Celiac Plexus Neurolysis: an Effective Alternative for the Treatment Of

Educational Essay

Celiac plexus neurolysis: an effective alternative for the treatment of persistent abdominal pain Ángela Bettiana Cura, Verónica Andrea Salto, Renzo Sebastián Mestas Nuñez, Favio Augusto Mestas Nuñez, Héctor Alberto Canosa.

Resumen Abstract

Introducción: La neurólisis del plexo celíaco (NPC) es Introduction: Celiac Plexus Neurolysis (CPN) is a percu- un procedimiento percutáneo que permite la inyec- taneous procedure performed to inject a local neurolytic ción de un agente neurolitíco local, proporcionando agent that provides a prolonged analgesia in patients una analgesia prolongada en pacientes con dolor with persistent or intractable upper abdominal pain. abdominal superior persistente o intratable. Hasta un 60 to 80% of patients suffering from oncologic eso- 80% de los pacientes con dolor oncológico de ori- phageal, gastric, pancreatic or biliary pain can benefit gen esofágico, gástrico, pancreático o biliar pueden from this technique and reduce the use of opiates and beneficiarse con este tratamiento, disminuyendo el their adverse effects. Objectives: To demonstrate the uso de opiáceos y sus efectos adversos. Objetivos: posterior intervertebral disc CT-guided access path for Demostrar el abordaje intervertebral discal posterior the performance of CPN and to describe its complica- guiado por TC para la realización de NPC y describir tions. Revision: The celiac plexus is a visceral plexus sus complicaciones. Revisión: El plexo celíaco es un located in the retroperitoneum. It provides sympathe- plexo visceral que se localiza en el retroperitoneo. tic, parasympathetic and sensory innervation to upper Proporciona inervación simpática, parasimpática y abdominal viscera. CT is a precise guide for the injection sensitiva a las vísceras del abdomen superior. La TC of a neurolytic agent (phenol or ethanol). The poste- permite una excelente guía para la inyección de un rior access path through the intervertebral disc is an

Contact information: Ángela Bettiana Cura. Diagnóstico San Lucas - Posadas, Misiones. Recibido: 14 de agosto de 2015 / Aceptado: 2 de febrero de 2016 E-mail: [email protected] Received: August 14, 2015 / Accepted: February 2, 2016

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agente neurolítico (fenol o etanol). La vía de abordaje excellent choice. The CPN has low complication rates. posterior a través del disco intervertebral es una exce- The most common complications are pain radiating into lente opción. Tiene baja tasa de complicaciones, tales the dorsal region, orthostatic hypotension and diarrhea. como dolor irradiado a la región dorsal, hipotensión Conclusion: CT-guided CPN is a safe procedure with low ortostática y diarrea. Conclusión: la NPC guiada por TC complication rates and highly effective for the treat- es un procedimiento seguro con bajas tasas de compli- ment of persistent abdominal pain. Appropriate knowle- caciones y altamente efectivo para el tratamiento del dge of this procedure is key for the multidisciplinary dolor abdominal persistente. El conocimiento de sus approach in the control of intractable abdominal pain. indicaciones es clave en al abordaje multidisciplinario de la terapéutica del dolor abdominal intratable.

Palabras clave: Bloqueo nervioso autonómico, plexo Key words: Autonomic nerve block, celiac plexus, abdo- celíaco, dolor abdominal. minal pain.

Introduction Revision Celiac Plexus Neurolysis (CPN) is a percutaneous The celiac plexus, also known as solar plexus, is procedure performed to inject a local neurolytic located in the retroperitoneum on the anterolateral agent. The term neurolysis refers to the destruction wall of the aorta, between the adrenal glands cap- of the plexus by means of an injection of ethanol sules and around the origin of the celiac trunk and or phenol. It provides relief for prolonged pain, as the superior mesenteric artery. It provides sympathe- opposed to the block, which is temporary and uses tic, parasympathetic and sensory innervation to the steroids and analgesics (1-2). pancreas, liver, biliary tract, bladder, spleen, adrenal The resulting abdominal pain from abdominal neo- gland, mesentery, kidneys, stomach and part of trans- plasia is a serious and frequent problem that affects verse colon. the quality of life and survival of the patient. The There are two access paths to locate and access management of the oncologic abdominal pain is the celiac plexus: percutaneous access and surgical a complex challenge and it requires high doses of access. The percutaneous access path requires ima- analgesics with its unwanted adverse effects. 60 to ging guidance. Fluoroscopic guidance was described 80% of patients suffering from oncologic esophageal, in the 1950s, tomographic guidance in the 1970s, gastric, pancreatic or biliary pain can benefit from and finally ultrasound guidance was described in the this technique (2-4). 1990s (1-2, 9). Today, tomographic guidance is more The innervation of upper abdominal viscera origi- widely used since it offers a better spatial resolution, nates in the splenic nerve and in the celiac plexus which helps to assess possible anatomical variants, to (5). An effective way to relieve abdominal pain is to control localization and to administer the neurolytic interrupt the impulses of nociceptors at this level. agent. The main indications and contraindications Imaging-guided CPN is an invaluable therapeutical are summarized in Figure 2. The main disadvantage option for pain management in this group of pa- of this procedure is radiation (7). tients (8). Neurolytic agents destroy the nerve cell membra- ne. Agents most used are phenol and ethanol, and their main properties are (9):

 Revista Argentina de Diagnóstico por Imágenes Cura Á. B. et al. Celiac plexus neurolysis

Phenol: much more frequent, but in general, they are tempo- - Less effective and more viscous than ethanol. rary and well tolerated (2, 6) (Figure 5). - It does not produce pain during its administration. One of the key points to obtain successful results Ethanol: is to adequately inform the patient and his/her family - It has to be used in concentrations over 50% for it about the usefulness and limitations of the procedu- to be effective re. Another key point is the timely indication of neu- - Its administration produces temporary pain that can rolysis since there are better results when the pain is be treated adding a local anesthetic (bupivacaine) to- in initial stages. The most common causes of thera- gether with iodine contrast to assess its distribution. peutic failure are related to a bad propagation of the The patient has to be positioned in a way that it neurolytic agent in the celiac plexus due to alteration provides a simple path to perform the procedure (2) of the anatomy, infiltration, surgery, prior radiation or (Figure 3). insufficient dosage (2). The access path through the posterior intervertebral disc (which is the first choice at our center) is performed with the patient in prone position ente- Conclusion ring through the disk D12-L1 or L1-L2. This pathway CT-guided CPN is a safe procedure with low com- reduces the risk of injuring viscera. It is especially plication rates and highly effective for the treatment useful in those cases where it is difficult to access, of persistent abdominal pain. Appropriate knowled- such as the interposition of transverse apophysis or ge of this procedure is key for the multidisciplinary ribs, or due to a severe thoracic-lumbar arthrosis. It approach in the control of intractable abdominal can be unilateral or bilateral requiring an injection of pain. 25-30 ml of the neurolytic agent (2, 8, 10). Mayor complications of the procedure occur in less than 2% of the patients. Minor complications are

Figure 1. Anatomical diagram of the location of the node (N), their relationship with the celiac trunk (CT) and their sensory afferent fibers.

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Figure 2. Main indications and contraindications of CPN.

Figure 3. CT-guided access paths when performing CPN.

A B C

Figure 4. Posterior intervertebral disc access path with the patient in prone position. A) Planning and measuring of the site that will be punctured (D12-L1). B) Control of the entrance and path of the Chiba 20 G needle through the intervertebral disc D12-L1 with air injection and its diffusion. C) Injection and propagation of the neurolytic agent (phenol with contrast solution).

 Revista Argentina de Diagnóstico por Imágenes Cura Á. B. et al. Celiac plexus neurolysis

Figure 5. Major and minor complications of CPN.

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