Pudendal Nerve Block
: Pudendal nerve block is indicated for diagnostic, as a part of essential diagnostic criteria (Nantes criteria), and for treatment of pudendal neuralgia.
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Nantthasorn Zinboonyahgoon and Assia T. Valovska
Indications: Pudendal nerve block is indicated for diagnostic, as a part of essential diagnostic criteria (Nantes criteria), and for treatment of pudendal neuralgia. Anatomy: Pudendal nerve arises from S2 to S4 sacral nerve roots and travels inferiorly to exit the pelvic through the greater sciatic foramina, just inferior to the piriformis muscle. The nerve passes posterior to the ischial spine, along with internal pudendal artery, between sacrospinous ligament (anterior) and sacrotuberous ligament (posterior). It reenters pelvic through lesser sciatic foramen then pass through Alcock’s canal. Finally, it terminates into three branches: inferior rectal nerve (perianal sensation), peroneal nerve (perineum and posterior surface of scrotum/labia sensation), and dorsal nerve of the penis/clitoris (penis/clitoris sensation). Procedure: Pudendal nerve block can be attained by transvaginal/transrectal approach,
fluoroscopic or ultrasound-guided transgluteal approach, or fluoroscopic-guided transsacral S2– S4 block. No need for IV or antibiotic for the procedure.
Transvaginal/Transrectal Approach Patient is in lithotomy position, and the ischial spine is palpated through the vaginal wall (female) or rectal wall (male). Needle is advance through the vaginal wall or perianal area along with the guided finger. Ten to fifteen ml of local anesthetics is injected just posterior to ischial spine. However, this conventional technique inherits risk of accidental puncture of needle to physician and patient discomfort.
Fluoroscopic-Guided Transgluteal Approach CPT64430 N. Zinboonyahgoon, MD (*) Department of Anesthesiology, Siriraj Hospital, Mahidol University, 2 Phranok road, Siriraj, Bangkoknoi, Bangkok 10700, Thailand e-mail: [email protected] A.T. Valovska, MD Department of Anesthesiology, Perioperative and Pain medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA e-mail: [email protected]
1. Patient is in prone position, C-arm is set in AP view until pelvic inlet is visualized, and then highlight the ischial spine by 5–15° ipsilateral angulation of the C-arm (Fig. 94.1). 2. A 22 G spinal needle advances perpendicularly to C-arm aim at the tip of ischial spine. 3. Remove the stylet and check for negative aspiration for blood; inject 0.5 ml of contrast media to check the spread.
© Springer International Publishing Switzerland 2017 R.J. Yong et al. (eds.), Pain Medicine, DOI 10.1007/978-3-319-43133-8_94
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N. Zinboonyahgoon and A.T. Valovska
Fig. 94.1 Oblique view of pelvis—the needle tip points at ischial spine
4. After satisfied with needle position and spread, inject 3–4 ml of local anesthetics + − steroid as a final step.
identified as thin parallel line superficial to Sp, but deep to gluteus maximus. Pudendal nerve and artery lie in plane between the two ligaments (Fig. 94.3). 4. Insert 100 mm echogenic needle, in plane, Ultrasound-Guided Transgluteal aims at the plane between the ligaments. Inject some local anesth
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