Ganglion Impar Block with Fluoroscopy

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Final contrast spread after injection of the steroid/local anesthetic mixture.

By Chris Faubel, MD —

Final contrast spread after injection of the steroid/local anesthetic mixture.

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)
Position:  Prone
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.

With the patient prone and a lateral fluoroscopic view, locate the sacrococcygeal junction.

Needle approaching the sacrococcygeal junction.

Needle has been advanced to just anterior to the sacrum. Caution not to go too far anterior in order to avoid bowel puncture.

Contrast injected to show spread up and down the anterior sacrum.

Final contrast spread after injection of the steroid/local anesthetic mixture.