What is the treatment for ganglion impar (Impar ganglion)?

From the Guidelines

The CPT code for ganglion impar block is 64999, which is an unlisted procedure code for the nervous system. This code is used because there is no specific CPT code assigned for ganglion impar blocks. When billing with code 64999, it's essential to include detailed documentation describing the procedure, including approach, imaging guidance used, needle size, medication injected, and medical necessity 1.

Key Considerations

• The ganglion impar block is typically considered for patients with short life expectancy, as the block usually lasts 3-6 months 1.
• This procedure can be used to treat perineal pain, especially in cases of coccydynia, rectal/anal pain, and pelvic pain syndromes.
• The ganglion impar provides sympathetic innervation to the perineum, distal rectum, anus, distal urethra, vulva, and distal third of the vagina.

Billing and Reimbursement

• Some payers may require prior authorization for this procedure, and reimbursement rates vary significantly since it's billed as an unlisted procedure.
• It's crucial to follow the guidelines outlined in the management of cancer pain in adult patients, as stated in the ESMO clinical practice guidelines 1, to ensure proper use of neurolytic blocks, including the ganglion impar block.

Procedure Details

• The procedure typically involves a transsacrococcygeal, paracoccygeal, or intercoccygeal approach, with imaging guidance used, such as fluoroscopy.
• A combination of local anesthetic and steroid is usually injected, and the medical necessity of the procedure must be clearly documented.

From the Research

Ganglion Impar Block

• The ganglion impar, also known as the ganglion of Walther, is a solitary retroperitoneal structure at the level of the sacrococcygeal junction that provides nociceptive and sympathetic supply to the perineal structures 2.
• It is a therapeutic target for the management of chronic pelvic and perineal pain, and can be blocked using a transsacrococcygeal approach or other techniques 3, 4, 2, 5.

Efficacy of Ganglion Impar Block

• Studies have shown that ganglion impar block can be effective in reducing chronic pelvic and perineal pain, with significant pain relief reported in patients with both malignancy-related and non-malignant pain 3, 4, 5.
• The block can provide immediate and transient pain relief, as well as longer-term pain reduction, with some patients experiencing complete and permanent cessation of pain 3, 4.
• The efficacy of the block can be evaluated using various scales, including the Numeric Rating Scale (NRS) and the Visual Analogue Scale (VAS) 3, 4, 2.

Techniques and Safety

• Ganglion impar block can be performed using various techniques, including a transsacrococcygeal approach, and can be done under local anesthesia or with sedation 2, 5.
• The procedure is generally considered safe, with few reported complications, and can be performed on an outpatient basis 2, 5.
• The use of imaging guidance, such as computed tomography (CT) or fluoroscopy, can help to ensure accurate placement of the block 4, 5.

Indications and Patient Selection

• Ganglion impar block is typically considered for patients with chronic pelvic and perineal pain that has not responded to other treatments, including pharmacological management 3, 4, 5.
• Patient selection is important, and the block is usually recommended for patients with a clear diagnosis of chronic pelvic or perineal pain, and who have failed other treatments 5, 6.