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In the Article -
Discover how a Celiac Plexus Block can effectively manage pain in the abdomen caused by cancer or chronic pancreatitis. Learn more on our blog.
What is a coeliac Plexus Block?
A celiac plexus block is a type of nerve block that prevents the celiac plexus nerves from sending pain signals to the brain. These nerves are located in the upper abdomen and control the sensation of pain from the digestive organs, such as the pancreas, stomach, liver, and intestines. By blocking these nerves, you can experience significant pain relief from pancreatic cancer or chronic pancreatitis, which are conditions that can cause severe abdominal pain. A celiac plexus block can be done as an outpatient procedure, during surgery, or during an endoscopic ultrasound. Depending on the type of medication used, the pain relief can be temporary or permanent. A celiac plexus block can improve your quality of life, reduce your need for pain medications, and allow you to focus on other aspects of your cancer treatment. However, like any medical procedure, a celiac plexus block also has some risks and side effects, such as bleeding, infection, nerve damage, diarrhea, and low blood pressure.
When is a celiac plexus block recommended?
A celiac plexus block is a procedure that can help reduce severe abdominal pain that does not respond well to painkillers. The celiac plexus is a network of nerves that carries pain signals from the organs in the upper abdomen, such as the stomach, liver, gallbladder, pancreas, and intestines. By injecting medication near these nerves, the pain signals can be blocked or reduced. A celiac plexus block can be used to treat pain caused by both malignant and benign conditions that affect these organs. Some of the most common conditions that can benefit from a celiac plexus block are pancreatic cancer, liver cancer, chronic pancreatitis, and other types of abdominal cancer. Depending on the type and severity of the condition, different types of medication can be used for the celiac plexus block. Local anesthetics and steroids can provide temporary pain relief for benign conditions, while neurolytic agents can cause permanent nerve damage and pain relief for cancer-related pain. A celiac plexus block is only recommended for patients who have severe and persistent abdominal pain that cannot be controlled by other methods.
Who should not have a celiac plexus block?
A celiac plexus block is not suitable for everyone who has abdominal pain. Some patients may have other medical conditions or factors that make the procedure more risky or less effective. For example, patients who have a weak immune system due to cancer treatments may be more prone to infections from the injection. Patients who have bleeding disorders or take blood thinners may have more bleeding from the needle puncture. Using imaging techniques such as CT scans or X-rays does not guarantee that the needle will not damage any blood vessels or organs. Also, patients who have cancer that has spread to other parts of the body may not get the desired pain relief from the block. Therefore, before having a celiac plexus block, the patient should discuss with their doctor about their medical history and condition, and the possible benefits and risks of the procedure. Some of the contraindications to celiac plexus block are patient refusal or lack of consent, abnormal blood clotting or anticoagulation use, active infection, and abnormal anatomy that makes it hard to target the right nerves.
Approaches to Coeliac Plexus Block: An Overview of Techniques and Considerations -
Various methods have been proposed for approaching the Coeliac Plexus, each with its own merits. Literature suggests no clear superiority among these techniques, though outcomes from Splanchnic Nerve block at the T11 level seem more favorable than those from the trans-aortic approach. This article outlines the procedures for Coeliac Plexus Block through different approaches, including posterior trans-aortic, paravertebral (retro-crural), and trans-discal techniques.
It's worth noting that Coeliac Plexus Block can also be administered through surgical and endoscopic means, performed by a gastroenterologist. However, these methods are beyond the scope of this article. Additionally, there is a growing body of experience with anterior, ultrasound-guided techniques.
How to perform a celiac plexus block using the paravertebral (retro-crural) approach?
The paravertebral (retro-crural) approach is a technique that involves inserting a needle near the T12 vertebra and advancing it along the spine until it reaches the celiac plexus. To do this, you will need a fluoroscope, a C-arm, a 14G angiocatheter, a 20 or 22G stylet needle, an extension tube, a contrast agent, and a neurolytic agent. Here are the steps to follow:
First, find the T12 vertebra on a posterior-anterior (PA) view using the fluoroscope and mark it on the skin. Then, rotate the C-arm to a 45-degree angle on the side where you want to insert the needle. You should see the side of the diaphragm next to the vertebra. Watch how the diaphragm moves as the patient breathes in and out.
If the diaphragm covers the T12 vertebra and rib, look for the T11 rib instead. For both levels, the needle entry point on the skin is where the rib and the vertebra meet.
After numbing the skin at this point, insert the 14G angiocatheter under the fluoroscope, aiming for the target like the tip of a needle. Push the angiocatheter about two-thirds of its length, then take out the stylet and replace it with the 20 or 22G stylet needle.
Keep the C-arm at the same angle. Attach the extension tube to the needle. Move the needle tip forward in small (0.5 cm) steps, sliding it along the vertebra. Push both needles further, under the fluoroscope, past the T12 to L1 vertebra. Check if there is any blood or cerebrospinal fluid (CSF) by pulling back the plunger. The final needle position is checked on lateral views. After injecting the contrast agent, the lateral view should show it in front of the vertebra, while the PA view should show it within the spine outline.
Now you can slowly inject the neurolytic agent. Usually 20 ml of Neurolytic agent is injected Via each needle.
How to perform a celiac plexus block using the posterior trans-aortic technique?
The posterior trans-aortic technique is a method that involves inserting a needle through the aorta and reaching the celiac plexus from behind. To do this, you will need a fluoroscope, a C-arm, a 20 or 22-G stylet needle, a contrast agent, and a neurolytic agent. Here are the steps to follow:
First, place the patient in a prone position, with support under the abdomen to create a curve in the lower back. This will increase the space between the ribs and the iliac crest and between the transverse processes of the adjacent vertebrae. For comfort, the patient’s head should be turned sideways with the arms hanging down or above the head.
Next, mark the following landmarks on the skin with a pen: the iliac crest, the 12th rib, the midline of the back, the vertebrae, and the edge of the paraspinal muscles. Also, mark the point where the 12th rib and the paraspinal muscle meet on the left side (usually at the L2 level). Then, use a ruler to draw two parallel lines on both sides of the back, following the lower edge of the 12th rib. These lines, which cross the L1 vertebra, will guide the direction of the needle. Prepare and cover the surgery site with sterile drapes.
Then, numb the skin, fat, and muscles at the point where the needle will enter. Insert a 20 or 22G stylet needle from the left. Angle the needle at 45 degrees to the midline and 15 degrees upward to touch the L1 vertebra. Note the depth of the needle, then pull it back to the fat layer. Reposition the needle slightly to the side (at about 60 degrees to the midline) to slide along the side of the L1 vertebra. Do this under the fluoroscope. Carefully push the needle until you feel the pulse of the aorta in the needle. Take out the stylet from the needle, and pierce the wall of the aorta. Blood coming out of the needle means it is inside the aorta. Push the needle until no more blood comes out, meaning it is in front of the aorta. You may feel a “click” when the needle goes through the aorta. Use both PA and lateral views to check the needle position.
After the needle is in the right place, remove the stylet and look for blood, CSF, lymph fluid, or urine in the hub. Then, inject a small amount of contrast agent and check how it spreads with the C-arm. If the contrast agent does not spread well on both sides, you may need to insert another needle from the right side to inject the neurolytic agent. In the PA view, the contrast agent should be in the middle, around the T12 to L1 vertebrae. The contrast agent should not go beyond the edges of the vertebrae on the fluoroscope image. The lateral view of the vertebra should show a smooth back edge. The contrast agent should not go backward toward the nerve roots. Alternatively, if you use a CT scan, the contrast agent should appear on the sides and behind the aorta. If the contrast agent is only in the retro-crural space, the needles should be pushed deeper, to avoid the local anesthetic or the neurolytic agent reaching the somatic nerves.
Now you can slowly inject the neurolytic agent.
How to perform a celiac plexus block using the trans-discal approach?
The trans-discal approach is a technique that involves inserting a needle through the disc between the T12 and L1 vertebrae and reaching the celiac plexus from the front. To do this, you will need a fluoroscope, a C-arm, a needle, a contrast agent, and a neurolytic agent. Here are the steps to follow:
First, place the patient in a prone position, with a support under the iliac crest to make the disc space more accessible. Use the fluoroscope to find the T12 to L1 level. Then, tilt the C-arm to the left at a 15 to 20 degree angle. It is important to align the lower endplates of the vertebrae by rotating the C-arm up or down. The needle entry point is 5 to 7 cm from the midline of the back. After numbing the skin and fat at this point, insert the needle under the fluoroscope to the lower part of the facet joint. After going through the disc, inject 0.5 mL of contrast agent (Iohexol) to check the position of the needle in the disc. Then, push the needle until you feel no resistance, meaning the needle has come out of the T12 to L1 disc. After checking the final needle position with the contrast agent, inject 10 mL of phenol in 10% saline (or 10% phenol in glycerine), followed by 2 to 3 mL of air to prevent the neurolytic agent from leaking into the disc.
Intradiscal blocks with the retro-crural technique are done by injecting 12 to 15 mL of lidocaine 1% or 0.25% ropivacaine through both needles. Most researchers recommend doing therapeutic blocks by first injecting 10 to 16 mL of local anesthetic, followed by 10 to 16 mL of 96% ethyl alcohol, or a 10% solution of phenol in glycerine through both needles. Many researchers also inject a contrast agent at the same time to check how the neurolytic agent spreads. Before injecting the neurolytic solution, cover the area around the needle with wet gauze, and inject the solution in 1 mL parts. This prevents the neurolytic agent from reaching other structures and reduces the risk of complications.
After injecting the neurolytic agent, flush each needle with a local anesthetic to prevent fistula formation.
What are the complications of Coeliac Plexus Block?
Coeliac plexus block also has some potential complications. These may include:
Allergic reaction to the anesthesia or the contrast dye used to guide the needle placement.
Decreased blood flow to the spinal cord, which can cause numbness, weakness, or paralysis of the lower limbs.
Delayed emptying of stomach contents (gastroparesis), which can cause nausea, vomiting, bloating, or loss of appetite.
Kidney damage or other organ damage, due to accidental puncture of the blood vessels or organs near the coeliac plexus.
Nerve damage, which can cause pain, tingling, or burning sensations in the abdomen or back.
Paralysis due to a spinal cord injury, if the needle injures the spinal cord or the nerve roots.
The risk of complications depends on several factors, such as the type and dose of medication used, the technique and experience of the provider, the anatomy and condition of the patient, and the use of imaging guidance. Some complications are rare, but serious, and may require immediate medical attention.
"Samobathi Pain Clinic in Kolkata is the premier choice for coeliac plexus block, offering comprehensive pain management for various conditions. The clinic utilizes advanced techniques and equipment, ensuring precision and safety in procedures. Personalized and compassionate care is a hallmark, considering each patient's history and preferences. With positive reviews attesting to significant pain relief and improved quality of life, Samobathi Pain Clinic stands as a reliable and effective destination for coeliac plexus block. Explore their services on their website or contact them at +91 9830448748 for appointments."
About the Author -
Dr. Debjyoti Dutta, a distinguished pain physician, practices at Samobathi Pain Clinic and Fortis Hospital in Kolkata. As the registrar of the Indian Academy of Pain Medicine, he specializes in interventional pain management and musculoskeletal ultrasound. Globally renowned, Dr. Dutta has authored pivotal books such as "Musculoskeletal Ultrasound in Pain Medicine" and "Clinical Methods in Pain Medicine," providing comprehensive insights into the field of pain management.
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