59 Neurolysis of the
Sympathetic Axis for
Cancer Pain Management
Matthew J.P. LoDico | Oscar de Leon-Casasola
INTRODUCTION
Neurolytic blocks of the sympathetic axis were procedures
that were widely used in the past for control of chronic
upper abdominal pain or pelvic pain in patients with can-
cer. However, recent studies suggest that these blocks are not
effective in treating pain that is not visceral in origin. Conse-
quently, when there is evidence of disease outside the viscera,
for example, lymphadenopathy, the success rate decreases
significantly. Moreover, a controlled randomized study has
shown that even in the best-case scenario, the duration of
full pain control is 2 months. Thus we should reconsider the
indications for these procedures, and when indicated, they
should be performed early in the course of the disease.
Stretching, compressing, invading, or distending visceral
structures can result in poorly localized, noxious visceral
pain. Patients experiencing visceral pain often describe the
pain as vague, deep, squeezing, crampy, or colicky. Other
signs and symptoms include referred pain (e.g., shoulder
pain that appears when the diaphragm is invaded by tumor)
and nausea and vomiting as a result of vagal irritation.
Visceral pain associated with cancer may be relieved by
oral pharmacologic therapy, which classically includes
combinations of nonsteroidal anti-inflammatory drugs
(NSAIDs), opioids, and co-adjuvant therapy. NSAIDs have
begun to fall out of favor with some clinicians for the treat-
ment of chronic pain because they have been implicated in
thrombotic events. In addition to pharmacologic therapy,
neurolytic blocks of the sympathetic axis are also effective in
controlling visceral cancer pain and should be considered
as important adjuncts to pharmacologic therapy for relief
of severe visceral pain. These blocks rarely eliminate cancer
pain because patients frequently experience somatic and
neuropathic pain as well. Therefore, oral pharmacologic
therapy must be continued in the majority of patients with
advanced stages of their disease. The goals of performing
a neurolytic block of the sympathetic axis are to maximize
the analgesic effects of opioid or nonopioid analgesics and
reduce the dosage of these agents to alleviate side effects.
Since neurolytic techniques have a narrow risk-to-benefit
ratio, undesirable side effects and complications from neu-
rolytic blocks can be minimized by sound clinical judgment
and by assessment of the potential therapeutic effect of the
technique on each patient. This chapter discusses pertinent
information regarding neurolytic block of the celiac plexus,
superior hypogastric plexus, and ganglion impar.
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CELIAC PLEXUS BLOCK
The celiac plexus is situated retroperitoneally in the upper
part of the abdomen. It is at the level of the T12 and L1 ver-
tebrae, anterior to the crura of the diaphragm. The celiac
plexus surrounds the abdominal aorta and the celiac and
superior mesenteric arteries. The plexus is composed of
a network of nerve fibers from both the sympathetic and
parasympathetic systems. It contains two large ganglia that
receive sympathetic fibers from the three splanchnic nerves
(greater, lesser, and least). The plexus also receives para-
sympathetic fibers from the vagus nerve. Autonomic nerves
supplying the liver, pancreas, gallbladder, stomach, spleen,
kidneys, intestines, and adrenal glands, as well as blood ves-
sels, arise from the celiac plexus.
Neurolytic block of the celiac plexus has been used for
malignant and chronic nonmalignant pain. In patients with
acute or chronic pancreatitis, celiac plexus block has been
used with variable success.1 Likewise, patients with upper
abdominal cancer who have a significant visceral pain com-
ponent have responded well to this block.2
The Cochrane collaboration performed a systematic
review of all randomized controlled studies investigating the
effectiveness of celiac plexus block in the management of
pancreatic cancer pain. They concluded that despite only a
small amount of evidence for an increase in pain relief, the
improved side effect profile as a result of the reduced need
for opiates is desirable.3 It must be considered that many
of the studies comparing the various interventional proce-
dures with oral pharmacotherapy included NSAIDs. If more
protocols in the future exclude NSAIDs, there may become
a bigger statistical difference between the interventional
and pharmacotherapy groups.
Three approaches to block nociceptive impulses from
viscera in the upper abdominal region include the retro-
crural (or classic) approach, the anterocrural approach,
and neurolysis of the splanchnic nerves.4-7 Regardless of the
approach, the needle or needles are inserted at the level
of the first lumbar vertebra, 5 to 7 cm from the midline.
Then the tip of the needle is directed toward the upper
third of the body of L1 for the retrocrural and toward the
lower third of the body of L1 for the anterocrural technique
(Fig. 59.1). In the case of the retrocrural approach, the tip
of the needle is advanced no more than 0.5 cm anterior
to the anterior border of L1, and with the anterocrural
approach (see Fig. 59.1), the tip of the needle is advanced