Transsacrococcygeal approach to ganglion impar: radiofrequency application for the treatment of chronic intractable 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.

Assessment of Ganglion Impar Block Effect on Treatment Results of Coccydynia: A Cross-Sectional Study

Background

The ganglion impar block is a minimally invasive technique used for alleviating pain associated with coccydynia.

Objectives

This research evaluates the effectiveness of the ganglion impar block in treating patients with coccydynia who have not benefited from conservative treatments.

Methods

This cross-sectional analysis reviewed the clinical records of coccydynia patients who received ganglion impar block injections at Urmia Imam Khomeini Hospital, Urmia, Iran, between 2020 and 2022. Data regarding age, gender, body mass index (BMI), onset of pain, and levels of patient satisfaction post-treatment were gathered from the medical records.

Results

The study comprised 26 patients, with 4 (15.4%) being male and 22 (84.6%) female. The average age and BMI were 39.15 ± 14.24 years and 28.91 ± 2.14 kg/m2, respectively, which did not show significant variation (P = 0.19). The average Visual Analogue Scale (VAS) score before the ganglion impar block was 6.23 ± 2.35, which reduced to 4.47 ± 2.41 immediately after the procedure. At the 1-month follow-up, the average VAS score had further decreased to 3.47 ± 0.79. The decrease in VAS scores, both immediately after the procedure and at the 1-month follow-up, was statistically significant. The success rate of the block (defined as a reduction in pain of at least 20% from the baseline) was significantly high immediately and one-month post-procedure (P < 0.001). Out of the 26 patients treated with the impar block, satisfaction rates were 42.3% excellent, 27% good, 19.2% fair, and 11.5% poor.

Conclusions

The study endorses the trans-sacro-coccygeal "needle inside needle" method for providing relief to patients suffering from coccydynia. The findings revealed significant patient satisfaction, with the majority describing their experience as excellent.

Ganglion Impar Block: A Magic Bullet to Fix Idiopathic Coccygodynia

Coccygodynia (coccydynia) is a painful condition of the perineum in the region of the tailbone or coccyx, aggravated by sitting on hard surfaces. It is frequently associated with injuries to the coccyx following direct trauma. Nevertheless, idiopathic coccygodynia without antecedent trauma history is not uncommon. Most of these patients respond to anti-inflammatory medications and physical therapy. Those who are unresponsive may require additional intervention for pain relief. Blockade of ganglion impar, the terminal end of the pelvic sympathetic chain, can dramatically alleviate the pain in patients suffering from coccygodynia. In the current case series, four patients in the age range of 21 to 69 years suffering from chronic idiopathic coccygodynia (female: male ratio of 1:1) were treated with ganglion impar block. All four patients received a course of medical management, and two of the patients additionally received local infiltration of the coccyx before ganglion impar block administration. The block was performed with fluoroscopy guidance by either the trans-sacrococcygeal joint approach or the intra-coccygeal joint approach. The pre-intervention average numeric rating pain score (NRS) was 7.5. After a single ganglion impar block intervention, all four patients experienced complete pain relief (NRS=0). No patients required a repeat injection, and all were pain-free for the entire one-year follow-up period.

Coccydynia-The Efficacy of Available Treatment Options: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVE

To evaluate the efficacy of available treatment options for patients with persistent coccydynia through a systematic review.

METHODS

Original peer-reviewed publications on treatment for coccydynia were identified using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines by performing a literature search of relevant databases, from their inception to January 17, 2020, combined with other sources. Data on extracted treatment outcome was pooled based on treatment categories to allow for meta-analysis. All outcomes relevant to the treatment efficacy of coccydynia were extracted. No single measure of outcome was consistently present among the included studies. Numeric Rating Scale, (NRS, 0-10) for pain was used as the primary outcome measure. Studies with treatment outcome on adult patients with chronic primary coccydynia were considered eligible.

RESULTS

A total of 1980 patients across 64 studies were identified: five randomized controlled trials, one experimental study, one quasi-experimental study, 11 prospective observational studies, 45 retrospective studies and unpublished data from the DaneSpine registry. The greatest improvement in pain was achieved by patients who underwent radiofrequency therapy (RFT, mean Visual Analog Scale (VAS) decreased by 5.11 cm). A similar mean improvement was achieved from Extracorporeal Shockwave Therapy (ESWT, 5.06), Coccygectomy (4.86) and Injection (4.22). Although improved, the mean change was less for those who received Ganglion block (2.98), Stretching/Manipulation (2.19) and Conservative/Usual Care (1.69).

CONCLUSION

This study highlights the progressive nature of treatment for coccydynia, starting with noninvasive methods before considering coccygectomy. Non-surgical management provides pain relief for many patients. Coccygectomy is by far the most thoroughly investigated treatment option and may be beneficial for refractory cases. Future randomized controlled trials should be conducted with an aim to compare the efficacy of interventional therapies amongst each other and to coccygectomy.

Improvement in Pain Following Ganglion Impar Blocks and Radiofrequency Ablation in Coccygodynia Patients: A Systematic Review

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.

The interdisciplinary management of coccydynia: A narrative review

Pain that develops in the coccyx or surrounding tissues is known as coccydynia, which occurs as a result of many etiologies both traumatic and nontraumatic. Although coccydynia most commonly affects middle-aged women, it may be found in both sexes and in all age groups. The aim of this article is to provide an overview of the presentation, diagnostic imaging, and pathophysiology of coccydynia, and to comprehensively review the current treatment options. A review of publications from 1990 to 2020 using search words related to the treatment of coccydynia in PubMed and Google Scholar was completed. Level II evidence was found supporting stretching, manipulation, and extracorporeal shock wave therapy. There are no data from high-quality studies to support injection-based therapy including corticosteroids, prolotherapy, nerve blocks, and radiofrequency ablation, although there are small retrospective and prospective observational studies suggesting benefit. Level III evidence was found supporting coccygectomy for chronic/refractory coccydynia. There are no data from randomized controlled trials to support the use of neuromodulation (sacral burst and dorsal root ganglion stimulation), although there are case reports suggesting benefit. High-level, comparative studies are lacking to guide the treatment of coccydynia and should be a focus for future research studies.

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.

The efficacy of coccygectomy in patients with persistent coccydynia

AIMS

The aim of this study was to investigate the efficacy of coccygectomy in patients with persistent coccydynia and coccygeal instability.

METHODS

The Danish National Spine Registry, DaneSpine, was used to identify 134 consecutive patients who underwent surgery, performed by a single surgeon between 2011 and 2019. Routine demographic data, surgical variables, and patient-reported outcomes, including a visual analogue scale (VAS) (0 to 100) for pain, Oswestry Disability Index (ODI), EuroQol five-dimension questionnaire (EQ-5D), and the Physical Component Score (PCS) and Mental Component Score (MCS) of the 36-Item Short-Form Health Survey questionnaire (SF-36) were collected at baseline and one-year postoperatively.

RESULTS

A total of 112 (84%) patients with a minimum follow-up of one year had data available for analysis. Their mean age was 41.9 years, and 15 (13%) were males. At 12 months postoperatively, there were statistically significant improvements (p < 0.001) from baseline for the mean VAS for pain (70.99 to 35.34), EQ-5D (0.52 to 0.75), ODI (31.84 to 18.00), and SF-36 PCS (38.17 to 44.74). A total of 78 patients (70%) were satisfied with the outcome of treatment.

CONCLUSION

Patients with persistent coccydynia and coccygeal instability resistant to nonoperative treatment may benefit from coccygectomy. Cite this article: Bone Joint J 2021;103-B(3):542-546.

Factors associated with Successful Responses to Ganglion Impar Block: A Retrospective Study

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.

An overview of interventional strategies for the management of oncologic pain

Pain is a ubiquitous part of the cancer experience. Often the presenting symptom of malignancy, pain becomes more prevalent in advanced or metastatic disease and often persists despite curative treatment. Although management of cancer pain improved following publication of the WHO's analgesic ladder, when used in isolation, conservative approaches often fail to control pain and are limited by intolerable side effects. Interventional strategies provide an option for managing cancer pain that remains refractory to pharmacologic therapy. The purpose of this review is to investigate these strategies and discuss the risks and benefits which must be weighed when considering their use. Therapies anticipated to have an increasingly important role in the future of cancer pain management are also discussed.

Coccydynia Treated with Dorsal Root Ganglion Stimulation

Coccydynia can be difficult to resolve with conventional treatment options. Dorsal root ganglion (DRG) stimulation has recently emerged as a treatment for chronic pain, but its application has not been described in the context of coccydynia. We used DRG stimulation treatment in a patient suffering from intractable coccyx pain. At long-term follow-up, the patient experienced a decrease in pain intensity and improvement in function, without any complications. DRG stimulation may be a treatment modality for coccydynia refractory to other approaches.

Ganglion blocks as a treatment of pain: current perspectives

The inputs from sympathetic ganglia have been known to be involved in the pathophysiology of various painful conditions such as complex regional pain syndrome, cancer pain of different origin, and coccygodynia. Sympathetic ganglia blocks are used to relieve patients who suffer from these conditions for over a century. Many numbers of local anesthetics such as bupivacaine or neurolytic agents such as alcohol can be chosen for a successful block. The agent is selected according to its duration of effect and the purpose of the injection. Most commonly used sympathetic blocks are stellate ganglion block, lumbar sympathetic block, celiac plexus block, superior hypogastric block, and ganglion Impar block. In this review, indications, methods, effectiveness, and complications of these blocks are discussed based on the data from the current literature.