NEUROLYTIC BLOCKS Dr.R.SILAMBAN MADRAS MEDICAL COLLEGE

NEUROLYTIC BLOCKS  Involves blocking of sympathetic chain at various levels  Prevents transmission of pain impulses from the target organs to the brain

NEUROLYTIC BLOCKS  The nerves have the tendency to regenerate  Blocking effect is temporary

DURATION  3 months to 24 months

COMMON NEUROLYTIC BLOCKS  Stellate ganglion block  Thoracic sympathetic chain block  Coeliac plexus block  Lumbar sympathetic block  Superior hypogastric block  Ganglion impar block

STELLATE GANGLION BLOCK Stellate ganglion formed by union of  Middle cervical  Lower cervical  First thoracic segment

STELLATE GANGLION BLOCK Pain relief to structures of  Neck  Face  Upper limb  Upper thorax upto T 5

THORACIC SYMPATHETIC CHAIN BLOCK  Not used widely  High risk of pneumothorax  Middle and lower thoracic region

LUMBAR SYMPATHETIC BLOCK  Needle introduced at the level of L 2 or L 2 + L 4  Pain relief to pelvis and lower limb  Volume required – 8 to 10ml

SUPERIOR HYPOGASTRIC PLEXUS BLOCK  From splenic flexure of colon to middle 3 rd of rectum  Pain relief to pelvis and lower limb

 Most difficult block to perform  Needle has to enter through a small triangular space between iliac crest and transverse process of L 5  Volume required - 7ml for each side SUPERIOR HYPOGASTRIC PLEXUS BLOCK

GANGLION IMPAR BLOCK  Walther’s ganglion - lies in front of S 2, S 3  Pain relief for lower rectum, anal canal and perineum including vulva and vagina

 Patient in lithotomy or lateral position  Bent 10cm needle introduced in front of the coccyx  Finger inserted into rectum to guide the needle close to the sacral curvature  Volume required - 10ml GANGLION IMPAR BLOCK

Coeliac plexus block

HISTORY 1914 – KAPPIS – first block in lateral position 1920 – WELDING – anterior approach – LABAT – now followed retrocrural approach in prone position – SINGLERS – CT guided transcrural approach 1983– ISCHIA – posterior transaortic approach

LOCATION

FORMATION

AREA OF SUPPLY  LOWER END OF ESOPHAGUS UPTO SPLENIC FLEXURE.  LIVER,SPLEEN  RETROPERITONEAL STRUCTURES LIKE PANCREAS, KIDNEY.

INDICATIONS Chronic malignant & non malignant visceral pain 1. Upper g.i. malignancy 2. Chronic pancreatitis 3. Acute pancreatitis 4. Repeated abdominal surgeries 5. HIV related sclerosing cholangitis 6. Diagnostic purposes 7. Abdominal angina

ROLE IN CHRONIC PANCREATITIS Controversial Useful in  Few selected cases  Acute exacerbations

ROLE IN ACUTE PANCREATITIS  Steroids improved morbidity and mortality  Continuous infusion for pain relief

CONTRAINDICATIONS ABSOLUTE  Anti coagulant therapy  Coagulopathy  Anti-blastic cancer therapy  Bowel obstruction  Patient on disulfuram therapy

CONTRAINDICATION RELATIVE  Drug seeking behaviour to pain  Patient on CNS depressant drugs

TECHNIQUE Posterior approach Anterior approach  Retrocrural  Antecrural  transaortic

RETROCRURAL APPROACH

 Bilateral Posterior approach  Splanchnic block  Drug deposited behind the crus of diaphragm

MARKINGS

ANTECRURAL APPROACH

 Unilateral approach  Right sided only  Needle placed anterior to crus of diaphragm. ANTECRURAL APPROACH

MARKINGS

CONTINUOUS PLEXUS BLOCK

COMPLICATIONS MINOR  HYPOTENSION  POSTURAL HYPOTENSION  DIARRHEA  PAIN  CHEMICAL COMPLICATIONS

COMPLICATIONS CHEMICAL ALCOHOL FACIAL FLUSHING, PALPITATIONS, DIAPHORESIS PHENOL TRANSIENT TINNITUS, FLUSHING,MALAISE CNS STIMULATION, MYOCLONUS, SEIZURES,HYPERTENSION,ARRYTHMIAS,HEPAT IC &RENAL INSUFFICIENCY

COMPLICATIONS  VISCERAL INJURY  EJACULATION FAILURE  NERVE ROOT INJURY MODERATE

COMPLICATION  PARAPLEGIA  LUNG INJURY  VASCULAR TRAUMA  EPIDURAL & SUB ARACHNOID INJECTION MAJOR

EFFICACY OF COELIAC PLEXUS BLOCK Controversy Regarding  Efficacy relative to opioid therapy  Efficacy relative to various approaches  Comittment to neurolysis despite remote risk of paraplegia

ADVANTAGE OF COELIAC PLEXUS NEUROLYSIS  Better long term pain relief  Decrease drug dose for maintainance  Better quality of life  Improved performance status  Overcomes the G.I.T effects of opioids  In weight and survival rate

 Delayed application  Tumour extension  Poor technique FAILURE DUE TO

DRUGS  ALCOHOL  PHENOL  LOCAL ANAESTHETICS

ALCOHOL  COMMONLY USED  HYPOBARIC  CEPHALAD SPREAD RADIOGRAPHICALLY  USED IN CONCENTRATION OF %  VOLUME REQUIRED-40 ml

ALCOHOL ADVANTAGES  LONGER DURATION OF ACTION  EASILY AVAILABLE  IMMEDIATE NEUROLYSIS  PAIN ON INJECTION CONFIRMS CORRECT PLACEMENT IN THE BLIND APPROACH  LESS AFFINITY FOR VASCULAR TISSUES

ALCOHOL DISADVANTAGES  PAIN ON INJECTION  CANNOT BE COMBINED WITH DYE

PHENOL  HYPERBARIC  CAUDAL SPREAD RADIOGRAPHICALLY  7.5 – 10% SOLUTION PREFFERED  MAXIMUM DOSE – 40 mg/kg

PHENOL ADVANTAGES  NO PAIN ON INJECTION  IMMEDIATE ANAESTHETIC EFFECT  CAN BE COMBINED WITH DYES

PHENOL DISADVANTAGES  NO COMMERCIAL PREPARATION  HIGH AFFINITY FOR VASCULAR TISSUES  SHORTER DURATION OF ACTION THAN ALCOHOL

LOCAL ANAESTHETICS  0.25% BUPIVACAINE PREFFERED FOR INTERMITTENT ADMINISTRATION  6-8 ml/hr 0F 0.1% BUPIVACAINE PREFFERED FOR CONTINUOUS ADMINISTRATION  KEPT FOR MAXIMUM OF 7 DAYS

SUMMARY  Very useful tool in the armamentarium of the Interventional pain specialist  Applied early for better results  Training in the PG period under expert hands is a must

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