Blockade of the ganglion impar (walther), using ultrasound and a loss of resistance technique

Clinical efficacy of ultrasound-guided pulsed radiofrequency combined with ganglion impar block for treatment of perineal pain

BACKGROUND

Ganglion impar block alone or pulsed radiofrequency alone are effective options for treating perineal pain. However, ganglion impar block combined with pulsed radiofrequency (GIB-PRF) for treating perineal pain is rare and the puncture is usually performed with X-ray or computed tomography guidance.

AIM

To evaluate the safety and clinical efficacy of real-time ultrasound-guided GIB-PRF in treating perineal pain.

METHODS

Thirty patients with perineal pain were included and were treated by GIB-PRF guided by real-time ultrasound imaging between January 2015 and December 2016. Complications were recorded to observe the safety of the ultrasound-guided GIB-PRF procedure, and visual analogue scale (VAS) scores at 24 h before and after treatment and 1, 3, and 6 mo later were analyzed to evaluate clinical efficacy.

RESULTS

Ultrasound-guided GIB-PRF was performed successfully in all patients, and no complications occurred. Compared with pretreatment scores, the VAS scores were significantly lower (P < 0.05) at the four time points after treatment. The VAS scores at 1 and 3 mo were slightly lower than those at 24 h (P > 0.05) and were significantly lower at 6 mo after treatment (P < 0.05). There was a tendency toward lower VAS scores at 6 mo after treatment compared with those at 1 and 3 mo (P > 0.05).

CONCLUSION

Ultrasound-guided GIB-PRF was a safe and effective way to treat perineal pain. The 6-mo short-term clinical efficacy was favorable, but the long-term outcomes need future study.

Comparative evaluation of transsacrococcygeal and transcoccygeal approach of ganglion impar block for management of coccygodynia

BACKGROUND AND AIMS

Coccygodynia or Coccydynia is pain in the area of coccyx and ganglion impar block is commonly used technique for treatment of coccygodynia.

MATERIAL AND METHODS

Forty patients of either sex in the age group of 20-70 years suffering from coccygodynia, who failed to respond to six weeks of conservative treatment were enrolled in the study. All patients were subjected to detailed clinical history, examination in the Pain Management Centre (Pain Clinic) of our Institute and imaging studies were reviewed. The patients were randomly divided into two groups of 20 each by a computer generated randomization number table: Group-TS (n = 20): Patients were administered ganglion Impar block by trans-sacrococcygeal approach Group-TC (n = 20): Patients were administered ganglion Impar block by trans-coccygeal approach with 8 ml of 0.5% bupivacaine plus 2 ml of 40mg/ml methylprednisolone acetate under fluoroscopic guidance.

RESULTS

Both the techniques of ganglion Impar block were effective and provided good pain relief to the patients with coccygodynia. There was a statistically and clinically significant improvement in pain score after ganglion Impar block in both the groups at all time intervals during the study period. (p < 0.05). The mean pain score after ganglion Impar block was <2 at all time intervals throughout the three month study period in all patients in the two groups. All patients in both the groups had excellent satisfaction immediately after ganglion Impar block. Five patients each in both groups required second ganglion Impar block during the three months study period.

CONCLUSION

Both trans-sacrococcygeal and trans-coccygeal approaches of ganglion Impar block with a combination of local anaesthetic and steroid are safe and effective for management of coccygodynia. Trans-coccygeal ganglion Impar block through the first intra-coccygeal joint is better in terms of improvement in pain score, functional disability, patient satisfaction and ease of administration.

MR-guided perineural injection of the ganglion impar: technical considerations and feasibility

OBJECTIVE

Perineural ganglion impar injections are used in the management of pelvic pain syndromes; however, there is no consensus regarding the optimal image guidance. Magnetic resonance imaging (MRI) provides high soft tissue contrast and the potential to directly visualize and target the ganglion. The purpose of this study was to assess the feasibility of MR-guided percutaneous perineural ganglion impar injections.

MATERIALS AND METHODS

Six MR-guided ganglion impar injections were performed in six human cadavers. Procedures were performed with a clinical 1.5-Tesla MRI system through a far lateral transgluteus approach. Ganglion impar visibility, distance from the sacrococcygeal joint, number of intermittent MRI control steps required to place the needle, target error between the intended and final needle tip location, inadvertent punctures of non-targeted vulnerable structures, injectant distribution, and procedure time were determined.

RESULTS

The ganglion impar was seen on MRI in 4/6 (66 %) of cases and located 0.8 mm cephalad to 16.3 mm caudad (average 1.2 mm caudad) to the midpoint of the sacrococcygeal joint. Needle placement required an average of three MRI control steps (range, 2-6). The average target error was 2.2 ± 2.1 mm. In 6/6 cases (100 %), there was appropriate periganglionic distribution and filling of the presacrococcygeal space. No punctures of non-targeted structures occurred. The median procedure time was 20 min (range, 12-29 min).

CONCLUSION

Interventional MRI can visualize and directly target the ganglion impar for accurate needle placement and successful periganglionic injection with the additional benefit of no ionizing radiation exposure to patient and staff. Our results support clinical evaluation.

Evidence-based Clinical Practice Guidelines for Interventional Pain Management in Cancer Pain

Intractable cancer pain not amenable to standard oral or parenteral analgesics is a horrifying truth in 10-15% of patients. Interventional pain management techniques are an indispensable arsenal in pain physician's armamentarium for severe, intractable pain and can be broadly classified into neuroablative and neuromodulation techniques. An array of neurolytic techniques (chemical, thermal, or surgical) can be employed for ablation of individual nerve fibers, plexuses, or intrathecalneurolysis in patients with resistant pain and short life-expectancy. Neuraxial administration of drugs and spinal cord stimulation to modulate or alter the pain perception constitutes the most frequently employed neuromodulation techniques. Lately, there is a rising call for early introduction of interventional techniques in carefully selected patients simultaneously or even before starting strong opioids. After decades of empirical use, it is the need of the hour to head towards professionalism and standardization in order to secure credibility of specialization and those practicing it. Even though the interventional management has found a definite place in cancer pain, there is a dearth of evidence-based practice guidelines for interventional therapies in cancer pain. This may be because of paucity of good quality randomized controlled trials (RCTs) evaluating their safety and efficacy in cancer pain. Laying standardized guidelines based on existing and emerging evidence will act as a foundation step towards strengthening, credentialing, and dissemination of the specialty of interventional cancer pain management. This will also ensure an improved decision-making and quality of life (QoL) of the suffering patients.