Hypogastric Plexus Block - Technique and Overview

Table of Contents

Name of Procedure

Hypogastric Plexus Block

Sample Opnote

Goal

To block and/or administer medications to the hypogastric plexus

Indications

(coming soon)

Contraindications

Common contraindications

Anatomy

The superior hypogastric plexus is a confluence of the lumbar sympathetic chains and comes together just anterior to the L5 and S1 bodies. It innervates the pelvic viscera:

Note that this diagram shows a sample needle trajectory in yellow that is similar to what is demonstrated below. However, this yellow arrow ends slightly inferior to what is described below.

Equipment/Skills/Setup

Core Equipment/Disposables: See our disposables/equipment article for “core” items that are common to all procedures.

Core Skills: See our guides to obtain images of the cervical, thoracic, or lumbar spine. Then steer a needle to direct it under the skin.

Special items and suggested setup for this procedure:

22g x 7″ quincke needle as your primary needle (x2)
3cc contrast in a 3cc syringe
10cc 0.25% bupivacaine in a 10cc syringe for injectate
3cc 1% lidocaine in a 5cc syringe attached to a 25g x 1.5″ hypodermic needle for subcutaneous local anesthetic

Landmarks and Patient Positioning

Position the patient in a basic prone position so that the bottom of the c-arm can go under the table below the area of the spine that is being treated (L5).

The goal:
- land the needle tip at the anterior border of L5 on a lateral view
- and between the lateral and midline border of the vertebral body on an AP view.
- and then do the same thing on the contralateral side.

Different trajectories can get you here:

One trajectory runs along the top of the L5 vertebral body:

Hypogastric Plexus Block AP and Oblique fluoroscopy

The other is near the bottom of the body, very similar to how we do a lumbar sympathetic block.

The difference between this procedure and a LSB is that the iliac crest gets in the way of the needle path. This often leaves a narrow path to the bottom of the vertebral body and sometimes means you don’t use as oblique of a view as you might for a LSB (the more oblique the view the more the iliac crest closes off that path). Note the narrow window in which to reach the bottom of the vertebral body, causing you to steer anterior after passing over the crest.

Hypogastric Plexus Block AP and Oblique fluoroscopy annotated borders — Hypogastric Plexus Block AP and Oblique fluoroscopy – initial needle placement prior to advancing anterior/medial

We’ll run through an example assuming that you can target the inferior border of the vertebral body, but you’ll adjust your entry point and target based on patient specific anatomy.

Technique

Pick either side to start on.
Obtain a scotty-dog view on the side being treated
1. From here further oblique rotation might be useful, but will be limited by the iliac crest as discussed above.
Your entry point is a few cm lateral to the infero-lateral corner of the vertebral body:
1. Anesthetize the skin with the target being the inferolateral corner of the L5 vertebral body.
Insert a 22g x 7″ quincke needle to contact that corner of the vertebral body.

From there, “walk” off laterally till you can feel/see the needle advance slightly anterior/lateral to the vertebral body.
Now change to a lateral view
Continue to advance the needle with a lateral-to-medial and anterior-to-posterior trajectory (Imaging you’re trying to wrap the needle around the vertebral body).
Keep advancing till the needle tip is just a few millimeters past the anterior border of the vertebral body.

Hypogastric Plexus Block Lateral fluoroscopy before contrast

Once in position, aspirate to ensure that no blood returns
1. Inject contrast under live fluoroscopy. This is to look for superior-inferior spread and to exclude vascular uptake.
2. Once you confirm it’s appropriate spread you can inject your primary medication (we often use ~10mL of 0.25% bupivacaine).
3. This can be done slowly and with with frequent aspiration.

Hypogastric Plexus Block Lateral fluoroscopy with contrast

The procedure is then repeated on the contralateral side.

Sample Images

Lateral fluoro views showing needle placement and contrast spread

Tips

Starting with a far lateral needle entry point helps by giving you a more lateral to medial needle direction. So that by the time the needle is sufficiently anterior, it will also be sufficiently medial.
1. This is just like a lumbar sympathetic block, but as noted above, you may be limited by how far lateral you can start and still not hit the iliac crest.
Once the needle is past the anterior border of the vertebral body, make small changes.

References