NEUROLYTICBLOCKS

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 SYMPATHETICBLOCK

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

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

SUPERIOR HYPOGASTRIC PLEXUS BLOCK

GANGLION IMPAR BLOCK

Walther’s ganglion - lies in front of S2, S3

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

HISTORY1914 – 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.

INDICATIONSChronic malignant & non malignant visceral pain

1. Upper g.i. malignancy2. Chronic pancreatitis3. Acute pancreatitis4. Repeated abdominal surgeries5. HIV related sclerosing cholangitis6. Diagnostic purposes7. Abdominal angina

ROLE IN CHRONICPANCREATITIS

Controversial

Useful in

Few selected cases

Acute exacerbations

ROLE IN ACUTEPANCREATITIS

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

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

COMPLICATIONSCHEMICAL

ALCOHOL FACIAL FLUSHING, PALPITATIONS, DIAPHORESIS

PHENOL TRANSIENT TINNITUS, FLUSHING,MALAISE CNS STIMULATION, MYOCLONUS, SEIZURES,HYPERTENSION,ARRYTHMIAS,HEPATIC

&RENAL INSUFFICIENCY

COMPLICATIONS

VISCERAL INJURY

EJACULATION FAILURE

NERVE ROOT INJURY

MODERATEMODERATE

COMPLICATION

PARAPLEGIA

LUNG INJURY

VASCULAR TRAUMA

EPIDURAL & SUB ARACHNOID INJECTION

MAJORMAJOR

EFFICACY OF COELIACPLEXUS 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

ALCOHOLCOMMONLY USED

HYPOBARIC

CEPHALAD SPREAD RADIOGRAPHICALLY

USED IN CONCENTRATION OF 50-100%

VOLUME REQUIRED-40 ml

ALCOHOLADVANTAGES

LONGER DURATION OF ACTION

EASILY AVAILABLE

IMMEDIATE NEUROLYSIS

PAIN ON INJECTION CONFIRMS CORRECT PLACEMENT IN THE BLIND APPROACH

LESS AFFINITY FOR VASCULAR TISSUES

ALCOHOLDISADVANTAGES

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