Unilateral celiac plexus block

Unilateral

Gmerpatn,

Celiac Plexus Block,

oral mmphine su&te,

dim

block

The use of bilateral neumiytic celiac plexus blolk to relieve intractable pain due to tipper abdominal malignancy is’ well established.‘.A This block is typically performed using a large volume and high concentration of alcoh,bl. Efficacy rates have been in the range oi @I%94% (good to excellent relief), with varied durations.‘S-S” The technique requirss skill and is not free from ‘side effects. Wilh the advent of oral opioid therapy, the indications have become more limited. Unilateral neurolytic block ma); have benefit ‘in reducing the complications of neurolysis.“~’ It may also be analgesic and reduce the requirement for oiioids in ‘some settings. We describe our experience wi+ this block as an Add&s reprinf wpsts to: Arbma Prasanna, &tD. Multidisciplinary Centre for Pain Relief and Pallikive Care, Department of Anesthesia, Kasturba Ha+tal, Manipal 576 119, India. Acceptedfwpublicatioion: June 28, 1995.

adjuvant morphine

approach sulfate

for ,patients receiving s+uion (OMS).

oral ‘.

Methods During a 2-year period between January 1992 and December 1993, patients with upper abdomiilll malignaticy referred to the MultidiscipIinary Centre far Pain Relief and Palliative Care at Kasrurba Hospital were systematically followed.’ At presentation, all patients wefe receiving oral morphine suIfate (OMS) solution in syrup form 60-80 mg/day in divided doses for a month or two. Twenty-five of 200 patients developed moderate ‘(score 4-5 on a pain intensit); visual analogue scale) dragging pain on the left side df the abdomen and discomfort in the epigastrium for at feast 1 month (Table 1). The pain was constant and insidious in onset, causing cpncern to the patients. There was no ptecipi-, tating factor. An increase in dose of OMS (120 mg/day) did not relieve the sympioms, but inc,reased,side effects such as drowsiness, nau088~3924/96/615.00

SSDI 088.54924(95)0016~

P&?nt Type of malignancy

” No. or pa&m

ca pancreas Ca stomach Ca gallbladder Set in liver

: i

Hepatoma

1

T&lel cbaneteristics

Age range (years) 3M5 50-70

O/J 2/6 4/4 3/2

XI-60 70-80

sea, vomiting, listlessness, and constipation. A leftsided unilateral neurolytic cetiac plexus block was performed in all these patients.

Tichniqzu All patients were hydrated on the ave of the procedure with 1000 mL of 5% dextrose in saline over a 12hr period. The morning dose of OMS was omitted in order to judge the immediate effect of the block on pain. A leftsided unilateral celiac plexus block was performed using Hegedus’” modification of Kappis’” technique under an image intensifier. The injectate wds 20 ml; of 50% alcohol with 0.5% plain lidocaine. The patient was positioned prone, with a pill,ow below the abdomen and the head turned towards one side on a doughnut (head rest). The arms were placed forward on the fluoro scopic table. A point.75 cm from midline at the Ll spini level’ws chosen on the left side, which corresponded to a point just below the twelfth rib. After raising a skin weal with 0.5% plain iidocaine, a 201m ZO-gauge needle was introduced at a 654egiee angle in the cephalad direction toward the body of the 12th the racic vertebra while dsualizin~ the anteropostenor view of fluoroscopy. After just passing the’midpoint ofthe lateral border of the body of 12th tboracic vertebra, the needle was viewed from the LateA arm c. ‘f fhtoroscopy and negotiated Curther so th-t the tip of needle was in front of.midpoint of the body, of the 12th thotacic vertebra. Five milliliters of 1% lidocaine without epinephrine was injeitcd through the needle to confirm proper needle placement using pain relief as guide. An atrempt was made to I,ook for aortic pulsation transmitted by the needle. After ascertaining proper needle placement tidiologically (confirmed by the radiologist) and by obtaining pain relief with ‘the local anesthetic, 20 mL. of 50% absolute alcohol (10

Gender

60

O/l

(F/M)

-_.;Pain iniensiy (mean)

VA5

5 4 4 5

4

mL of 100% absolute alcohol + 10 mL of 1% lidocaine without epinephrine = 20 mL of 50% alcohol and 0.5% hdocaine without epinephrine) was injected through the needle. After the injection, 3 mL of air was injected through :he needle. The patient was advised to remair. in the prone position for 20 min before turning supine. Patients ,were examined immediately for hemodynamic stability and neurdogic deficit. They were advised to remain in bed in the supine posture for the next 6 hr. Ail patients were monitored for pain relief, hemodynamic stability, and sedation for 24 hr after block. OMS was restarted at the original ‘. ,dose (604Kt mg in divided doses) 12 hr after completion of neuro@tic block. Patients were discharged after 48 hr. They were instructed to report for follow-ut? on recurrence of pain or : discomfort, or at monthly intervals. The block w&as iepeated on recurrence of pain or discomfort:

Results :

.All 25 patients experienced pain relief immediately folloN+ng the block. There was no hemodynamic instability or diarrhea observed ,after the hl&k. ‘Fifteen patients ‘complained of stiffness of the ,back after 24 hours, which resolved without treatment The pain intensiq scores at discharge were o-i. Twenty-two patients bad complete pai; relief until death, with no mcrease’in the original dose of O;MS (W-SO mg/day) (Table 2). The duration of re?ief varied from 15 to 75 ‘day3 in 22 patients and SC, days in 3 patients. Twenq of the 25 patients were ambulatory until a week before death, and 3 x-ere ambula: tory until 3 weeks prior to death..Two patients 1were bedridden, despite complete pain relief until death.

Three patients with carcinoma of slomach had recurrence of dragging pain and discomfort after 90 days. An increase in the OMS dose again did not relieve the symptoms. A repeat block resulted in complete relief until death 3 months later. There were no side effects attributable to the repeat ,btock.

Discussion E’aiu associated with intra-abdominal matignancy can be severe. ” Although drug therapy continues to be the mainstay of treatment, neurolytic cetiac plexus block is often believed to be valuable.‘“’ The procedure is considered when opioid requirements start to escalate From a previously stable dosage, side effects such as nausea and sedation persist, or opidid therapy cannot be tolerated. Abdominal pain may be comeyed Ga affei ent fiben that traverse sptanchnic sympathetic, vagus, phrenic’, or tumbai somaric #nerves. Depending on tumor size and metastases, any or all of these nerves might be involved;” afferems that run with the sympathetic system are . the primary pain p&way in most pauents. “,” The classic technique of “workieg” needles LO the ventral surface of the vertebral body usually positions the needles just posterior to the diaphragmatic crura instead of anterior to rhem. Contrast medium injected in. this position spreads superiorly and posteriorly around the splanchnic nerves.ls This approach can block these afferents. Alternat+ ap*>roaches to the classic percutaneous poster& rctrocruml technique include unilateral compute&r-d tomography-guided btock,7 trahsaortic apprpach,6*‘4 anteeor approach,‘” and others. Different injectate _ otumes have been recommended depending on the technique. The volume with the classic approach is usually 25

mL through each needle, or 50 mL’.‘s if a single needle technique is used. This amo~!nt is necessary to reach the cetiac plexus and its subsidiary plexuses, but risks unwanted spread tov;ard the spinal canal or lumbosacrat plexus. The transaortic approach is a single needle technique that ‘can be performed with 15-30 mL of solution.‘i*‘4 It may achieve the block with a decreased incidence .of complications. The anterior approach, us& 20-40 mL through a single needlet In this stuciy, the left-sided approach was preferred for two reasons. First, the pain was of the cetiac type (continuous visceral) on the left side’” in all 25 @en&. Second, the anatomy in cancer patients may be attered, and the aorta would act as a guide for the depth and placement of the needle. The unilaterally injected drug spreads more cephatad and also caudad, although the extent of spread is not similar to a bilateral injectiom’s The primary cephalad spread. may block the thoracic sptanchnic, vagal, and sensory afferems that converge to form the cetiac ptezus, and thereby alleviate the pain and the epigastric discomfort.‘s Thus, it, may be reasonably .argued that left-sided block atone may be sufficient for predo’minantty left-sided pain. A reductiqn in the:votume of 50% atcohol injected was used as it was anticipated that residual pain could he controlled on ‘OMS, as it had been prior t6 rhe occurrence of dragging pain and epigastric discomfort. Use of a smaller volume reduced the potential for side. effects from tie procedure. Overall, this unilateral approach presstnably decreased the risks associated with needle parictute-and the neurolytic agent.‘” Moreover, it is less painful to the patient. The use of tidocaine prior to the block and. along with rhe neurotydc agent helped to blunt the pain .of neurolysis and establish correct placement of the needle. Plain tidocaine WE. preferred: to bupivacaine because of its faster onset of action. A 0.5%-l% concentration would not contribute to side effects such as hypotension after. the block. Absence of hypotension was also possibly due LO adequate prehtock hydration and use of a small volum& of neurolytic agent Ischia et al., who used a small volume of 30’ mL of 50% atcqhol, I4 and Liebermann and Watdman!G who used 15 mL, reported post-

block diarthea in 60% and 54%, respuctivdy. This complication was attritiuted to sympathetic blockade of gut, increased \;agaI tone. and, possibly, reduced use oi opioids.” None af the patients had diarrhea in’ this study. Absence of diarrhea could have been due to the small vohmie of neurolytic agent and continuation of the original stablilized dose of OMS 12 hr post-black (6MC mg/day of oral morphine), which cot@ hav: counter& the sympathetic blockade: effect on the gut. The minor complication of stiffness of the back on the side of the injection was noticed in 60% (151’25) of our patients. Unlike Lisbermann and Waldman’s series, in which the complaint wx noted for several days, tke duration in the present series was only 48 hr. In this study, much of the severiq of the pain had been controlled by OMS, prior to occurrence of dragging pain and epigastric discomfort. Hence, t!te unilateral block with reduced volume by the classic posterior retrocrurdl approach wx sufficient to get complete pain relief.

Comlh We conclude *at the occurrence of the dragging pain and epigastric discomfort in patients with upper abdominal malignancy stabilized,on oral doses of,opioids can be treated by unilateral neurolytic celiac plexus block, particularly when i,ncreasing the dose has not shoivn any penefit. A jmall volume of 40 mL of 50% alcohol can provide good, relief with no serious side effects. This procedure does no1 require reduction in th’e dose of oral,opioids and can be used as part of combined therapy. It ‘can also be repeated if necessary.

ACkT2QWWg.!?ld 1 wish to thank my colleague, Dr. Yasodananda I&mar, Associate ProCessor of Anesthesia at Kasturba Hospital, for his unstinting support in preparing and editing the manuscript.

Ref&es 1. Brown

Bi,

Buliey

C&

Ouiet

EC. Neorol@

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pain k 197%135:

9. Kappis ,M. Sensilbilitat aud Lokale anaesthrsic im chirugischen Gobect der Bauchhohle mir besonderer Berticksichrtigung. Dcr SplanchnicusAnasthesia’ B&r Rlin Chit 1919;119:161-175. 10. Ld-foirz Abf, Lejkotit; M. Pain m;nage:nent of pancreatic carcinomd: a r&ew. Pain 19EEWl-11. 11. Moore DC. Regional block, 4th ed. Springf?dd, IL: Charles C. Thomas, 1979. !.

Bridenbaugh

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