Celiac Plexus Blockade in Children Using a Three-Dimensional Fluoroscopic Reconstruction Technique: Case Reports
Kenneth R. Goldschneider, M.D., John M. Racadio, M.D., and Norbert J. Weidner, M.D.
Background and Objectives: We present three cases wherein a new radiologic technique was used to facilitate performance of retrocrural celiac plexus blockade. Three patients presented to our institution for performance of celiac plexus block for relief of intractable upper abdominal pain. One carried the diagnosis of chronic pancreatitis, one abdominal pain and gastrointestinal dysmotility, the other adrenocortical carcinoma.
Methods: We applied the technology used in 3-dimensional rotational angiography to determine spread of the injected medication in three dimensions, and facilitate the blocks.
Results: Three-dimensional rotational angiography was used with clinical success.
Conclusions: Three-dimensional rotational angiography shows promise for understanding the spread of medication necessary to accomplish a successful block, and may help explain failures in cases where anatomic distortion may interfere with proper injectate flow. Reg Anesth Pain Med 2007;32:510-515.
Key Words: Abdominal pain, Celiac plexus block, Children, Rotational angiography.
C eliac plexus blockade (CPB) is a useful pain relief modality for a number of conditions in- volving foregut-derived structures. Pancreatic can- cer pain is the most well-known indication for the block, but pain from hepatic tumors, pancreatitis, and stomach malignancies can also be relieved by this technique.1,2 CPB has been used to good effect in both children and adults.3-5 Due to the plexus’ proximity to the neuraxis and great vessels, radio- graphic assistance is required for accurate place- ment of the needles and to confirm that the injec- tate is not being placed into a blood vessel or other nontargeted structure. Standard fluoroscopy has long been used for this purpose.6,7 More recently, computed tomography (CT)8,9 and magnetic reso- nance imaging (MRI)10 have been used to facilitate
CPB. Both modalities are 2-dimensional in nature although there is one report of 3-dimensional CT used for this purpose.11 Consequently, there has been minimal documentation of 3-dimensional spread of injectate. How the injectate invests itself around nearby structures and the exact nature of the spread is academically intriguing, and may help elucidate why some blocks are successful and others are not. A few studies correlate 2-dimensional spread of injectate with clinical results,8,11-14 but spread of injectate has not been examined in chil- dren.
Clinically useful since 1998, 3-dimensional rota- tional angiography (3DRA) was initially developed to enhance spatial understanding of vasculature, primarily neurovascular anatomy in adults.15 Dur- ing angiographic injection of contrast the c-arm of the angiography system rotates around the patient in a 180 degree arc, acquiring 120 to 240 digital images in 5 to 8 seconds. Three dimensional recon- structions are then rendered in 3 minutes. 3DRA technology can be applied to nonvascular settings, allowing a fascinating view of the spread of ra- diopaque injectate in 3 dimensions.16 Prior to nee- dle placement 3DRA can also provide a 3-dimen- sional bony “road map” of the spine or other
From the Departments of Anesthesia (K.R.G., N.J.W.) and Radiology (J.M.R.), Cincinnati Children’s Hospital Medical Cen- ter, Cincinnati, OH.
Accepted for publication June 15, 2007.
Reprint requests: Kenneth R. Goldschneider, M.D., Division of Pain Management, Department of Anesthesia, Cincinnati Chil- dren’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-3039. E-mail: Kenneth.goldschneider@cchmc.org
@ 2007 by the American Society of Regional Anesthesia and Pain Medicine.
doi:10.1016/j.rapm.2007.06.005
Library of Medicine .
radiopaque structures, which can be correlated with live fluoroscopy to plan the most appropriate skin entry site and needle trajectory. An analogous approach has been described for MRI-guided celiac plexus injection.10 Further, the reconstructed 3-di- mensional images can be displayed in any obliquity and a virtual “cutaway” tool can dissect anatomy in any plane for greater investigation of anatomic re- lationships. This report describes the application of this new imaging technology for CPB in children.
Methods
Three patients presented for CPB via the “classic” retrocrural (deep splanchnic) approach,17 during which 3DRA was utilized. Institutional Review Board approval for de-identified information use was obtained prior to manuscript preparation.
Case Reports
Case 1. A 5-and-a-half-year-old, 22 kg male with cystic fibrosis presented with acute on chronic pancreatitis. Long-term opioids were not felt to be appropriate in the setting of his multi-organ system disease. The patient had undergone a CPB with bupivacaine and triamcinolone at another institu- tion with excellent results. After 5 months, his ab- dominal pain had flared and he required another block. Informed consent was obtained from his par- ents, and the patient was anesthetized in the inter- ventional radiology suite. The patient was posi- tioned prone. A bilateral, retrocrural approach to the celiac plexus commenced. Two, 22-gauge 10 cm spinal needles were placed at the superior aspect of L1 and advanced to the anterolateral aspect of the vertebral body. The right-sided needle was reposi- tioned due to resistance on first injection. Needle position and test dose spread were confirmed in 2 and 3 dimensions (Fig 1) with injection of 1 mL iohexol 180 mg/mL contrast through each needle. After aspiration in 4 quadrants, a total of 19 mL of injectate was injected under real-time fluoroscopy in fractionated fashion, with minimal resistance, in evenly divided doses. The injectate comprised 16 mL 0.25 bupivacaine (weight-dependent dosing), 20 mg triamcinolone (1 mL) and 1 mL iohexol 180 mg/mL. No vascular or neuraxial flow was seen, nor were any electrocardiogram changes noted. The final spread of injectate was examined in both 2 and 3 dimensions (Fig 1C and D). The patient’s mother reported 3 to 4 weeks of moderate relief from this block. The patient later underwent pancreatectomy with islet cell transplant and was lost to follow-up.
Case 2. A 19-year-old male with metastatic, adrenocortical carcinoma causing abdominal pain, “pressure” and “fullness,” came to us for palliative
care after prolonged curative efforts. Opioid and adjunct therapies had been only moderately help- ful, and the patient rated his pain at 8/10. A retro- crural CPB was performed. A 2-needle technique was used to inject 20 mL 0.25% bupivacaine with depot-form methylprednisolone after a test dose of 3 mL of 1% lidocaine with 1:200,000 epinephrine and iohexol 180 mg/mL. The injection provided good analgesia for 3 weeks. The patient re-presented to the interventional radiology suite for neurolytic block with alcohol. After informed consent, conscious sedation, and sterile preparation were achieved, two 22-gauge 15 cm spinal needles were placed bilaterally, 7 cm from the midline, at the level of the L1 vertebral body. The needles were advanced under standard fluoroscopic guidance to the anterolateral position at the superior aspect of L1 (Fig 2A). Bupivacaine (3 mL 0.25%) with epinephrine was injected into each nee- dle, with no electrocardiogram evidence of intravas- cular placement. Ten mL of 0.25% bupivacaine was then injected through each needle in fractionated fashion, followed by 20 mL of absolute alcohol, mixed with 2 mL iohexol 180 mg/mL. Three-dimensional confirmation of injectate spread was achieved using 3DRA (Philips Medical Systems, Integris Allura sys- tem with 3DRA, Best, The Netherlands). Of note, existing surgical clips in the immediate vicinity caused significant metallic streak artifact, leading to hazy im- ages. The patient obtained good pain relief (pain score 4/10) for 2 months. He died shortly thereafter, having required additional oral and intravenous opioid treat- ment for a preterminal increase in his pain.
Case 3. A 5-year-old male presented with a complex history, including mitochondrial disorder (leading to neural degeneration, gastrointestinal dysmotility, and immunodeficiency), and a history of meningococcemia. The gastrointestinal (GI) dys- motility was accompanied by pain and dependence on total parenteral nutrition. Parenteral opioids were of benefit, but worsened his GI function. The patient presented for CPB for relief of pain and enhancement of GI motility. Informed consent was obtained from his parents, and the procedure com- menced under sterile conditions with the 2-needle, retrocrural technique described earlier. Two 10 cm, 22-gauge spinal needles were introduced 5 cm lateral to the L1 vertebral body. As shown in Fig- ure 3, the needles were placed into the retrocrural space, and after dye confirmation and negative aspirations, a total of 14 mL of bupivacaine (weight-dependent dosing) with 24 mg of depot form of methylprednisolone was injected with 2 mL of iohexol 180 mg/mL. Good spread was ob- served on both 2-dimensional and 3DRA views (Figure 3). Over the next month, the mother
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reported a significant reduction in pain and greater participation in his usual activities.
Results
These 3 cases describe CPB performed with the assistance of 3DRA software. The images clearly and accurately depict the spread and final distribution of injectate under conditions in which a successful block was accomplished. In all cases, the injectate spread approximately 3.5 vertebral levels, at least
partially encircled the aorta, and extended retrolat- erally to approximately the midpoint of the verte- bral body. Thus, a three-dimensional radiographic cast of the retrocrural space was created.
Discussion
Although we most commonly use the “classic retrocrural” technique, the 3DRA technology should be useful to those who prefer other approaches to splanchnic and celiac plexus blocks. While a post
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injection CT scan with subsequent 3-dimensional reconstruction could produce similar images, 3DRA uses approximately one-fourth the radiation dose and, unlike CT, fluoroscopy allows real-time eval- uation of the spread of the injectate to guard against intravascular injection. Further, 3DRA differs from standard operating room “c-arm” units in its ability to collimate the beam, and use a “low dose setting” to reduce radiation exposure. Limitations of this technique include that the equipment is not porta- ble and that this iteration of software does not allow
display of soft tissues. Standard 2-dimensional flu- oroscopy has been used effectively for many years, but when a block does not work, it is not always clear why. Having a firm understanding of how the dye spreads and the final distribution of the inject- ate may be very useful in predicting success and understanding failure of CPB.
In the cases presented, 3-dimensional reconstruc- tions were created within 3 minutes of rotational image acquisition. Approximately 420 3DRA-equipped fluoroscopic units are available in the United States,
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with the newer generation technology available in approximately 50 centers (R. Heugen, Marketing BU Cardio/Vascular Phillips Medical, Best, Nether- lands, personal communication, 2006). The latest 3DRA technology can provide more rapid recon- structions, which can be integrated into the move- ment of the c-arm, such that a “3-dimensional roadmap” is superimposed over live fluoroscopy to facilitate needle placement. 3DRA road mapping may have great potential for other blocks such as facet joint, sacroiliac joint, and selective nerve root injections, which become especially challenging
when bony anatomy is distorted by trauma, surgery or disease. This next generation 3DRA can also create a CT-like data set that provides excellent soft tissue visualization, which has obvious advantages for blocks such as that of the celiac plexus. Three dimensional rendering of the injection for these and other blocks may help clarify exactly where the medication needs to spread to obtain the best clin- ical effect. In summary, we present examples of 3DRA imaging for CPB. 3DRA has the potential to enhance our technique as well as our understand- ing of regional anesthesia.
Technique for Celiac Plexus Block in Children
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