New MRI before SCS?

[Timeoutofmind]

I get a number of consults that are around 3-6 months out from spine surgery.

Referred for SCS.

Non-focal neuro exam.

Would you Re-MRI before SCS? Obviously, if I am planning another injection I would...but often they have had a bunch of injections pre-surgery, and at times are not interested, and I honestly wonder how much relief they can even expect from an injection at this point...prob not much is the real answer.

Does it matter to you if they have ongoing post-surgical radicular pain versus just axial? Again, tempting for me to re-scan if radicular, but if the surgeon is not re-scanning its not like there is something structural he is wanting to fix anyway (which makes sense in the presence of a non-focal neuro exam).

Thanks in advance.

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[Taus]

Yes. Surprising to hear about a post op spine patient, in enough pain to be referred for stim, not having a post op MRI by surgeon first to rule out something operable i.e. recurrent hnp, adjacent level stenosis etc. or complications. Also, I want imaging of L and T spine to prove clear and safe entry levels and cephalad path of lead.


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[Timeoutofmind]

Yes. Surprising to hear about a post op spine patient, in enough pain to be referred for stim, not having a post op MRI by surgeon first to rule out something operable i.e. recurrent hnp, adjacent level stenosis etc. or complications. Also, I want imaging of L and T spine to prove clear and safe entry levels and cephalad path of lead.


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A little confused...do you routinely order MRI T spine on all stim trials/perms, or only if they have had previous lumbar surgery?

 

[Taus]

Yes, All get T spine MRIs. All have had lumbar MRI at some point after surgery.


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[Dr. Ice]

I get a number of consults that are around 3-6 months out from spine surgery.

Referred for SCS.

Non-focal neuro exam.

Would you Re-MRI before SCS? Obviously, if I am planning another injection I would...but often they have had a bunch of injections pre-surgery, and at times are not interested, and I honestly wonder how much relief they can even expect from an injection at this point...prob not much is the real answer.

Does it matter to you if they have ongoing post-surgical radicular pain versus just axial? Again, tempting for me to re-scan if radicular, but if the surgeon is not re-scanning its not like there is something structural he is wanting to fix anyway (which makes sense in the presence of a non-focal neuro exam).

Thanks in advance.

Many spine surgeons that do a lot of instrumentation don't recommend repeat MRI within 3-6 months post surgery because of "inflammatory changes that may obscure." And most of them are probably not enthused about going back in there so soon even if there was a new finding unless patient has new neuro deficits. Not sure how they would feel about MRI so soon if a simpler decompression was carried out but think logic would be similar. Agree with MRI t spine on all stim candidates

 

[bedrock]

I would definitely repeat lumbar MRI if no MRI after surgery.

I get pre SCS thoracic MRI on all patients. Used to just do on older patients, until I found thoracic stenosis in a 35 yr old. Now all SCS patients get a t-spine MRI.

 

[DOctorJay]

I found some sort of vascular malformation in a young woman's lower T spine right where I would have passed the lead. I think she went for an open trial.

I always get T spine MRI pre-stim and refer to this case if I need to do a peer to peer for auth.


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[Taus]

Many spine surgeons that do a lot of instrumentation don't recommend repeat MRI within 3-6 months post surgery because of "inflammatory changes that may obscure." And most of them are probably not enthused about going back in there so soon even if there was a new finding unless patient has new neuro deficits. Not sure how they would feel about MRI so soon if a simpler decompression was carried out but think logic would be similar. Agree with MRI t spine on all stim candidates

Agreed re the issues w MRI in those cases. I generally see them CT to eval fusion/hardwear


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[Taus]

I found some sort of vascular malformation in a young woman's lower T spine right where I would have passed the lead. I think she went for an open trial.

I always get T spine MRI pre-stim and refer to this case if I need to do a peer to peer for auth.


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I only do about 1 Scs trial a month and in this past year have had 2 patients whose T spine MRI had essentially incidental finding of severe stenosis. 1 really shocked me as 50s w prior L decompression. 1 older guy had prior acdf for cervical spondylitic myelopathy. He had some persistent mild balance issues and clonus on exam. I figured was residual from his neck as had myelomalacia on MRI. His T spine had frank cord compression as well. Glad I didn't try to pass a lead through that....

Perhaps someone should do a study on frequency of perc Scs trial contraindications found on screening T MRI...


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[Ducttape]

ill bet you find it extraordinarily low.

and like everything else in medicine... 1/2 will argue that there is the chance of finding something, even if it is 0.000001%, so you have to image everyone, while the other 1/2 will argue that the likelihood without symptoms is sooo low and the cost to healthcare so high, that its a ridiculous waste of money and time......

 

[bronchospasm]

So what is standard of care?? . I obviously do not MRI Tspine if they are asymptomatic.

 

[bedrock]

So what is standard of care?? . I obviously do not MRI Tspine if they are asymptomatic.

If the three examples listed above of possible catastrophic injuries that could have happened with perc SCS trial were performed on these patients, hasn't convinced you to order T spine MRIs for stim trials, then I'm seriously worried about you. These patients usually don't have t spine symptoms, but could have suffered SCI if perc trial was performed.

You're crazy not to get T-spine MRI on all patients before standard SCS trial. It's rare, but what would you do for your mother? I know what I'd do.

 

[bronchospasm]

If the three examples listed above of possible catastrophic injuries that could have happened with perc SCS trial were performed on these patients, hasn't convinced you to order T spine MRIs for stim trials, then I'm seriously worried about you. These patients usually don't have t spine symptoms, but could have suffered SCI if perc trial was performed.

You're crazy not to get T-spine MRI on all patients before standard SCS trial. It's rare, but what would you do for your mother? I know what I'd do.

Honestly, I do not do an MRI of the thoracic spine if they are a symptomatic. In fact this is the first time that I am hearing about it. Even in fellowship , peer to peer discussions, industry sponsored SCS courses, ISIS courses etc -- this has never come up.

I understand that you are placing the lead in the thoracic spine and subsequent justification for it.

Maybe I should start doing it from now on.

Just curious, How many of you are doing MRIs of the T SPINE on patients prior to SCS trial for lumbar radic / failed back syndrome issues even if they have no thoracic complaints?

Seniors in the group please chime in.

Thanks.

 

[lobelsteve]

Honestly, I do not do an MRI of the thoracic spine if they are a symptomatic. In fact this is the first time that I am hearing about it. Even in fellowship , peer to peer discussions, industry sponsored SCS courses, ISIS courses etc -- this has never come up.

I understand that you are placing the lead in the thoracic spine and subsequent justification for it.

Maybe I should start doing it from now on.

Just curious, How many of you are doing MRIs of the T SPINE on patients prior to SCS trial for lumbar radic / failed back syndrome issues even if they have no thoracic complaints?

Seniors in the group please chime in.

Thanks.

I dont get it. If tbey have it I look at it. It is necessary for lami lead placement. Think how many folks have been trialed with those same asymtpomatic findings.

 

[gdub25]

I don't get thoracic MRI, never did in training and my attendings never did in their training either. Pts are awake for the trial, if I run into stenosis I don't push too hard and wouldn't the patient let me know before I caused a spinal cord injury?

 

[Tapspatellas]

I don't usually get one, but I have a low threshold of ordering one in my older patients if they have any thoracic complaints or if the degenerative changes are severe. Like Lobelsteve if there is one I will look at it, and I will look at any surrogate I can get my hands on, such as CT A/P or chest. I warn all my patients that if I run into anything that requires more than a slight nudge, I don't advance any further and the leads come out. I did see one in training when someone had pushed too hard and injured a thoracic root.

 

[Timeoutofmind]

Update that may be of interest to you guys:

I was reexamining this issue after a talk at ASRA where there was previously undetected severe thoracic stenosis and the trial had to aborted. After asking around on this form and thinking about it, I decided to get a thoracic MRI in a patient for lumbar stim planning.

He had cancer in the thoracic spine! Is 71 yrs old with basically a normal neuro exam. No h/o cancer.

Imagine if I would have ram rodded the lead through that cancer...as a newish attending...would have been devastating.

Sobering.

 

[lonelobo]

There is no down side in getting a Thoracic MRI prior to SCS trial

 

[DOctorJay]

and now you have your own case to discuss with peer to peer reviewers if they try to deny the T spine MRI!

seriously though good on you for diagnosing this for your patient

 

[clubdeac]

I personally don't get one but I probably should after reading this thread... then again I use depo for my TFESIs 😉

 

[unchockey21]

We had a patient this year who did great with trial. Best coverage near the top of the leads so placed them a level higher for implant. Complete relief of back pain but at 1 month follow up was complaining of new abdominal pain. Ended up getting abdominal imaging and celiac plexus block before her T spine got imaged. Herniated disc right where the tip of the lead was. Went for revision to pull the lead down and has been doing great since. MRI T spine for everyone now!

 

[Taus]

We had a patient this year who did great with trial. Best coverage near the top of the leads so placed them a level higher for implant. Complete relief of back pain but at 1 month follow up was complaining of new abdominal pain. Ended up getting abdominal imaging and celiac plexus block before her T spine got imaged. Herniated disc right where the tip of the lead was. Went for revision to pull the lead down and has been doing great since. MRI T spine for everyone now!

Interesting

Abdominal pain decrease with stim turned off? Or was mechanically poking the disc/nerve/or mass effect on cord?

Why the celiac? What pathology was it for?

I now have 3 cases in around 15 months where the T MRI altered my plan. 1 w cord compression that was essentially clinically silent that went for decompression. 1 needed open surgical trial. 1 I just had to enter higher than typical to avoid needle entry at level w mild-moderate stenosis. That last one also had a another decent hnp and moderate stenosis at t78, so I knew not to push lead that high.

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[studentologist]

Have you had any problems getting MRI Thoracic spine covered by insurance? What do you put for the reason: Rule out contraindication to SCS?

 

[painfree23]

We had a patient this year who did great with trial. Best coverage near the top of the leads so placed them a level higher for implant. Complete relief of back pain but at 1 month follow up was complaining of new abdominal pain. Ended up getting abdominal imaging and celiac plexus block before her T spine got imaged. Herniated disc right where the tip of the lead was. Went for revision to pull the lead down and has been doing great since. MRI T spine for everyone now!

Celiac??? For wat???

 

[Taus]

Have you had any problems getting MRI Thoracic spine covered by insurance? What do you put for the reason: Rule out contraindication to SCS?

No trouble so far.

Diagnosis on script: thoracic stenosis. In comment I write for pre- surgical planning, please verify patent dorsal epidural space for spinal cord stimulator placement.


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[DOctorJay]

I do what Taus does. Have had to do one or two peer to peers. Discussed my concerns and always get them approved. I also have in my SCS plan template the reason I want the MRI and I have it in all bold and that has helped as well.


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[bedrock]

No trouble so far.

Diagnosis on script: thoracic stenosis. In comment I write for pre- surgical planning, please verify patent dorsal epidural space for spinal cord stimulator placement.


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Good template by Taus.

I say something similar. Never had it denied, never even needed a peer to peer, and I've ordered hundreds of T-spine MRI for this purpose.

 

[deleted185747]

Dr down the street from me caused epidural hematoma during SCS perc implant. California Medical board found that not obtaining appropriate imaging prior to SCS trial/implant was "gross negligence"


http://www2.mbc.ca.gov/BreezePDL/do...0012395.DID&licenseType=G&licenseNumber=75296

 

[Taus]

Dr down the street from me caused epidural hematoma during SCS perc implant. California Medical board found that not obtaining appropriate imaging prior to SCS trial/implant was "gross negligence"


http://www2.mbc.ca.gov/BreezePDL/do...0012395.DID&licenseType=G&licenseNumber=75296

Wow on that account and also the rest.... 9th injection in 12 months...


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[unchockey21]

Interesting

Abdominal pain decrease with stim turned off? Or was mechanically poking the disc/nerve/or mass effect on cord?

Why the celiac? What pathology was it for?

I now have 3 cases in around 15 months where the T MRI altered my plan. 1 w cord compression that was essentially clinically silent that went for decompression. 1 needed open surgical trial. 1 I just had to enter higher than typical to avoid needle entry at level w mild-moderate stenosis. That last one also had a another decent hnp and moderate stenosis at t78, so I knew not to push lead that high.

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Celiac??? For wat???

It was a mechanical issue. Cord was essentially being sandwiched between the disc and the leads. Between the postop incision check and 1 month f/u, she presented to the ED a few times with nausea, vomiting, bloating, abdominal pain. We order imaging at follow up visit but before she gets it done she gets admitted again. GI does RUQ ultrasound, HIDA scan, CT abdomen. They diagnose her with gastritis and start treating for H pylori. GI attending and my attending decide on celiac block in house by IR. She got complete relief for a few weeks. Symptoms come back, we repeat block. No benefit this time. And that's when we finally get the thoracic myelogram that shows the herniation.

 

[lobelsteve]

It was a mechanical issue. Cord was essentially being sandwiched between the disc and the leads. Between the postop incision check and 1 month f/u, she presented to the ED a few times with nausea, vomiting, bloating, abdominal pain. We order imaging at follow up visit but before she gets it done she gets admitted again. GI does RUQ ultrasound, HIDA scan, CT abdomen. They diagnose her with gastritis and start treating for H pylori. GI attending and my attending decide on celiac block in house by IR. She got complete relief for a few weeks. Symptoms come back, we repeat block. No benefit this time. And that's when we finally get the thoracic myelogram that shows the herniation.

Case report. Should publish. And patients should learn to not make these things so complicated by presenting with more textbook like symptoms.

 

[unchockey21]

Case report. Should publish. And patients should learn to not make these things so complicated by presenting with more textbook like symptoms.

All referrals shall hence forth go through a USMLE designated physician prior to their new patient visit so they may be properly standardized.

 

[deleted185747]

All referrals shall hence forth go through a USMLE designated physician prior to their new patient visit so they may be properly standardized.

I couldn't agree more. Standard patients get sent to standard MD. Fringe/special/multiple allergy/paradoxic responders/high pain tolerance/non-vaccers/gluten intolerant/lupus/anyone who utters the term "Medical Marijuana", gets sent to DC or fringe MD for CAM.

 

[painfree23]

It was a mechanical issue. Cord was essentially being sandwiched between the disc and the leads. Between the postop incision check and 1 month f/u, she presented to the ED a few times with nausea, vomiting, bloating, abdominal pain. We order imaging at follow up visit but before she gets it done she gets admitted again. GI does RUQ ultrasound, HIDA scan, CT abdomen. They diagnose her with gastritis and start treating for H pylori. GI attending and my attending decide on celiac block in house by IR. She got complete relief for a few weeks. Symptoms come back, we repeat block. No benefit this time. And that's when we finally get the thoracic myelogram that shows the herniation.

I still don't understand the celiac.... AT ALL.
It is a high risk procedure and the indication for this is n/v/abdominal pain with gastritis???? Am I missing something?? Just curious, your training background?

 

[unchockey21]

I still don't understand the celiac.... AT ALL.
It is a high risk procedure and the indication for this is n/v/abdominal pain with gastritis???? Am I missing something?? Just curious, your training background?

To be fair, maybe I'm the one missing something. I wasn't involved with the decision to do the block. Just going off of chart review and talking to those involved so it's possible I left something out. The point of posting was that the patient had an expensive work up and added risk that could've been avoided had a thoracic MRI been done preop.
A month of n/v/abd pain/weight loss with multiple ED trips that didn't respond to conservative therapy. I can see why they gave a celiac block a shot. For the sake of discussion, what would you have done? My background is anesthesia.

 

[Ducttape]

maybe someone came up with the diagnosis of chronic pancreatitis?

 

[unchockey21]

maybe someone came up with the diagnosis of chronic pancreatitis?

No mention of pancreatitis anywhere. I get that gastritis isn't the classic reason to do a celiac. But I'm missing why it'd be unheard of to try the block. She a had a month of symptoms refractory to conservative measures, had been a reliable patient in the past, and had pain in a visceral organ innervated by the celiac plexus.

 

[painfree23]

No mention of pancreatitis anywhere. I get that gastritis isn't the classic reason to do a celiac. But I'm missing why it'd be unheard of to try the block. She a had a month of symptoms refractory to conservative measures, had been a reliable patient in the past, and had pain in a visceral organ innervated by the celiac plexus.[/QUOT

What would u say in a court if she had a bad complication? Doctor, "don't u know gastritis is not an indication for a celiac plexus block"? I mean u could argue for it, but if they have another MD on the other side of that bench, don't expect any sympathy.
Any one else?

 

[painfree23]

No mention of pancreatitis anywhere. I get that gastritis isn't the classic reason to do a celiac. But I'm missing why it'd be unheard of to try the block. She a had a month of symptoms refractory to conservative measures, had been a reliable patient in the past, and had pain in a visceral organ innervated by the celiac plexus.

What would u say in a court if she had a bad complication? Doctor, "don't u know gastritis is not an indication for a celiac plexus block"? I mean u could argue for it, but if they have another MD on the other side of that bench, don't expect any sympathy.
Any one else?

 

[Ducttape]

we don't have sufficient information based on his reports as to why the celiac plexus block was done. I think you are pointing fingers in the air hoping that something will "hit".

im not sure your assessment of the risk of celiac plexus block is so high as to completely eliminate the consideration for its use, if there were appropriate clinical indications. we do not commonly think gastritis is one of these indications. however:

INDICATIONS
Indications for celiac plexus block are several. Celiac plexus block with local anesthetic is indicated as a diagnostic tool to determine whether flank, retroperitoneal, or upper abdominal pain is sympathetically mediated via the celiac plexus.17

this is directly from Celiac plexus - ScienceDirect Topics and also from Waldman's Atlas of Interventional Pain Management.

 

[lobelsteve]

we don't have sufficient information based on his reports as to why the celiac plexus block was done. I think you are pointing fingers in the air hoping that something will "hit".

im not sure your assessment of the risk of celiac plexus block is so high as to completely eliminate the consideration for its use, if there were appropriate clinical indications. we do not commonly think gastritis is one of these indications. however:

INDICATIONS
Indications for celiac plexus block are several. Celiac plexus block with local anesthetic is indicated as a diagnostic tool to determine whether flank, retroperitoneal, or upper abdominal pain is sympathetically mediated via the celiac plexus.17

this is directly from Celiac plexus - ScienceDirect Topics and also from Waldman's Atlas of Interventional Pain Management.

Have never been asked nor have I ever heard of anyone ever doing a Dx celiac block.

 

[bedrock]

Have never been asked nor have I ever heard of anyone ever doing a Dx celiac block.

agree. celiac block was not indicated for this patient, and that would be my professional opinion on the stand if I was asked about a complication.

 

[painfree23]

agree. celiac block was not indicated for this patient, and that would be my professional opinion on the stand if I was asked about a complication.

My point exactly. We need to get away from doing procedures because there is "nothing else left". I saw a referral the other day from another pain physician on an abdominal patient, who tried LESI and facets for it...said in his note he thought maybe the facets were referring to the abdomen...yea right...prlly just wanted to milk this patient.

The celiac plexus is a high risk block and the reward u get from it is that u possibly may block some sympathetic innervation. What if it worked but was short lived? Would they have done a alcohol/phenol lesion?? Even more risky...just my opinion.

For the record, Not criticizing OP because OP was not involved in the decision making. Just wanted to see what everyone else felt about the celiac part of this discussion.

 

[unchockey21]

My point exactly. We need to get away from doing procedures because there is "nothing else left". I saw a referral the other day from another pain physician on an abdominal patient, who tried LESI and facets for it...said in his note he thought maybe the facets were referring to the abdomen...yea right...prlly just wanted to milk this patient.

The celiac plexus is a high risk block and the reward u get from it is that u possibly may block some sympathetic innervation. What if it worked but was short lived? Would they have done a alcohol/phenol lesion?? Even more risky...just my opinion.

For the record, Not criticizing OP because OP was not involved in the decision making. Just wanted to see what everyone else felt about the celiac part of this discussion.

No worries. I didn't even need to use my safe space! I just like the discussion on it.

To answer some of the hypotheticals and keep it going, in a court situation, assuming proper informed consent was done, then the burden would be to prove the procedure couldn't reasonably done for that indication. My response to an expert witness would be something along the lines of what Ducttape posted... "Doctor, what's the sympathetic innervation of the pancreas? Is that not also the same for the stomach? So you're saying a celiac block can be used to disrupt sympathetic outflow to one organ but not the other?" Beats me if it'd work. I've never been in court. But it sounded good in my head in a Jack McCoy from Law & Order voice.

I agree that alcohol/phenol would be ridiculous for non-cancer pain. But why not a splanchnic RFA instead?

Turns out they didn't do it for gastritis in the first place. The thought was that the nausea, vomiting, and abd pain was related to gastroparesis.

 

[Ducttape]

its stated that celiac plexus blocks is a high risk block. intuitively, that might seem appropriate. however, please post the actual complication rates that are documented. I find little evidence for exact complication rates for this procedure, and the sparse info out there suggests 1.6% complication rate. pubmed lists 2 deaths, 3 paraplegia case reports since 1989...

I understand why ppl are afraid to do the injection. im interested in the dogma of "Tho Shalt Not Do Celiacs", however.

first, this case occurred in academia, where the theoretical is possible. second, celiac block is not a new procedure, like sticking a needle in to a disc and sticking glue, or shaking up a jigger full of blood and squirting it god knows where.

in the situation presented, the patient was a puzzle with no obvious cause for abdominal pain requiring multiple ER visits and ultimately admission, and has had a full work up including CT, has been seen by GI attending, etc. seen by pain attending, who must have looked at the CT prior to doing the celiac (I do... unfortunate that the lead problem was not seen on abd CT).

if the celiac block worked, and the pain was sympathetically mediated, then splanchnic nerve pulsed RFA may be a consideration for chronic pain management - cant do neuromodulation because stim is in. or adjust the stim to see if it would cover the abdominal pain.

fyi, articles on indications for celiac plexus block (I cant link to Waldman's book):

Blockades for Sympathetically Maintained Pain (SMP)

There is no gold standard criteria to determine if the neuropathic pain syndrome is SMP or not; some have suggested that two or more of the following four test to be positive. The four tests include:

1. good pain relief following sympathetic blockade which is directly related to the duration of the local anesthetic agent used, preferably a local anesthetic agent should be used versus a placebo;
2. response to intravenous phentolamine infusion which produces system sympathetic blockade;
3. aggravation of the pain following infusion of norepinephrine;
4. the relief of the pain with infusion of clonidine or application of clonidine patch.

The classical targets for sympathetic blockade are the sphenopalatine ganglia (for vascular headache, and cranial neuralgias), stellate (cervicothoracic) sympathetic ganglia (for SMP and vascular disorders, in the upper extremities), celiac/splanchnic plexus (abdominal SMP and visceral malignant and non-malignant pain), lumbar sympathetic ganglia (lower extremity SMP and related pain syndromes), superior hypogastric (for pelvic pain and pelvic visceral malignancies), and ganglia impar (peri-anal and rectal pain).

Celiac plexus - ScienceDirect Topics

Splanchnic and Celiac Plexus Nerve Block
Steven D. Waldman, Richard B. Patt, in Pain Management, 2007.
▪ INDICATIONS
Indications for celiac plexus block are several. Celiac plexus block with local anesthetic is indicated as a diagnostic tool to determine whether flank, retroperitoneal, or upper abdominal pain is sympathetically mediated via the celiac plexus.17 Daily celiac plexus blocks with local anesthetic are also useful in the palliation of pain secondary to acute pancreatitis.18,19 Clinical reports suggest that early implementation of celiac plexus block with local anesthetic and/or steroid markedly reduces the morbidity and mortality associated with acute pancreatitis.20,21 Celiac plexus block is also used successfully to palliate the acute pain of arterial embolization of the liver for cancer therapy and to reduce the pain of abdominal “angina” associated with visceral arterial insufficiency.22 Celiac plexus block with local anesthetic may be used for prognosis before performing celiac plexus neurolysis.23

Celiac plexus block in the management of chronic abdominal pain. - PubMed - NCBI

See comment in PubMed Commons below
Curr Pain Headache Rep. 2014 Feb;18(2):394. doi: 10.1007/s11916-013-0394-z.
Celiac plexus block in the management of chronic abdominal pain.
Rana MV1, Candido KD, Raja O, Knezevic NN.
Author information
1
Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 W. Wellington Ave. Suite 4815, Chicago, IL, 60657, USA, [email protected].
Abstract
Chronic abdominal pain is a devastating problem for patients and providers, due to the difficulty of effectively treating the entity. Both benign and malignant conditions can lead to chronic abdominal pain. Precision in diagnosis is required before effective treatment can be instituted. Celiac Plexus Block is an interventional technique utilized for diagnostic and therapeutic purposes in the treatment of abdominovisceral pain. The richly innervated plexus provides sensory input about pathologic processes in the liver, pancreas, spleen, omentum, alimentary tract to the mid-transverse colon, adrenal glands, and kidney. Chronic pancreatitis and chronic pain from pancreatic cancer have been treated with celiac plexus block to theoretically decrease the side effects of opioid medications and to enhance analgesia from medications. Historically, the block was performed by palpation and identification of bony and soft tissue anatomy; currently, various imaging modalities are at the disposal of the interventionalist for the treatment of pain. Fluoroscopy, computed tomography (CT) guidance and endoscopic ultrasound assistance may be utilized to aid the practitioner in performing the blockade of the celiac plexus. The choice of radiographic technology depends on the specialty of the interventionalist, with gastroenterologists favoring endoscopic ultrasound and interventional pain physicians and radiologists preferring CT guidance. A review is presented describing the indications, technical aspects, and agents utilized to block the celiac plexus in patients suffering from chronic abdominal pain

fwiw, Ive only done celiacs for pancreatic cancer and chronic pancreatitis (and none of those in over a year), so...