Technique of Superior Hypogastric Plexus Block

The patient is positioned on the fluoroscopy table in prone position. Using fluoroscopic guidance, the L4-5 spinal process is identified. Going laterally, a 7-cm skin marker is made and this will be the point of needle entry. The lumbarsacral area is prepped and draped in a sterile manner. Multiple approaches have been described, including a lateral approach, medial approach, and the intradiskal approach - the approach that is most often used is the lateral approach (Figure 9-4.2). At 7-cm lateral to the L4-5 interspace, the skin and deeper tissue and muscles are infiltrated with lidocaine 0.5% using a 20-gauge 6-in needle. The needle is directed 45 degrees medially and cau-dally to miss the transverse process of L5 and the sacral ala on anteroposterior (AP) fluoroscopy view (Figure 9-4.3). The needle must be more than 1 cm from the bony outline. On the lateral view, the needle tip should be at the anterior

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Figure 9-4.2. Lateral view of superior hypogastric block.

surface of the junction of L5-S1. It is further advanced, and loss of resistance usually occurs at this point. Confirmation of the location of the needle is done with injection of radio-opaque dye and the spread is followed both in AP and lateral views. After confirmation of the position of the needle and negative blood aspiration, a test dose of bupi-vacaine 0.375% (2-3mL) is injected. Patient evaluation is done a few minutes after the injection, to confirm there is no sensory or motor blockade. A total of 12 to 15 mL of bupivacaine 0.375% is injected with intermittent aspiration. The block is performed unilaterally or bilaterally depending on the patient's symptoms. Patients usually get pain relief in 15 to 20 minutes. The patient is subsequently monitored in the postanesthesia care unit for the duration of pain relief, which should be for several hours. If it is short-lived (15-30 minutes), it is usually a placebo effect. CT guidance can be used for this block.2

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