CT-guided Celiac Plexus Neurolysis in the Management of Severe Upper Abdominal Pain





neurolysis, sympatholysis, celiac plexus, solar plexus, pancreatic cancer, abdominal pain, pain management


Abdominal pain is a significant problem in patients with malignant tumors of the abdominal cavity, which dramatically affects the quality of life and survival. Chronic pain is experienced by about half of all cancer patients and more than 70  % in the late stages of the disease, the prevalence is even higher in patients with pancreatic cancer. Usually, pain management in a given cohort of patients is a very difficult issue, often requiring the chronic use of high doses of narcotic and non-narcotic analgesics or a combination thereof. Opioids are more effective, relieve pain, but have several side effects, causing nausea and vomiting, constipation, itching, dry mouth, severe sedation or delusions, hallucinogenic effects, the need to increase the dose as tolerance develops, and also intolerance to drugs. Inadequate pain management not only negatively impacts the quality of life but also correlates with poorer clinical survival rates for patients.

The work deals with the anatomy of the celiac plexus (CP), features of innervation, comparison of different techniques of CP neurolysis, practical aspects of performing, indications and contraindications, possible complications, as well as recommendations for the successful conduct of CT-guided sympatholysis.

Sympatholysis is a safe and effective way of treating severe pain in patients with malignant neoplasms of the upper half of the abdominal cavity. CP neurolysis should be used as one of the key techniques for a multidisciplinary approach to treatment, which provides significant relief of the pain syndrome intensity, reduces the use of opioid drugs and, thus, their side effects. A thorough understanding of the various methods and techniques allows the interventionist to optimize the approach for each patient and thus successfully carry out sympatholysis while minimizing complications.

Author Biographies

Aleksey A. Eroshkin, Central Hospital of Ministry of Internal Affairs of Ukraine (Central Police Hospital), Kyiv

Department of Neurosurgery

Dmytro M. Romanukha, Central Hospital of Ministry of Internal Affairs of Ukraine (Central Police Hospital), Kyiv

Department of Neurosurgery


1. Wong GY, Schroeder DR, Carns PE, Wilson JL, Martin DP, Kinney MO, Mantilla CB, Warner DO. Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial. JAMA. 2004 Mar 3;291(9):1092-9. [CrossRef] [PubMed]

2. de Oliveira R, dos Reis MP, Prado WA. The effects of early or late neurolytic sympathetic plexus block on the management of abdominal or pelvic cancer pain. Pain. 2004 Jul;110(1-2):400-8. [CrossRef] [PubMed]

3. Koulouris AI, Banim P, Hart AR. Pain in Patients with Pancreatic Cancer: Prevalence, Mechanisms, Management and Future Developments. Dig Dis Sci. 2017 Apr;62(4):861-870. [CrossRef] [PubMed]

4. Castleberry AW, White RR, De La Fuente SG, Clary BM, Blazer DG 3rd, McCann RL, Pappas TN, Tyler DS, Scarborough JE. The impact of vascular resection on early postoperative outcomes after pancreaticoduodenectomy: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database. Ann Surg Oncol. 2012 Dec;19(13):4068-77. [CrossRef] [PubMed]

5. Jadad AR, Browman GP. The WHO analgesic ladder for cancer pain management. Stepping up the quality of its evaluation. JAMA. 1995 Dec 20;274(23):1870-3. [CrossRef] [PubMed]

6. Kaufman M, Singh G, Das S, Concha-Parra R, Erber J, Micames C, Gress F. Efficacy of endoscopic ultrasound-guided celiac plexus block and celiac plexus neurolysis for managing abdominal pain associated with chronic pancreatitis and pancreatic cancer. J Clin Gastroenterol. 2010 Feb;44(2):127-34. [CrossRef] [PubMed]

7. Mantyh PW. Cancer pain and its impact on diagnosis, survival and quality of life. Nat Rev Neurosci. 2006 Oct;7(10):797-809. [CrossRef] [PubMed]

8. Müller MW, Friess H, Köninger J, Martin D, Wente MN, Hinz U, Ceyhan GO, Blaha P, Kleeff J, Büchler MW. Factors influencing survival after bypass procedures in patients with advanced pancreatic adenocarcinomas. Am J Surg. 2008 Feb;195(2):221-8. [CrossRef] [PubMed]

9. Loukas M, Klaassen Z, Merbs W, Tubbs RS, Gielecki J, Zurada A. A review of the thoracic splanchnic nerves and celiac ganglia. Clin Anat. 2010 Jul;23(5):512-22. [CrossRef] [PubMed]

10. Penman ID. Coeliac plexus neurolysis. Best Pract Res Clin Gastroenterol. 2009;23(5):761-6. [CrossRef] [PubMed]

11. Hirai I, Kimura W, Ozawa K, Kudo S, Suto K, Kuzu H, Fuse A. Perineural invasion in pancreatic cancer. Pancreas. 2002 Jan;24(1):15-25. [CrossRef] [PubMed]

12. Bapat AA, Hostetter G, Von Hoff DD, Han H. Perineural invasion and associated pain in pancreatic cancer. Nat Rev Cancer. 2011 Sep 23;11(10):695-707. [CrossRef] [PubMed]

13. Dobosz Ł, Kaczor M, Stefaniak TJ. Pain in pancreatic cancer: review of medical and surgical remedies. ANZ J Surg. 2016 Oct;86(10):756-761. [CrossRef] [PubMed]

14. Cornman-Homonoff J, Holzwanger DJ, Lee KS, Madoff DC, Li D. Celiac Plexus Block and Neurolysis in the Management of Chronic Upper Abdominal Pain. Semin Intervent Radiol. 2017 Dec;34(4):376-386. [CrossRef] [PubMed] [PubMed Central]

15. Kambadakone A, Thabet A, Gervais DA, Mueller PR, Arellano RS. CT-guided celiac plexus neurolysis: a review of anatomy, indications, technique, and tips for successful treatment. Radiographics. 2011 Oct;31(6):1599-621. [CrossRef] [PubMed]

16. Mohamed RE, Amin MA, Omar HM. Computed tomography-guided celiac plexus neurolysis for intractable pain of unresectable pancreatic cancer. The Egyptian Journal of Radiology and Nuclear Medicine. 2017 Sep 1;48(3):627-37. [CrossRef]

17. Bahn BM, Erdek MA. Celiac plexus block and neurolysis for pancreatic cancer. Curr Pain Headache Rep. 2013 Feb;17(2):310. [CrossRef] [PubMed]

18. Titton RL, Lucey BC, Gervais DA, Boland GW, Mueller PR. Celiac plexus block: a palliative tool underused by radiologists. AJR Am J Roentgenol. 2002 Sep;179(3):633-6. [CrossRef] [PubMed]

19. Zhang XM, Zhao QH, Zeng NL, Cai CP, Xie XG, Li CJ, Liu J, Zhou JY. The celiac ganglia: anatomic study using MRI in cadavers. AJR Am J Roentgenol. 2006 Jun;186(6):1520-3. [CrossRef] [PubMed]

20. Penman ID, Gilbert D. Basic technique for celiac plexus block/neurolysis. Gastrointest Endosc. 2009 Feb;69(2 Suppl):S163-5. [CrossRef] [PubMed]

21. Wang PJ, Shang MY, Qian Z, Shao CW, Wang JH, Zhao XH. CT-guided percutaneous neurolytic celiac plexus block technique. Abdom Imaging. 2006 Nov-Dec;31(6):710-8. [CrossRef] [PubMed]

22. Choi EJ, Choi YM, Jang EJ, Kim JY, Kim TK, Kim KH. Neural Ablation and Regeneration in Pain Practice. Korean J Pain. 2016 Jan;29(1):3-11. [CrossRef] [PubMed] [PubMed Central]

23. Teixeira MJ, Neto ER, da Nóbrega JC, Dos Ângelos JS, Martin MS, de Monaco BA, Fonoff ET. Celiac plexus neurolysis for the treatment of upper abdominal cancer pain. Neuropsychiatr Dis Treat. 2013;9:1209-12. [CrossRef] [PubMed] [PubMed Central]

24. Wiersema MJ, Wiersema LM. Endosonography-guided celiac plexus neurolysis. Gastrointest Endosc. 1996 Dec;44(6):656-62. [CrossRef] [PubMed]

25. Wyse JM, Chen YI, Sahai AV. Celiac plexus neurolysis in the management of unresectable pancreatic cancer: when and how? World J Gastroenterol. 2014 Mar 7;20(9):2186-92. [CrossRef] [PubMed] [PubMed Central]

26. Sakamoto H, Kitano M, Komaki T, Imai H, Kamata K, Kudo M. Endoscopic ultrasound-guided neurolysis in pancreatic cancer. Pancreatology. 2011;11 Suppl 2:52-8. [CrossRef] [PubMed]

27. Sachdev AH, Gress FG. Celiac Plexus Block and Neurolysis: A Review. Gastrointest Endosc Clin N Am. 2018 Oct;28(4):579-586. [CrossRef] [PubMed]

28. Rai P, Cr L, Kc H. Endoscopic ultrasound-guided celiac plexus neurolysis improves pain in gallbladder cancer. Indian J Gastroenterol. 2020 Feb 17. [CrossRef] [PubMed]

29. Seicean A. Celiac plexus neurolysis in pancreatic cancer: the endoscopic ultrasound approach. World J Gastroenterol. 2014 Jan 7;20(1):110-7. [CrossRef] [PubMed] [PubMed Central]

30. Guo X, Cui Z, Hu Z. Role of endoscopic ultrasound in treatment of pancreatic cancer. Endosc Ultrasound. 2013 Oct;2(4):181-9. [CrossRef] [PubMed] [PubMed Central]

31. Hol PK, Kvarstein G, Viken O, Smedby O, Tønnessen TI. MRI-guided celiac plexus block. J Magn Reson Imaging. 2000 Oct;12(4):562-4. [CrossRef] [PubMed]

32. Liu S, Fu W, Liu Z, Liu M, Ren R, Zhai H, Li C. MRI-guided celiac plexus neurolysis for pancreatic cancer pain: Efficacy and safety. J Magn Reson Imaging. 2016 Oct;44(4):923-8. [CrossRef] [PubMed]

33. Jin G, Qiu X, Ding M, Dai M, Zhang X. Navigated magnetic resonance imaging-guided celiac plexus neurolysis using an open magnetic resonance system for pancreatic cancer patients with upper abdominal pain. J Cancer Res Ther. 2019;15(4):825-830. [CrossRef] [PubMed]

34. Souguir A, Hammami A, Kadri K, Mansour I, Jaziri H, Zayene, A, Slama A, Ksiaa M, Brahem A, Ajmi S, Jmaa, A. CT-Guided Celiac Plexus Neurolysis in the Management of Pain Related to Unresectable Pancreatic Cancer: About 2 Cases. Open Journal of Gastroenterology, 2015;5:37-41. [CrossRef]

35. Erdine S. Celiac ganglion block. Agri. 2005 Jan;17(1):14-22. [PubMed]

36. Levy MJ, Topazian MD, Wiersema MJ, Clain JE, Rajan E, Wang KK, de la Mora JG, Gleeson FC, Pearson RK, Pelaez MC, Petersen BT, Vege SS, Chari ST. Initial evaluation of the efficacy and safety of endoscopic ultrasound-guided direct Ganglia neurolysis and block. Am J Gastroenterol. 2008 Jan;103(1):98-103. [CrossRef] [PubMed]

37. Fusaroli P, Caletti G. Is there a role for celiac plexus block for chronic pancreatitis? Endosc Int Open. 2015 Feb;3(1):E60-2. [CrossRef] [PubMed] [PubMed Central]

38. Goodman AJ, Gress FG. The endoscopic management of pain in chronic pancreatitis. Gastroenterol Res Pract. 2012;2012:860879. [CrossRef] [PubMed] [PubMed Central]

39. Lee CJ, Kim BK, Yoon KB, Lee HY, Dominiczak AF, Touyz RM, Jennings GLR, Cho EJ, Hering D, Park S. Case of Refractory Hypertension Controlled by Repeated Renal Denervation and Celiac Plexus Block: A Case of Refractory Sympathetic Overload. Hypertension. 2017 Jun;69(6):978-984. [CrossRef] [PubMed]

40. Lee SH, Lim DH, Lee JH, Chang K, Koo JM, Park HJ. Long-Term Blood Pressure Control Effect of Celiac Plexus Block with Botulinum Toxin. Toxins (Basel). 2016 Feb 19;8(2):51. [CrossRef] [PubMed] [PubMed Central]

41. Rana MV, Candido KD, Raja O, Knezevic NN. Celiac plexus block in the management of chronic abdominal pain. Curr Pain Headache Rep. 2014 Feb;18(2):394. [CrossRef] [PubMed]

42. Amr YM, Makharita MY. Comparative study between 2 protocols for management of severe pain in patients with unresectable pancreatic cancer: one-year follow-up. Clin J Pain. 2013 Sep;29(9):807-13. [CrossRef] [PubMed]

43. Dolly A, Singh S, Prakash R, Bogra J, Malik A, Singh V. Comparative evaluation of different volumes of 70 % alcohol in celiac plexus block for upper abdominal malignsancies. South Asian J Cancer. 2016 Oct-Dec;5(4):204-209. [CrossRef] [PubMed] [PubMed Central]

44. Koyyalagunta D, Engle MP, Yu J, Feng L, Novy DM. The Effectiveness of Alcohol Versus Phenol Based Splanchnic Nerve Neurolysis for the Treatment of Intra-Abdominal Cancer Pain. Pain Physician. 2016 May;19(4):281-92. [PubMed]

45. Arcidiacono PG, Rossi M. Celiac plexus neurolysis. JOP. 2004 Jul;5(4):315-21. [PubMed]

46. Noble M, Gress FG. Techniques and results of neurolysis for chronic pancreatitis and pancreatic cancer pain. Curr Gastroenterol Rep. 2006 Apr;8(2):99-103. [CrossRef] [PubMed]

47. Sekhadia M, Chekka K. Standards of care for celiac plexus neurolysis: radiologic guidance and fellowship training. J Support Oncol. 2009 May-Jun;7(3):89-90. [PubMed]

48. Montero Matamala A, Vidal Lopez F, Inaraja Martinez L. The percutaneous anterior approach to the celiac plexus using CT guidance. Pain. 1988 Sep;34(3):285-8. [CrossRef] [PubMed]

49. Nagels W, Pease N, Bekkering G, Cools F, Dobbels P. Celiac plexus neurolysis for abdominal cancer pain: a systematic review. Pain Med. 2013 Aug;14(8):1140-63. [CrossRef] [PubMed]

50. Gafanovich I, Shir Y, Tsvang E, Ben-Chetrit E. Chronic diarrhea--induced by celiac plexus block? J Clin Gastroenterol. 1998 Jun;26(4):300-2. [CrossRef] [PubMed]

51. Davies DD. Incidence of major complications of neurolytic coeliac plexus block. J R Soc Med. 1993 May;86(5):264-6. [PubMed] [PubMed Central]

52. Moore DC. The dreaded complications from neurolytic celiac plexus blocks are preventable! Reg Anesth Pain Med. 2004 Jul-Aug;29(4):377-8. [CrossRef] [PubMed]

53. McAninch SA, Raizada MS, Kelly SM. Pulmonary embolism following celiac plexus block and neurolysis. Proc (Bayl Univ Med Cent). 2016 Jul;29(3):329-30. [CrossRef] [PubMed] [PubMed Central]

54. Erdek MA, Halpert DE, González Fernández M, Cohen SP. Assessment of celiac plexus block and neurolysis outcomes and technique in the management of refractory visceral cancer pain. Pain Med. 2010 Jan;11(1):92-100. [CrossRef] [PubMed]

55. Ischia S, Ischia A, Polati E, Finco G. Three posterior percutaneous celiac plexus block techniques. A prospective, randomized study in 61 patients with pancreatic cancer pain. Anesthesiology. 1992 Apr;76(4):534-40. [CrossRef] [PubMed]

56. De Cicco M, Matovic M, Balestreri L, Fracasso A, Morassut S, Testa V. Single-needle celiac plexus block: is needle tip position critical in patients with no regional anatomic distortions? Anesthesiology. 1997 Dec;87(6):1301-8. [CrossRef] [PubMed]

57. Eisenberg E, Carr DB, Chalmers TC. Neurolytic celiac plexus block for treatment of cancer pain: a meta-analysis. Anesth Analg. 1995 Feb;80(2):290-5. [CrossRef] Erratum in: Anesth Analg 1995 Jul;(81)1:213. [PubMed]

58. Arcidiacono PG, Calori G, Carrara S, McNicol ED, Testoni PA. Celiac plexus block for pancreatic cancer pain in adults. Cochrane Database Syst Rev. 2011 Mar 16;2011(3):CD007519. [CrossRef] [PubMed] [PubMed Central]

59. McGreevy K, Hurley RW, Erdek MA, Aner MM, Li S, Cohen SP. The effectiveness of repeat celiac plexus neurolysis for pancreatic cancer: a pilot study. Pain Pract. 2013 Feb;13(2):89-95. [CrossRef] [PubMed]

60. Rykowski JJ, Hilgier M. Efficacy of neurolytic celiac plexus block in varying locations of pancreatic cancer: influence on pain relief. Anesthesiology. 2000 Feb;92(2):347-54. [CrossRef] [PubMed]

61. Molnár I, Hegyi G, Zsom L, Saahs C, Vagedes J, Kapócs G, Kovács Z, Sterner MG, Szőke H. Celiac plexus block increases quality of life in patients with pancreatic cancer. J Pain Res. 2019 Jan 14;12:307-315. [CrossRef] [PubMed] [PubMed Central]



How to Cite

Eroshkin, A. A., & Romanukha, D. M. (2020). CT-guided Celiac Plexus Neurolysis in the Management of Severe Upper Abdominal Pain. Ukrainian Neurosurgical Journal, 26(2), 34–45. https://doi.org/10.25305/unj.201779



Review articles