Celiac Plexus Neurolysis: An Underutilized Palliative Therapy

Background: Celiac plexus neurolysis is an image-guided, therapeutic procedure wherein a neurolytic agent is injected into the celiac plexus resulting in permanent loss of the nerve plexus and subsequent pain reduction. Although it has been demonstrated to be safe and effective, celiac plexus neurolysis is an underutilized tool for pain management in the setting of palliative care. Case Information: A 40-year-old female was found to have an extensive, infiltrative gastric cancer with metastatic spread to the peritoneum and bones, as well as retroperitoneal invasion along the course of the celiac artery with invasion of the celiac plexus. Given her severe intractable abdominal pain requiring high opioid narcotic use, interventional radiology was consulted for celiac plexus neurolysis. The patient was a candidate for the procedure following a thorough evaluation of the patient with a multidisciplinary team and she consented after a discussion of the risks and benefits. Based on the current literature, a posterior paravertebral approach was deemed the most appropriate. Guided by computed tomography (CT), two 20-gauge Chiba needles were placed using a bilateral posterior paravertebral antecrural approach. Test injections were used to confirm needle position and satisfactory spread of the injection into the antecrural space. A 10 mL mixture of a 2 mL dilute contrast (1 mL Isovue-370 mixed in 20 mL normal saline) and 8 mL 1% lidocaine was made. The mixture was injected through both 5 mL Chiba needles. Ideally 25-30 mL of 95-100% ethanol is recommended, however due to a nationwide shortage of ethanol associated with the COVID-19 pandemic, 20 mL of 75% ethanol was injected instead through each needle. Post-procedure imaging confirmed dispersed spread of the neurolytic agent within the preaortic space. Conclusion: Following the procedure, the patient achieved temporary abdominal pain relief. However, her pain eventually returned to similar pre-procedure level. Factors that may have contributed to the ineffectiveness include her advanced disease status and tumor invasion into the celiac plexus, multifactorial pain associated with metastatic disease, and the dilution of ethanol. In an ideal situation, percutaneous celiac plexus neurolysis has been shown to improve pain in 70-90% of patients with abdominal cancer with low complication rate, decrease the need for daily analgesic medications, and improve patient survival rate. Therefore, the shortcoming of our case study should not discourage physicians to consider the procedure for palliative care.