt Ltd (India )

ISSN (Print): 0971-3026

ISSN (Electronic): 1998-3808

Publication date (Print): Jul-Sep 2017

Volume: 27

Issue: 3

Pages: 324-328

Affiliations

[1]Department of Physical Medicine and Rehabilitation, AIIMS, Jodhpur, Rajasthan, India

[1 ]Department of Diagnostic and Interventional Radiology, AIIMS, Jodhpur, Rajasthan, India

[2 ]Department of Community and Family Medicine, AIIMS, Jodhpur, Rajasthan, India

[3 ]Department of Pharmacology, AIIMS, Jodhpur, Rajasthan, India

Author notes

Correspondence: Dr. Nitesh Gonnade, Department of Physical Medicine and Rehabilitation, AIIMS, Jodhpur, Rajasthan, India. E-mail: drniteshgonnade9@ 123456gmail.com

Article

Publisher ID: IJRI-27-324

DOI: 10.4103/ijri.IJRI_294_16

PMC ID: 5644328

PubMed ID: 29089683

SO-VID: 252af9e1-effc-4fea-82ae-43657e367c9f

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Ganglion impar block in patients with chronic coccydynia

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Abstract

Introduction:

Materials and Methods:

Results:

Conclusion:

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Most cited references 13

Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain.

Causes and mechanisms of common coccydynia: role of body mass index and coccygeal trauma.

Transsacrococcygeal approach to ganglion impar block for management of chronic perineal pain: a prospective observational study.

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