ÖZLEM SAĞIR, Sabri ÖZASLAN, Ahmet KÖROĞLU

Koksiks dislokasyonlu hastada impar ganglion bloğu uygulaması

Sakrokoksigeal dislokasyon nadir rastlanan bir yaralanmadır. İmpar ganglion (Walther ganglion olarakta bilinen) rektumun arkasında sakrokoksigeal bileşke veya koksiksin önünde yerleşen tek küçük soliter sempatik bir gangliondur. Perine bölgesinin nosiseptif ve sempatik duyusunu sağlar. İmpar ganglion blokajı klinik pratikte rutin olarak kullanılan analjezi ve anestezi yöntemi değildir. Beş gün önce sandalyeden düşme sonucu koksiks dislokasyonu gelişen kadın hastaya elektif intrarektal manuel düzeltme planlandı. Rutin monitorizasyondan sonra fluoroskopi eşliğinde 22 gauge spinal iğne kullanılarak sakrokoksigeal yaklaşımla impar ganglion bloğu uygulandı. Bloktan önce ve blok sonrası üç dakika aralıklarla kan basıncı, kalp hızı, periferik oksijen satürasyonu ve vizüel analog skala (VAS) kaydedildi. Bloktan önce VAS’si 8 olan hastanın 6 dakika sonra VAS’si %50 azaldı. Dokuzuncu dakikada VAS 0 olan hastaya intrarektal manuel düzeltme uygulandı. İşlem sırasında ve sonrasında hemodinamik veriler normal sınırlarda kaydedildi ve motor blok gelişmedi. Bloktan sonra 2. ve 6. saatlerde VAS 0 olan hasta evine taburcu edildi. Bloktan sonra 24. ve 48. saatlerde telefonla VAS 0 olarak belirlendi. Sonuç olarak, impar ganglion bloğu, koksiks dislokasyonlu hastada intrarektal düzeltme sırasında ve sonrasında herhangi bir komplikasyona neden olmadan yeterli analjezi sağladı. Fakat bu tekniğin perianal bölgedeki yapılacak diğer işlemlerde de güvenirlilik ve etkinliğinin kanıtlanması için daha ileri klinik çalışmalara ihtiyaç olduğunu düşünmekteyiz.

Application of ganglion impar block in patient with coccyx dislocation

Sacrococcygeal dislocation is a rare injury. The ganglion impar (also called the ganglion of Walther) is a single, small solitary, sympathetic ganglion located in the retrorectal space, anterior to the sacrococcygeal joint or coccyx. It provides the nociceptive and sympathetic supply to the perineal structure. Ganglion impar blockade is not a routinely used anesthetic and analgesic procedure in clinical practice. An elective intrarectal manuel treatment was planned for a woman patient with coccyx dislocation due to falling down from a chair 5 days ago. Ganglion impar block was performed with saccrococcygeal approach using 22 gauge spinal needle along with fluoroscopy following routine monitorization. Blood pressure, heart rate, peripheral oxygen saturation and visual analog scale (VAS) were recorded before and, after block with three minute intervals. VAS value of the patient, 8 before the procedure, decreased 50% 6 minutes after block. Intrarectal manuel treatment was applied to the patient with VAS of 0 at 9th minute. Hemodynamic values were within normal limits during and after the procedure and no motor block was observed. The patient with VAS of 0 at 2nd and 6th hour after block was discharged. VAS of 0 was determined at 24th and 48th hour by phone call. In conclusion, ganglion impar block provided adequate analgesia without causing any complications during and after the intrarectal manuel treatment for the patient with coccyx dislocation. However, we believe that further clinical studies are required to establish the safety and efficiency of this technique for other procedures at perianal region.

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1. Maigne JY, Doursounian L, Chatellier G. Causes and mechanisms of common coccydynia: role of body mass index and coccygeal trauma. Spine (Phila Pa 1976) 2000;25(23):3072-9.
2. Maigne JY, Lagauche D, Doursounian L. Instability of the coccyx in coccydynia. J Bone Joint Surg Br 2000;82(7):1038-41.
3. Oh CS, Chung IH, Ji HJ, Yoon DM. Clinical implications of topographic anatomy on the ganglion impar. Anesthesiology 2004;101(1):249-50.
4. Datir A, Connell D. CT-guided injection for ganglion impar blockade: a radiological approach to the management of coccydynia. Clin Radiol 2010;65(1):21-5.
5. Postacchini F, Massobrio M. Idiopathic coccygodynia. Analysis of fifty-one operative cases and a radiographic study of the normal coccyx. J Bone Joint Surg Am 1983;65(8):1116-24.
6. Başağan Moğol E, Türker G, Kelebek Girgin N, Uçkunkaya N, Sahin S. Blockade of ganglion impar through sacrococcygeal junction for cancer-related pelvic pain. Agri 2004;16(4):48- 53.
7. Toshniwal GR, Dureja GP, Prashanth SM. Transsacrococcygeal approach to ganglion impar block for management of chronic perineal pain: a prospective observational study. Pain Physician 2007;10(5):661-6.
8. Nebab EG, Florence IM. An alternative needle geometry for interruption of the ganglion impar. Anesthesiology 1997;86(5):1213-4.
9. Plancarte R, Amescua C, Patt RB, Allende S. Presacral blokade of the ganglion of walther (ganglion impar). Anesthesiology 1990;73:A751.
10. Wemm K Jr, Saberski L. Modified approach to block the ganglion impar (ganglion of Walther) Reg Anesth 1995;20(6):544- 5.
11. Foye PM, Patel SI. Paracoccygeal corkscrew approach to ganglion impar injections for tailbone pain. Pain Pract 2009;9(4):317-21.
12. Foye PM, Buttaci CJ, Stitik TP, Yonclas PP. Successful injection for coccyx pain. Am J Phys Med Rehabil 2006;85(9):783-4.
13. Gupta D, Jain R, Mishra S, Kumar S, Thulkar S, Bhatnagar S. Ultrasonography reinvents the originally described technique for ganglion impar neurolysis in perianal cancer pain. Anesth Analg 2008;107(4):1390-2.
14. Ho KY, Nagi PA, Gray L, Huh BK. An alternative approach to ganglion impar neurolysis under computed tomography guidance for recurrent vulva cancer. Anesthesiology 2006;105(4):861-2.
15. McAllister RK, Carpentier BW, Malkuch G. Sacral postherpetic neuralgia and successful treatment using a paramedial approach to the ganglion impar. Anesthesiology 2004;101(6):1472-4.
16. Usta B, Gozdemir M, Sert H, Muslu B, Demircioglu RI. Fluoroscopically guided ganglion impar block by pulsed radiofrequency for relieving coccydynia. J Pain Symptom Manage 2010;39(6):e1-2.