Conus infarction after non-guided transcoccygeal ganglion impar block using particulate steroid for chronic coccydynia

Ganglion impar block in chronic cancer-related pain - A review of the current literature

Oncologic chronic pain is often difficult to control, especially in anatomical areas with multiple and complex innervation, such as the pelvic/perineal region. The ganglion impar block (GIB) is a procedure with growing interest and varied applicability. It has been used in several benign and malignant causes of pelvic and perineal pain refractory to pharmacological treatment. We conducted a review of all articles published in PUBMED® until the 30th of October 2022 regarding GIB in oncologic pain. 19 articles were identified with a total of 278 patients. Both chronic cancer pain and chronic postcancer treatment pain patients were included. We reviewed the various techniques, approaches, and therapeutic options that were employed. No serious adverse effects were reported. GIB appears to be an effective and safe procedure that should be considered in patients with intractable perineal cancer-related pain.

Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections - guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, the International Pain and Spine Intervention Society, and the North American Spine Society

BACKGROUND

There is potential for adverse events from corticosteroid injections, including increase in blood glucose, decrease in bone mineral density and suppression of the hypothalamic-pituitary axis. Published studies note that doses lower than those commonly injected provide similar benefit.

METHODS

Development of the practice guideline was approved by the Board of Directors of American Society of Regional Anesthesia and Pain Medicine with several other societies agreeing to participate. The scope of guidelines was agreed on to include safety of the injection technique (landmark-guided, ultrasound or radiology-aided injections); effect of the addition of the corticosteroid on the efficacy of the injectate (local anesthetic or saline); and adverse events related to the injection. Based on preliminary discussions, it was decided to structure the topics into three separate guidelines as follows: (1) sympathetic, peripheral nerve blocks and trigger point injections; (2) joints; and (3) neuraxial, facet, sacroiliac joints and related topics (vaccine and anticoagulants). Experts were assigned topics to perform a comprehensive review of the literature and to draft statements and recommendations, which were refined and voted for consensus (≥75% agreement) using a modified Delphi process. The United States Preventive Services Task Force grading of evidence and strength of recommendation was followed.

RESULTS

This guideline deals with the use and safety of corticosteroid injections for sympathetic, peripheral nerve blocks and trigger point injections for adult chronic pain conditions. All the statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Board of Directors of the participating societies also approved all the statements and recommendations. The safety of some procedures, including stellate blocks, lower extremity peripheral nerve blocks and some sites of trigger point injections, is improved by imaging guidance. The addition of non-particulate corticosteroid to the local anesthetic is beneficial in cluster headaches but not in other types of headaches. Corticosteroid may provide additional benefit in transverse abdominal plane blocks and ilioinguinal/iliohypogastric nerve blocks in postherniorrhaphy pain but there is no evidence for pudendal nerve blocks. There is minimal benefit for the use of corticosteroids in trigger point injections.

CONCLUSIONS

In this practice guideline, we provided recommendations on the use of corticosteroids in sympathetic blocks, peripheral nerve blocks, and trigger point injections to assist clinicians in making informed decisions.

Imaging findings and treatment in coccydynia - update of the recent study findings

BACKGROUND

Coccydynia is one of the most overlooked symptoms in clinical practice. The diagnosis and radiologic findings of traumatic coccyx can be more easily detected unless it is delayed and postponed. For idiopathic coccydynia, which accounts for one third of cases, patients present with long-standing pain and multiple physician visits.

METHOD

The keywords coccyx, coccydynia, coccygodynia were searched in PubMed, Embase, Scopus databases in the last 5 years. Research articles, reviews and case reports were analyzed. The studies conducted in the last 5 years were presented under the headings of etiology, radiologic assessment, interventional and surgical treatments.

RESULTS AND CONCLUSION

The first step is dynamic X-ray of the coccyx in standing and sitting position. In this way, morphologic parameters and hypermobility causing idiopathic coccydynia can be evaluated. Morphologic and morphometric features of the coccyx described in previous CT and MR studies have explained the relationship with coccydynia. The key features are as follows: Type II coccyx morphology, subluxation of the intercoccygeal joint, presence of bony spicules. Knowledge of these definitions as well as the differential diagnosis in this anatomical region will help in reaching the correct diagnosis. The treatment of coccydynia is stepwise like the diagnosis. Conservative treatments are initiated first. Manipulations, ganglion impar block, injections, radiofrequency and shock treatments and finally coccygectomy are treatment methods reported. Radiologists should not overlook this region and should be familiar with the coccyx's morphologic appearance and the sacrococcygeal region's differential diagnosis.

KEY POINTS

· The etiology of coccydynia usually includes trauma, obesity and female sex, special coccyx morphology, and coccygeal hypermobility.. · Coccyx fractures are defined into three groups as flexion type 1, compression type 2, and extension type 3.. · When evaluating coccydynia, the first step is a dynamic X-ray examination of the coccyx in standing and sitting position.. · Hypermobility is defined as more than 25 % posterior subluxation while sitting or more than 25° flexion while sitting.. · More than 35° posterior subluxation is considered significant hypermobility..

CITATION FORMAT

· Sukun A, Cankurtaran T, Agildere M et al. Imaging findings and treatment in coccydynia - update of the recent study findings. Fortschr Röntgenstr 2024; 196: 560 - 572.

Coccydynia: A Review of Anatomy, Causes, Diagnosis, and Treatment

» Coccydynia is a painful condition affecting many patients at the terminal caudal end of the spine.» An understanding of coccyx anatomy and variations of morphology is necessary for proper diagnosis. A multifactorial etiology for pain may be responsible for this clinical entity.» Several treatment options exist. Successful outcomes for patients depend on individual patient characteristics and the etiology of pain.

Encephalopathy after unintentional intrathecal gadolinium: A letter to the editor

Objective

Raise awareness of gadolinium encephalopathy, a rare cause of neurological symptoms.

Setting

An L5-S1 interlaminar epidural steroid injection (IL-ESI) was performed with a gadolinium-based contrast agent (GBCA) due to the patient's history of allergic reaction to iodine-based contrast agents.

Discussion

Several hours after administration of GBCA, the patient had nausea and vomiting with altered mental status. Patient was treated with dexamethasone IV, and was discharged on day 2. Patient had no residual deficits at follow-up two weeks later. Current literature shows that caution should be used to prevent inadvertent intrathecal GBCA, and doses >2.0 mmols are associated with serious adverse effects, including death.

Conclusions

Intrathecal administration of GBCAs should be limited to less than 0.5 mmol. If adverse effects are experienced, IV steroids should be administered as soon as possible, and a CSF drain should be considered.

Fibrocartilaginous embolism of the posterior spinal artery: A case report regarding the responsible intervertebral disc on magnetic resonance imaging

INTRODUCTION

Fibrocartilaginous embolism (FCE) of the spinal cord is an ischemic myelopathy caused by rupture of the intervertebral disc and subsequent entrance of the nucleus polposus material into the nearby vasculature. However, responsible disc lesions frequently cannot be determined, which may cause diagnostic difficulty.

CASE PRESENTATION

A 63-year-old man suddenly felt a strange sensation in the lower limbs and noticed that he could not walk. The patient was brought to our hospital, where he was hospitalized. On neurological examination, his proprioception and vibratory sense were disturbed in the lower limbs. Spine magnetic resonance imaging (MRI) revealed a hyperintense cord lesion located at the C4-5 vertebral level of the posterior spinal artery region on diffusion-weighted sequence. He was diagnosed as having spinal cord infarction and treated with antiplatelet medication. Follow-up MRI was performed 5 days later, which displayed a collapsed C3/4 disc and a defected C4 vertebral body that were not evident on earlier MRI. These findings suggested the disc lesion was active and responsible for the infarction, leading to the diagnosis of FCE. The patient gradually improved and had no gait difficulty at the time of discharge.

DISCUSSION

In the presented case, MRI did not reveal the responsible disc lesion when the diagnosis of spinal cord infarction was made; however, it became evident 5 days later. Although such a disc signal change within several days has not been described as a clue suggesting FCE, follow-up MRI with a relatively short interval may elucidate the responsible lesion and correct diagnosis.

Low incidence of vascular uptake during ganglion impar sympathetic nerve blocks for coccydynia

Context:

Focal sympathetic nerve blocks of the ganglion impar are often effective treatments for coccydynia (coccyx pain) and other pelvic pain syndromes. These injections are generally performed under contrast-enhanced fluoroscopic guidance. Vascular uptake may potentially occur during the injection and vascular uptake rates have been reported for other spinal injections, but never for ganglion impar blocks.

Aims:

The purpose of the study was to determine vascular uptake rates during fluoroscopy-guided ganglion impar blocks.

Settings and Design:

An academic/University-based Coccyx Pain Center.

Methods and Materials:

A total of 78 consecutive trans-coccygeal ganglion impar blocks were analyzed for vascular uptake of contrast as determined by intermittent fluoroscopy.

Statistical Analysis Used:

Direct calculation of incidence.

Results:

Only one patient (1.3%) demonstrated a vascular uptake pattern, which was readily recognized and corrected by slightly adjusting the position of the needle tip and thereby subsequently obtaining the desired contrast pattern at the ganglion impar.

Conclusions:

Vascular uptake incidence is low during ganglion impar blocks. This information can be one of the multiple factors considered when a physician is deciding whether or not to use contrast in an individual patient.