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CT-Guided Neurolytic Splanchnic Nerve Block by an Anterior Approach
268
Letters
Table 1 Categories of Patient Responses to the Open-Ended Question: “What would be the most useful way I can be of help to you today?”
Types of Responses
% of Patient Responses (n 413)
Relief of physical symptoms (most common pain, fatigue, nausea) Companionship Help coping, emotional support Domestic help (cooking, cleaning, laundering, etc.) Personal care (bathing, getting out of bed, dressing, etc.) Help with medications (organizing it, remembering when to take it) Help communicating with doctors and other professionals Basic needs (food, heating, cooling, telephone, etc.) Help with finances and money worries
32 30 12 8 5 5 4 2 2
nant themes. Although not mutually exclusive, these represent two distinct sets of needs, calling for different forms of “therapy.” This highly pragmatic approach to determining and prioritizing patient needs does not obviate the type of existential work that can lead to significant intra- and inter-personal growth at life’s end. However, under circumstances when time is of the essence, this simplistic approach has great merit. By gaining an immediate and clear focus of what matters the most to each patient on a given day, the trust required to enter a deeper relationship can be more readily gained so that patients may be more willing and capable of going the next step. Perry G. Fine, MD Pain Management Center, University of Utah Salt Lake City, Utah, USA and VistaCare, Inc., Scottsdale, Arizona, USA David Peterson University of Utah Salt Lake City, Utah, USA PII S0885-3924(01)00397-9
References 1. Yedidia MJ, MacGregor B. Confronting the prospect of dying: reports of terminally ill patients. J Pain Symptom Manage 2001;22:807–819.
Vol. 23 No. 4 April 2002
CT-Guided Neurolytic Splanchnic Nerve Block by an Anterior Approach To the Editor: Abdominal visceral sympathetic block can be performed by injection of neurolytic solution, either behind the crura of the diaphragm (splanchnic nerve block) or anterior to the crus (celiac plexus block).1 The splanchnic block may be useful, as the retrocrural structures are better preserved than the preaortic area in patients with upper abdominal malignancy. Although the use of computed tomography (CT) is not mandatory for guaranteeing target destruction when performing either a bilateral splanchnic block or a celiac neurolysis, CTguide technique allows a three-dimensional view, rather than the two-dimensional one of fluoroscopy, which might reduce the risk of organ injury and give a good view of the spread of neurolytic solution in the area chosen. The advantages may be more evident when the normal anatomy is distorted by malignancy. CT-guide neurolytic splanchnic nerve block has been traditionally performed by a posterior approach.2 CT-imaging is particularly useful when the anterior approach is planned. The theoretical advantages of the abdominal anterior approach include reduced discomfort during the procedure by avoiding a prolonged prone position and other benefits associated with a supine position (e.g., easier sedation for those who are at risk and require meticulous monitoring and good ventilation.3 We describe CT-guided neurolytic splanchnic nerve block using an anterior approach in patients scheduled for celiac plexus block, in whom distorted anatomy prevented the traditional celiac plexus neurolysis.
Case Report Five patients referred to the Pain Relief and Palliative Care Unit for the management of pain due to pancreatic cancer had the characteristics shown in Table 1. After informed consent was obtained, they were scheduled for a celiac plexus block by CT-scan guided anterior route. No premedication was given. The patients were supine during the procedure. CTimages of the abdomen (5 mm slice thickness) were obtained at the T12–L1 level. As it appeared evident that the celiac area was inaccessible and the diffusion of the neurolytic solu-
Vol. 23 No. 4 April 2002
Letters
Fig. 1. Bilateral diffusion of the contrast medium in the selected area. The pre-aortic area is completely occupied by neoplastic masses that would render the spread of the injection unreliable.
tion would be virtually prevented, it was decided to perform a splanchnic nerve block, maintaining the patient in a supine position and using the same planned anterior approach. A light anesthesia with boluses of propofol and inhalation of a N2O-O2 mixture was given, according to the department policies. The skin was sterilized and the site of puncture was infiltrated with lidocaine 2%. A 20-cm-long needle with a stylet was inserted and CT-images were obtained to assure correct needle direction passing through the aorta-vena cava space to reach the retrocrural area on the right. On the left, the best trajectory was chosen to avoid organ perforation and to place the tip of the needle in the left retrocrural area. Two ml of contrast medium were injected through both needles to confirm the proper spread (see Fig. 1). Neurolysis was achieved by injecting 12 ml of 75% alcohol through each needle. The whole procedure lasted 30–45 minutes. Post-operative orders included the administration of two liters of plasma expanders in the Table 1 Characteristics of Patients Before the Block (preEAS), Two Weeks After (2-post-EAS), and 1 Week Before Dying (1 EAS) Survival 22 45 32 18 41
Age-Sex
Pre-EAS
2-Post-EAS
1 EAS
65-M 59-M 53-M 61-M 42-F
300 28 24 40 76
15 21 18 12 40
45 21 20 21 45
269
first 24 hours, as standard protocol to prevent immediate hypotension, and patient-controlled administration of morphine. No complications were observed. Opioid doses were given in the following days on the basis of patients’ demand. Pain relief was good (between 2 and 4 on a 10 cm visual analogue scale [VAS]) before discharging the patients home. The equianalgesic score (EAS) was calculated before neurolysis and then two weeks after, according to the following formula: (1 M/10) VAS, where 1 indicates the administration of anti-inflammatory drugs at fixed times and at full dosage, M indicates the dosage of opioids in oral morphine equivalents (mg), and VAS indicates the visual analogue on a 0–10 cm scale. This number has been validated to monitor the efficacy of a treatment in time, taking into consideration both pain intensity and opioid consumption.4–6 A relevant decrease in EAS was still evident two weeks after the block and one week before death in all the patients, occurring on average 9 weeks after performing the block, thus confirming the efficacy of this approach (Table 1).
Comment CT-guided celiac plexus block by an anterior approach has gained popularity during the past few years. The detailed anatomical display obtained with the three-dimensional view of CT provides an excellent means of accurate localization of the celiac axis and has the advantage that the optimum needle direction may be planned, avoiding important local structures.2 The celiac plexus is contained in a relatively large amount of fat tissue, in which distorted anatomy due to tumor mass, may influence the spread of the substances injected. It has been found that the neurolytic spread in the celiac area is highly affected by the regional anatomic alterations.7 Disadvantages of a posterior approach include the prone position, which is uncomfortable or dangerous when using even a light anesthesia for patients. The procedure is quite disturbing and a light anesthesia is commonly preferred by patients. On the other hand, an anterior approach involves the passage of the needle through the viscera. However, this is not associated with relevant complications.1 Splanchnic nerves may be blocked placing the needle tip in the retrocrural space.
270
Splanchnic nerve neurolysis by an anterior approach has never been described. It may be a useful alternative technique to traditional celiac plexus block, when after starting an abdominal anterior approach CT scan shows large lesions that prevent access to the celiac plexus. This avoids turning the patient for a traditional posterior approach for splanchnic block. Moreover, a light anesthesia to make patients comfortable during the procedure is better performed in supine patients than in prone position. The retrocrural structure is seldom involved by the invasion of tumor masses. Although the diaphragmatic crura represents a barrier for the spread of neurolytic solution, it may flow in the anterior space through some gaps in the crus. Since the greater and lesser splanchnic nerves pierce the diaphragm at the crus, the site chosen to perform the block was optimal due to the large area easily accessible by the anterior route. In a study on retrocrural CT anatomy in patients with and without cancer, despite the greater cross-sectional area on the right, simulated right-sided needle placement was predicted to be less likely to succeed than left-sided needle placement when using a posterior approach in cancer patients.8 The needle on the right may be unable to be placed in the retrocrural right triangle, which is larger but less accessible when compared with the left side. An anterior approach may benefit from the advantage of having either an accessible or a larger retrocrural space. In conclusion, CT-images offer advantages when performing an abdominal sympathetic block in the celiac area because it allows an individualized intervention in pancreatic cancer patients on the basis of the specific anatomic situation. The approach described may be a helpful alternative in such conditions. Changing position to perform the technique by the traditional posterior route is not needed, and the approach may give the best angle to place the needles in the retrocrural spaces. Further studies with a large number of patients are needed to confirm this preliminary observation. Sebastiano Mercadante, MD La Maddalena Cancer Center and SAMOT Salvatore La Rosa, MD Buccheri La Ferla Fatebenefratelli Hospital
Letters
Vol. 23 No. 4 April 2002
Patrizia Villari, MD La Maddalena Cancer Center Palermo, Italy PII: S0885-3924(01)00422-5
References 1. Mercadante S, Nicosia F. Celiac plexus block: a reappraisal. Reg Anesth Pain Med 1998;21:407–413. 2. Fujita Y. CT-guided neurolytic splanchnic nerve block with alcohol. Pain 1993;55:363–366. 3. Matamala AM, Lopez FV, Aguilar JL, Bach DL. Percutaneous anterior approach to the coeliac plexus using ultrasound. Br J Anaesth 1989;62:637–640. 4. Mercadante S. Celiac plexus block versus analgesics in pancreatic cancer pain. Pain 1993;52:187–192. 5. Mercadante S, Dardanoni G, Selvaggio L, Armata MG, Agnello A. Monitoring of opioid therapy in advanced cancer patients. J Pain Symptom Manage 1997;13:204–212. 6. Mercadante S, Fulfaro F, Casuccio A, Agnello A, Barresi L. Investigation on an opioid response categorization in advanced cancer patients. J Pain Symptom Manage 1999;18:347–352. 7. Di Cicco M, Matovic M, Balestreri L, et al. Single-needle celiac plexus block. Is needle position critical in patients with no regional anatomic distortion? Anesthesiology 1997;87:1301–1308. 8. Weber JG, Brown DL, Stephens DH, Wong GY. Celiac plexus block. Retrocrural computed tomographic anatomy in patients with and without pancreatic cancer. Reg Anesth 1996;21:407–413.
Problems Recruiting Cancer Patients to a Comparative Clinical Trial of Drug Treatments for Neuropathic Pain in Palliative Care To the Editor: Neuropathic pain is a common problem in patients with advanced cancer, and a frequent reason for referral to specialist palliative care services. Management of neuropathic pain in this population may be particularly difficult because of the increased toxicity of drugs in frail, cachectic patients; polypharmacy; and the rapidly progressing pattern of the disease and associated
Letters
Table 1 Categories of Patient Responses to the Open-Ended Question: “What would be the most useful way I can be of help to you today?”
Types of Responses
% of Patient Responses (n 413)
Relief of physical symptoms (most common pain, fatigue, nausea) Companionship Help coping, emotional support Domestic help (cooking, cleaning, laundering, etc.) Personal care (bathing, getting out of bed, dressing, etc.) Help with medications (organizing it, remembering when to take it) Help communicating with doctors and other professionals Basic needs (food, heating, cooling, telephone, etc.) Help with finances and money worries
32 30 12 8 5 5 4 2 2
nant themes. Although not mutually exclusive, these represent two distinct sets of needs, calling for different forms of “therapy.” This highly pragmatic approach to determining and prioritizing patient needs does not obviate the type of existential work that can lead to significant intra- and inter-personal growth at life’s end. However, under circumstances when time is of the essence, this simplistic approach has great merit. By gaining an immediate and clear focus of what matters the most to each patient on a given day, the trust required to enter a deeper relationship can be more readily gained so that patients may be more willing and capable of going the next step. Perry G. Fine, MD Pain Management Center, University of Utah Salt Lake City, Utah, USA and VistaCare, Inc., Scottsdale, Arizona, USA David Peterson University of Utah Salt Lake City, Utah, USA PII S0885-3924(01)00397-9
References 1. Yedidia MJ, MacGregor B. Confronting the prospect of dying: reports of terminally ill patients. J Pain Symptom Manage 2001;22:807–819.
Vol. 23 No. 4 April 2002
CT-Guided Neurolytic Splanchnic Nerve Block by an Anterior Approach To the Editor: Abdominal visceral sympathetic block can be performed by injection of neurolytic solution, either behind the crura of the diaphragm (splanchnic nerve block) or anterior to the crus (celiac plexus block).1 The splanchnic block may be useful, as the retrocrural structures are better preserved than the preaortic area in patients with upper abdominal malignancy. Although the use of computed tomography (CT) is not mandatory for guaranteeing target destruction when performing either a bilateral splanchnic block or a celiac neurolysis, CTguide technique allows a three-dimensional view, rather than the two-dimensional one of fluoroscopy, which might reduce the risk of organ injury and give a good view of the spread of neurolytic solution in the area chosen. The advantages may be more evident when the normal anatomy is distorted by malignancy. CT-guide neurolytic splanchnic nerve block has been traditionally performed by a posterior approach.2 CT-imaging is particularly useful when the anterior approach is planned. The theoretical advantages of the abdominal anterior approach include reduced discomfort during the procedure by avoiding a prolonged prone position and other benefits associated with a supine position (e.g., easier sedation for those who are at risk and require meticulous monitoring and good ventilation.3 We describe CT-guided neurolytic splanchnic nerve block using an anterior approach in patients scheduled for celiac plexus block, in whom distorted anatomy prevented the traditional celiac plexus neurolysis.
Case Report Five patients referred to the Pain Relief and Palliative Care Unit for the management of pain due to pancreatic cancer had the characteristics shown in Table 1. After informed consent was obtained, they were scheduled for a celiac plexus block by CT-scan guided anterior route. No premedication was given. The patients were supine during the procedure. CTimages of the abdomen (5 mm slice thickness) were obtained at the T12–L1 level. As it appeared evident that the celiac area was inaccessible and the diffusion of the neurolytic solu-
Vol. 23 No. 4 April 2002
Letters
Fig. 1. Bilateral diffusion of the contrast medium in the selected area. The pre-aortic area is completely occupied by neoplastic masses that would render the spread of the injection unreliable.
tion would be virtually prevented, it was decided to perform a splanchnic nerve block, maintaining the patient in a supine position and using the same planned anterior approach. A light anesthesia with boluses of propofol and inhalation of a N2O-O2 mixture was given, according to the department policies. The skin was sterilized and the site of puncture was infiltrated with lidocaine 2%. A 20-cm-long needle with a stylet was inserted and CT-images were obtained to assure correct needle direction passing through the aorta-vena cava space to reach the retrocrural area on the right. On the left, the best trajectory was chosen to avoid organ perforation and to place the tip of the needle in the left retrocrural area. Two ml of contrast medium were injected through both needles to confirm the proper spread (see Fig. 1). Neurolysis was achieved by injecting 12 ml of 75% alcohol through each needle. The whole procedure lasted 30–45 minutes. Post-operative orders included the administration of two liters of plasma expanders in the Table 1 Characteristics of Patients Before the Block (preEAS), Two Weeks After (2-post-EAS), and 1 Week Before Dying (1 EAS) Survival 22 45 32 18 41
Age-Sex
Pre-EAS
2-Post-EAS
1 EAS
65-M 59-M 53-M 61-M 42-F
300 28 24 40 76
15 21 18 12 40
45 21 20 21 45
269
first 24 hours, as standard protocol to prevent immediate hypotension, and patient-controlled administration of morphine. No complications were observed. Opioid doses were given in the following days on the basis of patients’ demand. Pain relief was good (between 2 and 4 on a 10 cm visual analogue scale [VAS]) before discharging the patients home. The equianalgesic score (EAS) was calculated before neurolysis and then two weeks after, according to the following formula: (1 M/10) VAS, where 1 indicates the administration of anti-inflammatory drugs at fixed times and at full dosage, M indicates the dosage of opioids in oral morphine equivalents (mg), and VAS indicates the visual analogue on a 0–10 cm scale. This number has been validated to monitor the efficacy of a treatment in time, taking into consideration both pain intensity and opioid consumption.4–6 A relevant decrease in EAS was still evident two weeks after the block and one week before death in all the patients, occurring on average 9 weeks after performing the block, thus confirming the efficacy of this approach (Table 1).
Comment CT-guided celiac plexus block by an anterior approach has gained popularity during the past few years. The detailed anatomical display obtained with the three-dimensional view of CT provides an excellent means of accurate localization of the celiac axis and has the advantage that the optimum needle direction may be planned, avoiding important local structures.2 The celiac plexus is contained in a relatively large amount of fat tissue, in which distorted anatomy due to tumor mass, may influence the spread of the substances injected. It has been found that the neurolytic spread in the celiac area is highly affected by the regional anatomic alterations.7 Disadvantages of a posterior approach include the prone position, which is uncomfortable or dangerous when using even a light anesthesia for patients. The procedure is quite disturbing and a light anesthesia is commonly preferred by patients. On the other hand, an anterior approach involves the passage of the needle through the viscera. However, this is not associated with relevant complications.1 Splanchnic nerves may be blocked placing the needle tip in the retrocrural space.
270
Splanchnic nerve neurolysis by an anterior approach has never been described. It may be a useful alternative technique to traditional celiac plexus block, when after starting an abdominal anterior approach CT scan shows large lesions that prevent access to the celiac plexus. This avoids turning the patient for a traditional posterior approach for splanchnic block. Moreover, a light anesthesia to make patients comfortable during the procedure is better performed in supine patients than in prone position. The retrocrural structure is seldom involved by the invasion of tumor masses. Although the diaphragmatic crura represents a barrier for the spread of neurolytic solution, it may flow in the anterior space through some gaps in the crus. Since the greater and lesser splanchnic nerves pierce the diaphragm at the crus, the site chosen to perform the block was optimal due to the large area easily accessible by the anterior route. In a study on retrocrural CT anatomy in patients with and without cancer, despite the greater cross-sectional area on the right, simulated right-sided needle placement was predicted to be less likely to succeed than left-sided needle placement when using a posterior approach in cancer patients.8 The needle on the right may be unable to be placed in the retrocrural right triangle, which is larger but less accessible when compared with the left side. An anterior approach may benefit from the advantage of having either an accessible or a larger retrocrural space. In conclusion, CT-images offer advantages when performing an abdominal sympathetic block in the celiac area because it allows an individualized intervention in pancreatic cancer patients on the basis of the specific anatomic situation. The approach described may be a helpful alternative in such conditions. Changing position to perform the technique by the traditional posterior route is not needed, and the approach may give the best angle to place the needles in the retrocrural spaces. Further studies with a large number of patients are needed to confirm this preliminary observation. Sebastiano Mercadante, MD La Maddalena Cancer Center and SAMOT Salvatore La Rosa, MD Buccheri La Ferla Fatebenefratelli Hospital
Letters
Vol. 23 No. 4 April 2002
Patrizia Villari, MD La Maddalena Cancer Center Palermo, Italy PII: S0885-3924(01)00422-5
References 1. Mercadante S, Nicosia F. Celiac plexus block: a reappraisal. Reg Anesth Pain Med 1998;21:407–413. 2. Fujita Y. CT-guided neurolytic splanchnic nerve block with alcohol. Pain 1993;55:363–366. 3. Matamala AM, Lopez FV, Aguilar JL, Bach DL. Percutaneous anterior approach to the coeliac plexus using ultrasound. Br J Anaesth 1989;62:637–640. 4. Mercadante S. Celiac plexus block versus analgesics in pancreatic cancer pain. Pain 1993;52:187–192. 5. Mercadante S, Dardanoni G, Selvaggio L, Armata MG, Agnello A. Monitoring of opioid therapy in advanced cancer patients. J Pain Symptom Manage 1997;13:204–212. 6. Mercadante S, Fulfaro F, Casuccio A, Agnello A, Barresi L. Investigation on an opioid response categorization in advanced cancer patients. J Pain Symptom Manage 1999;18:347–352. 7. Di Cicco M, Matovic M, Balestreri L, et al. Single-needle celiac plexus block. Is needle position critical in patients with no regional anatomic distortion? Anesthesiology 1997;87:1301–1308. 8. Weber JG, Brown DL, Stephens DH, Wong GY. Celiac plexus block. Retrocrural computed tomographic anatomy in patients with and without pancreatic cancer. Reg Anesth 1996;21:407–413.
Problems Recruiting Cancer Patients to a Comparative Clinical Trial of Drug Treatments for Neuropathic Pain in Palliative Care To the Editor: Neuropathic pain is a common problem in patients with advanced cancer, and a frequent reason for referral to specialist palliative care services. Management of neuropathic pain in this population may be particularly difficult because of the increased toxicity of drugs in frail, cachectic patients; polypharmacy; and the rapidly progressing pattern of the disease and associated