By Chris Faubel, MD —
The ganglion impar is a group of sympathetic ganglia which are located anterior to the sacrococcygeal junction; it carries nociceptive signals from the perineum area.
Coccydynia is pain in the area of coccyx (tailbone pain), and is seen frequently in patients with a history of falling directly on their coccyx (tailbone). If the pain does not resolve on its own, and after a course of antiinflammatories and donut cushion, the ganglion impar is blocked under fluoroscopic guidance (or ultrasound guidance).
Billing / Coding
- ICD-9 code: 724.79 (Coccydynia)
- ICD-10 code: M53.3 (Sacrococcygeal disorders, not elsewhere classified)
CPT codes: There is no consensus on the correct code to use. Some use:
- 64530 (Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring).
- 64999 (Unlisted procedure, nervous system) and submit documentation of medical necessity.
- **64520 (Injection, anesthetic agent; lumbar or thoracic paravertebral sympathetic). This one seems the most appropriate, as the sacral sympathetic plexus is just the caudal extension from this lumbar region.
- Note: Fluoroscopic needle guidance is built in to this codes
Procedure technique: (see the pics below for more details)
Fluoroscopy: A lateral fluoroscopic view is used to visualize the sacrococcygeal junction.
Technique: A 22-25 gauge, 2+-inch needle (I use a 25-gauge, 2-inch) is used to advance through the sacrococcygeal ligament until the needle tip is just barely anterior to the sacrum. Contrast is then injected to visualize correct spread/placement. Finally, a local anesthetic (and sometimes corticosteroid) is injected.
Injectate mixture: 40mg of Kenalog or Depo-Medrol (or 7.2mg of Celestone) with 5+ml of local anesthetic (bupivacaine 0.5%)
Expectations: Patient should have significant reduction in pain within a minute or two if this is the real source of his/her pain; this injection is then both diagnostic and therapeutic.