Transcript Slide 1

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 T5
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
L2 or L2 + L4
 Pain relief to pelvis and lower limb
 Volume required – 8 to 10ml
SUPERIOR HYPOGASTRIC
PLEXUS BLOCK
 From splenic flexure of colon to
middle 3rd of rectum
 Pain relief to pelvis and lower limb
SUPERIOR HYPOGASTRIC
PLEXUS BLOCK
 Most difficult block to perform
 Needle has to enter through a small
triangular space between iliac crest
and transverse process of L5
 Volume required - 7ml for each side
GANGLION IMPAR BLOCK
 Walther’s ganglion - lies in front of
S 2 , S3
 Pain relief for lower rectum, anal canal
and perineum including vulva and
vagina
GANGLION IMPAR BLOCK
 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
Coeliac plexus block
HISTORY
1914 – KAPPIS
– first block in lateral
position
1920 – WELDING – anterior approach.
1927 – LABAT
– now followed retrocrural
approach in prone position.
1982 – 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
 Retrocrural

Antecrural

transaortic
Anterior approach
RETROCRURAL
APPROACH
RETROCRURAL APPROACH
 Bilateral Posterior approach
 Splanchnic block
 Drug deposited behind the
crus of diaphragm
MARKINGS
ANTECRURAL
APPROACH
ANTECRURAL APPROACH
 Unilateral approach
 Right sided only
 Needle placed anterior to
crus of diaphragm.
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,HEPATI
C &RENAL INSUFFICIENCY
COMPLICATIONS
MODERATE
 VISCERAL INJURY
 EJACULATION FAILURE
 NERVE ROOT INJURY
COMPLICATION
MAJOR
 PARAPLEGIA
 LUNG INJURY
 VASCULAR TRAUMA
 EPIDURAL & SUB ARACHNOID
INJECTION
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
FAILURE DUE TO
 Delayed application
 Tumour extension
 Poor technique
DRUGS
 ALCOHOL
 PHENOL
 LOCAL ANAESTHETICS
ALCOHOL
COMMONLY USED
HYPOBARIC
CEPHALAD SPREAD
RADIOGRAPHICALLY
USED IN CONCENTRATION OF 50-100%
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