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Celiac Plexus Block/Neurolysis: your preferred technique?

Discussion in 'Pain Medicine' started by Ligament, 12.29.06.

  1. Ligament

    Ligament Interventional Pain Management SDN Advisor

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    Hi All,

    I've been doing a number of celiac blocks and neurolysis lately, seeing a lot of different techniques out there and wondering which technique the illuminati on here recommend.

    Currently I am favoring a left sided flouro guided technique, using a bent tip 7 inch quinke needle (have a lot of fat patients), c arm at an oblique so the L1 transverse process distal tip lines up with the lateral margin of the L1 vertebral body, coaxial technique. This will usually end up transaortic (just love seeing the needle hub twist back and forth in unison with the pulse, the bent tip acts like a rudder in the stream of blood). Contrast to demonstrate anterocrural position. Usually use 20 cc of marcaine w/epi for block or 10cc Marcaine w/ EPI and 20 cc ETOH.

    I know the MD anderson boys on SDN do a butt load of these blocks, all opinions welcome...

    thanks!
  2. Ligament

    Ligament Interventional Pain Management SDN Advisor

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    Thought this was an interesting editorial:

    The Dreaded Complications From Neurolytic
    Celiac Plexus Blocks Are Preventable!
    To the Editor:
    Navarro-Martinez et al.1 report a case of a neurolytic
    celiac plexus block (NCPB) using ultrasonic guidance for
    needle placement and 40 mL of 50% alcohol for benign
    intractable pain which resulted in “. . .a leak of a pancre-
    atojejunostomy, a large abscess around the celiac plexus,
    and a small lesion in the mesenteric vein.” It generated an
    editorial by McKay and McKay2 on the use of NCPBs for
    such pain. I wish to comment on statements in both
    publications.
    Navarro-Martinez et al.1 state: “Serious complications
    (from NCPBs). . .are rare.” And, referencing myself,3*
    “The incidence of neurological complications (from
    them) is 0.1%.” That article does not state 0.1%.* Its
    publication date was 1979, not 1997. Although from the
    sparsity of published cases, the dreaded complications,
    particularly paralysis, from NCPBs, may appear to be rare,
    this may not be the case. In the United States, they
    become medicolegal cases and are settled out of court
    without the defendant(s) admitting or denying fault.
    Therefore, these settlements are filed “under seal,” which
    makes the details of the complication confidential and
    not public. As a result, they are markedly more numerous
    than published.4-6 Indeed, McKay and McKay also note
    the following: “Under-reporting of complications further
    limits our understanding of the risk associated with
    NCPB.”2
    The McKays,2 referencing the publication by Moore et
    al.7† stated the following. First, “The posterior approach,
    with a single needle, has been widely described in the
    literature and has been the standard of care for over 20
    years.” Second, “When needle placement by “feel” rather
    than by imaging was first analyzed by computed tomog-
    raphy (CT) and fluoroscopy (F), investigators found that
    needles frequently were not where they were expected or
    intended to be, even by those with experienced hands.”
    And lastly, “The introduction of CT scanning greatly im-
    proved our accuracy of needle placement by allowing
    clear visualization of structures and has reduced the vol-
    ume of alcohol needed to perform an adequate block
    (from 50 mL down to 15 mL).” I have never advocated
    (1) using a single needle—it may now be the predomi-
    nate but questionably the “standard of care,” (2) the use
    of F,3-8 or (3) reducing the volume of the injected neu-
    rolytic solution.3-8 After the investigation published in
    1981,7 I have recommended only CT for NCPBs, not F or
    any other imaging technique.4-6
    The McKays2 also stated, “We are unable to find any
    published description of a complication from NCPB when
    performed from a posterior approach with fluoroscopic or
    CT guidance.” In all probability, this occurred because
    legally they were “under seal.” Nevertheless, publications
    in peer-review journals present evidence that regardless
    of approach, dreaded complications, particularly myelop-
    athies, resulted when F rather than CT4-6 was used to
    verify correct position of the needle’s bevel and point
    immediately before injecting a neurolytic agent. In the
    only instance in which CT was used and a devastating
    *Reference 10 in their case report. That article noted that
    during 30 years using “feel” and/or posteroanterior and lateral
    roentgenograms to verify needle placement, 1 of 186 patients
    (0.53%) receiving NCPBs injecting 25 mL of 50% alcohol
    through each needle “developed a partial unilateral leg paraly-
    sis,” which was not incapacitating.
    complication resulted (paralysis), the authors stated
    “with the patient in the prone position, CAT scanning
    was used to visualize the coeliac trunk where it emerges
    from the lumbar aorta and the measurements necessary
    to introduce the needles were made.”9 In that case, there
    is no evidence that CT imagining was used to reveal
    precisely the location of the needle’s points before the
    injection of the neurolytic agent (30 mL of absolute al-
    cohol).
    Regarding offering a NCPB to a patient with intractable
    benign pain, the editorial correctly states the following,
    which are also applicable to cancer pain.2 First, “In doing
    so, it is of utmost importance to employ techniques with
    the greatest known record of safety, and to avoid those
    where vulnerable anatomic structures may be violated.”
    Second, “It is imperative that we do so in the safest and
    most effective manner.” Lastly, “Unfortunately, not all of
    the novel approaches have arisen out of concern for
    accuracy and safety, but instead convenience.” Whose
    convenience, not to mention remuneration—the physi-
    cian treating the intractable pain, the patient, or both?
    To conclude, from presently available published data in
    peer-reviewed journals,4-6,9 no doubt exists when per-
    forming NCPBs for intractable pain (benign or cancer)
    that only CT of the various imaging techniques precisely
    locates the position of the needle’s point and bevel im-
    mediately before injection of the neurolytic agent,
    thereby avoiding its complications. One wonders if pa-
    tients and their caregivers were informed of this, how
    many would acquiesce to F?
    Daniel C. Moore, M.D.
    Emeritus
    Virginia Mason Medical Center
    Seattle, Washington
    References
    1. Navarro-Martinez J, Montes A, Comps O, Sitges-Serra A.
    Retroperitoneal abscess after neurolytic celiac plexus
    block from the anterior approach. Reg Anesth Pain Med
    2003;28:528-530.
    2. McKay WR, McKay RE. Neurolytic celiac plexus block for
    benign pain: Still a question (editorial)? Reg Anesth Pain
    Med 2003;28:495-497.
    3. Moore DC. Celiac (splanchnic) plexus block with alcohol for
    cancer pain of the upper intra-abdominal viscera. Adv
    Pain Res Ther 1979;2:357-371.
    4. Moore DC, Kaplan R. Neurolytic celiac plexus block: Can
    paraplegia and death after neurolytic celiac plexus be
    eliminated (correspondence)? Anesthesiology 1996;84:
    1522-1523.
    5. Moore DC, Ischia S, Polati E. Computed tomography elimi-
    nates paraplegia and/or death from neurolytic celiac
    plexus block (letters). Reg Anesth Pain Med 1999;24:483-
    486.
    6. Moore DC, Rathmell JP, Brown DL. Despite waffling and
    minimaxing computed tomography is optimal when per-
    forming a neurolytic celiac plexus block (letters). Reg
    Anesth Pain Med 2001;26:285-287.
    7. Moore DC, Bush WH, Burnett LL. Celiac plexus block: A
    roentgenographic, anatomic study of technique and
    spread of solution in patients and corpses. Anesth Analg
    1981;60:369-379.
    8. Moore DC. Regional Block. Springfield, IL: Charles C. Thomas
    Publisher; 1965.
    9. Vistentin M, Trentin L, Cappelari F. Paraplegia following
    coeliac plexus block. Pain Clin 1992;5:249-252.
    Accepted for publication February 9, 2004.
    doi:10.1016/j.rapm.2004.02.001
    Horner’s Syndrome Is Not a Complication of a
    Brachial Plexus Block
    To the Editor:
    I read with interest the report by Boezaart et al. about
    continuous cervical paravertebral block using a stimulat-
    ing catheter.1 Boezaart and colleagues describe the ap-
    pearance of Horner’s syndrome as a complication of the
    brachial plexus block. The stellate ganglion (cervicotho-
    racic ganglion) lies normally next to the seventh cervical
    and first thoracic vertebrae. By anesthetizing the brachial
    plexus, which is formed by the ventral rami of (C4) C5 to
    C8 (T1), it is obvious that the stellate ganglion may also
    be anesthetized (according to Greengrass in up to 50% of
    interscalene blocks2). The Horner’s syndrome itself has
    no clinical consequences for the patient. It, therefore,
    definitely cannot be described as a complication. It is the
    same case for ipsilateral diaphragmatic paresis (phrenic
    nerve, C3 to C5) and hoarseness (recurrent laryngeal
    nerve), which may occur as associated effects after bra-
    chial plexus blocks. Only if they have clinical conse-
    quences to the patient can they be labeled as “complica-
    tions.”
    Alexander Avidan, M.D.
    Department of Anesthesiology and Critical Care Medicine
    Hadassah—Hebrew University Medical Center
    Jerusalem, Israel
    E-mail: alex@avidan.co.il
    References
    1. Boezaart AP, De Beer JF, Nell ML. Early experience with
    continuous cervical paravertebral block using a stimulat-
    ing catheter. Reg Anesth Pain Med 2003;28:406-413.
    2. Greengrass R, Steele S, Moretti G, et al. Common techniques
    for regional anesthesia. In: Raj PP, ed. Textbook of Regional
    Anesthesia. Philadelphia, PA: Churchill Livingstone, 2002:
    325-377.
    Accepted for publication February 16, 2004.
    doi:10.1016/j.rapm.2004.02.006
    Cancer Patients Pose a Risk for Hematoma
    Formation After Neuraxial Blocks Per Se
    To the Editor:
    Sidiropoulou et al. recently reported a case of epidural
    hematoma after thoracic epidural catheter removal. Al-
    though we fully endorse the objectives of this report,
    which were to enhance awareness that an epidural he-
    matoma can occur in the absence of risk factors,1 we
    378 Regional Anesthesia and Pain Medicine Vol. 29 No. 4 July–August 2004
  3. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    Nice article above.
    We do 10cc 0.5% bupivicaine and repeat if partial relief is given.
    Posterior approach 22G6" or 8" needle. We will choose the side of the greatest pain or perform b/l if diffuse abd pain. Para-aortic and not transaortic. 4-5cm anterior to the the anterior vertebral body margin in lateral and even with the lateral vertebral body in AP. Omnipaque to assess for vascular, intraluminal, or IM flow. L1 level. Netter is very useful in understanding all the stuff you do not want to puncture via this approach.
    We have not used neurolytic block for the celiac in our practice. We will use pulsed when needed with expected results.:laugh:
  4. drusso

    drusso Moderator Emeritus Lifetime Donor

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    We favor the retrocrural bilateral splanchnic nerve blocks over true celiac plexus blocks: Safer, similar efficacy. Impaling the celiac trunk or the myriad of other complications that can go wrong with the trans-aortic or trans-discal approaches just seems to make for a bad day at work IMHO...

    Efficacy of coeliac plexus and splanchnic nerve blockades in body and tail located pancreatic cancer pain.

    Suleyman Ozyalcin N, Talu GK, Camlica H, Erdine S.
    Department of Algology, Istanbul Medical Faculty, Istanbul University, Capa Klinikleri, 34390 Istanbul, Turkey.

    Palliative treatment, pain therapy and quality of life (QOL) are very important in pancreatic cancer patients. We evaluated the pain relieving efficacy, side effects and effects on QOL of neurolytic coeliac plexus blockade (NCPB) and splanchnic nerves neurolytic blockade (SNB) in body and tail located pancreatic cancer. The study protocol was approved by the local ethics committee. Patients were randomly divided into two groups. Coeliac group; GC, N = 19 were treated with coeliac plexus blockade, whereas the patients in splanchnic group; GS, N = 20 were treated with bilateral splanchnic nerve blockade. The VAS values, opioid consumption and QOL (Patient satisfaction scale=PSS, performance status scale=PS) were evaluated prior to the procedure and at 2 weeks intervals after the procedure with the survival rates. The demographic features were found to be similar. The VAS differences (difference of every control's value with baseline value) in GS were significantly higher than the VAS differences in GC on every control meaning that VAS values in GS decreased more than the VAS values in GC. GS patients were found to decrease the opioid consumption significantly more than GC till the 6th control. GS patients had significant improvement in PS values at the first control. The mean survival rate was found to be significantly lower in GC. Two patients had severe pain during injection in GC and 5 patients had intractable diarrhoea in GC. Comparing the ease, pain relieving efficacy, QOL-effects of the methods, splanchnic nerve blocks may be an alternative to coeliac plexus blockade in patients with advanced body and tail located pancreatic cancer.
  5. Ligament

    Ligament Interventional Pain Management SDN Advisor

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    Hey Dave, do you use this approach for neurolysis as well? Hope all is well!

  6. drusso

    drusso Moderator Emeritus Lifetime Donor

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    You bet! We do the neuroloysis with pharmaceutical grade ETOH. What's left over mixes up great with those little cranberry cocktail juices we give patients in the recovery area! :)

    I recently reviewed this literature for a talk I gave the palliative care folks. My favorite study is the 2004 Wong et al in JAMA from "the Mayo." Improved pain relief but no difference in quality of life or survival. I think it is probably one of the most "humanistic" interventions we do in pain medicine...truely palliative. It's the kind of consult I don't mind getting on a Friday at 4:30PM. As opposed to the usual, "We've tried absolutely nothing and are completely out of ideas."

    Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial.

    Wong GY, Schroeder DR, Carns PE, Wilson JL, Martin DP, Kinney MO, Mantilla CB, Warner DO.

    Department of Anesthesiology and Division of Pain Medicine, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA. wong.gilbert@mayo.edu

    CONTEXT: Pancreatic cancer is an aggressive tumor associated with high mortality. Optimal pain control may improve quality of life (QOL) for these patients. OBJECTIVE: To test the hypothesis that neurolytic celiac plexus block (NCPB) vs opioids alone improves pain relief, QOL, and survival in patients with unresectable pancreatic cancer. DESIGN, SETTING, AND PATIENTS: Double-blind, randomized clinical trial conducted at Mayo Clinic, Rochester, Minn. Enrolled (October 1997 and January 2001) were 100 eligible patients with unresectable pancreatic cancer experiencing pain. Patients were followed up for at least 1 year or until death. INTERVENTION: Patients were randomly assigned to receive either NCPB or systemic analgesic therapy alone with a sham injection. All patients could receive additional opioids managed by a clinician blinded to the treatment assignment. MAIN OUTCOME MEASURES: Pain intensity (0-10 numerical rating scale), QOL, opioid consumption and related adverse effects, and survival time were assessed weekly by a blinded observer. RESULTS: Mean (SD) baseline pain was 4.4 (1.7) for NCPB vs 4.1 (1.8) for opioids alone. The first week after randomization, pain intensity and QOL scores were improved (pain intensity, P< or =.01 for both groups; QOL, P<.001 for both groups), with a larger decrease in pain for the NCPB group (P =.005). From repeated measures analysis, pain was also lower for NCPB over time (P =.01). However, opioid consumption (P =.93), frequency of opioid adverse effects (all P>.10), and QOL (P =.46) were not significantly different between groups. In the first 6 weeks, fewer NCPB patients reported moderate or severe pain (pain intensity rating of > or =5/10) vs opioid-only patients (14% vs 40%, P =.005). At 1 year, 16% of NCPB patients and 6% of opioid-only patients were alive. However, survival did not differ significantly between groups (P =.26, proportional hazards regression). CONCLUSION: Although NCPB improves pain relief in patients with pancreatic cancer vs optimized systemic analgesic therapy alone, it does not affect QOL or survival.
  7. Ligament

    Ligament Interventional Pain Management SDN Advisor

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    Per Raj in his Radiographic Imaging for Regional Anesthesia and Pain Management:

    "Apart from the common risks associated with celiac and splanchnic nerve blocks, the rates of pneumothorax, thoracic duct injury, and inadvertent spread of the injected drug to the somatic nerve roots are higher for the splanchnic nerve block than for the celiac plexus block." (no source for these claims cited)

    Would hate to get ETOH to the nerve roots or cord. This is one advantage of the anterocrural celiac block technique specifically when performing neurolysis...

  8. Kwijibo

    Kwijibo Member

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    Neurolysis of the Splanchnic is not done with Etoh. It is done with radiofrequency ablation.
  9. Ligament

    Ligament Interventional Pain Management SDN Advisor

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    It is also done with phenol, so I'm not sure where you get your information.

  10. ParaVert

    ParaVert Interventional Pain

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    Hey Ligament,

    Are u going to AAPM? Hope to see u there.

    Anyways, regarding the whole celiac thing, we probably do more than anywhere. Truth is, there is virtually no good data comparing efficacy of techniques for celiac block. Of note, GI has started doing endoscopic, transgastric ultrasound to perform celiac neurolytic (ouch).

    First off, we never do RF for celiac, superior hypogastrics, or ganglion impars. I personally think that it is kinda bogus. There is a reason that volume is your friend here--the splanchnics can arise from anywhere from T9-L1. And just because Netter says that they all collect and penetrate the crus at T12, who knows how much anatomic variability exists within the population. Sure, you may be able to get a little bit of the plexus, you may feel good about yourself if you can get epigastric sensory stim prior to lesioning, but it isn't just one nerve you're after. RF is perhaps safer, but then again so is doing nothing.

    We primarily use phenol for celiacs. There are two main reasons why we don't use alcohol. First, alcohol neuritis of the dorsal roots from posterior flow really sucks. Secondly, there is significant data to support the notion that alcohol can cause vasospasm of spinal arterioles. This is the proposed mechanism of paralysis after celiac neurolytic.

    We often use a retrocrural approach, aka "splanchnic plexus block." We put the needles in at T12, just posterior to the anterior border of the vertebral body. Inject dye to prove that we're behind the diaphragm. We do 10cc chloroprocaine through each needle and check motor function after 3 minutes. If all is well, we do 10cc of 5% phenol through each needle.

    Celiacs seem to help, but they are rarely a homerun in my experience.
  11. Pain_doc

    Pain_doc New Member

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    Wanted to re-visit this topic. I seem to be getting some more referrals from the oncologists. In the past, I performed a two needle technique. Lately, I've been doing a single needle transaortic. Excluding a couple of patients with tumor burden preventing spread (even with R & L needles), I don't seem any difference. Of course, puncturing the aorta does wonders for enhancing my bowel regularity.... Anyone doing anything different since last discussed? thanks
    Last edited: 10.12.09
  12. Jcm800

    Jcm800

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    i used to do these under CT. man its nice, but what a waste of time...

    i go at L1, i put in 2 needles, almost always. I inject from the left first, and if i get good spread that crosses midline, then i only inject through it. I inject about 7 ccs of dye, give or take, and if i get the spread i want, I inject about 12cc of local ( theoretically you could just inject the 7, but...)

    i use alcohol, because its easy. I mix it with 0.25% bupiv. I usually inject 5 cc of lido plus epi, to make sure first then 10-15cc per needles as needed, see above. I almost never put more than 25 cc total, and almost only 18-20 cc of ETOH if its bil, and maybe 10 cc of etoh plus 5cc of bupiv if its unilateral and i inject a full 15 cc...

    its my way, and everyone has their own way. My partner used to do these blind and they worked, so we could try and say why our way is better, but...
  13. Pain_doc

    Pain_doc New Member

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    Doc Shark are you trying to avoid the aorta? If you get in, do you just advance through? Or do you just limit how far you advance the needle (anteriorly) in the first place.
  14. Jcm800

    Jcm800

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    im not avoiding the aorta per se, but im not aiming for it. If i get it, i just advance through it, and almost always can do it all through the one needle. I prefer not to hit it... but alas, the big artery is there
  15. lonelobo

    lonelobo New Member

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    I don't do many , but do Trans aortic with single needle, I do get pre procedure CT if one not done recently. R/o Aneurysm which could be problem when 22 g pierces it.
  16. Pain_doc

    Pain_doc New Member

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    In these cancer patients, I always review their most recent CT images. I kind of get a better idea of where I don't want the needle to go. If I'm using alcohol (for the neurolysis, not personally), I use a 25g needle. Can't inject phenol through a 6 or 8 inch 25g, so I use a 22g in those instances.
  17. Jcm800

    Jcm800

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    i used to use phenol, but it became difficult to get, and i just started using ETOH, and since i mix it a little, i havent had any problems. But phenol is good. I agree, sludgy...
  18. Pain Applicant

    Pain Applicant

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    For what it's worth, I've recently had a paper accepted by Pain Medicine looking at several variables. We found the following significantly associated with a positive outcome (>50% pain relief at one month post procedure):

    1. lower morphine doses prior to procedure
    2. absence of sedative administration prior to procedure

    While the following fell short of statistical significance, they were associated with a strong trend towards a positive outcome:

    1. use of lower local anesthetic volumes (<20ml)
    2. procedure preformed under CT guidance compared to fluoro

    Hope it helps.
  19. Pain Applicant

    Pain Applicant

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    Oh... also, for what it's worth, we found no difference between many other variables, including ante vs. retrocrural approach or single vs double needles.

    The anesthetic volume listed in my previous post is used during the diagnostic block.

    Also, if it helps, I published a separate article reviewing management for a certain type of cancer pain. These were some of the techniques I referenced:

    1. Garcia X, Mayoral V, Montero A, Serra J, Porta J: Josep
    Celiac plexus block: a new technique using the left
    lateral approach. Clin J Pain 2007, 23(7):635&#8211;637.
    doi:10.1097/AJP.0b013e31812e6aa8.

    2. Erdine S: Celiac ganglion block. Intervent Treat 2005,
    17(1):14&#8211;22.

    3. Romanelli D, Beckmann C, Heiss F: Celiac plexus
    block: efficacy and safety of the anterior approach.
    Am J Roentgenologt 1993, 160(3):497&#8211;500.
    Last edited: 10.16.09
  20. foxtrot

    foxtrot Member

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    I have never done these under CT guidance but it seems like a much safer alternative. How do you learn how to do these under CT? Is there some course out there for those of you who do them under CT.
  21. Jcm800

    Jcm800

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    dont waste your time doing them under CT. I have done plenty and hate it. In theory its nice. but under fluoro is still quite safe if done with appropriate precaution.

    remember this was done blind prior, and tpically without complication
  22. nvrsumr

    nvrsumr Member

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    What was the blind technique? Ive done stellates "blind" and that was enough of a sphincter tightener to last me awhile.
  23. Jcm800

    Jcm800

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    feel for T12 (find the ribs) draw this stupid triangle thing like 8 cm lateral. Go till you hit the veterbral body, then re-direct till you "walk" anterior to the vertebral body...yikes

    i have done blind Cervicals...
  24. clubdeac

    clubdeac

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    Hey Steve, how do you know when you're getting close to the aorta? Do you feel it? Does anyone use blunt needles? I just don't want to go through the aorta if I can help it. Paravert mentioned going just posterior to the anterior vert body for the retrocrural approach. Would that work? I'm gonna try one on a guy with ADPKD and chronic flank pain from hemorrhagic renal cysts. Good idea?
  25. Jcm800

    Jcm800

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    bad idea, with regard to the patient selection, not the approach

    but you feel the wall of the aorta, and you can aspirate when you get close, and sometimes you can feel the pulsatile wall...take the stylet off and watch the blood come out with each heart beat, fascinating and horrifying at the same time
    Last edited: 12.10.09
  26. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    Para-aortic approach is favorable. Trans-aortic is fine.
    I use fluoro to guide me for the block (but don't do neurolytics becuase I feel the CT is safer).

    We know where the aorta should be, and if we can sneak past it, great. If not, keep the stylet in and keep going. I cannot feel the difference with a syletted needle but can see and feel the difference with an unstyletted needle on a 10cc syringe. Hold on to the plunger and keep going. COntrast to know you're through.
  27. Tenesma

    Tenesma Senior Member

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    the problem with these is the rarity with which we do them - unless at a major cancer center.... so if something goes wrong, and the plaintiff's attorney deposes you and asks "how many of these did you do in the last three years" and your answer is "2" then you are going to look really silly in front of the jury...
  28. Jcm800

    Jcm800

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    i do one month maybe...
  29. Ligament

    Ligament Interventional Pain Management SDN Advisor

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    I've done the transaortic technique with epimed blunt needles, hoping that the needle would deflect off the wall of the aorta and slide around it. No dice, it went right through the aorta just like a quincke needle. I like the transaortic route, the plexus is on the ventral side of the aortic wall, no better place to put the needle. Also, if you run live fluoro on a lateral view, you will see the aorta pulsing, and contrast surrounding the pulsing aorta, confirming your medication is in the right spot.
  30. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    I'm in for one a month to every other month.

    Does this mean we need to send out patients to MD Anderson?
    Rare is rare, but it does not mean much in regards to technical competence.

    Complication rate of 1/863 is reported (for major complications)
  31. nvrsumr

    nvrsumr Member

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    I havent done one since fellowship but would feel comfortable performing one if it came up. Ive only done them for pancreatic cancer pain. Anyone have success for blocks in nonmalignant abd pain? dx?

    Thanks
  32. clubdeac

    clubdeac

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    Why is this a bad idea as far as patient selection? Aren't the kidneys innervated by the celiac? Is it cause he's sick as snot. I just don't know what else I can offer this guy other than ever increasing doses of narcs . . .
  33. Jcm800

    Jcm800

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    definitly not!
  34. Jcm800

    Jcm800

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    i dont do neurolytic plexus blocks in non-malingnant cases, thats why i think the patient selection isnt great.

    While the innervation is there, in my experience, and i dont work at MD anderson, is that the best organ treated with celiacs are the pancreas, everything else has never been so good in terms of results...
  35. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    I limit my neurolytics to peripheral nerves, stumps, scars, and intercostals.

    I do celiac and hypogastric blocks for non-malignant, but not the neurolytics.
    Above the navel= celiac, below the navel = superior hypogastric.
    That's as rough a guide to give. Knowing the innervation is a little more important becuae if you turn off the wrong one, you get no relief.

    Problem arises when you cannot find a Neurolytic performing doc in your area (except for malignancy). With fluoro, I'd be tempted to perform pulsed RF on hypogastric and celiac's, but no good data to suggest benefit. At least harm would be minimized.
  36. Jcm800

    Jcm800

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    i used to PRF the hypogastrics, never worked. Did maybe 5, so not that many.

    i agree in the textbooks the innervation is very clear what is supplies by the celiac and hypogastric plexi, what i am saying is that IMHO, when i have used the celiacs for organs other than the pancreas, but still innervated by the celiac plexus, the results ahve been disappointing, at least in my hands. Granted i used do more of this, and more than most out there (unfortunately) but i certainly dont do as much as someone in an academic program with lots of cancer pain. So my opinion is my opinion.

    this is the same for non-malignant pelvix and rectal pain that is attempted to be treated with hypogastric plexus blocks/neurolytics. my limited experience has all but led me away from doing this, as it is RARELY completly organic and soemthing that can not be effectively treated with the blocks...


    Steve, why do a diagnostic plexus but not the neurolytic? THis is why i dont even offer diagnostic blocks for chronic pancreatitis or whatever, since i wont do the neurolytic...
    there is not too much diagnostic utility in the block, it tells you something hurts from the lower part of the stomach to the splenic flexture...
  37. Jcm800

    Jcm800

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    ironically, this is a 3 year long discussion!
  38. lovebailey2001

    lovebailey2001

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    Hi e'body! Is anybody using Trans discal approach for celiacs! I did one, via T12-L1 disc with flouroscopy, from left side in patient of RCC with mets, predominantly Lt. flank pain, gave 15 ml. Bupi .25% followed by 12 ml. 6% phenol. Immidiate response was 20-30% relief. But afterwards patient says that from that day he is feeling more sick and feeling more pain.

    Got a recent CECT abd. done there are mets in Pancreatic head, renal mass (lt.) and extension in Lt. renal vein and artery, apart from lung n vertebral mets (T12). Have put him on narcs. Should I repeat the celiac or splanchnic? Please guide:confused:
  39. Jcm800

    Jcm800

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    WHY WOULD YOU DO THIS APPROACH!!!! Not to attack... There are case reports of severe discitis with inadvertant puncture of the bowel, then pulling through the disc...i think there are better approaches. get an MRI or bone scan, make sure isnt a discitis...
  40. lovebailey2001

    lovebailey2001

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    I did it for the ease of technique(in my opinion) and to avoid aorta, took the proper aseptic measure and 1 gm Cefazolin 30 mins. before and also bit in disc. No, it doesn't look like discitis, coz pain is essentially in the pre-procedural distribution, no fever, no rise in counts. Though dint confirmed by MRI or Bone scan!

    Now if anybody have some opinion regrding the depth of needle past disc, coz I only went 1.5 cm ahead on a lat. flouro. May be I just couldn't reach the plexus! Plz guide...:confused::oops:
  41. lovebailey2001

    lovebailey2001

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    Also I used LOR for passing through the disc in lat. flouro, so slim chances of bowel encounter...

    Should I do it again or simply continue with narcs!!!
  42. drf

    drf New Member

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    I'd be worried about the cord at T12/L1. I generally first try a Antecrural approach at L1. If that doesn't work or works poorly I'll consider the retrocrural at T12 (ie kill the splanchnic nerves) especially if the cancer is encroaching on the celiac artery.

    Of note, I've had a couple of benign pancreatic pain who responded to local at the celiac plexus who then went on to do well with a SCS trial (2 leads at T5-6). Still haven't moved to SCS implant for it though for 1. insurance reasons and 2. "I want to try some alternative techniques for the pain and learn to live with it" Yay for that guy!
  43. clubdeac

    clubdeac

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    Had a question about splanchnics. I was taught in fellowship to note the position of the diaphragm in later and if covering T12, go to T11. My attending would even have me advance only during inspiration so to "avoid the diaphragm".

    Well I was getting ready to do one today and the guy's diaphragm on lateral was all the way up to T10. It would drop a little during inspiration making T10 a possible choice but I didn't want to chance it. Anyway, the guy started vomiting on the table so I aborted the procedure.

    My question: do you guys worry about where the diaphragm is when you do your splanchnics? Why would my attending be so concerned about that when you cross L1 for celiacs w/o worrying about diaphragm? Any thoughts, I'm debating what I'm gonna do on this guy.....

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