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Pain management
Published in J. Richard Smith, Giuseppe Del Priore, Robert L. Coleman, John M. Monaghan, An Atlas of Gynecologic Oncology, 2018
Andrew Lawson, Paul Farquhar-Smith
Ganglion impar block has been described for the treatment of intractable perineal and pelvic pain where the sympathetic nerve seems to predominate. The ganglion impar is a retroperitoneal structure located at the level of the sacrococcygeal junction. The technique involves placement of a needle through the skin under x-ray control to lie anterior to the coccyx close to the sacrococcygeal junction. Retroperitoneal location of the needle is demonstrated by the injection of contrast medium. Local anesthetic and/or neurolytic solutions can then be injected. Care must be taken to ensure that puncture of the rectum and accidental trans-bone injection into the epidural space are avoided (Figure 40.4).
The Bladder (BL)
Published in Narda G. Robinson, Interactive Medical Acupuncture Anatomy, 2016
Ganglion impar: The only unpaired, autonomic ganglion in the body, marking the end of the sympathetic chain. It represents the pelvic portion of the sympathetic trunk, situated ventral to the sacrum and medial to the ventral sacral foramina. It consists of four to five, small, sacral sympathetic ganglia that connect by means of interganglionic cords. The ganglion impar is located about level with the coccyx but may occur anywhere from 10mm to 30mm ventral to it. In conjunction with the local somatic nerves and the ganglion impar, BL 35 represents a somatosympathetic convergence site and multifaceted treatment opportunity.
Development of palliative medicine in the United Kingdom and Ireland
Published in Eduardo Bruera, Irene Higginson, Charles F von Gunten, Tatsuya Morita, Textbook of Palliative Medicine and Supportive Care, 2015
Lumbar plexus sympathectomies have shown mixed results for painful limb ischemia (Sanni et al. 2005). Ganglion impar blocks are used for perineal pain in prostate, colorectal, and vulvar cancers (Agarwal-Kozlowski et al. 2009; Eker et al. 2008; Ho et al. 2006). Stellate ganglion blocks are typically used for sympathetically mediated pain of the head and neck, though there are also case reports and series in palliative care patients for refractory angina (Chester et al. 2000 ; Moore et al. 2005), postmastectomy pain (Nabil Abbas et al. 2011), and hot flashes in breast cancer survivors (Haest et al. 2012).
Pharmacological Treatments for Localized Provoked Vulvodynia: A Scoping Review
Published in International Journal of Sexual Health, 2023
Krisztina Bajzak, Alex Rains, Lisa Bishop, Michelle Swab, Michelle E. Miller, Gabrielle S. Logan, Victoria Jackman, Liam Jackman, Diana L. Gustafson
In 2021, Hong et al. postulated that ganglion impar block (GIB) may be beneficial for vulvodynia because the ganglion impar, a collection of sympathetic nerves located between the rectum and the coccyx, carries pain signals from the perineum and a preliminary report described efficacy of GIB for coccygodynia. They described a case series of four individuals with vulvodynia treated with GIB, of which one met our inclusion criteria for LPV. The woman, in her 30s, described burning, stabbing, throbbing, and electric shock-like vulvar pain on contact with the vulvar vestibule, including severe dyspareunia. Symptoms began after pelvic cancer treatment, persisted for 18 months and did not improve with oral medications for neuropathic pain or hydromorphone. On examination, they describe CST as “show[ing] hyperalgesia to the pin-prick test,” with “VAS” score of 9 (presumably NRS). Fluoroscopy-guided GIB was performed using a trans-sacrococcygeal ligament approach with the patient in a prone position, identifying the ligament under fluoroscopic guidance. After confirming correct needle placement using radiocontrast, a mixture of 5 mL of 0.5% lidocaine (local anesthetic) and 20 mg triamcinolone (a steroid) was performed “3 times every 2 weeks.”
Influence of psychiatric disorders and chronic pain on the surgical outcome in the patient with chronic coccydynia: a single institution’s experience
Published in Neurological Research, 2020
Kristopher A. Lyon, Jason H. Huang, David Garrett
In addition to the coccygeal plexus nerves, the ganglion impar, located directly in front of the coccyx between the sacrococcygeal joint and the tip of the coccyx serves as the primary relay for the sympathetic efferents and nociceptive afferents from the perineum and terminal urogenital regions [19,22]. The ganglion impar is one of the primary targets for nerve blocks in patients with chronic coccydynia and in patients with chronic pain arising from rectal, anal, colon, bladder, and cervical cancers [23]. In addition to pelvic cancer-related pain, many spinal pathologies such as sacroiliac joint dysfunction and lumbar radiculopathies can mimic or overlap with coccygeal pain, leading the practitioner to be uncertain of the exact origin of the patient’s pain. For this reason, some physicians have warned against performing coccygectomy on patients with concomitant low back pain [15].
Interventional pain management in patients with cancer-related pain
Published in Postgraduate Medicine, 2020
Celiac plexus blocks have been widely acknowledged to treat pain in pancreatic cancer and could be used in managing pain in cancers involving lower esophagus, stomach, gall bladder, and bowel [9–11]. Unilateral blockade and lower injectate volume can minimize the side-effects of diarrhea and postural hypotension. Other serious complications like pneumothorax, vascular injury, retroperitoneal hematoma and hematuria, and serious neurological injury have been reduced with improved imaging guidance with fluoroscopy, CT and endoscopic ultrasound-guided approaches to inject lower volumes precisely. Radiofrequency ablation and retrocrural block of the splanchnic nerves are often effective in patients where celiac plexus blockade is not possible or ineffective due to tumor infiltration [7]. Hence, there is a compelling argument for early referral for neurolytic celiac plexus blocks for managing pain in patients diagnosed with pancreatic cancer, as it would become technically difficult to approach the plexus through the tumor mass. Additionally, there are significant cost benefits as most of these interventions are carried out as day case procedures and could prevent lengthy hospital or hospice stays to titrate opiates and other medications to effect. This could also help prevent the negative impact on quality of life due to the undesirable side effects of systemic medications. Superior and inferior hypogastric plexus blocks can be effective for pelvic cancer pain and ganglion impar block is often used to manage pain in localized anal cancers [12]. Ischemic and other sympathetically mediated pain in the lower limb could respond to lumbar sympathetic blockade, while stellate ganglion and T1-2 sympathetic block can be used to manage pain in head and neck cancers and upper limb pain.