Celiac Plexus Block

Anatomy of the Celiac Plexus

The celiac plexus is the largest ganglia of the sympathetic nervous system located at prevertebral level of body of first lumbar vertebra. It innervates abdominal viscera and contains visceral afferent and efferent fibers. It also contains parasympathetic fibers from the vagus nerve. It does not contain any somatic fibers. Right-sided ganglion lies medial to inferior vena cava, while left-sided ganglia lies anterior to abdominal aorta (Waldman 2001, Wong and Brown 1997). Preganglionic axons from T5 through T12 leave the spinal cord with the ventral spinal routes to join the white communicating rami en route to the sympathetic chain. These axons do not synapse in the sympathetic chain but they pass through the chain to synapse at distal sites, including the celiac ganglia. Preganglionic nerves from T5 through T9 travel caudally from the sympathetic chain along the anterolateral aspects of the vertebral bodies. At the level of T9 and T10, the axons coalesce to form the greater splanchnic nerve. Sympathetic nerves from T10 through T11 and occasionally T12 combine to form the lesser splanchnic nerve. Their course parallels the greater splanchnic nerve in a posterolateral position and ends in either the celiac plexus or aorticorenal ganglion. The least splanchnic nerves arise from T12, parallel posteriorly the lesser splanchnic nerve, and synapse in the aorticorenal ganglion.

Indication of Celiac Plexus Block

The most common indication for celiac plexus block is malignancy in the gastrointestinal tract up to the transverse colon. The most common indication is cancer of the pancreas. The following are some common indications for celiac plexus block:

1. Intra-abdominal visceral analgesia

2. Upper abdominal surgery combining intercostal block and celiac block

3. Intra-abdominal malignancy

4. Cancer of stomach

5. Pancreatic cancer

6. Gall bladder cancer

7. Adrenal mass

8. Common bile duct cancer

9. Chronic pancreatitis

10. Diagnostic neural blockade

11. Abdominal pain due to active intermittent porphyria

The efficacy of celiac plexus neurolytic block is related to the location and extends of cancer. It is overall considered as a good adjuvant to the pain management in cancer pain from the upper gastrointestinal tract. The main goal of this block is to eliminate the pain or decrease it, so oral opioids can control the pain without side effects.

Techniques

There are multiple techniques that can block visceral pain from the upper abdomen (Eisenberg et al. 1995).

These techniques include retrocrural posterior approach (behind diaphragm), transcrural posterior approach (through diaphragm), trans-aortic posterior approach, splanchnic nerve block, or an anterior approach which can be accomplished with either CT or ultrasound guidance. Table 28.7 and Figs. 28.5, 28.6, 28.7, and 28.8 compare the common techniques for posterior approach for celiac plexus block. Injection of dye is essential which shows good spread of the contrast at the anterolateral border of the corresponding vertebral body. If the patient has difficulty positioning prone, then anterior approach under CT guidance may be

Table 28.7 Comparison of the common techniques for posterior approach for celiac plexus block.

(Fig. 28.5)

Transcrural (Fig. 28.6)

Trans-aortic (Fig. 28.7)

Splanchnic (Fig. 28.8)

Position

Prone

Prone

Prone or right lateral down

Prone

position

Fluoroscopy use

Mandatory

Mandatory

Mandatory

Mandatory

Number of needles

Two

Two

One

Two

Type of needle

22G 5-7 in.

22G 5-7 in.

22G 7 in.

22G 5-7 in.

Level of needle

first lumbar

first lumbar vertebrae 7 cm

first lumbar vertebrae 7 cm

first lumbar vertebrae 7 cm

insertion

vertebrae 7 cm

from midline bilaterally

from midline on the left side

from midline bilaterally

from midline

bilaterally

Direction of the

L1

L1

L1

T12

needle

Final position of

Posterior to the

Through the diaphragm and

Through the diaphragm and

Posterior to the aorta

the left needle

aorta

posterior to the aorta

aorta. The needle tip just

pass the wall of the aorta

through continuous

aspiration

Final position of

1 cm deeper than

Through the diaphragm

N/A

1 cm deeper than the left

the right needle

the left needle

needle

N/A=not applicable.

N/A=not applicable.

Kidney

Greater splanchnic n.

Spleen

Pancreas

Colon Stomach

Kidney

Greater splanchnic n.

Spleen

Pancreas

Colon Stomach

Kidney Diaphragm Retrocrural space Inf. vena cava Liver

Celiac ganglia Abdominal aorta Figure 28.5 Retrocrural approach to the celiac plexus.

Kidney Diaphragm Retrocrural space Inf. vena cava Liver

Celiac ganglia Abdominal aorta Figure 28.5 Retrocrural approach to the celiac plexus.

Kidney Diaphragm Abdominal aorta Inf. vena cava Liver

Anterocrural spread Figure 28.6 Transcrural approach to the celiac plexus.

Kidney Spleen Pancreas Colon Celiac ganglia Stomach

Anterocrural spread Figure 28.6 Transcrural approach to the celiac plexus.

Kidney Diaphragm Abdominal aorta Inf. vena cava Liver appropriate. For a diagnostic block, 10 ml of bupivacaine 0.25-0.5% is injected on each side. For a neurolytic block, 15 ml of alcohol 100% mixed with 5 ml of lidocaine 2% (to avoid pain on injection) in each needle is injected. As an alternative, phenol 10% 10 ml can be injected in each needle without associated pain.

Complications

The most common side effect of celiac plexus block is orthostatic hypotension and is due to sympathetic block (Davies 1993, de Leon-Casasola 2000). It is usually transient and resolves

Anterocrural spread Figure 28.7 Transaortic approach to the celiac ganglia.

Kidney Spleen Pancreas Colon Celiac ganglia Stomach

Anterocrural spread Figure 28.7 Transaortic approach to the celiac ganglia.

Kidney :— Diaphragm

Abdominal aorta Inf. vena cava Liver

Celiac ganglia

Figure 28.8 Splanchnic nerve block at the level of T12.

Celiac ganglia

Figure 28.8 Splanchnic nerve block at the level of T12.

in 3-7 days. It is important to avoid sudden change in position in the first few days after the block. For the immediate effect after the procedure, we recommend a bolus of 500-1000 ml of normal saline before or during the procedure if the patient condition permits. Another common side effect is diarrhea, which is due to sympathetic block and usually is self-limited but should be treated with fluid resuscitation in debilitated or dehydrated patients. Paraplegia has been reported and has been attributed to injury or spasm of the lumbar segmental artery that supplies the spinal cord. This can be temporary or permanent. Another serious complication is retroperitoneal hematoma which can occur more frequently in patients who are on anticoagulation at the time of the procedure. The most common complaint after the procedure is back pain. A thorough patient history and physical examination will differentiate between back pain from needle placement and hematoma. CT scan is essential to rule out hematoma.

The Splanchnic Nerve Block

The indications for the splanchnic nerve block are similar to those for the celiac plexus block. It is indicated for patients with retroperitoneal pain and with upper abdominal pain not responding to the celiac plexus block because of the higher rate of complications associated with this block. The sympathetic supply for the abdominal viscera arises from the anterolateral horn of the spinal cord. Preganglionic fibers from T5 to T12 exit the spinal cord along with the ventral nerve roots and synapse in the celiac ganglia. Most of the preganglionic contribution to the celiac plexus is obtained from the greater, lesser, and least splanchnic nerves. The two needle retrocrural approach for the splanchnic nerve block is similar to that for the celiac plexus block, except that the needles are inserted in a more cephalad direction to rest on the anterolateral aspect of the T12 vertebral body (Shah et al. 2003).

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