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A modified needle-inside-needle technique for the ganglion impar block

[Une technique modifiée pour le bloc du ganglion coccygien : une aiguille dans une aiguille]

Muhammad A. Munir, MD^*, Junming Zhang, MS MD and Mahmood Ahmad, MD

^* From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts;
Department of Anesthesiology, and
the United Pain Care, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.

Address correspondence to: Dr. Muhammad A. Munir, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, Massachusetts, USA. Phone: 617-732-6708; Fax: 617-731-5453; E-mail: mmunir{at}partners.org

Purpose: The ganglion impar is the fused terminus of the paired sympathetic chain located at the level of the sacrococcygeal junction. It has been blocked using a bent and a curved spinal needle via the anococcygeal ligament. It has also been approached through the sacrococcygeal disc using a straight spinal needle. We describe a needle-inside-needle modification of the latter approach.

Technical features: A 22-gauge (G), 1-inch (38 mm) needle is introduced through the sacrococcygeal ligament under fluoroscopy via the sacrococcygeal disc. A 25-G, 2-inch (50 mm) needle is introduced through the 22-G needle. Placement is confirmed with injection of iopamidol 300, 0.2 mL in the retroperitoneal space with the comma sign.

Conclusions: The bent and curved needle techniques are associated with significant discomfort, tissue trauma and risk of rectal perforation due to difficulty in obtaining a midline needle tip position. The straight spinal needle approach minimizes these problems, however there is increased risk of discitis and a longer spinal needle may help also raise incidence of needle breakage. The needle-inside-needle technique may reduce these risks.