Presentation
Chronic pain secondary to loin pain hematuria syndrome, requiring opiate medication.
Patient Data
The patient was positioned prone and prepped and draped in the usual sterile
fashion. I planned for a bilateral paraspinal approach. Intravenous sedoanalgesia was administered in divided doses to a total of 200 mcg fentanyl and 7 mg midazolam.
Following subcutaneous and deep infiltration with 1% lidocaine, a 20 gauge 20 cm Chiba needle was inserted via a right paraspinal approach under CT guidance, passing medial to the kidney and going through the right crus of the diaphragm. The procedure was technically difficult due to patient obesity. In order to eliminate artifact and obtain satisfactory visualization of the celiac plexus anatomy, it was necessary to perform repeated limited spiral CT scans rather than using the CT fluoroscopy mode. The needle tip was in a good position in the expected location of the celiac plexus (just inferior to the celiac axis origin).
Injection of a small volume of dilute contrast mixed with 1% lidocaine showed satisfactory spread. A mixture of 18 ccs 100% ethanol, 9 ccs 0.5% bupivacaine and 3 cc contrast was injected. Final CT showed an excellent bilateral spread of injectate in the preaortic space.
The needle was flushed with normal saline and removed. Having regard for this satisfactory appearance, the duration of the procedure thus far, and the radiation dose the patient was receiving via repeated CT, I elected to end the procedure at this point, omitting a left-sided paraspinal injection.
Case Discussion
Technically successful celiac plexus neurolysis, via a posterior paravertebral antecrural approach. This was a unilateral rather than the more usual bilateral approach. Other approaches include anterior, posterior paravertebral retrocrural, posterior transintervertebral disc, or posterior transaortic.
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