The three pairs of splanchnic nerves descending to the celiac plexus are
1) Greater splanchnic nerves from T5-T9
2) Lesser splanchnic nerves from T10 and T11 segments
3) Least splanchnic from T12
The three pairs of ganglia in the plexus are
1)Celiac ganglia2)Superior mesenteric ganglia
Agents used for blockade are 0.5% bupivacaine with adrenaline1:200000 around 30ml, 15 ml on either side with or without steroids(dexamethasone) for chronic pain. Neurolytic blockade is indicated in abdominal malignancies where alcohol 50-100% or 10% phenol is used. The pain on injection of alcohol can be minimised with combination of bupivacaine 1:1 ratio
- Pain relief in upper abdominal malignancies from stomach, pancreas, gall blader, and liver.(Indication for neurolytic block)
- Pain after multiple abdominal surgeries. Local anesthetic and steroids indicated.
- For evaluation of upper abdominal pain, local anaesthetic alone used
- Chronic inflammatory conditions like chronic pancreatitis, neurolytic block advised.
1) Informed consent
2) IV access monitors
3) Prone position with pillow beneath hip to minimise lumbar lordosis
Aseptic preparation of the skin, infiltrate the skin and muscle with local anaesthetic use a 12-18 cm long ,20-22 gauge needle and introduce(the left side needle first) at a 45degree angle relative to the sagittal plane running through the spine. The direction is towards the L1 spine and proceeds to hit on the L1 vertebral body.(more superficial bony contact may be the L1 transverse process)The needle contacts the L1 vertebral body at a depth of. 7-10 cm. A skin marker is placed on the needle. The needle is then withdrawn deep to the subcutaneous plane and re introduced laterally until it just slips from the lateral border of the vertebral body Slowly advance the needle further, feeling for the transmitted pulsations of the aorta and stop advancing once pulsations are felt. On the right side advance further 1 cm.
Paramedian approach: Needle is inserted caudad to 12 th spinous process at a point 3 cm lateral to the midline in a plane perpendicular to the skin
Anterior approach: Through the anterior abdominal wall under fluoroscopic and ultrasound guidance.
Direct block: Retroperitoneal surgeries, pancreatectomy or whipples resection block given by surgeon for post op analgesia or neurolytic block for malignant conditions.
Endoscopic Ultrasound Guided Method: See Ref: below.
- Hypotension due to sympathetic blockade minimised by giving 500-1000 ml of RL before the block.
- Orthostatic hypotension may persisit after a neurolytic block for about one week.but self limiting.
- Other complications are back ache due to retroperitoneal hamatoma or injury to lumbar plexus, injury to kidney, bowel, retroperitoneal hematoma ,intrathecal injection, pneumothorax.,infection, aortic dissection, paraplegia or local anaesthetic toxicity.
Wylie Churchil Davidson Practise of Anaesthesia Seventh edition pp1261-62
Michael Mulroy,Christopher Bernards, et al; A Practical approach to Regional Anaesthesia, Fourth Edition