Extra Topic 2.2 -- Cancer Pain (Celiac Plexus Block)

Question 1

What treatment modalities would you recommend?

(A young man with pancreatic cancer is taking oral pain medications, 100 mg of controlled-release morphine sulfate (MS Contin) every 8 hours and 30 mg of immediate-release morphine sulfate every 3 hours, as needed for breakthrough pain. He presents to you with inadequate pain control, nausea, vomiting, and constipation.)

Answer 1

I would recommend the addition of adjuvant therapies, such as –

• antidepressants and anticonvulsants for neuropathic pain;
• corticosteroids to reduce inflammation;
• bisphosphonates and calcitonin for bone pain; and
• octreotide to relieve pain due to bowel obstruction.

I would also consider opioid rotation, a celiac plexus block, neuromodulation therapy (e.g., spinal cord stimulation, TENS, acupuncture, e-Stim, etc.), sedatives, and psychological therapy.

Question 2

How would you perform a celiac plexus block?

(A young man with pancreatic cancer is taking oral pain medications, 100 mg of controlled-release morphine sulfate (MS Contin) every 8 hours and 30 mg of immediate-release morphine sulfate every 3 hours, as needed for breakthrough pain. He presents to you with inadequate pain control, nausea, vomiting, and constipation.)

Answer 2

A celiac plexus block is performed with the patient in the prone position,

at the level of the L1 vertebral body.

Needles are placed approximately 5-7 cm lateral to the midline, and advanced under fluoroscopic guidance to lie anterior to the vertebral body.

A test block is usually performed with local anesthetic to ensure benefit from the procedure.

If the patient achieves good pain relief from the local benefit from the procedure.

If the patient achieves good pain relief from the local anesthetic, a neurolytic block, with either alcohol or phenol, is then performed.

Question 3

What are the complications of celiac plexus block?

(A young man with pancreatic cancer is taking oral pain medications, 100 mg of controlled-release morphine sulfate (MS Contin) every 8 hours and 30 mg of immediate-release morphine sulfate every 3 hours, as needed for breakthrough pain. He presents to you with inadequate pain control, nausea, vomiting, and constipation.)

Answer 3

Complications related to celiac plexus blockade can be serious, so extensive discussion should take place concerning the risks and benefits of the procedure.

The most serious complications is paralysis, due to spread of the neurolytic agent into the spinal or epidural space, or secondary to damage of vital arterial supply to the spinal cord (i.e., the artery of Adamkiewicz).

Other complications include –

• postural hypotension (most common),
• accidental intravascular injection,
• retroperitoneal hemorrhage,
• sexual dysfunction,
• pneumothorax,
• diarrhea, and
• damage to the kidneys or pancreas.

A celiac plexus block is contraindicated in the presence of systemic anticoagulation, sepsis, local infection, or bowel obstruction.

Question 4

What would you do if he refuses a celiac plexus block despite your recommendation?

(A young man with pancreatic cancer is taking oral pain medications, 100 mg of controlled-release morphine sulfate (MS Contin) every 8 hours and 30 mg of immediate-release morphine sulfate every 3 hours, as needed for breakthrough pain. He presents to you with inadequate pain control, nausea, vomiting, and constipation.)

Answer 4

If the block were refused, I would utilize alternative treatment modalities as mentioned before, and treat his side effects with antiemetics, stool softeners, and laxatives.

However, I would make the patient aware that constipation would likely continue as long as he is taking opioids.