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Celiac Plexus Neurolysis


Medical editor Arve Nordbø
Cand.med.
Anesthesiology
Specialist in pain management
Oslo University Hospital

General

Neurolytic procedures can produce long-term blocking by destroying nerve tissue. This kind of nerve blockage lasts until the nerves regenerate. Pain is not only conducted by the afferent and sensory nerve fibers, but also the sympathetic nerve system. Most neurolysis procedures are directed toward the sympathetic nerve structures.

Today, by means of CT guidance, the neurolytic drug can be injected with high precision with a minimal risk of exposing the surrounding structures to the neurolytic chemicals. CT guidance also provides for a better possibility for optimal placement of the needle in cases where tumor masses have changed the normal anatomical conditions of the retroperitoneal room. The procedure is performed in cooperation with interventional radiologists.

Invasive techniques still play an important role in treating cancer pain in a correct selected group of patients. The quality of the blockages increases when the procedure is guided by imaging and with the help of an interventional radiologist. Neurolytic blockades should never be considered an isolated treatment form, but as part of a broader treatment strategy, where one of the goals is to reduce the need of strong opioids and other analgesic.

Celiac plexus neurolysis is the most common neurolytic blockage for patients with pain associated with cancer. It has been shown that patients with pancreatic cancer can obtain significant pain relief from a single (sympathetic nerve) blockade for the remainder of their life, on condition that distribution to sympathetic nerves are satisfactory.

Access to the celiac plexus is reached by:

  • Posterior antecrural or retrocrural access. May be done with C-bow, but preferably CT.
  • Endoscopic ultrasound-guided access (via gastroscopy with ultrasound.)
  • Open abdominal.  Neurolysis can be performed preoperatively (in connection to exploratory laparotomy.)

Indications

Pain, often deep, diffuse and localized to the upper abdomen with radiating pain to the back. This treatment is primarily for patients with pancreatic cancer, but also those with malignant tumors in the upper abdomen, suffering from visceral pain, may benefit from this blockage.

Refractory nausea for the same patient group.

Neurolysis of the celiac plexus (sympathetic nerves) may be appropriate for different cancer types in the upper abdomen, but is mostly utilized for pancreatic cancer. Visceral pain is the one that can be alleviated by this blockade. Sensory and sympathetic nerve fibers from all organs in the upper part of the abdominal cavity, including bowel up to and including proximal part of colon, goes through the celiac plexus.

Goals

Improved pain control and reduced side effects from opioid pain relievers due to dosage reduction.




Equipment

  • Needles (22 G) and equipment for local anesthesia.
  • Contrast medium to confirm correct position before the neurolysis.
  • Local skin anesthetic also for testing effect ahead of the neurolysis.
  • Alcohol, concentration minimum 50%.
  • Intensive care with vital signs (pulse rate, blood pressure, EKG and SaO2).
  • Medications for sedation and pain relief.

Preparation

  • Blood tests: INR, thrombocytes and  hematological tests, leukocytes, CRP, electrolytes and kidney function.
  • Agreement for possible cessation of anticoagulants and antiplatelet agents is made individually.
  • Any fasting ahead is agreed individually for each patient. Some sedation is common in addition to local anesthesia. If the patient requires deep sedation/sleep, fasting for 6 hours before the procedure is necessary.
  • Prone, supine, or lateral position. Anterior access is primarily used when the patient cannot lie on their abdomen or the lateral decubitus position or when anatomical conditions do not allow posterior access.

Implementation

The celiac plexus (sympathetic nerve fibers) lies retroperitoneal at the level of the L1 vertebra. The fibers are arranged as a network in front of the aorta and around the celiac trunk.

  • With the patient in the prone or lateral position, the needle is inserted at level of the T12 and L1 vertebrae using local anesthesia.
  • The direction of the needle is guided by CT. The needle is guided a few cm to the side of the midline on each side of the spine with the tip close to both sides of the aorta.
  • After a test dose of  local anesthesia, and confirmation of correct position by injection of contrast medium, 75-95% alcohol is injected, 20-30 ml on each side.
  • In some cases it may be difficult to achieve good dispersion of the neurolysis because of tumor masses filling up the retroperitoneal space. In such cases the blockade may be inserted  retrocrurally, also at level of the T12 and L1, but with less volume. The effect is then substantially as a result of blockade of the splanchnic nerves proximally to the celiac plexus.

Follow-up

Complications can occur but are uncommon.

  • Temporary side effects in the form of orthostatic hypotension and diarrhea are relatively common the first 24-48 hours.
  • Back pain, usually in the form of soreness for 2-4 days is experienced by some.
  • Retroperitoneal bleeding, aortic dissection and paraplegia are very rare, but have been reported.

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