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Daily D, Bridges J, Mo WB, Mo AZ, Massey PA, Zhang AS. Coccydynia: A Review of Anatomy, Causes, Diagnosis, and Treatment. JBJS Rev 2024; 12:01874474-202405000-00004. [PMID: 38709859 DOI: 10.2106/jbjs.rvw.24.00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
» 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.
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Affiliation(s)
- Drayton Daily
- Department of Orthopaedic Surgery, Louisiana State University-Shreveport, Shreveport, Louisiana
| | - James Bridges
- School of Medicine, Louisiana State University-Shreveport, Shreveport, Louisiana
| | - William B Mo
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Andrew Z Mo
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Patrick Allan Massey
- Department of Orthopaedic Surgery, Louisiana State University-Shreveport, Shreveport, Louisiana
| | - Andrew S Zhang
- Department of Orthopaedic Surgery, Louisiana State University-Shreveport, Shreveport, Louisiana
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Oliveira J, Bem G, Agrelo A. Ganglion impar block in chronic cancer-related pain - A review of the current literature. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024:S2341-1929(24)00081-7. [PMID: 38670492 DOI: 10.1016/j.redare.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/16/2023] [Accepted: 01/26/2024] [Indexed: 04/28/2024]
Abstract
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.
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Affiliation(s)
- J Oliveira
- Anesthesiology and Critical Care Department, Instituto Português de Oncologia do Porto Francisco Gentil, Porto, Portugal.
| | - G Bem
- Anesthesiology and Critical Care Department, Instituto Português de Oncologia do Porto Francisco Gentil, Porto, Portugal
| | - A Agrelo
- Anesthesiology and Critical Care Department, Instituto Português de Oncologia do Porto Francisco Gentil, Porto, Portugal; Pain Unit, Anesthesiology and Critical Care Department, Instituto Português de Oncologia do Porto Francisco Gentil, Porto, Portugal
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3
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Vogel JJ. Pain specialist management of sexual pain: III-neuromodulation. Sex Med Rev 2023; 11:89-97. [PMID: 36763955 DOI: 10.1093/sxmrev/qeac006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/29/2022] [Accepted: 10/31/2022] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Some women with sexual pain do not respond to conservative multi-modal care modalities. Neuromodulation is a group of methods which alter nerve activity by delivering electrical energy or pharmaceutical agents directly to target neural structures. Multiple forms of neuromodulation may provide durable treatment options to fill the unmet therapeutic need of a certain population of women with chronic sexual pain. OBJECTIVES To provide a current review of neuromodulation treatments used for female sexual pain and introduce neuromodulation techniques which may be applied in novel ways to specific sexual pain phenotypes. METHODS Internet, PubMed and Cochrane Library were searched for relevant articles on female sexual pain within the clinical purview and scope of practice of pain management. RESULTS A thorough review of the literature was conducted to include basic science studies, clinical trials, systematic reviews, consensus statements, and case-reports. A sampling of information on real-world patient outcomes was included. The amount and quality of evidence for neuromodulation to treat female sexual pain is low-moderate. Descriptions of neuromodulation procedures for sexual pain were made and clinical studies reviewed. The effects of autonomic nervous system (ANS) dysregulation on the experience of pain were discussed with consideration of interventional procedures to facilitate restoration of ANS equilibrium. CONCLUSION Treating female sexual pain is complex. There are considerable numbers of women who have unsatisfactory sexual pain relief despite evidence-based interdisciplinary care. These women may benefit from referral to consider neuromodulation treatment options. Neuromodulation is a relatively new capability in the arsenal of pain management and other specialists that can be considered for women with treatment refractory sexual pain.
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Affiliation(s)
- John J Vogel
- Innovative Pain Care, Marietta, Georgia 30062, United States
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Wu R, Majdalany BS, Lilly M, Prologo JD, Kokabi N. Agents Used for Nerve Blocks and Neurolysis. Semin Intervent Radiol 2022; 39:387-393. [PMID: 36406019 PMCID: PMC9671686 DOI: 10.1055/s-0042-1757315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The recognition of pain and the treatments used for it are vital for all practitioners. Many types of pain can be treated in a locoregional fashion, which has significant implications not just for any individual patient but for society as a whole. These treatments are most effective when performed in a minimally invasive, image-guided fashion. Interventional radiologists should play a central role in providing these lifestyle-limiting treatments. This article describes the medications most typically used for spinal and extra-axial treatments in the management of patients in pain.
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Affiliation(s)
- Richard Wu
- Emory University School of Medicine, Atlanta, Georgia
| | - Bill S. Majdalany
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Meghan Lilly
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - J. David Prologo
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Nima Kokabi
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
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Choudhary R, Kunal K, Kumar D, Nagaraju V, Verma S. Improvement in Pain Following Ganglion Impar Blocks and Radiofrequency Ablation in Coccygodynia Patients: A Systematic Review. Rev Bras Ortop 2021; 56:558-566. [PMID: 34733426 PMCID: PMC8558944 DOI: 10.1055/s-0041-1735829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 04/07/2021] [Indexed: 10/26/2022] Open
Abstract
Nearly 90% of cases of coccydynia can be managed with conservative medical treatment; the remaining 10% need other invasive modalities for pain relief, such as ganglion impar block (GIB) or radiofrequency ablation (RFA) of the ganglion impar. A systematic research was conducted of PubMed, MEDLINE, and Google Scholar to identify studies reporting pain relief in terms of visual analogue scale (VAS), or its counterparts, following GIB or RFA in coccydynia patients with the purpose to determine the efficacy of GIB and RFA of the ganglion impar in controlling pain in coccydynia patients. Seven studies were delineated, with a total of 189 patients (104 in GIB group and 85 in RFA group). In the GIB group, the mean VAS improved from 7.83 at baseline to 3.11 in the short-term follow-up, 3.55 in the intermediate-term follow-up, and 4.71 in the long-term follow-up. In the RFA group, the mean VAS improved from 6.92 at baseline to 4.25 in the short-term follow-up, and 4.04 in the long-term follow-up. In the GIB group, a 13.92% failure rate (11/79) and a 2.88% complication rate (3/104) were reported, while in the RFA group, a 14.08% failure rate (10/71) and no complications (0%) were reported. Total success rate was > 85% with either modality. Ganglion impar block and RFA of the ganglion impar are reliable and probably excellent methods of pain control in coccydynia patients not responding to conservative medical treatment. However, a demarcation between responders, non-responders, and late non-responders should be considered, and larger studies with a longer follow-up (> 1 year) are needed.
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Affiliation(s)
- Ranjeet Choudhary
- Department of Orthopaedics, Instituto de Ciências Médicas da Índia (AIIMS), Raipur, Chhattisgarh, Índia
| | - Kishor Kunal
- Department of Orthopaedics, Instituto de Ciências Médicas da Índia (AIIMS), Jodhpur, Rajasthan, Índia
| | - Dhirendra Kumar
- Department of Orthopaedics, Instituto de Ciências Médicas da Índia (AIIMS), Jodhpur, Rajasthan, Índia
| | - Venishetty Nagaraju
- Department of Orthopaedics, Instituto de Ciências Médicas da Índia (AIIMS), Raipur, Chhattisgarh, Índia
| | - Shilp Verma
- Department of Orthopaedics, Instituto de Ciências Médicas da Índia (AIIMS), Raipur, Chhattisgarh, Índia
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Kim JY, Sim SE, Yoo S, Joo M, Park HJ. A new technique of ganglion impar pulsed radiofrequency ablation. Chin Med J (Engl) 2021; 134:1221-1223. [PMID: 33840742 PMCID: PMC8143771 DOI: 10.1097/cm9.0000000000001423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Indexed: 11/19/2022] Open
Affiliation(s)
- Ji Yeong Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
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Park JH, Kim R, Na SH, Kwon SY. Effect of botulinum toxin in stellate ganglion for craniofacial hyperhidrosis: a case report. J Int Med Res 2021; 49:3000605211004213. [PMID: 33788638 PMCID: PMC8020114 DOI: 10.1177/03000605211004213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 11/17/2022] Open
Abstract
Craniofacial hyperhidrosis causes sweating of the face and scalp due to excessive action of the sweat glands and manifests when patients become tense/nervous or develop an elevated body temperature. If noninvasive treatments are ineffective, invasive treatments such as a sympathetic block and resection are considered. A 32-year-old woman with no specific medical history was referred for uncontrolled craniofacial hyperhidrosis that included excessive sweating and hot flushing. Physical examination showed profuse sweating, and infrared thermography showed higher temperature in the neck and face than in the trunk. The patient underwent several stellate ganglion blocks, and her symptoms improved; however, the treatment effect was temporary. Botulinum toxin was then injected into the stellate ganglion. At the time of this writing, her sweating had been reduced for about 6 months and she was continuing to undergo follow-up. Craniofacial hyperhidrosis is a clinical condition in which patients experience excessive sweating of their faces and heads. It is less common than palmar and plantar hyperhidrosis. Botulinum toxin injection into the stellate ganglion is simple and safe and produces longer-lasting effects than other treatments, such as endoscopic sympathectomy and a single nerve block.
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Affiliation(s)
- Jung Hyun Park
- Department of Anesthesiology and Pain Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
| | - Rip Kim
- Department of Anesthesiology and Pain Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
| | - Sang Hoon Na
- Department of Anesthesiology and Pain Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
| | - So Young Kwon
- Department of Anesthesiology and Pain Medicine, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
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Kim CS, Jang K, Leem JG, Shin JW, Kim DH, Choi SS. Factors associated with Successful Responses to Ganglion Impar Block: A Retrospective Study. Int J Med Sci 2021; 18:2957-2963. [PMID: 34220323 PMCID: PMC8241784 DOI: 10.7150/ijms.60962] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 05/24/2021] [Indexed: 11/05/2022] Open
Abstract
Background: The ganglion impar (ganglion of Walther) block has been used to manage coccygeal and perineal (perianal and genital) pain due to both benign and malignant causes. However, the factors associated with successful responses to ganglion impar block are unknown. Therefore, in the present study, we aimed to identify the independent factors associated with successful responses to ganglion impar block in patients with chronic pain in coccygeal and perineal regions. Methods: From January 2008 to December 2017, we performed a retrospective review of 106 patients who underwent ganglion impar block. Patients were considered successful responders if they reported a decrease of more than 50% or 4 points on the 11-point (0 = no pain and 10 = worst possible pain) numerical rating scale 1 month after the procedure, while others were considered non-responders. Logistic regression analysis was performed to identify factors independently associated with successful responses at 1 month after the procedure. Results: Multivariable logistic regression analysis showed that cancer-related causes were significantly associated with successful responses at 1 month after ganglion impar block (odds ratio = 2.60, 95% confidence interval = 1.05 to 6.43, P = 0.038). Conclusion: Ganglion impar block may be more effective in cancer-related pain than pain due to benign causes.
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Affiliation(s)
- Chan-Sik Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyounghwan Jang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Gil Leem
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin-Woo Shin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Vijayakumar V, Agarwal A, Shamshery C, Gautam S. Intractable anal pain in B-cell acute lymphocytic leukemia patients: treatment options. Korean J Pain 2019; 32:55-56. [PMID: 30671206 PMCID: PMC6333574 DOI: 10.3344/kjp.2019.32.1.55] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 07/10/2018] [Accepted: 07/12/2018] [Indexed: 01/01/2023] Open
Affiliation(s)
| | - Anil Agarwal
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Chetna Shamshery
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Sujeet Gautam
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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10
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Turchan A, Fahmi A, Subianto H. Impar Ganglion Block with Combination of Neurolysis Drugs and Radiofrequency Thermocoagulation for Perineal Pain. Asian J Neurosurg 2018; 13:838-841. [PMID: 30283560 PMCID: PMC6159014 DOI: 10.4103/ajns.ajns_306_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Since it was first introduced, a variety of modification techniques to block the impar ganglion appear such as transsacrococcygeal ligament technique, sacrococcygeal transdiscal approach, paramedian approach, and a two-needle technique using fluoroscopy or computed tomography scan. For therapeutic purposes, a combination of steroid and local anesthetic, neurolysis agents such as alcohol, phenol, cryolesioning, and heat lesioning using radiofrequency thermocoagulation could be used. Here, we reported a successful outcome in treating chronic perineal pain in a 65-year-old patient using combination of neurolysis agent which was alcohol 96% and radiofrequency thermocoagulation.
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Affiliation(s)
- Agus Turchan
- Department of Neurosurgery, Division of Stereotactic and Functional Neurosurgery, Faculty of Medicine, Airlangga University/Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Achmad Fahmi
- Department of Neurosurgery, Division of Stereotactic and Functional Neurosurgery, Faculty of Medicine, Airlangga University/Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Heri Subianto
- Department of Neurosurgery, Division of Stereotactic and Functional Neurosurgery, Faculty of Medicine, Airlangga University/Dr. Soetomo General Hospital, Surabaya, Indonesia
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11
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Lee Y, Lee CJ, Choi E, Lee PB, Lee HJ, Nahm FS. Lumbar Sympathetic Block with Botulinum Toxin Type A and Type B for the Complex Regional Pain Syndrome. Toxins (Basel) 2018; 10:toxins10040164. [PMID: 29671801 PMCID: PMC5923330 DOI: 10.3390/toxins10040164] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/09/2018] [Accepted: 04/16/2018] [Indexed: 11/23/2022] Open
Abstract
A lumbar sympathetic ganglion block (LSB) is a therapeutic method for complex regional pain syndrome (CRPS) affecting the lower limbs. Recently, LSB with botulinum toxin type A and B was introduced as a novel method to achieve longer duration of analgesia. In this study, we compared the botulinum toxin type A (BTA) with botulinum toxin type B (BTB) in performing LSB on patients with CRPS. LSB was performed with either BTA or BTB on patients with CRPS in their lower extremities. The length of time taken for patients to return to the pre-LSB pain score and the adverse effect of LSB with BTA/BTB were investigated. The median length of time taken for the patients to return to the pre-LSB pain score was 15 days for the BTA group and 69 days for the BTB group (P = 0.002). Scores on a visual analogue scale decreased in the patients of both groups, and no significant adverse effects were experienced. In conclusion, the administration of either BTA or BTB for LSB is a safe method to prolong the sympathetic blocking effect in patients with CRPS. BTB is more effective than BTA to prolong the sympathetic blocking effect in CRPS patients.
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Affiliation(s)
- Yongki Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea.
| | | | - Eunjoo Choi
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea.
| | - Pyung Bok Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea.
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea.
| | - Francis Sahngun Nahm
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea.
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12
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Usmani H, Dureja GP, Andleeb R, Tauheed N, Asif N. Conventional Radiofrequency Thermocoagulation vs Pulsed Radiofrequency Neuromodulation of Ganglion Impar in Chronic Perineal Pain of Nononcological Origin. PAIN MEDICINE 2018; 19:2348-2356. [DOI: 10.1093/pm/pnx244] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Hammad Usmani
- Department of Anaesthesiology, Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh, India
| | - G P Dureja
- Department of Pain Medicine, Indian Spinal Injuries Centre, New Delhi, India
| | - Roshan Andleeb
- Department of Anaesthesiology, Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh, India
| | - Nazia Tauheed
- Department of Anaesthesiology, Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh, India
| | - Naiyer Asif
- Department of Orthopaedic Surgery, Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh, India
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Intérêt de l’infiltration du ganglion Impar dans les vulvodynies rebelles : à propos d’une série de 8 cas. Prog Urol 2016; 26:1213-1221. [DOI: 10.1016/j.purol.2016.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 08/07/2016] [Accepted: 08/09/2016] [Indexed: 11/19/2022]
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Marker DR, U-Thainual P, Ungi T, Flammang AJ, Fichtinger G, Iordachita II, Carrino JA, Fritz J. MR-guided perineural injection of the ganglion impar: technical considerations and feasibility. Skeletal Radiol 2016; 45:591-7. [PMID: 26791162 DOI: 10.1007/s00256-016-2333-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 01/03/2016] [Accepted: 01/07/2016] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- David R Marker
- Russell H. Morgan Department of Radiology and Radiological Science, Musculoskeletal Radiology, Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 3140A, Baltimore, MD, 21287, USA
| | - Paweena U-Thainual
- Department of Mechanical and Materials Engineering, Queen's University, 99 University Avenue, Kingston, ON, Canada
| | - Tamas Ungi
- School of Computing, Queen's University, 557 Goodwin Hall, Queen's University, Kingston, ON, Canada
| | - Aaron J Flammang
- Siemens Corporate Research, Center for Applied Medical Imaging, Baltimore, MD, USA
| | - Gabor Fichtinger
- School of Computing, Queen's University, 557 Goodwin Hall, Queen's University, Kingston, ON, Canada
| | - Iulian I Iordachita
- Department of Mechanical Engineering and Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N. Charles St., Hackerman 112, Baltimore, MD, 21218, USA
| | - John A Carrino
- Russell H. Morgan Department of Radiology and Radiological Science, Musculoskeletal Radiology, Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 3140A, Baltimore, MD, 21287, USA
| | - Jan Fritz
- Russell H. Morgan Department of Radiology and Radiological Science, Musculoskeletal Radiology, Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 3140A, Baltimore, MD, 21287, USA.
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15
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Lee SH, Lim DH, Lee JH, Chang K, Koo JM, Park HJ. Long-Term Blood Pressure Control Effect of Celiac Plexus Block with Botulinum Toxin. Toxins (Basel) 2016; 8:51. [PMID: 26907344 PMCID: PMC4773804 DOI: 10.3390/toxins8020051] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 01/31/2016] [Accepted: 02/14/2016] [Indexed: 12/27/2022] Open
Abstract
Celiac plexus block (CPB) is one of the main treatment options for patients resistant to conventional antihypertensive drugs. We present a case of resistant hypertension (RHTN) that was treated with CPB using botulinum toxin. An 18-year-old male patient with RHTN, who suffered from persistent hypertension even after combination therapy and a renal denervation procedure, was referred to our pain center for CPB. CPB using botulinum toxin following the use of only local anesthetics resulted in control of systolic blood pressure (BP) at ~150 mmHg for at least three months.
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Affiliation(s)
- Sung Hyun Lee
- Department of Anaesthesiology & Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
| | - Dae Hwan Lim
- Department of Anaesthesiology & Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
| | - Ju Ho Lee
- Department of Anaesthesiology & Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
| | - Jung Min Koo
- Department of Anaesthesiology & Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
| | - Hue Jung Park
- Department of Anaesthesiology & Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
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Moon YE, Choi JH, Park HJ, Park JH, Kim JH. Ultrasound-Guided Nerve Block with Botulinum Toxin Type A for Intractable Neuropathic Pain. Toxins (Basel) 2016; 8:toxins8010018. [PMID: 26761032 PMCID: PMC4728540 DOI: 10.3390/toxins8010018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 01/02/2016] [Accepted: 01/05/2016] [Indexed: 11/30/2022] Open
Abstract
Neuropathic pain includes postherpetic neuralgia (PHN), painful diabetic neuropathy (PDN), and trigeminal neuralgia, and so on. Although various drugs have been tried to treat neuropathic pain, the effectiveness of the drugs sometimes may be limited for chronic intractable neuropathic pain, especially when they cannot be used at an adequate dose, due to undesirable severe side effects and the underlying disease itself. Botulinum toxin type A (BoNT-A) has been known for its analgesic effect in various pain conditions. Nevertheless, there are no data of nerve block in PHN and PDN. Here, we report two patients successfully treated with ultrasound-guided peripheral nerve block using BoNT-A for intractable PHN and PDN. One patient had PHN on the left upper extremity and the other patient had PDN on a lower extremity. Due to side effects of drugs, escalation of the drug dose could not be made. We injected 50 Botox units (BOTOX®, Allergan Inc., Irvine, CA, USA) into brachial plexus and lumbar plexus, respectively, under ultrasound. Their pain was significantly decreased for about 4–5 months. Ultrasound-guided nerve block with BoNT-A may be an effective analgesic modality in a chronic intractable neuropathic pain especially when conventional treatment failed to achieve adequate pain relief.
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Affiliation(s)
- Young Eun Moon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, 222 Banpo-Daero, Seoul 137-701, Korea.
| | - Jung Hyun Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, 222 Banpo-Daero, Seoul 137-701, Korea.
| | - Hue Jung Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, 222 Banpo-Daero, Seoul 137-701, Korea.
| | - Ji Hye Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, 222 Banpo-Daero, Seoul 137-701, Korea.
| | - Ji Hyun Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, 222 Banpo-Daero, Seoul 137-701, Korea.
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Bhatnagar S, Gupta M. Evidence-based Clinical Practice Guidelines for Interventional Pain Management in Cancer Pain. Indian J Palliat Care 2015; 21:137-47. [PMID: 26009665 PMCID: PMC4441173 DOI: 10.4103/0973-1075.156466] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Sushma Bhatnagar
- Department of Onco-Anaesthesia, Pain and Palliative Care, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Maynak Gupta
- Department of Anaesthesia, Shri Guru Rai Institute of Medical and Health Sciences, Shri Mahant Indiresh Hospital, Dehradun, Uttarakhand, India
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Drinovac V, Bach-Rojecky L, Babić A, Lacković Z. Antinociceptive effect of botulinum toxin type A on experimental abdominal pain. Eur J Pharmacol 2014; 745:190-5. [PMID: 25446429 DOI: 10.1016/j.ejphar.2014.10.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 10/16/2014] [Accepted: 10/22/2014] [Indexed: 02/08/2023]
Abstract
Visceral pain, especially in the abdominal region, represents one of the most common types of pain. Its chronic form is usually very hard to treat by conventional analgesic agents and adjuvants. We investigated the antinociceptive effect of botulinum toxin type A (BTX-A) in male Wistar rats in two models of visceral pain: peritonitis induced by intraperitoneal injection of 1% acetic acid and colitis induced by intracolonic instillation of 0.1% capsaicin. Pain was measured as the number of abdominal writhes. Additionally, referred mechanical sensitivity in the ventral abdominal area was evaluated by von Frey test and the extent of spinal c-Fos expression was immunohistochemically examined. BTX-A significantly reduced the number of abdominal writhes in both models of visceral pain after intrathecal application in a dose of 2 U/kg. In the experimental colitis model, BTX-A (2 U/kg) reduced both referred mechanical allodynia and c-Fos expression in the dorsal horn of the spinal cord (S2/S3 segments). In contrast to intrathecal administration, BTX-A (2 U/kg) administered into the cisterna magna had no effect on pain suggesting that the primary site of its action is a spinal cord.
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Affiliation(s)
- Višnja Drinovac
- Department of Pharmacology, University of Zagreb Faculty of Pharmacy and Biochemistry, 10000 Zagreb, Croatia
| | - Lidija Bach-Rojecky
- Department of Pharmacology, University of Zagreb Faculty of Pharmacy and Biochemistry, 10000 Zagreb, Croatia
| | - Ana Babić
- Department of Pharmacology, University of Zagreb Faculty of Pharmacy and Biochemistry, 10000 Zagreb, Croatia
| | - Zdravko Lacković
- Laboratory of Molecular Neuropharmacology, Department of Pharmacology and Croatian Brain Research Institute, University of Zagreb Medical School, 10000 Zagreb, Croatia.
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Walters A, Muhleman M, Osiro S, Bubb K, Snosek M, Shoja MM, Tubbs RS, Loukas M. One is the loneliest number: a review of the ganglion impar and its relation to pelvic pain syndromes. Clin Anat 2013; 26:855-61. [PMID: 23339118 DOI: 10.1002/ca.22193] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Revised: 09/15/2012] [Accepted: 09/25/2012] [Indexed: 11/06/2022]
Abstract
The ganglion impar is often overlooked as a component of the sympathetic nervous system. Despite its obscurity, this ganglion provides a pathway for neurons by accommodating postganglionic sympathetics, visceral afferents, and somatic fibers traveling to and from the pelvis. Its classic anatomic location as described in the 1720's held up until recently, with the current literature now revealing a great deal of anatomical variability. This variation becomes important when the ganglion impar is used as a treatment target for patients with chronic pelvic pain - its primary clinical implication. The aim of this review was to provide a better understanding of the anatomy of ganglion impar, accounting for variation in size, shape, and location. In addition, the clinical importance and treatment modalities associated with the ganglion impar are outlined.
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Affiliation(s)
- Andrew Walters
- St. George's University School of Medicine, Grenada, West Indies; Carilion Clinic - Virginia Tech Carilion Family Medicine Residency Program, Roanoke, Virginia
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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. [PMID: 22373806 DOI: 10.14712/23362936.2015.37] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The ganglion impar is an unpaired sympathetic structure located at the level of the sacrococcygeal joint. Blockade of this structure has been utilised to treat chronic perineal pain. Methods to achieve this block often involve the use of fluoroscopy which is associated with radiation exposure of staff involved in providing these procedures. We report a combined loss of resistance injection technique in association with ultrasound guidance to achieve the block. Ultrasound was used to identify the sacrococcygeal joint and a needle was shown to enter this region. Loss of resistance was then used to demonstrate that the needle tip lies in a presacral space. The implication being that any injectate would be located in an adequate position. The potential exception would be a neurodestructive procedure as radiographic control of needle tip in relation to the rectum should be performed and recorded. However when aiming for a diagnostic or local anaesthetic based treatment option we feel that this may become an accepted method.
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Affiliation(s)
- P J Johnston
- Department of Anaesthetics, Antrim Area Hospital, Antrim, UK
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Choi EJ, Byun JM, Nahm FS, Lee PB. Obturator nerve block with botulinum toxin type B for patient with adductor thigh muscle spasm -a case report-. Korean J Pain 2011; 24:164-8. [PMID: 21935496 PMCID: PMC3172331 DOI: 10.3344/kjp.2011.24.3.164] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Revised: 08/05/2011] [Accepted: 08/05/2011] [Indexed: 11/25/2022] Open
Abstract
Obturator nerve block has been commonly used for pain management to prevent involuntary reflex of the adductor thigh muscles. One of several options for this block is chemical neurolysis. Neurolysis is done with chemical agents. Chemical agents used in the neurolysis of the obturator nerve have been alcohol, phenol, and botulinum toxin. In the current case, a patient with spasticity of the adductor thigh muscle due to cervical cord injury had obturator nerve neurolysis done with botulinum toxin type B (BoNT-B). Most of the previous studies have used BoNT-A with only a few reports that have used BoNT-B. BoNT-B has several advantages and disadvantages over BoNT-A. Thus, we report herein a patient who successfully received obturator nerve neurolysis using BoNT-B to treat adductor thigh muscle spasm.
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Affiliation(s)
- Eun Joo Choi
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Les infiltrations du système nerveux sympathique dans la prise en charge thérapeutiques des douleurs pelvipérinéales chroniques. Prog Urol 2010; 20:1124-31. [DOI: 10.1016/j.purol.2010.08.047] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Accepted: 08/16/2010] [Indexed: 11/22/2022]
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