Celiac Plexus Block and Neurolysis Protocol 2026: Complete IR Guide

Introduction to celiac plexus block and neurolysis

Celiac plexus block and neurolysis represent essential interventions in interventional radiology for managing intractable visceral pain originating from the upper abdomen.[1] The celiac plexus, located at the T12-L1 vertebral level anterior to the aorta, transmits nociceptive signals from the pancreas, liver, gallbladder, spleen, and upper gastrointestinal tract. Destruction or inhibition of this plexus provides profound analgesia without the systemic side effects of high-dose opioid therapy.[2]

Celiac plexus anatomy and target localization

The celiac plexus is a dense network of sympathetic and parasympathetic fibers surrounding the celiac artery at the level of the T12-L1 intervertebral disc.[5] It receives preganglionic sympathetic input from the greater (T5-T10), lesser (T10-T11), and least (T12) splanchnic nerves, as well as parasympathetic contributions from the vagus nerve. Postganglionic fibers radiate along the hepatic, splenic, left gastric, and superior mesenteric arteries to innervate target viscera.

Accurate target localization is fundamental to procedural success. The celiac artery trunk arises from the abdominal aorta approximately 1-2 cm below the aortic hiatus of the diaphragm. On cross-sectional imaging, the plexus occupies the retroperitoneal space between the crura of the diaphragm, anterior to the aorta and posterior to the pancreatic body and lesser sac.[6] Anatomic variants including celiac-mesenteric trunk, hepatosplenic trunk, and replaced hepatic arteries must be recognized to avoid nontarget injection.

Clinical indications and patient selection

The primary indication for celiac plexus neurolysis is moderate-to-severe visceral pain from upper abdominal malignancy, particularly pancreatic cancer, gastric cancer, hepatocellular carcinoma, and cholangiocarcinoma.[7] Pain characterized as deep, boring, epigastric radiation to the back that is poorly controlled with systemic analgesics predicts favorable response. Early neurolysis (within 4-6 weeks of pain onset) demonstrates superior outcomes compared to delayed intervention.[8]

Chronic pancreatitis with recurrent acute flares and intractable abdominal pain constitutes the main benign indication for diagnostic celiac plexus block.[9] Patients who achieve greater than 50% pain relief following a diagnostic local anesthetic block are candidates for repeat therapeutic blocks or permanent neurolysis. Other indications include pain from chronic cholecystitis, visceral arterial insufficiency, and post-radiation enteritis.[10]

Imaging guidance modalities

CT guidance is the preferred imaging modality for percutaneous celiac plexus procedures, providing excellent visualization of the aorta, celiac axis, adjacent organs, and needle trajectory.[11] Multiplanar reconstructions enable precise depth measurement and crural identification. CT-fluoroscopy combines real-time needle guidance with cross-sectional anatomic detail, reducing procedure time and radiation exposure compared to conventional CT step-and-shoot protocols.

Endoscopic ultrasound (EUS) guidance allows transgastric anterior approach to the celiac plexus with Doppler verification of vascular structures.[12] EUS-guided celiac plexus neurolysis (EUS-CPN) is performed by gastroenterologists and offers the advantage of avoiding posterior musculature puncture. However, EUS-CPN is limited by restricted needle angulation and the inability to access the true retroperitoneal space in some patients.

Fluoroscopic guidance alone is rarely used in contemporary practice due to limited soft-tissue visualization, though it remains valuable for lateral scout confirmation of needle depth and for combined CT-fluoroscopy workflows.[13] Magnetic resonance guidance is investigational and not widely available for routine clinical use.

Technique selection and procedural steps

The posterior paravertebral approach is the most widely utilized percutaneous technique in interventional radiology. The patient is positioned prone with a pillow under the abdomen to reduce lumbar lordosis. Using CT guidance, a 20-22 gauge needle is advanced via a posterior paravertebral trajectory at the T12-L1 level, targeting the anterolateral aortic margin at the celiac artery origin.[14] Bilateral needle placement ensures comprehensive plexus coverage.

The transdiscal approach involves needle passage through the T12-L1 intervertebral disc space, offering a direct anterior trajectory toward the celiac plexus while avoiding the pleural reflections and kidneys.[15] This technique requires careful disc space identification and is contraindicated in patients with significant disc degeneration or infection. The anterior approach via transabdominal or transgastric routes is reserved for EUS-guided procedures or specific anatomic scenarios where posterior access is compromised.

Following needle placement, diagnostic contrast injection (1-2 mL of non-ionic iodinated contrast per side) confirms extravascular, extradural distribution along the aortic wall without intravascular uptake or retroperitoneal extravasation.[16] For neurolysis, the neurolytic agent is injected slowly in 1-2 mL aliquots with intermittent contrast verification. Total neurolytic volume ranges from 10-20 mL per side depending on patient size and anatomic distribution.

Medication selection and dosing protocols

For diagnostic celiac plexus block, local anesthetic alone is administered to confirm visceral pain mediation and predict neurolysis response. Bupivacaine 0.25-0.5% (10-15 mL per side) provides sustained blockade with onset within 15-30 minutes and duration of 4-8 hours.[17] Ropivacaine 0.2-0.5% offers a similar sensory profile with reduced motor block and lower cardiotoxicity risk. Addition of epinephrine 1:200,000 prolongs block duration and serves as an intravascular injection marker.

For neurolytic celiac plexus neurolysis, absolute ethanol (95-100%) is the most commonly employed agent, producing irreversible protein denaturation and Wallerian degeneration of sympathetic fibers.[18] Typical dosing is 20-30 mL total (10-15 mL per side) diluted to 50-70% with contrast or saline to improve visualization and reduce injection pain. Phenol 6-12% in aqueous or glycerin solution provides an alternative neurolytic with less immediate injection pain but potentially shorter duration of action.[19]

Some operators advocate combined protocols involving initial local anesthetic injection followed by neurolytic administration after pain relief confirmation. Steroid adjuncts (triamcinolone 40 mg or methylprednisolone 80 mg) may reduce perineural inflammation and prolong analgesic duration in chronic pancreatitis patients undergoing repeated blocks.[20]

Radiation protection with SATPro during celiac procedures

CT-guided celiac plexus procedures require intermittent scanning during needle insertion, contrast verification, and post-procedure assessment, resulting in cumulative radiation exposure for both patients and operators. CT-fluoroscopy workflows, while reducing total scan time, deliver continuous low-dose radiation that elevates scatter exposure to the interventional team.[21]

SATPro provides essential scatter protection during these CT-fluoroscopy guided interventions. The bismuth-based nanomaterial core absorbs low-energy scatter radiation, achieving dose reductions up to 70% for operators and ancillary staff.[22] For posterior paravertebral approaches where the operator’s hands and torso are positioned close to the CT gantry aperture, SATPro’s disposable sterile drape configuration offers comprehensive protection that conventional ceiling-mounted shields cannot provide.

The lightweight design eliminates physical fatigue during prone patient positioning and needle manipulation, which often requires sustained forward flexion of the operator’s trunk. Unlike reusable lead aprons that restrict movement during bilateral needle adjustments, SATPro maintains full mobility while delivering continuous attenuation.[23] The patented lead-free composite produces no imaging artifacts during CT-fluoroscopy or diagnostic CT verification, preserving the anatomic detail essential for identifying the celiac artery, aortic margin, and adjacent renal vessels.

For departments performing high volumes of oncologic pain interventions, SATPro supports ALARA principles without compromising procedural efficiency. The drape’s compatibility with all major CT-fluoroscopy systems ensures universal deployment across interventional suites. The antibacterial integrated membrane further supports infection control during these sterile field procedures where multiple needle passes and medication exchanges increase contamination risk.[24]

SATMix and medication precision in neurolysis

Celiac plexus neurolysis demands precise medication preparation to ensure consistent neurolytic concentration and predictable distribution. SATMix, SATMED Health’s single-use mixing kit, provides standardized preparation for contrast-ethanol dilutions, local anesthetic mixtures, and combined neurolytic cocktails used during celiac plexus interventions.[25]

For ethanol neurolysis, dilution to 50-70% with iodinated contrast (1:1 to 1:2 ratio) improves radiopacity and enables real-time visualization of neurolytic spread during CT-fluoroscopy. Inconsistent mixing produces variable ethanol concentrations that may result in inadequate neurolysis or excessive tissue irritation. SATMix features 24-hour ethanol-resistant polymers and a closed-loop 4-port stopcock design that enables standardized mixing protocols without alcohol degradation or leakage.[26]

Local anesthetic preparation for diagnostic blocks requires precise dilution and bubble-free delivery. The SATMix closed system eliminates air bubble introduction, a crucial safety consideration given the proximity of the celiac plexus to major arterial trunks and the risk of paradoxical air embolism.[27] When steroid adjuncts are combined with local anesthetic, SATMix ensures homogeneous suspension without particle aggregation that could compromise microcatheter or needle delivery.

The SATMix Calculator provides evidence-based guidance for neurolytic dilution ratios based on patient body habitus and target volume requirements. For celiac plexus neurolysis, this translates to optimal ethanol-contrast mixtures that maximize plexus coverage while minimizing total alcohol volume. Departments utilizing SATMix for pain interventions report improved medication consistency, reduced preparation time, and more predictable analgesic outcomes.[28]

Expected outcomes and success rates

Technical success rates for CT-guided celiac plexus neurolysis exceed 90-98% when defined by appropriate needle position and contrast-confirmed periaortic distribution.[29] For pancreatic cancer, complete or partial pain relief is achieved in 70-90% of patients at 3 months, with durable benefit persisting in 50-60% at 6 months.[30] Early neurolysis (within 4-6 weeks of pain onset) demonstrates superior outcomes, with some studies suggesting improved median survival when performed at diagnosis.

For chronic pancreatitis, diagnostic celiac plexus block achieves greater than 50% pain relief in 50-70% of patients, though the duration is typically shorter (weeks to months) compared to malignant indications.[31] Repeated blocks or permanent neurolysis may be required for sustained benefit. Opioid consumption decreases by 30-50% following successful neurolysis, with corresponding improvements in constipation, sedation, and quality of life scores.[32]

Complications and risk mitigation

Orthostatic hypotension occurs in 20-40% of patients due to sympathetic blockade and unopposed parasympathetic vasodilation, typically resolving within 24-48 hours with intravenous hydration and gradual mobilization.[33] Diarrhea results from unopposed parasympathetic gastrointestinal activity and affects 10-30% of patients, usually self-limiting within 1-2 weeks.

Serious complications are uncommon but include retroperitoneal hemorrhage (1-2%), pneumothorax from pleural transgression during high thoracic approaches (1-3%), and paraplegia from accidental arterial of Adamkiewicz injury or spinal cord ischemia (rare, less than 0.1%).[34] Meticulous needle positioning, contrast verification before neurolytic injection, and avoidance of intravascular delivery mitigate catastrophic risks. Infection is rare but may present as retroperitoneal abscess; prophylactic antibiotics are not routinely required.[35]

Contraindications

Absolute contraindications include uncorrectable coagulopathy, active infection at the puncture site, and patient inability to tolerate prone positioning.[36] Relative contraindications encompass significant aortic aneurysm or dissection at the celiac level, extensive retroperitoneal tumor infiltration obscuring anatomic landmarks, and prior failed neurolysis with suspected anatomic disruption. Severe contrast allergy may be managed with premedication or CO2 verification.[37]

Follow-up protocol

Post-procedure monitoring includes vital signs every 15 minutes for 2 hours to detect orthostatic hypotension. Pain scores are assessed at 30 minutes, 2 hours, and 24 hours to document initial response.[38] For diagnostic blocks, pain relief greater than 50% at 24 hours predicts favorable neurolysis response. Patients are discharged with instructions to maintain hydration, rise slowly from seated positions, and monitor for fever or worsening back pain.

Follow-up clinical evaluation at 1-2 weeks assesses analgesic duration and opioid reduction. Repeat block or neurolysis is indicated for recurrent pain following an initial successful response. For malignant indications, imaging every 2-3 months evaluates disease progression and identifies alternative pain generators requiring additional interventions.[39]

Patient preparation

Pre-procedural evaluation includes complete blood count, coagulation studies, and comprehensive metabolic panel. Cross-sectional imaging (CT or MRI) within 4 weeks confirms anatomic landmarks and identifies variant vascular anatomy. Fasting for 4-6 hours is required. Intravenous access is established for hydration and sedation. Type and screen is obtained for patients with coagulopathy risk. Prophylactic antibiotics are not routinely administered.[40]

Further reading

1. Strategic Advancements in Interventional Radiology: Emulsion Dynamics in cTACE and NBCA Glue Embolization
2. Y-90 Radioembolization 2026: Complete TARE Protocol Guide
3. Prostate Artery Embolization: Complete Protocol for Radiologists
4. Uterine Artery Embolization: Complete 2026 Protocol
5. Top 100 Free Radiology Websites in 2026: A Global Guide

Conclusion

Celiac plexus block and neurolysis remain essential interventions for managing intractable visceral pain from upper abdominal malignancy and chronic pancreatitis. Success depends on precise anatomic targeting, appropriate technique selection, and rigorous medication preparation. Integration of SATPro radiation protection and SATMix medication precision into the procedural workflow enhances staff safety, medication consistency, and analgesic outcomes. For interventional radiologists, mastery of these advanced pain interventions ensures optimal patient care across oncologic and benign pancreatic disease populations.

References

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