Superior Hypogastric Nerve Block

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Overview

Superior hypogastric block (SHNB) or superior hypogastric plexus neurolysis is a less common interventional procedure. The procedure is commonly used in the setting of a temporary nerve block for patients undergoing uterine fibroid embolization. Additionally, SHNB or neurolysis can be using in the setting of pain management for visceral pain related to pelvic malignancy. SHNB is utilized to reduce the amount of narcotics and antiemetics needed following uterine fibroid embolization. There are multiple different approaches for a superior hypogastric nerve block. Understanding the anatomy and basic fluoroscopic needle placement techniques are the foundation for safely accessing the superior hypogastric plexus (SHP). Pain regimens vary between operators but having a firm understanding of the patient's pain and the mechanism of action of the administered drugs is critical for maximizing effectiveness of this procedure.

Pre-Procedure Prep

Indications

• Intraoperative pain control for uterine artery embolization
• Intractable pain related to pelvic neoplasm, endometriosis, etc.

Contraindications

• Uncorrected coagulopathy
• Allergy

Superior Hypogastric Nerve Block Procedure Steps

Positioning

Supine or prone

Procedure often performed in setting of uterine fibroid embolization

• If femoral access, helpful to advance catheter to contralateral internal iliac artery to delineate aortic bifurcation
• If radial access, can use contrast injection to outline the bifurcation
Infraumbilical abdomen prepped
Needle: 15 cm, 20-25g Chiba or spinal needle

Target

• Midline; lower half of L5 vertebral body
• Flatten the endplates of L5 using caudal tilt
• Advance needle to periosteum of L5 vertebral body
• Avoid disc
Collimate and use hemostats to avoid fluoroscopic exposure to hands

Confirm Position

• Lateral view
• Inject contrast: retroperitoneal, nonvascular

Medication Administration

• 3 way stopcock and microbore connection tubing helpful
• 15-25 mL of long acting anesthetic such as 0.5% Ropivacaine, 0.25% Bupivacaine, 0.5% Bupivacaine
• Maintain gentle forward pressure of needle
Remove needle

Post-Procedure

Complications

• Intravascular injection resulting in cardiac arrest or seizure
• Bowel or vascular injury
• Infection: discitis
• Bleeding
• Major complications uncommon

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Join The Discussion

References

[1] Pereira K, Morel-Ovalle LM, Taghipour M, Sherwani A, Parikh R, Kao J, Vaheesan K. Superior hypogastric nerve block (SHNB) for pain control after uterine fibroid embolization (UFE): technique and troubleshooting. CVIR Endovasc. 2020 Sep 27;3(1):50. doi: 10.1186/s42155-020-00141-2. PMID: 32886271; PMCID: PMC7474042.
[2] Yoon J, Valenti D, Muchantef K, et al. Superior Hypogastric Nerve Block as Post-Uterine Artery Embolization Analgesia: A Randomized and Double-Blind Clinical Trial. Radiology. 2018;289(1):248-254.
[3] Spencer EB, Stratil P, Mizones H. Clinical and periprocedural pain management for uterine artery embolization. Semin Intervent Radiol. 2013;30(4):354-63.
[4] Rasuli P, Jolly EE, Hammond I, et al. Superior hypogastric nerve block for pain control in outpatient uterine artery embolization. J Vasc Interv Radiol. 2004;15(12):1423-9.

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