- Email: [email protected]
Reply to Traycoff et al. ‘Letter-to-the-Editor’ and comments on DeConno and Brown
235 Traycoff, R.B., Khardori, R. and Zhong, W., Letter, Pain (1994). Van Dongen, R.T.M. and Crul, B.J.B., Paraplegia following celiac plexus block, Anaesthesia, 46 (1991) 862-863. Woodham, M.J. and Hanna, M.H., Paraplegia after celiac plexus block, Anaesthesia, 44 (1989) 487-489. Franco De Conno Augusto Caraceni Vittorio Ventafridda Pain Therapy and Palliatir,e Care Division National Cancer Institute of Milan, Via Venezian 1, 20133 Milan~ Italy
Luca Aldrighetti Gianfranco Ferla Clinical Surgery Department San Raffaele Hospital, Via Olgettina, Milan, Italy
Giuseppe Magnani Giancarlo Comi Neurology Department IV San Raffaele Hospital Via Olgettina, Milan, Italy SSDI 0304-3959(94)00201-0
PAIN 2759
Reply to Traycoff et al. 'Letter-to-the-Editor' and Comments on DeConno and Brown The accompanying Letter-to-the-Editor by Traycoff et al., highlights that patients undergoing neurolytic celiac block occasionally develop neurologic changes following a technically adequate block (Traycoff et al. 1994). I congratulate the authors on describing the development of paraplegia in their patient, and 1 think they are correct in asserting that they are reporting the first patient developing paraplegia with an anterocrural (transaortic) technique. It remains that numerous experienced pain medicine specialists detail paraplegia as one outcome of 'technically adequate' celiac neurolysis (Lo and Buckley 1982; Woodham and Hanna 1989; Van Dongen and Crul 1991; De Conno et al. 1993). Traycoff et al. suggest that the transaortic technique limits the number of confounding variables potentially associated with paraplegia, although evidence for this view is at best speculative. Their assertion that the transaortic technique is somehow simpler re-develops an earlier theme by Singler (1982). This assertion, however, is strongly questioned by Moore et al. (1982). As example, Traycoff et al. suggest that mechanical damage to a major lumbar feeding artery (artery of Adamkiewicz) is unlikely in their patient, though their opinion is hypothetical. Similarly, as they outline, it is not possible clinically to exclude dislodgment of intraluminal aortic particles (such as an atherosclerotic plaque) in this case or in many of the other examples cited (Lo and Buckley 1982; Woodham and Hanna 1989; Van Dongen and Crul 1991; De Conno et al. 1993). Our prior work (Brown and Rorie 1994) shows that ethanol produces an increase in vascular tone of dog's lumbar arteries with low concentrations (3-6%) of ethanol, and may be supported by these worker's clinical report. However, their patient's paraplegia
seems slower to develop than similar 'paraplegia' reports (Lo and Buckley 1982; Van Dongen and Crul 1991; De Conno et al. 1993). I find it intriguing that their patient's right lower extremity motor function remained for a significant time following onset of the neurologic changes in his left lower extremity, possibly indicating slowly developing edema of the spinal cord contributing to the changes (Steegmann 1952). The return of function in the patient's right lower extremity 5 days after onset of weakness, also hints that edema in that portion of the spinal cord may have been at least partially responsible for the neurologic changes. I would also be interested in what kind of spinal cord protective therapy, if any, was instituted in their patient. I believe Traycoff et al. patient's experience is important for those of us caring for patients with intra-abdominal cancer pain; however, I think the authors have drawn an unwarranted conclusion which needs considerable modification. Their suggestion that "spinal analgesia and intraoperative denervation may have more acceptable risk benefit profiles, and that the use of lytic celiac plexus blocks should be limited to situations where other options are less attractive" is misleading. There are many patients who receive benefit from including celiac neurolysis in their analgesia regimen, both as inpatients and outpatients, at a lower cost than possible with either spinal analgesia or operative denervation of the splanchnic nerves. This may be especially important after considering the data of Lillimoe et al. (1993) showing that patients with pancreatic cancer survived significantly longer when celiac plexus neurolysis was performed intraoperatively, compared to similar patients receiving an intraoperative saline celiac plexus block. Ischia et al. (1992) also suggest that pain is better controlled in patients with pancreatic cancer if the celiac block is performed earlier in the course of the patient's disease. Further, I wonder whether the neurologic changes that potentially may be associated with spinal analgesia and intra-operative denervation will be lower than the already very low incidence of neurologic changes accompanying neurolytic ethanol celiac plexus block (Brown et al. 1987). In my own practice, I will continue to recommend celiac plexus ethanol neurolysis to my patients with pancreatic cancer, and earlier in the course of their illness than I did in the past based on the work of Lillimoe et al. and Ischia et al. Nevertheless, I will advise each of these patients and their main care-giver (often the wife or husband) that paralysis is a rare but reported complication.
References Brown, D.L. and Rorie, D.K., Altered reactivity of isolated segmental lumbar arteries of dogs following exposure to ethanol and phenol, Pain 56 (1994) 139-143. Brown, D.L., Bulley, C.K. and Quiel, E.L., Neurolytic celiac plexus block for pancreatic cancer pain, Anesth. Analg. 66 (1987) 869873. De Conno, F., Caraceni, A., Aldrighetti, L., Magnani, G., Ferla, G., Comi, G. and Ventafidda, V., Paraplegia following coeliac plexus block, Pain 55 (1993) 383-385. Ischia, S., Ischia, A., Polati, E. and Finco, G., Three posterior percutaneous celiac plexus block techniques: a prospective, randomized study in 61 patients with pancreatic cancer pain, Anesthesiology, 76 (1992) 534-540. Lillimoe, K.D., Cameron, J.L., Kaufman, H.S., Yeo, C.J., Pitt, H.A. and Suater, P.K., Chemical splanchnicectomy in patients with unresectable pancreatic cancer: a prospective randomized trial, Ann. Surg. 217 (1993) 447-457. Lo, J.N. and Buckley, J.J., Spinal cord ischemia: a complication of coeliac plexus block, Reg. Anesth., 7 (1982) 66-68. Moore, D.C., Bush, W.H. and Burnett, L.L., Letter-to-the Editor. An improved technique for celiac plexus block may be more theoretical than real, Anesthesiology 57 (1982) 347-348.
236 Singler, R,C., An improved technique for alcohol neurolysis of the celiac plexus, Anesthesiology, 56 (1982) 137-14t. Steegmann, A.T., Syndrome of anterior spinal artery, Neurology 2 (1952) 15-35. Traycoff, R.B., Khardori, R. and Zhong, W., Letter-to-the-Editor. Pain (1994) in press. Van Dongen, R.T.M. and Crul, B.J.P., Paraplegia following coetmc plexus block, Anaesthesia, 46 (1991) 862-863. Woodham, M.J. and Hanna, M.H., Paraplegia after coeliac plexus block, Anaesthesia, 44 (1989) 487-489.
D.L. Brown
Dept. oJ Anesthesioh~gy Mayo Clinic 200 kTrwt Street SW Rochester. MN 5590,5, USA
"¢5l)1 03(14-3959(94t00251-7
Luca Aldrighetti Gianfranco Ferla Clinical Surgery Department San Raffaele Hospital, Via Olgettina, Milan, Italy
Giuseppe Magnani Giancarlo Comi Neurology Department IV San Raffaele Hospital Via Olgettina, Milan, Italy SSDI 0304-3959(94)00201-0
PAIN 2759
Reply to Traycoff et al. 'Letter-to-the-Editor' and Comments on DeConno and Brown The accompanying Letter-to-the-Editor by Traycoff et al., highlights that patients undergoing neurolytic celiac block occasionally develop neurologic changes following a technically adequate block (Traycoff et al. 1994). I congratulate the authors on describing the development of paraplegia in their patient, and 1 think they are correct in asserting that they are reporting the first patient developing paraplegia with an anterocrural (transaortic) technique. It remains that numerous experienced pain medicine specialists detail paraplegia as one outcome of 'technically adequate' celiac neurolysis (Lo and Buckley 1982; Woodham and Hanna 1989; Van Dongen and Crul 1991; De Conno et al. 1993). Traycoff et al. suggest that the transaortic technique limits the number of confounding variables potentially associated with paraplegia, although evidence for this view is at best speculative. Their assertion that the transaortic technique is somehow simpler re-develops an earlier theme by Singler (1982). This assertion, however, is strongly questioned by Moore et al. (1982). As example, Traycoff et al. suggest that mechanical damage to a major lumbar feeding artery (artery of Adamkiewicz) is unlikely in their patient, though their opinion is hypothetical. Similarly, as they outline, it is not possible clinically to exclude dislodgment of intraluminal aortic particles (such as an atherosclerotic plaque) in this case or in many of the other examples cited (Lo and Buckley 1982; Woodham and Hanna 1989; Van Dongen and Crul 1991; De Conno et al. 1993). Our prior work (Brown and Rorie 1994) shows that ethanol produces an increase in vascular tone of dog's lumbar arteries with low concentrations (3-6%) of ethanol, and may be supported by these worker's clinical report. However, their patient's paraplegia
seems slower to develop than similar 'paraplegia' reports (Lo and Buckley 1982; Van Dongen and Crul 1991; De Conno et al. 1993). I find it intriguing that their patient's right lower extremity motor function remained for a significant time following onset of the neurologic changes in his left lower extremity, possibly indicating slowly developing edema of the spinal cord contributing to the changes (Steegmann 1952). The return of function in the patient's right lower extremity 5 days after onset of weakness, also hints that edema in that portion of the spinal cord may have been at least partially responsible for the neurologic changes. I would also be interested in what kind of spinal cord protective therapy, if any, was instituted in their patient. I believe Traycoff et al. patient's experience is important for those of us caring for patients with intra-abdominal cancer pain; however, I think the authors have drawn an unwarranted conclusion which needs considerable modification. Their suggestion that "spinal analgesia and intraoperative denervation may have more acceptable risk benefit profiles, and that the use of lytic celiac plexus blocks should be limited to situations where other options are less attractive" is misleading. There are many patients who receive benefit from including celiac neurolysis in their analgesia regimen, both as inpatients and outpatients, at a lower cost than possible with either spinal analgesia or operative denervation of the splanchnic nerves. This may be especially important after considering the data of Lillimoe et al. (1993) showing that patients with pancreatic cancer survived significantly longer when celiac plexus neurolysis was performed intraoperatively, compared to similar patients receiving an intraoperative saline celiac plexus block. Ischia et al. (1992) also suggest that pain is better controlled in patients with pancreatic cancer if the celiac block is performed earlier in the course of the patient's disease. Further, I wonder whether the neurologic changes that potentially may be associated with spinal analgesia and intra-operative denervation will be lower than the already very low incidence of neurologic changes accompanying neurolytic ethanol celiac plexus block (Brown et al. 1987). In my own practice, I will continue to recommend celiac plexus ethanol neurolysis to my patients with pancreatic cancer, and earlier in the course of their illness than I did in the past based on the work of Lillimoe et al. and Ischia et al. Nevertheless, I will advise each of these patients and their main care-giver (often the wife or husband) that paralysis is a rare but reported complication.
References Brown, D.L. and Rorie, D.K., Altered reactivity of isolated segmental lumbar arteries of dogs following exposure to ethanol and phenol, Pain 56 (1994) 139-143. Brown, D.L., Bulley, C.K. and Quiel, E.L., Neurolytic celiac plexus block for pancreatic cancer pain, Anesth. Analg. 66 (1987) 869873. De Conno, F., Caraceni, A., Aldrighetti, L., Magnani, G., Ferla, G., Comi, G. and Ventafidda, V., Paraplegia following coeliac plexus block, Pain 55 (1993) 383-385. Ischia, S., Ischia, A., Polati, E. and Finco, G., Three posterior percutaneous celiac plexus block techniques: a prospective, randomized study in 61 patients with pancreatic cancer pain, Anesthesiology, 76 (1992) 534-540. Lillimoe, K.D., Cameron, J.L., Kaufman, H.S., Yeo, C.J., Pitt, H.A. and Suater, P.K., Chemical splanchnicectomy in patients with unresectable pancreatic cancer: a prospective randomized trial, Ann. Surg. 217 (1993) 447-457. Lo, J.N. and Buckley, J.J., Spinal cord ischemia: a complication of coeliac plexus block, Reg. Anesth., 7 (1982) 66-68. Moore, D.C., Bush, W.H. and Burnett, L.L., Letter-to-the Editor. An improved technique for celiac plexus block may be more theoretical than real, Anesthesiology 57 (1982) 347-348.
236 Singler, R,C., An improved technique for alcohol neurolysis of the celiac plexus, Anesthesiology, 56 (1982) 137-14t. Steegmann, A.T., Syndrome of anterior spinal artery, Neurology 2 (1952) 15-35. Traycoff, R.B., Khardori, R. and Zhong, W., Letter-to-the-Editor. Pain (1994) in press. Van Dongen, R.T.M. and Crul, B.J.P., Paraplegia following coetmc plexus block, Anaesthesia, 46 (1991) 862-863. Woodham, M.J. and Hanna, M.H., Paraplegia after coeliac plexus block, Anaesthesia, 44 (1989) 487-489.
D.L. Brown
Dept. oJ Anesthesioh~gy Mayo Clinic 200 kTrwt Street SW Rochester. MN 5590,5, USA
"¢5l)1 03(14-3959(94t00251-7