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Correspondence  |   November 2003
Low Volume Neurolytic Celiac Plexus Block with Computed Tomography Guidance
Author Affiliations & Notes
  • Eric H. Busch, M.D.
    *
  • *Ochsner Clinic Foundation, New Orleans, Louisiana.
Article Information
Correspondence
Correspondence   |   November 2003
Low Volume Neurolytic Celiac Plexus Block with Computed Tomography Guidance
Anesthesiology 11 2003, Vol.99, 1243-1244. doi:
Anesthesiology 11 2003, Vol.99, 1243-1244. doi:
To the Editor:—
The use of neurolytic celiac plexus block in the treatment of pain arising from upper abdominal structures is widely recognized by physicians. 1 The block has been performed using surface landmarks, fluoroscopy, ultrasound, and with computed tomography guidance. 2–4 We present an interesting case in which the celiac plexus was only accessible from the right side because of extensive tumor infiltration. The plexus was blocked successfully from the contralateral side with a very small volume of alcohol.
A 58-yr-old man with metastatic non–small cell lung cancer was hospitalized for the management of severe pain in the left hypochondrium. He was known to have a large (9 × 7 cm) metastatic lesion in his left adrenal gland occupying the space between the adrenal gland and the aorta. Because the mass obliterated the left periaortic space at the L1 level, a right-sided single-needle approach using computed tomographic (CT) guidance was chosen. Under light sedation, a 22-gauge 51/2-inch needle was placed using traditional surface landmarks, as first described by Kappis. CT-generated coordinates were then used as the needle was targeted anterolateral to the aorta, superior to takeoff of the superior mesenteric artery, and anterior to the crux of the diaphragm. 5 A solution of 16 ml bupivacaine 0.75% and 4 ml Omnipaque 180 was injected incrementally over 10 min (fig. 1). The patient reported significant pain relief for 10 hours, as evidenced by a decrease in his Dilaudid infusion from 40 mg/h to 5 mg/h. Two days later, a neurolytic procedure was performed. Using the same surface landmarks and CT guidance, the needle was replaced. A solution of 8 ml 2% lidocaine 1:200,000 epinephrine and 2 ml Omnipaque 180 was injected. After 20 min, a thorough sensory and motor examination was performed without change from a preprocedure examination; 10 ml anhydrous alcohol was injected. The patient reported good pain relief, and his Dilaudid infusion was decreased from 40 mg/h to 15 mg/h. The patient was converted to a fentanyl infusion and discharged to home 5 days after the neurolytic block. At that time he had good pain control. He was seen in follow-up 3 weeks later with progression of his metastatic disease, pulmonary embolism, dehydration, and increased pain. He died 2 weeks later.
Fig. 1. Computed tomographic image of the left adrenal gland between the adrenal gland and the aorta. A  = left adrenal mass; a  = aorta; B  = contrast injected from needle; S  = superior mesenteric artery.
Fig. 1. Computed tomographic image of the left adrenal gland between the adrenal gland and the aorta. A 
	= left adrenal mass; a 
	= aorta; B 
	= contrast injected from needle; S 
	= superior mesenteric artery.
Fig. 1. Computed tomographic image of the left adrenal gland between the adrenal gland and the aorta. A  = left adrenal mass; a  = aorta; B  = contrast injected from needle; S  = superior mesenteric artery.
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Because of the anatomical considerations in this case, we believe that the use of CT guidance, as opposed to fluoroscopy or blind techniques, provided the only effective approach to neurolytic blockade of the celiac plexus. With the mass occupying the periaortic space on the left, accurate placement of the single needle from the right was required to offer any chance of effective blockade. In addition, CT guidance allowed us to avoid vascular puncture. Although vascular puncture would be unlikely to lead to significant morbidity, blood may dilute local anesthetics and neurolytic agents, decreasing their effectiveness. 6 
The literature and textbooks of neural blockade describe a variety of neurolytic volumes. Volumes from 15–80 ml are described, with most references using 20–40 ml of total solution. 7 In his important textbook, Moore describes the use of 50 ml. 2 In this case, we found that 10 ml of alcohol was enough volume to provide an effective neurolytic block. Although we cannot prove this hypothesis, limiting the volume of neurolytic solution would intuitively seem to decrease tissue destruction and the potential for neurologic injury.
References
Loeser JD, Butler SH, Chapman CR, Turk DC: Applied anatomy relevant to pain, Cancer pain: Management, General considerations of abdominal pain, Bonica's Management of Pain, 3rd edition. Philadelphia, Lippincott Williams & Wilkins, 2001 pp 212–6, 679–81, 1243–52
Moore DC: Intercostal nerve block combined with celiac plexus (splanchnic) block, regional block, A Handbook for Use in the Clinical Practice of Medicine and Surgery, 4th edition. Springfield, Charles C Thomas, 1981 pp 145–62
Lee JM: CT guided celiac plexus block for intractable abdominal pain. J Korean Med Sci 2000; 15: 173–8Lee, JM
Hahn MB, McQuillan PM, Sheplock GJ: Celiac plexus, regional anesthesia, An Atlas of Anatomy and Technique, St. Louis, Mosby, 1996, pp 175–82
Lee MJ, Mueller PR, Van Sonnenberg E, Dawson SL, D'Agostino H, Saini S, Cats AM: CT guided celiac ganglion block with alcohol. AJR Am J Roentgenol 1993; 161: 633–6Lee, MJ Mueller, PR Van Sonnenberg, E Dawson, SL D'Agostino, H Saini, S Cats, AM
Romanelli DF, Beckman CF, Heise FW: Celiac plexus block: Efficacy and safety of the anterior approach. AJR Am J Roentgenol 1993; 160: 497–500Romanelli, DF Beckman, CF Heise, FW
Guroszeniuk T, di Vadi P: Use of contrast before percutaneous neurolytic block. Reg Anesth Pain Med 2000; 25: 437–8Guroszeniuk, T di Vadi, P
Fig. 1. Computed tomographic image of the left adrenal gland between the adrenal gland and the aorta. A  = left adrenal mass; a  = aorta; B  = contrast injected from needle; S  = superior mesenteric artery.
Fig. 1. Computed tomographic image of the left adrenal gland between the adrenal gland and the aorta. A 
	= left adrenal mass; a 
	= aorta; B 
	= contrast injected from needle; S 
	= superior mesenteric artery.
Fig. 1. Computed tomographic image of the left adrenal gland between the adrenal gland and the aorta. A  = left adrenal mass; a  = aorta; B  = contrast injected from needle; S  = superior mesenteric artery.
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