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Patients with advanced pelvic malignancies present with pain of varying severity. Their pain can be effectively managed using a systemic pharmacologic approach, including oral administration of morphine. However, morphine can lead to constipation, which may be especially troublesome in patients with rectal carcinoma. Neurolytic blocks such as of the ganglion impar may alleviate sympathetically mediated pain and help in reducing opioid requirement. However, use of a ganglion impar block may rarely be associated with side effects such as rectal puncture, neuritis, and cauda equina syndrome. We report a rare neurologic complication after a fluoroscopic-guided ganglion impar block.
Keywords: Ganglion impar block, malignancy, pain.
Patients with advanced rectal carcinoma may have severe pain mandating the use of opioids. However, opioids in higher doses may have associated side effects such as constipation, which may be undesirable in patients with rectal carcinomas. Those having pain refractory to opioids or who experience intolerable side effects due to opioid treatment can benefit from interventional nerve blocks. The ganglion impar is an unpaired ganglion located at the level of the sacrococcygeal junction in the front of the coccyx and consists of the end of the sympathetic chains on both sides.1 It is linked with pain originating from blood vessels, nerves, and other tissues, such as the lower third of the rectum and anus, the perineum, the urethra, the vagina, the vulva, or the scrotum. Therefore, sympathetically mediated perineal visceral pain in patients with rectal malignancies may be treated effectively with ganglion impar block.2 Several techniques for performing ganglion impar block have previously been reported. Various complications, such as bleeding, infection, perforation of the rectum and/or bowel, bladder incontinence, hematoma, and nerve root injury, have been associated with ganglion impar block.3,4 The transsacrococcygeal approach for a ganglion impar block was first described by Wemm and Saberski.5 A fluoroscopic-guided transcoccygeal technique remains the most popular choice because of its technical feasibility and reduced risk of visceral injuries compared with a conventional technique.4,5 We report a rare neurologic complication after a fluoroscopic-guided transcoccygeal ganglion impar block.
Case Summary
A 30-year-man with advanced rectal carcinoma presented to the pain clinic with severe pain in the lower aspect of the abdomen and the perineal region for the past month. His pain was burning and nonradiating,...