Chapter 46: Celiac Plexus Block Using Fluoroscopic Guidance

INDICATIONS

The celiac (coeliac) plexus (CP) is a group of 1 to 5 ganglia of varying sizes that are interconnected by a dense mesh-like network of neural fibers, located in the upper abdomen, anterolateral to the aorta at the level of the first lumbar vertebrae. The CP carries afferent innervation of the upper abdominal viscera, from the distal esophagus and stomach to the mid-transverse colon, as well as the pancreas, kidneys, gall bladder, adrenals, and portions of the small bowel. CP blocks are indicated for the diagnosis and treatment of upper abdominal pain as it can be performed to help separate out visceral from somatic pains, and can be used as a treatment for chronic cancer–related pain as well as non-cancer-related pain. It is important to note that pain carried by somatic nerve fibers will not be affected when the CP is blocked.

Local anesthetic blocks, with or without steroids and alcohol neurolytic blocks are all performed. The literature is relatively clear that alcohol neurolysis is effective in reducing pain in patients with pancreatic and other upper abdominal cancers as well as retroperitoneal structures. CP blocks can be very effective when opiate therapy is causing significant side effects and can decrease the amount of opiates necessary to control pain, improves mood, and may improve life expectancy.¹ The role of alcohol neurolysis in nonmalignant pancreatic pain is more controversial.

This is extremely successful in the treatment of upper abdominal cancer pain and should therefore be considered early on in the treatment algorithm.²

The indications for a celiac plexus block include:

• Treatment of visceral, poor localizing, abdominal pain, with or without malignancy

• Diagnostic block to differentiate somatic versus visceral complaints

• Pancreatic adenocarcinoma³

• Cholangiocarcinoma³

• Abdominal visceral pain syndrome

• Upper abdominal malignancies²

• Retroperitoneal malignancies

• Hepatobiliary disorders, including biliary sphincteric disorder

• Abdominal angina

• Pancreatitis, acute or chronic

RELEVANT ANATOMY

• The innervation of visceral abdominal structures largely comes from the sympathetic terminals of T5-T12.

• The preganglionic fibers leave the spine with the exiting nerve root and travel with the white communicating rami to the level of the celiac ganglion.

• The greater splanchnic nerves (T5-T9) lesser splanchnic nerves (T10-T11) and least splanchnic nerves (T11-T12) travel along the lateral border of the thoracic vertebral body and dive anterior to travel through crus of the diaphragm to become the celiac ganglion.

• The greater, lesser, and least splanchnic nerves travel together to become the celiac plexus. The celiac plexus lies anterior to the vertebral body at approximately T12 to L1, and usually lies near the takeoff of the celiac and superior mesenteric artery, which can be visualized on a preoperative computerized topography (CT) scan.

• The celiac plexus lies posterolaterally to the aorta at the level of the T12, L1 interspace on AP orientation.

• It is important to note that in a minority of patients, the artery of ...