Hypogastric Plexus Block – Technique and Overview

Name of Procedure

  • Hypogastric Plexus Block

Sample Opnote

Goal

To block and/or administer medications to hypogastric plexus

Indications

Contraindications

Anatomy

(coming soon…)

Equipment/Skills/Setup

See our disposables/equipment article for “core” supplies that are common to all procedures. Highlights below:

  • Core Equipment
    • c-arm, c-arm compatible bed
  • Core Disposables
    • Procedure tray. As outlined in the above link, core supplies include a pointer, syringes for subcutaneous local, syringe for injectate, drape.

Special items and suggested setup for this procedure (see quick guide video above for example tray prep):

  • 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 primary goal is to 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:

  1. One trajectory runs along the top of the L5 vertebral body
Hypogastric Plexus Block AP and Oblique fluoroscopy
Hypogastric Plexus Block AP and Oblique fluoroscopy
  1. The other is near the bottom of the body, very similar to how we do a lumbar sympathetic block.
Hypogastric Plexus Block AP and Oblique fluoroscopy
Hypogastric Plexus Block AP and Oblique fluoroscopy

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.

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

  1. Pick either side to start on.
  2. 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.
  3. Your entry point is a few cm lateral to the bottom end of the vertebral body:
    1. Anesthetize the skin with the target being the inferolateral corner of the L5 vertebral body.
  4. Insert a 22g x 7″ quincke needle to contact that corner of the vertebral body.
Hypogastric Plexus Block AP and Oblique fluoroscopy
Hypogastric Plexus Block AP and Oblique fluoroscopy – initial needle placement prior to advancing anterior/medial
  1. From there, “walk” off laterally till you can feel/see the needle advance slightly anterior/lateral to the vertebral body.
  2. Then change to a lateral view
  3. 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).
  4. 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
Hypogastric Plexus Block Lateral fluoroscopy before contrast
  1. 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
Hypogastric Plexus Block Lateral fluoroscopy with contrast
  1. The procedure is then repeated on the contralateral side.

Sample Images

Lateral fluoro views showing needle placement and contrast spread

Tips

  1. 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.
  2. Once the needle is past the anterior border of the vertebral body, make small changes.

References