Reg Anesth Pain Med: first published as 10.1136/rapm-2022-103582 on 23 June 2022. Downloaded from http://rapm.bmj.
com/ on October 24, 2022 at Ruth Chacon. Protected by copyright.
Original research
Department of Pain Medicine,
University of Health Sciences
Gulhane Training and Research
Hospital, Ankara, Turkey
Correspondence to
Dr Alp Eren Celenlioglu,
Department of Pain Medicine,
University of Health Sciences
Gulhane Training and Research
Hospital, Ankara, Turkey;
​a.​celenlioglu@g​ mail.​com
Received 18 February 2022
Accepted 14 June 2022
Published Online First
23 June 2022
© American Society of Regional
Anesthesia & Pain Medicine
2022. No commercial re-­use.
See rights and permissions.
Published by BMJ.
To cite: Celenlioglu AE,
Sir E. Reg Anesth Pain Med
2022;47:598–603.
598    Celenlioglu AE, Sir E. Reg Anesth Pain Med 2022;47:598–603. doi:10.1136/rapm-2022-103582
Predictive factors affecting treatment success in
ganglion impar block applied in chronic coccygodynia
Alp Eren Celenlioglu ‍ ‍, Ender Sir ‍ ‍
ABSTRACT
Background This study aimed to determine the
predictive factors affecting the success of ganglion impar
block applied in chronic coccygodynia.
Methods Patients who received ganglion impar block
to treat coccygodynia between January 1, 2018 and
January 1, 2021 were retrospectively screened. Of the
195 patients, 102 met the final analysis criteria and were
included in the study. Demographic data, coccygodynia
etiology, coccygodynia symptom duration, history of
coccyx fracture, regular opioid use, and presence of other
musculoskeletal chronic pain conditions accompanying
coccygodynia were obtained from patient records.
In addition, coccyx radiography was examined, and
coccyx curvature type, permanent subluxation, and
posterior spicule presence were evaluated. The criterion
for treatment success was set as ≥50% reduction in
Numerical Rating Scale pain scores in the third month
after treatment.
Results Treatment was successful of the patients in
69.6% (95% CI 60.4% to 78.7%). A significant cut-­off
value (24.5 months) was determined for coccygodynia
symptom duration using receiver operating characteristic
analysis. Symptom duration above the cut-­off value was
defined as prolonged symptom duration. Multivariable
logistic regression analysis was performed to determine
the predictive factors affecting treatment success in
the third month after injection. In the final model, the
presence of permanent subluxation (yes vs no), and the
prolonged symptom duration (yes vs no) were found to
have significant effects on treatment success (OR 9.56,
95% CI 1.44 to 63.40, p=0.02; OR 137.00, 95% CI
19.59 to 958.03, p<0.001).
Conclusion Treatment success of ganglion impar block
for coccygodynia is high. However, longer preprocedure
symptom duration and the presence of permanent
subluxation were associated with a decrease likelihood
of treatment success.
INTRODUCTION
Pain and tenderness caused by the most distal struc-
ture of the spine, the coccyx (tailbone), and the
surrounding anatomical structures is called coccy-
godynia or coccydinia.1 2 Although the incidence
and prevalence of coccygodynia are not clear, the
disease is more common in women than in men.3
Diagnosis is based on patient history, physical
examination, and imaging methods. Physical exam-
ination is focused on sensitivity of the sacrococcy-
geal compound and coccyx. The most common and
typical symptom is increased pain on sitting.4
The etiology of coccygodynia can be classified
as traumatic, idiopathic and malignant origin. The
KEY MESSAGES
⇒ Ganglion impar block is an effective treatment
method in coccygodynia resistant to
conservative treatment.
most common cause, 50%–65%, is direct trauma
to the sacrococcygeal compound and coccyx due to
falls, repetitive microtraumas, or difficult delivery.5
High body mass index (BMI), abnormal mobility
of the coccyx, presence of posterior spicule at the
distal end of the coccyx, and intercoccygeal joint
subluxation have been defined as the risk factors
for the development of coccygodynia.4 6 Postacchini
and Massobrio7 have identified variations in coccy-
geal morphology and have developed a classifica-
tion system accordingly. It has been reported that
type II, III, and IV anatomical variants of the coccyx
are associated with coccygodynia.
Studies in the literature2 6 8 9 have reported that
ganglion impar block (GIB) is a safe and effec-
tive treatment option with low complication rates
in managing chronic refractory coccygodynia.
However, contradicting treatment results have
been reported in patients receiving GIB, which
suggests that various parameters might have an
effect on the treatment outcomes. Although many
risk factors have been associated with the develop-
ment of coccygodynia, few studies have evaluated
the impact of these factors on the success of GIB.6 10
Thus, the effects of various demographic, clinical,
and radiological parameters on the success of GIB in
coccygodynia are yet to be fully elucidated. Hence,
this study aims to determine the predictive factors
affecting the treatment success of GIB applied in
chronic refractory coccygodynia attributed to trau-
matic or idiopathic causes.
METHODS
Study design and study population
Patients who underwent GIB for coccygodynia
treatment in University of Health Sciences Gulhane
Training and Research Hospital, outpatient pain
medicine center between January 1, 2018 and
January 1, 2021 were retrospectively screened.
Out of 195 patients who underwent GIB, 102 were
included in the study based on the screening criteria
(figure 1).
The inclusion criteria were as follows: (1) 18–80
years of age, (2) having coccygodynia due to non-­
malignant causes, (3) presence of coccygodynia
resistant to conservative treatments, such as anal-
gesic drugs and physical therapy modalities, (4)

Figure 1 Flow diagram of the study. GIB, ganglion impar block.
symptoms persisting for>3 months, and (5) Numerical Rating
Scale (NRS) pain score≥4.
The exclusion criteria were as follows: (1) receiving multiple
GIBs within a year, (2) having undergone coccygectomy or
anorectal or perineal surgery, (3) lack of medical records or
absence of coccyx radiography.
Data collection and assessment
Demographic data, including sex, age, and BMI, were obtained
from standard patient evaluation forms. In addition, clinical
data on symptom duration, cause of coccygodynia, history of
coccyx fracture, regular opioid use, and musculoskeletal chronic
pain conditions accompanying coccygodynia (MCPCAC) were
obtained. Malignant coccygodynia cases were not included in
the study, and the causes of coccygodynia were classified as
traumatic (due to falls, birth) and idiopathic. Having at least
MCPCAC was identified by an NRS pain score of ≥4 and the
condition persisting for at least 3 months.
As per the routine practices in our clinic, the patients were
evaluated before the procedure and in the third week and third
month after the procedure. Pain symptoms were assessed with
NRS (0–10, verbal). NRS scores before, 3 weeks, and 3 months
after the procedure were obtained from the medical records.
Treatment success was defined as a≥50% decrease in the NRS
scores compared with baseline.
Radiological assessment
Radiological evaluations were made by a radiologist with ample
experience in musculoskeletal radiology. Anteroposterior and
lateral coccyx X-­rays were acquired in a standing position. The
variations in coccyx curvature were radiographically classified
into four types as described by Postacchini and Massobrio.7 This
Celenlioglu AE, Sir E. Reg Anesth Pain Med 2022;47:598–603. doi:10.1136/rapm-2022-103582
Reg Anesth Pain Med: first published as 10.1136/rapm-2022-103582 on 23 June 2022. Downloaded from http://rapm.bmj.com/ on October 24, 2022 at Ruth Chacon. Protected by copyright.
Original research
Figure 2 According to the modified Postacchini and Massobrio
classification, coccygeal curvature variations are classified into six types.
Curvature types according to this classification are shown in the figure.
classification was then extended by Nathan et al to include type
5 and type 6 categories.11 The modified classification by Nathan
et al was employed for the radiographic evaluation in this study.
According to this classification, the type 1 coccyx has a partial
(very mild) curvature that follows the curvature of the sacrum.
Since the curvature is mild, the coccyx extends to the caudal. In
the type 2 coccyx, ventral spinning is more pronounced and, thus,
the coccyx is directed toward the anterior. In the type 3 coccyx,
there is acute anterior angling in the coccyx but no subluxation.
In the type 4 coccyx, there is anterior angling as well as sublux-
ation. In the type 5 coccyx, there is posterior angling. In the type
6 coccyx, there is scoliotic curvature or lateral deviation in the
coccyx (figure 2).11 The presence of permanent sacrococcygeal
or intercoccygeal subluxation and posterior bony spicule was
also evaluated in radiological assessment.7
Treatment protocol
GIB was applied using a transcoccygeal approach. After vascular
access was established, the patient was taken to the operating
room and monitored. The patient was then placed in the prone
position. Antisepsis was achieved with povidone iodine, and the
patient was covered in sterile fashion. Coccyx was displayed in
the anteroposterior and lateral axes with fluoroscopy (Ziehm
Vision FD). Skin anesthesia was provided with 2 cc (2%) lido-
caine. Entry point was identified on the skin at the first inter-
coccygeal joint. Transdiscal entry was performed at the first
intercoccygeal joint with a 22 G 3.5-­ inch Quincke needle
guided by intermittent imaging. The patient was given 1 cc of
iohexol to confirm the location of the needle tip. The spread
of the contrast agent in the shape of a ‘reverse comma’ was
confirmed, and there was no vascular spread. Subsequently, 40
mg of triamcinolone acetonide, 3 cc of 0.5% bupivacaine, and
1 cc of saline mixture was injected. After the procedure, the
patients were followed up for 1 hour in the postanesthesia care
unit for possible complications. Patients with no complications
were discharged.
599

Original research
Statistical analysis
Descriptive statistics were presented as mean, SD, median, and
IQR. Shapiro-­Wilks test was used to check whether the data
conformed to normal distribution. Successful treatment group
and unsuccessful treatment group were compared statistically.
Independent samples t-­test was used for variables with normal
distribution and Mann-­Whitney U test was used for variables
with non-­normal distribution. The effect of each demographic,
clinical, and radiological characteristic was examined individu-
ally. In addition, the relationship between GIB success and cate-
gorical characteristics of the patients was evaluated by Pearson
χ2 test. A significant cut-­off value was determined for coccygo-
dynia symptom duration using receiver operating characteristic
(ROC) analysis. Symptom duration above the cut-­off value was
defined as prolonged symptom duration. Thus, symptom dura-
tion was transformed into a categorical variable (prolonged
symptom duration, yes vs no). After these evaluations, multiple
binary logistic regression analysis was used to investigate the
Reg Anesth Pain Med: first published as 10.1136/rapm-2022-103582 on 23 June 2022. Downloaded from http://rapm.bmj.com/ on October 24, 2022 at Ruth Chacon. Protected by copyright.
combined effect on treatment success. Covariates included in
the model were determined by a p≤0.10. Age and sex were also
included based on their biologic importance in health outcomes.
A p<0.05 was accepted as statistically significant. SPSS (V.25)
program was used for statistical analyses.
RESULTS
Of the 195 patients who underwent GIB, 172 met the inclusion
criteria. A total of 70 patients were excluded from the study,
of which 22 patients received more than one GIB in 1 year, 5
patients with a history of coccygectomy or anorectal surgery,
and 43 patients were due to lack of medical records. A total of
102 patients (76 women, 26 men) were included in the analysis
(figure 1). Treatment was successful in 69.6% (71) of the patients
and treatment was unsuccessful in 30.4% (31) of the patients at
month 3.

Table 1 Patient and procedural characteristics

P
Treatment success value*†
Unsuccessful Successful
Sample size, n 31 71
Sex, n (%) Female 24 (31.6) 52 (68.4) 0.65
Male 7 (26.9) 19 (73.1)
Age Mean age (SD) in years 46.8 (13.7) 41.5 (12.1) 0.053
Medain age (IQR) in years 47.0 (37.0–55.0) 40.0 (33.0–50.0)
BMI Mean BMI (SD) in kg/m2 27.8 (6.7) 26.6 (4.1) 0.36
Prolonged symptom duration, n (%) No (symptom duration less than 24.5 months) 4 (5.9) 64 (94.1) <0.001
Yes (symptom duration longer than 24.5 months) 27 (79.4) 7 (20.6)
Etiology of coccygodinia, n (%) Idiopathic 11 (34.4) 21 (65.6) 0.76
Fall 19 (29.2) 46 (70.8)
Delivery 1 (20.0) 4 (80.0)
Opioid use, n (%) Absence 25 (26.9) 68 (73.1) 0.01
Presence 6 (66.7) 3 (33.3)
MCPCAC, n (%) Absence 19 (24.1) 60 (75.9) 0.01
Presence 12 (52.2) 11 (47.8)
Coccyx curvature types, n (%) 1 13 (36.1) 23 (63.9) 0.29
2 8 (38.1) 13 (61.9)
3 7 (36.8) 12 (63.2)
4 6 (33.3) 12 (66.7)
5 2 (33.3) 4 (66.7)
6 1 (50.0) 1 (50.0)
Posterior spicule, n (%) Absence 31 (31.6) 67 (68.4) 0.17
Presence 0 (0.0) 4 (100.0)
Permanent SC or IC subluxation, n (%) Absence 18 (23.4) 59 (76.6) <0.01
Presence 13 (52.0) 12 (48.0)
Coccyx fracture history n (%) Absence 26 (28.6) 65 (71.4) 0.25
Presence 5 (45.5) 6 (54.5)
Pain intensity Mean preprocedure NRS (SD) 7.8 (1.3) 7.6 (1.3) 0.36
Medain preprocedure NRS (IQR) 8.0 (7.0–9.0) 8.0 (7.0–8.0)
Mean NRS week 3 (SD) 5.7 (2.4) 1.1 (1.2) <0.001
Medain NRS week 3 (IQR) 6.0 (5.0–7.0) 1.0 (0.0–2.0)
Mean NRS month 3 (SD) 6.7 (1.9) 1.5 (1.3) <0.001
Median NRS month 3 (IQR) 7.0 (5.0–8.0) 2.0 (0.0–2.0)
Test used: Pearson χ2 test for categorical variables and Independent samples t-­test for numerical variables.
*P value compares treatment success, unsuccessful versus successful.
†Bold P values belong to the variables with statistically significant difference between the groups (p<0.05).
BMI, body mass index; IC, intercoccygeal; MCPCAC, musculoskeletal chronic pain conditions accompanying coccygodynia; NRS, Numerical Rating Scale; SC, sacrococcygeal.

600 Celenlioglu AE, Sir E. Reg Anesth Pain Med 2022;47:598–603. doi:10.1136/rapm-2022-103582
 Reg Anesth Pain Med: first published as 10.1136/rapm-2022-103582 on 23 June 2022. Downloaded from http://rapm.bmj.com/ on October 24, 2022 at Ruth Chacon. Protected by copyright.
Original research
terminal urogenital organs.9 GIB is used in the pain syndromes
Table 2 Exploration of predictive factors affecting treatment success
of these regions, it is also well established that the GIB is a safe
in the third month after ganglion impar block
and effective treatment method for coccygodynia.2 6 8 9 The
95% CI for OR innervation of the coccyx is very rich and complex, and the
Lower Upper OR* P value† mechanism of action in the treatment of coccygodynia of GIB
Sex 0.24 8.79 1.47 0.67 has not yet been clarified, since the neural pathways forming
Age 0.94 1.07 1.00 0.83 the ganglion impar have not been fully defined.12 13 However, it
MCPCAC (yes vs no) 0.05 1.70 0.31 0.17
is known that the sympathetic nervous system has an important
role in pain pathways at many levels of the neuraxis. Some
Permanent SC or 1.44 63.40 9.56 0.02
IC subluxation (yes experimental studies even suggest that the sympathetic nervous
vs no) system may control peripheral inflammation and nociceptive
Prolonged symptom 19.59 958.00 137.00 <0.001 activation.14 In coccygodynia, chronic irritation of the coccy-
duration of geal nerves causes increased sensitivity of the ganglion impar
coccygodinia (yes and somatosensory system.15 Injection given during GIB may
vs no) provide a secondary effect by blocking the anterior branches of
Regular opioid use 0.23 90.27 4.63 0.31 the coccygeal nerves running on the anterior aspect of the sacro-
(yes vs no) coccygeal junction.16 Steroids and local anesthetics are used to
*ORs are reported as the likelihood of treatment success with presence of suppress the inflammatory response due to chronic irritation
permanent subluxation or longer than 24.5 months for symptom duration. Presence and reduce pain in GIB. Local anesthetics block sodium chan-
of permanent subluxation and longer than 24.5 months of symptom duration of nels and cause a reversible loss of nociception by blocking nerve
coccygodynia reduce the likelihood of treatment success by 9.56 times and 137
times, respectively.
membrane excitability and action potentials.17 Furthermore,
†Bold P values belong to variables that have a statistically significant effect on local anesthetics have an anti-­inflammatory effect and, when
treatment success (p<0.05). injected around the neural structure, can ‘wash-­out’ inflamma-
IC, intercoccygeal; MCPCAC, musculoskeletal chronic pain conditions accompanying tory substances from the environment.18 19 Corticosteroids also
coccygodynia; SC, sacrococcygeal. have strong anti-­ inflammatory effects. Moreover, they cause
membrane stabilization, inhibition of neuropeptide synthesis
and blockade of ectopic signals.2 20 It is even possible that corti-
The descriptive characteristics of the patients in both groups costeroids and local anesthetics both suppress sensitization of
are given in table 1. Before GIB, the mean NRS pain score was chronic pain signals that cause neuroplasticity.20 Even though a
7.6 (7–8) in the successful treatment group and 7.8 (7–9) in precise duration cannot be determined, it can be predicted that
the unsuccessful treatment group (p>0.05). Three weeks after the combined use of steroids and local anesthetics will provide
GIB, the mean NRS score was 1.1 (0–2) in the successful treat- prolonged pain relief.
ment group and 5.7 (5–7) in the unsuccessful treatment group Although GIB has been reported to be an effective and reliable
(p<0.001). Three weeks after GIB, the mean NRS score was treatment for coccygodynia, there are limited studies6 10 evalu-
1.5 (0–2), in the successful treatment group and 6.7 (5–8) in the ating the predictive factors for treatment response. In a retro-
unsuccessful treatment group (p<0.001) (table 1). spective study, Sencan et al6 performed dynamic radiographic
There was a significant difference between the groups in terms evaluations on 37 patients and examined the effect of coccygeal
of regular opioid use, the presence of MCPCAC, and the presence dynamic pattern on GIB. The researchers reported no difference
of permanent subluxation (p<0.05) (table 1). In the ROC anal- between the groups in terms of treatment success in patients
ysis, the significant cut-­off value for the coccygodynia symptom with normally mobile coccyx and immobile coccyx. However,
duration was 24.5 months. According to this, symptom duration no studies have examined the effects of individual sacrococcy-
longer than 24.5 months was defined as prolonged symptom geal anatomical differences evaluated by static radiography on
duration. A significant difference was found between the groups treatment success. In the present research, the types of sacrococ-
in terms of prolonged symptom duration (p<0.001) (table 1). cygeal curvatures, permanent subluxation, and posterior bony
Although there was a significant difference between the two spicule, which are risk factors for coccygodynia development,
groups in terms of MCPCAC and opioid use, the adjusted effect were evaluated radiographically.7 21 It was found that curvature
was insignificant. In the final model, the presence of permanent types and the presence of posterior bony spicule had no effect on
subluxation (yes vs no), and the prolonged symptom duration treatment success. However, permanent subluxation was identi-
(yes vs no) were found to have statistically significant effects on fied as a predictive factor for treatment success. This observa-
treatment success (OR 9.56, 95% CI 1.44 to 63.40, p=0.02; OR tion may be due to the fact that deterioration is not expected
137.00, 95% CI 19.59 to 958.03, p<0.001) (table 2). in the distribution of material injected into the impar ganglion
located on the anterior side of the sacrococcygeal region in the
DISCUSSION presence of bony spicule and in different curvature variants.
In this study, the effects of various demographic, clinical, and However, the reason for the low success of the treatment in the
radiological characteristics on the response to GIB in patients presence of sacrococcygeal and/or intercoccygeal subluxation
with chronic refractory coccygodynia attributed to non-­ may be that the anatomical localization of the impar ganglion
malignant causes were investigated. The presence of permanent was affected and the injected material did not reach the target
subluxation, and the longer preprocedure symptom duration area in sufficient amount due to a backward or lateral leak. Datir
were determined to be the predictive variables for treatment et al22 performed CT-­guided GIB to the patients in their study
success. and determined the ganglion impar location in all blocks and
The ganglion impar is the terminal solitary ganglion of bilateral visualized the filling defect around the ganglion after contrast
paravertebral sympathetic chains, located in the retroperitoneal agent injection. Therefore, it can be possible to clearly evaluate
region, at the sacrococcygeal junction or coccyx.1 It provides whether the injected material reaches the ganglion in the pres-
nociception and sympathetic innervation of the perineum and ence of subluxation, with CT-­guided GIB studies.
Celenlioglu AE, Sir E. Reg Anesth Pain Med 2022;47:598–603. doi:10.1136/rapm-2022-103582 601

Original research
In a retrospective study of 102 patients, Kim et al10 reported
that demographic data, including age, sex, and BMI, had no
impact on the treatment success. Sencan et al6 also noted no
correlation between treatment success and age, sex, and BMI.
Consistent with the literature, the results of this study also
showed that demographic characteristics had no effect on treat-
ment success.
In the study by Sencan et al,6 the pain scores were found to
be higher in the third month after GIB in the group with a long
symptom duration, although not statistically significant. In the
present research, the effect of prolonged symptom duration on
treatment success was found to be statistically significant. This
result may be due to the fact that the difference in the mean
symptom duration between the successful and unsuccessful
treatment groups in this study was larger than that in the study
by Sencan et al,6 furthermore, the sample size was larger in our
study. It has been suggested that if chronic pain is not adequately
managed, time-­ dependent neuroplastic restructuring with the
potential to become irreversible occurs in the brain and the
pain may acquire a refractory character.23 24 Consistent with the
literature, treatment success was poor in patients with a long
symptom duration.
GIB was first described by Plancarte et al.25 In this technique,
the needle tip is advanced through the anococcygeal ligament
to the anterior surface of the sacrococcygeal ligament, but has
significant risk of rectal perforation.26 Paramedian double bent-­
needle approach has also been used for GIB in the past, but now
it’s not chosen because of its technical difficulty.27 Although
several other approaches for GIB have been described in the
literature, recently fluoroscopy-­guided transsacrococcygeal and
transcoccygeal approaches are the most frequently preferred
methods.2 8 13 21 However, transsacrococcygeal GIB applica-
tion may be difficult due to the high rate of fusion (51%) and
degenerative changes in the sacrococcygeal joint and frequent
calcification of ligaments around the joint.8 26 28 A rudimen-
tary intervertebral disc exists between coccyx 1 and coccyx
2.29 Therefore, it may be a site with higher potential for ease
of application than the transsacrococcygeal approach. Over and
above, human cadaver studies showed that the ganglion impar
is often localized in the upper coccyx rather than at the level
of the sacrococcygeal joint.28 For these reasons, the transcoccy-
geal approach was preferred instead of the transsacrococcygeal
approach for GIB in the study.
GIB was first used to treat coccygodynia of malignant origin
and is still used successfully in this patient group.10 Afterwards,
it was also started to be used in the treatment of non-­malignant
chronic coccygodynia, and its effectiveness has been well docu-
mented in many studies.2 6 8 9 Neuropathic components are very
high in malignant patients, and it is thought that the pain of
different regions in case of metastasis may have a great effect on
the patient’s pain perception. Therefore, to obtain a homoge-
neous study group, patients with traumatic and idiopathic coccy-
godynia were included, while patients with malignant origin
were excluded from the study. Furthermore, several clinical, and
radiological parameters were included in the evaluation, which
strengthened the results. To the best of our knowledge, this is
the first study to evaluate the effect of coccygeal curvature vari-
ances, permanent subluxation, and presence of posterior spicule
on treatment success. On the other hand, the limitations of the
study were its retrospective design, short follow-­up period, and
the lack of radiographic evaluation of the coccygeal dynamic
pattern. Besides, the lack of evaluation of the pattern of contrast
spread after injection is a significant limitation given its impor-
tance to determine validity of the intervention. Further studies
602 Celenlioglu AE, Sir E. Reg Anesth Pain Med 2022;47:598–603. doi:10.1136/rapm-2022-103582
Reg Anesth Pain Med: first published as 10.1136/rapm-2022-103582 on 23 June 2022. Downloaded from http://rapm.bmj.com/ on October 24, 2022 at Ruth Chacon. Protected by copyright.
can be conducted to evaluate whether there is sufficient spread
to ganglion impar during GIB in the presence of anatomical vari-
ation in the sacrococcygeal region.
CONCLUSION
In this study, longer preprocedure symptom duration, and
presence of permanent subluxation were identified as the
independent predictive factors for the success of GIB. These
results are likely to aid in the decision making regarding the
use of GIB in patients with chronic coccygodynia. Taking these
predictive factors into consideration in treatment decisions
can reduce the number of unnecessary procedures and avoid
the possible complications and unnecessary costs associated
with the intervention.
Acknowledgements We thank Assoc. Prof. Sinan Akay, MD for his valuable
contribution to the radiological evaluation of study patients.
Contributors All authors contributed to the study conception and design. Material
preparation, data collection and analysis were performed by AEC and ES. The
manuscript was written by AEC and ES. All authors read and approved the final
manuscript. AEC is responsible for the overall content as guarantor.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests None declared.
Patient consent for publication Not applicable.
Ethics approval In accordance with the routine practices of our clinic, written
and oral consents were obtained from all patients before GIB. The study protocol
was approved by the Institutional Ethics Committee (No: 2021/360). The study was
conducted in accordance with the principles of the Declaration of Helsinki revised in
2013.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available.
ORCID iDs
Alp Eren Celenlioglu http://orcid.org/0000-0001-8979-0392
Ender Sir http://orcid.org/0000-0003-2628-135X
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