Celiac plexus neurolysis has been shown to be an effective analgesic option for patients with visceral pain related to intraabdominal malignancies.1,2 There are 2 commonly used percutaneous techniques: transcrural (ie, antecrural) or retrocrural.3 In the transcrural technique, the celiac plexus is directly targeted adjacent to the aorta and anterior to the diaphragmatic crura. This technique may be performed with a single needle because the celiac plexus lies in a discrete location anterior to the aorta, although bilateral needle placement is often used. The presence of tumor burden encroaching near the celiac access may limit efficacy.4 In a retrocrural approach, the celiac plexus is not directly targeted. Rather, the site of neurolysis lies posterior to the crura of the diaphragm, targeting the bilateral thoracic splanchnic nerves. As such, this procedure typically requires bilateral needle placement and is sometimes labeled as a splanchnic nerve block rather than a retrocrural celiac plexus block.
Celiac plexus blockade has recently been described as a moderate bleeding risk procedure.5 However, variance in the anatomic configuration of major vascular structures or tumor burden may conceivably heighten the risk for periprocedural bleeding secondary to vascular puncture or inadvertent tumor infiltration. In addition, anatomical variation in organ position, which may be a direct result of tumor burden, can increase the risk for other procedural complications such as pneumothorax, hepatic or renal injury, or analgesic failure. Previously, a modified retrocrural single-needle approach has been described using computed tomography (CT) guidance and an ipsilateral aortic approach in cases where anatomy is not favorable for bilateral needle placement during traditional retrocrural celiac plexus block.6 In addition, a single-needle transaortic technique has been described under CT guidance.7 In this report, we describe an alternate and novel single-needle retrocrural technique with fluoroscopic, rather than CT, guidance, allowing for rapid blockade with a needle trajectory in a “safe-zone” contralateral to the aorta. Written informed consent was obtained.
A 73-year-old woman with metastatic colorectal cancer with bulky liver metastases was evaluated in our Pain Clinic. Although she described only 4 of 10 baseline abdominal pain, she experienced frequent escalations in pain severity that were debilitating, including reductions in sleep quality and functional capacity. She used immediate-release oxycodone (5 mg every 4 hours as needed). However, pain control was inadequate, and she experienced excessive somnolence. As such, she refrained from using oxycodone during daytime hours due to her desire to drive a motor vehicle. She was listed for celiac plexus neurolysis. Review of axial CT imaging revealed an aorta translated approximately 1.5 cm left of midline from the anterior surface of the L1 vertebral body with minimal retroaortic space (Figure 1). As such, there were concerns regarding heightened risk of aortic injury with needle advancement on the ipsilateral aortic (left) side.
Given these findings, we developed a technique that would allow for unilateral needle placement for retrocrural blockade using only fluoroscopy that would be directed from the contralateral aortic (right) side with the goal of depositing neurolytic medication at a midline location on the anterior surface of the L1 vertebral body to obtain bilateral retrocrural spread (Figure 2). To achieve this, we used a curved 25-gauge needle (Pakter needle, Cook Inc, Bloomington, IN) through a 21-gauge introducer needle, a technique similar to the 2-needle (needle-through-introducer needle) technique described for diagnostic diskography.8 Alternative techniques were also considered, including approaches under CT guidance; however, fluoroscopic guidance offered her the most expedient opportunity to have the procedure completed, and we were confident in our ability to safely obtain midline needle placement with a bilateral spread pattern while minimizing the risk for a bleeding complication. A thorough discussion was held with the patient regarding potential risks and benefits of this novel approach.
After positioning the introducer needle 0.5 cm posterior to the anterior surface of the L1 vertebral body in lateral view (Figure 3A), we then inserted the curved needle through the introducer advancing under intermittent fluoroscopic guidance until the needle achieved a midline position on the anterior surface of the vertebral body, as seen in lateral (Figure 3B) and posterior-anterior views (Figure 3C). Contrast was used to confirm optimal needle placement in lateral and posterior-anterior views (Figure 3D, E, respectively). Digital subtraction fluoroscopic imaging was used to minimize the likelihood of intravascular spread. After confirming excellent bilateral contrast spread in the prevertebral plane in the anticipated location of the splanchnic nerves, 9 mL of a solution of 0.25% bupivacaine with 1:200,000 epinephrine was injected. During a period of 5 minutes, the patient had relief of abdominal pain with stable hemodynamics and a normal bilateral lower extremity neurological examination. Subsequently, we injected 6 mL of 100% alcohol followed by a washout film (Figure 3F). The needles were flushed and removed. The patient tolerated the procedure without complication.
The patient did well from an analgesic standpoint. She experienced substantial short-term pain relief with improvements in pain scores to 2 of 10 in severity with improved sleep in the first week after the procedure. However, her metastatic disease continued to progress rapidly, ultimately leading to enrollment in an inpatient hospice center 2 weeks postprocedurally and death approximately 1 month later secondary to disease progression.
Celiac plexus blockade is an efficacious treatment for patients with visceral pain secondary to upper abdominal malignancies.1,9 The transcrural technique, which directly targets the celiac plexus anterior to the aorta, may be less efficacious in instances with substantial tumor burden abutting the plexus itself.4 Moreover, unique anatomical configurations may make this site difficult to reliably access, especially in the absence of CT guidance. The retrocrural approach avoids this problem by instead targeting the bilateral thoracic splanchnic nerves that relay pain signals from the celiac plexus to the spinal cord. While this typically requires bilateral injections, in this report, we describe a novel method using a unilateral needle-through-needle technique to facilitate medication deposition along the anterior surface of the vertebral body with bilateral retrocrural spread.
Two previous reports exist describing a single-needle approach to the retrocrural space. Ng et al10 described a unilateral retroaortic injection under fluoroscopic guidance performed in the lateral decubitus position, allowing for the injected contrast and local anesthetic to sink with gravity to the contralateral side. Of note, this was performed only for diagnostic purposes for fear that neurolytic solution would be too viscous to display gravitational dependence and reliably infiltrate the contralateral retrocrural space. In addition, the time required to obtain sufficient contralateral spread is unknown. More recently, Kamdar et al6 described a single-needle technique performed with CT guidance. This approach relies on accessing the aorta from the ipsilateral side (typically left) and then cautiously advancing the needle through the retroaortic fat plane under direct CT visualization to obtain access to the contralateral retrocrural space. An inherent limitation of this technique is the requirement for CT guidance, which is not universally available in all pain centers, increases radiation exposure and cost, and increases procedural time compared to fluoroscopy.6
In our approach, we use a Pakter needle, which can then be guided with fluoroscopy as it hugs around the anterior surface of the vertebral body to the contralateral aortic side. This decreases the risk of aortic or major organ injury on the contralateral side in patients with anatomical variation that precludes safe bilateral needle placement. Although larger studies are needed to ascertain the efficacy and limitations of the approach, we anticipate that single-needle placement could ultimately decrease total procedure time when compared to bilateral placement. The technique is simple to learn and not cost prohibitive (needle set cost of approximately $48 as of January 2018). The introducer needle is 21 gauge with available lengths of 10 and 15 cm. The curved needle is 25 gauge with 15- and 20-cm lengths.
Limitations to this approach include lack of familiarity with the needle or needle-through-introducer technique, because this is not a common therapeutic injection technique. However, we believe the learning curve to be limited in scope. Second, patients with insufficient retroaortic space theoretically may not experience bilateral spread of injectate leading to limitations in analgesic efficacy, although it is unclear how many patients this would include. In addition, while this technique potentially carries a lower risk of aortic puncture, the risk of clinically significant hemorrhage as a result of aortic puncture is likely to be low. Moreover, this technique does not decrease the risk for spinal artery injury or injection, and hence the possibility for severe neurological injury due to spinal cord ischemia persists.
In conclusion, we describe a novel single-sided needle-through a-needle retrocrural approach to the celiac plexus that can be performed with standard fluoroscopic guidance. Further study of this technique with emphasis on procedural efficiency and difficulty, analgesic efficacy, and periprocedural complications is clearly warranted before widespread endorsement of the technique can be given. In addition, it is unclear if this technique truly provides benefit over more traditional approaches. Perhaps most importantly, this report demonstrates the importance of assessing preprocedural imaging to tailor an optimal procedural approach suited to the patient’s unique anatomy and disease state.
The authors would like to acknowledge the contributions of David Cheney for providing the medical illustration.
Name: Nafisseh S. Warner, MD.
Contribution: This author helped draft and edit the manuscript.
Conflicts of Interest: None.
Name: Eleanor R. Trousdale, MD.
Contribution: This author helped prepare and revise the manuscript.
Conflicts of Interest: None.
Name: Tim J. Lamer, MD.
Contribution: This author helped revise the manuscript.
Conflicts of Interest: Dr Lamer has received research funding from Medtronic and Boston Scientific, with all funds paid to the author’s institution.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
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