Dr.R.SILAMBAN

1
NEUROLYTIC BLOCKS

• Dr.R.SILAMBAN
• MADRAS MEDICAL COLLEGE

2
NEUROLYTIC BLOCKS

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

3
NEUROLYTIC BLOCKS

• The nerves have the tendency to
• regenerate
• Blocking effect is temporary

4
DURATION

• 3 months to 24 months

5
COMMON NEUROLYTIC BLOCKS

• Stellate ganglion block
• Thoracic sympathetic chain block
• Coeliac plexus block
• Lumbar sympathetic block
• Superior hypogastric block
• Ganglion impar block

6
STELLATE GANGLION BLOCK
Stellate ganglion formed by union of

• Middle cervical
• Lower cervical
• First thoracic segment

7
STELLATE GANGLION BLOCK
Pain relief to structures of

• Neck
• Face
• Upper limb
• Upper thorax upto T5

8
THORACIC SYMPATHETIC CHAIN BLOCK

• Not used widely
• High risk of pneumothorax
• Middle and lower thoracic region

9
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

10
SUPERIOR HYPOGASTRIC PLEXUS BLOCK

• From splenic flexure of colon to
• middle 3rd of rectum
• Pain relief to pelvis and lower limb

11
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

12
GANGLION IMPAR BLOCK

• Walthers ganglion - lies in front of
• S2, S3
• Pain relief for lower rectum, anal canal
• and perineum including vulva and
• vagina

13
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

14
Coeliac plexus block
15
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

16
LOCATION
17
FORMATION
18
AREA OF SUPPLY

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

19
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

20
ROLE IN CHRONIC PANCREATITIS
Controversial
Useful in

• Few selected cases
• Acute exacerbations

21
ROLE IN ACUTE PANCREATITIS

• Steroids improved morbidity
• and mortality
• Continuous infusion for pain relief

22

• CONTRAINDICATIONS
• ABSOLUTE
  

• Anti coagulant therapy
• Coagulopathy
• Anti-blastic cancer therapy
• Bowel obstruction
• Patient on disulfuram therapy

23
CONTRAINDICATION

• RELATIVE

• Drug seeking behaviour to pain
• Patient on CNS depressant drugs

24
TECHNIQUE

• Posterior approach
• Anterior approach

• Retrocrural
• Antecrural
• transaortic

25
RETROCRURAL APPROACH
26
RETROCRURAL APPROACH

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

27
MARKINGS
28
(No Transcript)
29
(No Transcript)
30
(No Transcript)
31
ANTECRURAL APPROACH
32
ANTECRURAL APPROACH

• Unilateral approach
• Right sided only
• Needle placed anterior to
• crus of diaphragm.

33
MARKINGS
34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
CONTINUOUSPLEXUS BLOCK
38
(No Transcript)
39
COMPLICATIONS

• MINOR
• HYPOTENSION
• POSTURAL HYPOTENSION
• DIARRHEA
• PAIN
• CHEMICAL COMPLICATIONS

40
COMPLICATIONS

• CHEMICAL
• ALCOHOL
• FACIAL FLUSHING, PALPITATIONS, DIAPHORESIS
• PHENOL
• TRANSIENT TINNITUS, FLUSHING,MALAISE
• CNS STIMULATION, MYOCLONUS,
• SEIZURES,HYPERTENSION,ARRYTHMIAS,HEPATIC
  RENAL INSUFFICIENCY

41
COMPLICATIONS
MODERATE

• VISCERAL INJURY
• EJACULATION FAILURE
• NERVE ROOT INJURY

42
COMPLICATION
MAJOR

• PARAPLEGIA
• LUNG INJURY
• VASCULAR TRAUMA
• EPIDURAL SUB ARACHNOID
• INJECTION

43
EFFICACY OF COELIACPLEXUS BLOCK
Controversy Regarding

• Efficacy relative to opioid therapy
• Efficacy relative to various approaches
• Comittment to neurolysis despite remote
• risk of paraplegia

44
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

45
FAILURE DUE TO

• Delayed application
• Tumour extension
• Poor technique

46
DRUGS

• ALCOHOL
• PHENOL
• LOCAL ANAESTHETICS

47
ALCOHOL

• COMMONLY USED
• HYPOBARIC
• CEPHALAD SPREAD RADIOGRAPHICALLY
• USED IN CONCENTRATION OF 50-100
• VOLUME REQUIRED-40 ml

48
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

49
ALCOHOL

• DISADVANTAGES
• PAIN ON INJECTION
• CANNOT BE COMBINED WITH DYE

50
PHENOL

• HYPERBARIC
• CAUDAL SPREAD
• RADIOGRAPHICALLY
• 7.5 10 SOLUTION PREFFERED
• MAXIMUM DOSE 40 mg/kg

51
PHENOL

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

52
PHENOL

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

53
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

54
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

55
THANK YOU

• THANK YOU