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 needleit 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 needles 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 needles 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 remunerationthe 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 needles 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
Horners 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 Horners 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 Horners 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
HadassahHebrew University Medical Center
Jerusalem, Israel
E-mail:
[email protected]
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 JulyAugust 2004
