Ganglion blocks as a treatment of pain: current perspectives

Osman Hakan Gunduz, Ozge Kenis-Coskun, Osman Hakan Gunduz, Ozge Kenis-Coskun

Abstract

The inputs from sympathetic ganglia have been known to be involved in the pathophysiology of various painful conditions such as complex regional pain syndrome, cancer pain of different origin, and coccygodynia. Sympathetic ganglia blocks are used to relieve patients who suffer from these conditions for over a century. Many numbers of local anesthetics such as bupivacaine or neurolytic agents such as alcohol can be chosen for a successful block. The agent is selected according to its duration of effect and the purpose of the injection. Most commonly used sympathetic blocks are stellate ganglion block, lumbar sympathetic block, celiac plexus block, superior hypogastric block, and ganglion Impar block. In this review, indications, methods, effectiveness, and complications of these blocks are discussed based on the data from the current literature.

Keywords: cancer pain; complex regional pain syndrome; ganglion; pain management; sympathetic nervous system.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Fluoroscopic view of stellate ganglion block before and after the administration of contrast agent.
Figure 2
Figure 2
Fluoroscopic view of lumbar sympathetic block right after the injection of the contrast (A) and the dissemination of contrast material (B).
Figure 3
Figure 3
Fluoroscopic view of ganglion impar block before (A) and after (B) the administration of contrast agent.

References

    1. Drummond PD, Finch PM, Skipworth S, Blockey P. Pain increases during sympathetic arousal in patients with complex regional pain syndrome. Neurology. 2001;57(7):1296–1303.
    1. Ramer MS, Bisby MA. Adrenergic innervation of rat sensory ganglia following proximal or distal painful sciatic neuropathy: distinct mechanisms revealed by anti-NGF treatment. Eur J Neurosci. 1999;11(3):837–846.
    1. Jänig W, Baron R. Complex regional pain syndrome: mystery explained? Lancet Neurol. 2003;2(11):687–697.
    1. Narouze S. Ultrasound-guided stellate ganglion block: safety and efficacy. Curr Pain Headache Rep. 2014;18(6):424.
    1. Carron H, Litwiller R. Stellate ganglion block. Anesth Analg. 1975;54(5):567–570.
    1. Haaga JR, Kori SH, Eastwood DW, Borkowski GP. Improved technique for CT-guided celiac ganglia block. AJR Am J Roentgenol. 1984;142(6):1201–1204.
    1. Kapral S, Krafft P, Gosch M, Fleischmann D, Weinstabl C. Ultrasound imaging for stellate ganglion block: direct visualization of puncture site and local anesthetic spread. A pilot study. Reg Anesth. 1995;20(4):323–328.
    1. O’Connell NE, Wand BM, Gibson W, Carr DB, Birklein F, Stanton TR. Local anaesthetic sympathetic blockade for complex regional pain syndrome. Cochrane Database Syst Rev. 2016;7:CD004598.
    1. Makharita MY, Amr YM, El-Bayoumy Y. Effect of early stellate ganglion blockade for facial pain from acute herpes zoster and incidence of postherpetic neuralgia. Pain Physician. 2012;15(6):467–474.
    1. Abdi S, Zhou Y, Patel N, Saini B, Nelson J. A new and easy technique to block the stellate ganglion. Pain Physician. 2004;7(3):327–331.
    1. Lipov E, Ritchie EC. A review of the use of stellate ganglion block in the treatment of PTSD. Curr Psychiatry Rep. 2015;17(8):599.
    1. Hayase J, Patel J, Narayan SM, Krummen DE. Percutaneous stellate ganglion block suppressing VT and VF in a patient refractory to VT ablation. J Cardiovasc Electrophysiol. 2013;24(8):926–928.
    1. Guttuso T., Jr Stellate ganglion block for treating hot flashes: a viable treatment option or sham procedure? Maturitas. 2013;76(3):221–224.
    1. Hamelberg W, Jacoby J. Shoulder-hand syndrome: treatment with stellate ganglion block. J S C Med Assoc. 1959;55(2):53–55.
    1. Rodríguez RF, Bravo LE, Tovar MA, Castro F, Ramos GE, Méndez F. Determinación de la eficacia analgésica de los bloqueos del ganglio estrellado en el alivio del dolor mediado por el sistema nervioso simpático, en pacientes con síndrome doloroso regional complejo del miembro superior [Determination of the analgesic efficacy of stellate ganglion blockages in the relief of pain mediated by the sympathetic nervous system, in patients with complex regional pain syndrome of the upper limb] Rev Colomb Anestesiol. 2005;33(3):153–159. Spanish [with English asbtract]
    1. Ackerman WE, Zhang JM. Efficacy of stellate ganglion blockade for the management of type 1 complex regional pain syndrome. South Med J. 2006;99(10):1084–1088.
    1. Yucel I, Demiraran Y, Ozturan K, Degirmenci E. Complex regional pain syndrome type I: efficacy of stellate ganglion blockade. J Orthop Traumatol. 2009;10(4):179–183.
    1. Nascimento MS, Klamt JG, Prado WA. Intravenous regional block is similar to sympathetic ganglion block for pain management in patients with complex regional pain syndrome type I. Braz J Med Biol Res. 2010;43(12):1239–1244.
    1. Yoo SD, Jung SS, Kim HS, et al. Efficacy of ultrasonography guided stellate ganglion blockade in the stroke patients with complex regional pain syndrome. Ann Rehabil Med. 2012;36(5):633–639.
    1. Wei K, Feldmann RE, Jr, Brascher AK, Benrath J. Ultrasound-guided stellate ganglion blocks combined with pharmacological and occupational therapy in Complex Regional Pain Syndrome (CRPS): a pilot case series ad interim. Pain Med. 2014;15(12):2120–2127.
    1. Lipton JR, Harding SP, Wells JC. The effect of early stellate ganglion block on postherpetic neuralgia in herpes zoster ophthalmicus. Pain Clin. 1987;1:247–251.
    1. Lee IH, Kim BS, Lee SC, Jo DH. The effect of stellate ganglion block on the pain of acute stage and the prevention of postherpetic neuralgin in the treatment of senile herpes zoster patients. Korean J Dermatol. 1999;37(5):571–579.
    1. Kim HJ, Ahn HS, Lee JY, et al. Effects of applying nerve blocks to prevent postherpetic neuralgia in patients with acute herpes zoster: a systematic review and meta-analysis. Korean J Pain. 2017;30(1):3–17.
    1. Mekhail N, Malak O. Lumber sympathetic blockade. Tech Reg Anesth Pain Manag. 2001;5(3):99–101.
    1. Hong JH, Oh MJ. Comparison of multilevel with single level injection during lumbar sympathetic ganglion block: efficacy of sympatholysis and incidence of psoas muscle injection. Korean J Pain. 2010;23(2):131–136.
    1. König CW, Schott UG, Pereira PL, et al. MR-guided lumbar sympathicolysis. Eur Radiol. 2002;12(6):1388–1393.
    1. Schmid MR, Kissling RO, Curt A, Jaschko G, Hodler J. Sympathetic skin response: monitoring of CT-guided lumbar sympathetic blocks. Radiology. 2006;241(2):595–602.
    1. Moon JY, Choi JK, Shin JY, Chon SW, Dev S. A brief report on a technical description of ultrasound-guided lumbar sympathetic block. Korean J Pain. 2017;30(1):66–70.
    1. Abramov R. Lumbar sympathetic treatment in the management of lower limb pain. Curr Pain Headache Rep. 2014;18(4):403.
    1. Chaturvedi A, Dash HH. Sympathetic blockade for the relief of chronic pain. J Indian Med Assoc. 2001;99(12):698–703.
    1. Price DD, Long S, Wilsey B, Rafii A. Analysis of peak magnitude and duration of analgesia produced by local anesthetics injected into sympathetic ganglia of complex regional pain syndrome patients. Clin J Pain. 1998;14(3):216–226.
    1. Manjunath PS, Jayalakshmi TS, Dureja GP, Prevost AT. Management of lower limb complex regional pain syndrome type 1: an evaluation of percutaneous radiofrequency thermal lumbar sympathectomy versus phenol lumbar sympathetic neurolysis–a pilot study. Anesth Analg. 2008;106(2):647–649. table of contents.
    1. Carroll I, Clark JD, Mackey S. Sympathetic block with botulinum toxin to treat complex regional pain syndrome. Ann Neurol. 2009;65(3):348–351.
    1. Meier PM, Zurakowski D, Berde CB, Sethna NF. Lumbar sympa-thetic blockade in children with complex regional pain syndromes: a double blind placebo-controlled crossover trial. Anesthesiology. 2009;111(2):372–380.
    1. Freitas TS, Deusdara R, Kessler I. Pulsed radiofrequency of sympathetic lumbar plexus versus sympathetic block in the management of lower limb complex regional pain syndrome type 1. In: Roberts DW, Lebanon NH, editors. Stereotactic and Functional Neurosurgery. Vol. 91. Basel: Karger; 2013. p. 107.
    1. Erdine S. Celiac ganglion block. Agri. 2005;17(1):14–22.
    1. Waldman SD. Atlas of Interventional Pain Management. Elsevier Health Sciences; Philidelphia: 2009.
    1. Rathmell JP. Atlas of Image-Guided Intervention in Regional Anesthesia and Pain Medicine. Lippincott Williams & Wilkins; Philidelphia: 2011.
    1. Nitschke AM, Ray CE., Jr Percutaneous neurolytic celiac plexus block. Semin Intervent Radiol. 2013;30(3):318–321.
    1. Wang PJ, Shang MY, Qian Z, Shao CW, Wang JH, Zhao XH. CT-guided percutaneous neurolytic celiac plexus block technique. Abdom Imaging. 2006;31(6):710–718.
    1. Yasuda I, Wang HP. Endoscopic ultrasound-guided celiac plexus block and neurolysis. Dig Endosc. 2017;29(4):455–462.
    1. Eisenberg E, Carr DB, Chalmers TC. Neurolytic celiac plexus block for treatment of cancer pain: a meta-analysis. Anesth Analg. 1995;80(2):290–295.
    1. Rana MV, Candido KD, Raja O, Knezevic NN. Celiac plexus block in the management of chronic abdominal pain. Curr Pain Headache Rep. 2014;18(2):394.
    1. Kambadakone A, Thabet A, Gervais DA, Mueller PR, Arellano RS. CT-guided celiac plexus neurolysis: a review of anatomy, indications, technique, and tips for successful treatment. Radiographics. 2011;31(6):1599–1621.
    1. Ischia S, Ischia A, Polati E, Finco G. Three posterior percutaneous celiac plexus block techniques. A prospective, randomized study in 61 patients with pancreatic cancer pain. Anesthesiology. 1992;76(4):534–540.
    1. Mercadante S. Celiac plexus block versus analgesics in pancreatic cancer pain. Pain. 1993;52(2):187–192.
    1. Polati E, Finco G, Gottin L, Bassi C, Pederzoli P, Ischia S. Prospective randomized double-blind trial of neurolytic coeliac plexus block in patients with pancreatic cancer. Br J Surg. 1998;85(2):199–201.
    1. Lillemoe KD, Cameron JL, Kaufman HS, Yeo CJ, Pitt HA, Sauter PK. Chemical splanchnicectomy in patients with unresectable pancreatic cancer. A prospective randomized trial. Ann Surg. 1993;217(5):447–455. discussion 456–457.
    1. Wong GY, Schroeder DR, Carns PE, et al. Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial. JAMA. 2004;291(9):1092–1099.
    1. Zhong W, Yu Z, Zeng JX, et al. Celiac plexus block for treatment of pain associated with pancreatic cancer: a meta-analysis. Pain Pract. 2014;14(1):43–51.
    1. Amr YM, Makharita MY. Comparative study between 2 protocols for management of severe pain in patients with unresectable pancreatic cancer: one-year follow-up. Clin J Pain. 2013;29(9):807–813.
    1. Seicean A. Celiac plexus neurolysis in pancreatic cancer: the endoscopic ultrasound approach. World J Gastroenterol. 2014;20(1):110–117.
    1. Puli SR, Reddy JB, Bechtold ML, Antillon MR, Brugge WR. EUS-guided celiac plexus neurolysis for pain due to chronic pancreatitis or pancreatic cancer pain: a meta-analysis and systematic review. Dig Dis Sci. 2009;54(11):2330–2337.
    1. Shwita AH, AMr YM, Okab MI. Comparative Study of the Effects of the Retrocrural Celiac Plexus Block Versus Splanchnic Nerve Block, C-arm Guided, for Upper Gastrointestinal Tract Tumors on Pain Relief and the Quality of Life at a Six-month Follow Up. Korean J Pain. 28(1):22–31.
    1. Wyse JM, Carone M, Paquin SC, Usatii M, Sahai AV. Randomized, double-blind, controlled trial of early endoscopic ultrasound-guided celiac plexus neurolysis to prevent pain progression in patients with newly diagnosed, painful, inoperable pancreatic cancer. J Clin Oncol. 2011;29(26):3541–3546.
    1. Gress F, Schmitt C, Sherman S, Ikenberry S, Lehman G. A prospective randomized comparison of endoscopic ultrasound- and computed tomography-guided celiac plexus block for managing chronic pancre-atitis pain. Am J Gastroenterol. 1999;94(4):900–905.
    1. Gress F, Schmitt C, Sherman S, Ciaccia D, Ikenberry S, Lehman G. Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience. Am J Gastroenterol. 2001;96(2):409–416.
    1. LeBlanc JK, DeWitt J, Johnson C, et al. A prospective randomized trial of 1 versus 2 injections during EUS-guided celiac plexus block for chronic pancreatitis pain. Gastrointest Endosc. 2009;69(4):835–842.
    1. Santosh D, Lakhtakia S, Gupta R, et al. Clinical trial: a randomized trial comparing fluoroscopy guided percutaneous technique vs. endoscopic ultrasound guided technique of coeliac plexus block for treatment of pain in chronic pancreatitis. Aliment Pharmacol Ther. 2009;29(9):979–984.
    1. Sey MS, Schmaltz L, Al-Haddad MA, et al. Effectiveness and safety of serial endoscopic ultrasound-guided celiac plexus block for chronic pancreatitis. Endosc Int Open. 2015;3(1):E56–E59.
    1. Kaufman M, Singh G, Das S, et al. Efficacy of endoscopic ultrasound-guided celiac plexus block and celiac plexus neurolysis for managing abdominal pain associated with chronic pancreatitis and pancreatic cancer. J Clin Gastroenterol. 2010;44(2):127–134.
    1. Minaga K, Kitano M, Imai H, Miyata T, Kudo M. Acute spinal cord infarction after EUS-guided celiac plexus neurolysis. Gastrointest Endosc. 2016;83(5):1039–1040. discussion 1040.
    1. Köker IH, Aralaşmak A, Ünver N, Asil T, Şentürk H. Spinal cord ischemia after endoscopic ultrasound guided celiac plexus neurolysis: case report and review of the literature. Scand J Gastroenterol. 2017;52(10):1158–1161.
    1. Mercadante S, Klepstad P, Kurita GP, Sjøgren P, Giarratano A, European Palliative Care Research Collaborative (EPCRC) Sympathetic blocks for visceral cancer pain management: a systematic review and EAPC recommendations. Crit Rev Oncol Hematol. 2015;96(3):577–583.
    1. Nagels W, Pease N, Bekkering G, Cools F, Dobbels P. Celiac plexus neurolysis for abdominal cancer pain: a systematic review. Pain Med. 2013;14(8):1140–1163.
    1. Bosscher H. Blockade of the superior hypogastric plexus block for visceral pelvic pain. Pain Pract. 2001;1(2):162–170.
    1. Waldman SD, Wilson WL, Kreps RD. Superior hypogastric plexus block using a single needle and computed tomography guidance: description of a modified technique. Reg Anesth. 1991;16(5):286–287.
    1. Plancarte R, Amescua C, Patt RB, Aldrete JA. Superior hypogastric plexus block for pelvic cancer pain. Anesthesiology. 1990;73(2):236–239.
    1. de Leon-Casasola OA, Kent E, Lema MJ. Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Pain. 1993;54(2):145–151.
    1. Plancarte R, de Leon-Casasola OA, El-Helaly M, Allende S, Lema MJ. Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Reg Anesth. 1997;22(6):562–568.
    1. Cariati M, De Martini G, Pretolesi F, Roy MT. CT-guided superior hypogastric plexus block. J Comput Assist Tomogr. 2002;26(3):428–431.
    1. Ghoneim AA, Mansour SM. Comparative study between computed tomography guided superior hypogastric plexus block and the classic posterior approach: a prospective randomized study. Saudi J Anaesth. 2014;8(3):378–383.
    1. Turker G, Basagan-Mogol E, Gurbet A, Ozturk C, Uckunkaya N, Sahin S. A new technique for superior hypogastric plexus block: the posteromedian transdiscal approach. Tohoku J Exp Med. 2005;206(3):277–281.
    1. Gamal G, Helaly M, Labib YM. Superior hypogastric block: transdiscal versus classic posterior approach in pelvic cancer pain. Clin J Pain. 2006;22(6):544–547.
    1. Mishra S, Bhatnagar S, Gupta D, Thulkar S. Anterior ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain. Anaesth Intensive Care. 2008;36(5):732–735.
    1. Mishra S, Bhatnagar S, Rana SP, Khurana D, Thulkar S. Efficacy of the anterior ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain in advanced gynecological cancer patients. Pain Med. 2013;14(6):837–842.
    1. Gofeld M, Lee CW. Ultrasound-guided superior hypogastric plexus block: a cadaveric feasibility study with fluoroscopic confirmation. Pain Pract. 2017;17(2):192–196.
    1. Oh CS, Chung IH, Ji HJ, Yoon DM. Clinical implications of topographic anatomy on the ganglion impar. Anesthesiology. 2004;101(1):249–250.
    1. Scott-Warren JT, Hill V, Rajasekaran A. Ganglion impar blockade: a review. Curr Pain Headache Rep. 2013;17(1):306.
    1. Plancarte R, Amescua C, Patt RB, Allende S. Presacral blockade of the ganglion of Walther (ganglion Impar) J Am Soc Anesthesiol. 1990;73(3A):A751.
    1. Wemm K, Jr, Saberski L. Modified approach to block the ganglion impar (ganglion of Walther) Reg Anesth. 1995;20(6):544–545.
    1. Foye PM, Buttaci CJ, Stitik TP, Yonclas PP. Successful injection for coccyx pain. Am J Phys Med Rehabil. 2006;85(9):783–784.
    1. Huang JJ. Another modified approach to the ganglion of Walther block (ganglion of impar) J Clin Anesth. 2003;15(4):282–283.
    1. Lin CS, Cheng JK, Hsu YW, et al. Ultrasound-guided ganglion impar block: a technical report. Pain Med. 2010;11(3):390–394.
    1. Datir A, Connell D. CT-guided injection for ganglion impar blockade: a radiological approach to the management of coccydynia. Clin Radiol. 2010;65(1):21–25.
    1. Marker DR, U-Thainual P, Ungi T, et al. MR-guided perineural injection of the ganglion impar: technical considerations and feasibility. Skeletal Radiol. 2016;45(5):591–597.
    1. Reig E, Abejón D, del Pozo C, Insausti J, Contreras R. Thermocoagulation of the ganglion impar or ganglion of Walther: description of a modified approach. Preliminary results in chronic, nononcological pain. Pain Pract. 2005;5(2):103–110.
    1. 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):661–666.
    1. Agarwal-Kozlowski K, Lorke DE, Habermann CR, Am Esch JS, Beck H. CT-guided blocks and neuroablation of the ganglion impar (Walther) in perineal pain: anatomy, technique, safety, and efficacy. Clin J Pain. 2009;25(7):570–576.
    1. Demircay E, Kabatas S, Cansever T, Yilmaz C, Tuncay C, Altinors N. Radiofrequency thermocoagulation of ganglion impar in the management of coccydynia: preliminary results. Turk Neurosurg. 2010;20(3):328–333.
    1. Gopal H, Mc Crory C. Coccygodynia treated by pulsed radio frequency treatment to the Ganglion of Impar: a case series. J Back Musculoskelet Rehabil. 2014;27(3):349–354.
    1. Gunduz OH, Sencan S, Kenis-Coskun O. Pain relief due to transsacrococcygeal ganglion impar block in chronic coccygodynia: a pilot study. Pain Med. 2015;16(7):1278–1281.
    1. Adas C, Ozdemir U, Toman H, Luleci N, Luleci E, Adas H. Transsacrococcygeal approach to ganglion impar: radiofrequency application for the treatment of chronic intractable coccydynia. J Pain Res. 2016;9:1173–1177.
    1. Walters A, Muhleman M, Osiro S, et al. One is the loneliest number: a review of the ganglion impar and its relation to pelvic pain syndromes. Clin Anat. 2013;26(7):855–861.
    1. Robbins MS, Robertson CE, Kaplan E, et al. The sphenopalatine ganglion: anatomy, pathophysiology, and therapeutic targeting in headache. Headache. 2016;56(2):240–258.
    1. Berger JJ, Pyles ST, Saga-Rumley SA. Does topical anesthesia of the sphenopalatine ganglion with cocaine or lidocaine relieve low back pain? Anesth Analg. 1986;65(6):700–702.
    1. Levin M. Nerve blocks in the treatment of headache. Neurotherapeutics. 2010;7(2):197–203.
    1. DeMaria S, Jr, Govindaraj S, Chinosorvatana N, Kang S, Levine AI. Bilateral sphenopalatine ganglion blockade improves postoperative analgesia after endoscopic sinus surgery. Am J Rhinol Allergy. 2012;26(1):e23–e27.
    1. Candido KD, Massey ST, Sauer R, Darabad RR, Knezevic NN. A novel revision to the classical transnasal topical sphenopalatine ganglion block for the treatment of headache and facial pain. Pain Physician. 2013;16(6):E769–E778.
    1. Narouze S, Kapural L, Casanova J, Mekhail N. Sphenopalatine ganglion radiofrequency ablation for the management of chronic cluster headache. Headache. 2009;49(4):571–577.
    1. Bratbak DF, Nordgård S, Stovner LJ, et al. Pilot study of sphenopalatine injection of onabotulinumtoxin A for the treatment of intractable chronic cluster headache. Cephalalgia. 2016;36(6):503–509.
    1. Sanghavi PR, Shah BC, Joshi GM. Home-based application of sphenopalatine ganglion block for head and neck cancer pain management. Indian J Palliat Care. 2017;23(3):282–286.

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