Ganglion Impar Injection For Tailbone Coccydynia

Previously for ganglion injection, , injection through the sacrococcygeal joint has been suggested.  Recent information has found the ganglion is actually lower in the first intracoccygeal joint level.  Injection of this ganglion is an important treatment for coccydynia.

Safe ganglion Impar blocks for visceral and coccyx pain
Patrick M. Foye
Techniques in Regional Anesthesia and Pain Management (2008) 12, 122-123

Various techniques involved following:

Article suggests:

• sacrococcygeal approach will only work 49% of time as 51% of time, joint is fused; whereas the first intracoccygeal joint will work 87% of time.
• In thin patients I found a 30 guage needle could do at s-c joint level; in authors case, he used a 2 inch 25 guage needle. (suspect a long 27 would be enough)
• They used flouroscopy (xrays but with a finger in rectum while doing, it’s hardly necessary (not needed with shorter 30 guage)
• I would use 5% lidocaine without steroid.
• They make a big deal of preventing rectal perforation – but having patients have their rectums perforated 12 times in course of prostatic biopsies I’m not so frightened – a little Cipro 1 gm x 3 days prior and one would think would  take care of that (especially if not steroid). BYW – steroid will not go through a 30 guage needle and not even reliably through a 27 .. – learnt form having to “rejab” experience…

Results:

Foye PM, Buttaci CJ, Stitik TP, et al.
Successful injection for coccyx pain.
Am J Phys Med Rehabil. Sep 2006;85(9):783-4.

• They feel local into ganglion impar can give 50-75% relief of pain albeit maybe not permanent but subsequent injections can incur further benefits.

Here’s a pic going through sacrococcygeal level:

best results were with 10% phenol but this is generally only used in hopeless cases as can cause dysesthesias – permanent burning pains:
Plancarte R, Amescua C, Patt RB, et al. Presacral blockade of the ganglion of Walther (ganglion Impar). Anesthesiology. 1990;73(3a):A751.

• 20 injections  10% phenol
• relief obtained  varied from 20-75%, with most patients reporting 50-75% per injection, lasting weeks to months or longer.
• Repeat injections were helpful

An article in press:

Infiltration of ganglion impar and caudal in the management of traumatic coccydynia refractory to conventional analgesic treatment
M. Cortiñas Sáenza, , , J.A. Iglesias Cerrilloa, C. Vázquez Colomob, G. Salmerón Vélezb, A. Quirante Pizarroa and F. Jerez Colladoc
Revista Española de Cirugía Ortopédica y Traumatología Article in Press

• resistant to ordinary injections
• injected ganglion with 1% lidocaine 60-80 mg triamcinolone (don’t try that without a 25 or bigger guage needle) or siimilar dose caudal block
• Good results were obtained in 16 of the 21 patients with coccydynia due to trauma

Comment – this is the rub though – the resistant cases I have have it as part of a systemic illness (possible inflammatory arthropathy)/ widespread pain scenario  – not a result of trauma so not as likely to be first time permanent responders. However, the injection of the ganglion is getting easier… a combination of caudal and ganglion impar blocks looks like the best approach but in a widespread pain case one has top pick one’s target…
One orthopedic physican I talked to felt needling lower cervical spine was essential to clearing coccydynia – anyone got any comments?