Percutaneous neurolytic celiac plexus block.

Percutaneous neurolytic celiac plexus block (PNCPB) is an excellent treatment option for patients with intractable abdominal pain due to upper abdominal malignancies or chronic pancreatitis. In these patients, chronic refractory pain significantly decreases quality of life and often requires high doses of narcotics, which can lead to serious adverse side effects. PNCPB has been shown to have long-lasting improvement in abdominal pain and decreased narcotic usage in 70 to 90% of patients.1 In addition, with fewer than 2% of patients experiencing major complications, PNCPB is a quick, safe procedure.1 The celiac plexus is a network of ganglia that relay preganglionic sympathetic and parasympathetic efferent fibers and visceral sensory afferent fibers to the upper abdominal viscera. The visceral sensory afferent fibers transmit nociceptive impulses from the liver, gallbladder, pancreas, spleen, adrenal glands, kidneys, distal esophagus, and bowel to the level of the distal transverse colon. Located in the retroperitoneum just inferior to the celiac trunk and along the bilateral anterolateral aspects of the aorta, between the levels of T12–L1 disc space and L2, the celiac plexus can easily be reached by several different approaches.1,2 Most commonly, anterior or posterior approaches are chosen. In the anterior approach, a needle is inserted through the anterior abdominal wall directly into the region of the celiac plexus and neurolytic agent is injected into the antecrural space. Although this approach necessitates traversing abdominal structures including bowel and liver, this is generally inconsequential, well tolerated, and often quicker than other approaches (►Fig. 1). Additionally, the anterior approach may be more comfortable for the patient, as they are placed in a supine position, comparedwith less comfortable prone or oblique positions used for posterior approaches. In the posterior approach, a needle is inserted through the paraspinous musculature into the region of the celiac plexus and neurolytic agent injected into the antecrural space. Other less common approaches include transaortic and trans-intervertebral disc. At the authors’ institution, PNCPB is performed nearly always byan anterior approach under computed tomographic (CT) guidance. CT guidance is a safe, popular choice that allows for excellent visualization of abdominal anatomy, preplanning, precise placement of needles, and observation of contrast/neurolytic agent diffusion.1 Alternatively, neurolysis of the celiac plexus can be performed under fluoroscopic or ultrasound guidance, as well as endoscopic ultrasound guidance. Fluoroscopic guidance allows better visualization of the region of interest than the original blind approach first performed nearly 100 years ago; however, poor resolution of surrounding structures including the stomach, pancreas, bowel, aorta, and spinal cord makes it a less frequently utilized technique. Ultrasound guidance allows for direct visualization of important vascular structures, particularly the aorta, celiac trunk, and superior mesenteric artery. Additionally, it is cheap, simple, and allows the user to observe diffusion of the neurolytic agent without using contrast. However, ultrasound guidance is user dependent and its usage may be limited depending on patient body habitus. More recently, endoscopic ultrasound-guided celiac plexus neurolysis has become an increasingly popular and safe alternative that potentially allows for direct visualization and targeting of the celiac ganglion.