Conus infarction after non-guided transcoccygeal ganglion impar block using particulate steroid for chronic coccydynia

Abstract

Introduction Ganglion impar block (GIB) is a well-recognised treatment for chronic coccydynia. Several side effects have previously been described with this procedure, including transient motor dysfunction, bowel, bladder, and sexual dysfunction, neuritis, rectal perforation, impingement of the sciatic nerve, cauda equina syndrome, and infection. Case presentation We describe the first report of imaging-documented conus infarction after an unguided-GIB performed in theatre using particulate steroids for a 17-year-old patient with coccydynia. Immediately post-GIB, patient developed transient neurological deficits in her lower limbs of inability to mobilise her legs that lasted for 24 h. These include back and leg pain, decreased power and movement, increased tone, brisk reflexes, reduced light touch sensation and proprioception of legs up to the T10 level. Urgent MRI spine showed intramedullary hyperintense signal within the conus and mild restricted diffusion on the distal cord and conus, suggestive of an acute conus infarction. On follow-up, the GIB did not result in symptom improvement of coccydynia and there was persistent altered sensation of her legs. Discussion Various approaches of ganglion impar block have been described and performed in the past with different imaging techniques and injectants. A few cases of unusual neurological complications have been reported with the use of epidural steroid injections and ganglion impar block. Clinicians should be aware of the possible neurological complications following ganglion impar blocks and the risk of inadvertent intravascular injection of particulate steroids can potentially to be minimised by using imaging guidance.

Low incidence of vascular uptake during ganglion impar sympathetic nerve blocks for coccydynia

“…A recent case report published in November 2019 noted a ganglion impar injection without contrast or even image guidance, which appeared to cause significant complications including cauda equina syndrome. [ 8 ] That case further demonstrates the importance of using image guidance and contrast, when possible.…”

Coccydynia

“…Serving as the end point of the paravertebral sympathetic chain, the ganglion impar functions to relay nociception and sympathetic innervation of the perineal region 7,8 . Because of its possible role in pain generation of the region, blockage of the ganglion impar has shown significant utility 9 .…”

Imaging findings and treatment in coccydynia – update of the recent study findings

“…Side effects of GIB treatment include transient motor dysfunction; bowel, bladder, and sexual dysfunction; neuritis; rectal perforation; sciatic nerve compression; cauda equina syndrome; and infection. One patient with conus infarction after GIB without imaging guidance was reported, thus indicating that imaging should be guided to minimize inappropriate intravascular injection of particulate steroids 31 . In a prospective randomized double-blind study, scientists investigated the role of corticosteroids in impar blockade; one group received only anesthetic while the other group received local anesthetic and steroids.…”