Ganglion Impar Block

The two sympathetic chains unite at the level of sacrococcygeal ligament. Ganglion impar is a solitary sympathetic ganglia at that level. Ganglion impar provides sympathetic supply to the perineum, distal rectum and anus, distal urethra, vulva, and distal third of vagina. This block can relieve cancer pain originating from the perineum, distal rectum and anus, distal urethra, vulva, and distal third of vagina.

Technique

Ganglion impar can be blocked at the level of the sacrococcygeal ligament. Needle should be bent at 45° angle to avoid injury to the anal canal or the rectum. Table 28.9 describes the technique of the block, and Fig. 28.10 shows the final position of the needle. Injection of dye is

Table 28.9 Technique of ganglion impar block.

Position

Prone, lithotomy, or lateral position

Fluoroscopy use

Mandatory

Number of needles

One

Type of needle

22G3.5 in. bent45° angle

Level of needle insertion

Anococcygeal ligament

Direction of the needle

Midline concavity posterior close to the sacrum

Final position of the needle

Level of the sacrococcygeal ligament

essential that shows good spread of the contrast in the retroperitoneal space and posterior to the rectum. For diagnostic block, 4-5 ml of bupivacaine 0.25-0.5% is injected. For neurolytic block, phenol 10% 4-5 ml can be injected.

Complications

Retroperitoneal hematoma can occur more frequently in patients who are on anticoagulation at the time of the procedure. The most common complaint after the procedure is back pain. As already discussed for other blocks, a good patient history and physical examination will help differentiate between back pain from needle placement and hematoma. CT scan is essential to rule out hematoma or bleeding. Another common complaint is back pain which can be differentiated from back pain due to hematoma by the severity of pain and by performing serial exams. CT scan is diagnostic. Perforation of the rectum or anus can occur. Another potential complication is injection of the neurolytic medication in the rectum or the sacrum. Injection of contrast dye before injection of neurolytic substances is therefore essential.

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