|Year : 2016 | Volume
| Issue : 1 | Page : 55-57
Use of modified knee-chest position for fluoroscopy-guided celiac plexus block: A novel technique in patients with discomfort in prone position
Anurag Aggarwal1, Kiran K Girdhar2, Varun Suresh1
1 Department of Anaesthesia and Critical Care, Al-Sabah Hospital, Ministry of Health, Kuwait
2 Department of Anaesthesia and Critical Care, Safdarjang Hospital, New Delhi, India
|Date of Web Publication||7-Jan-2016|
Dr. Anurag Aggarwal
Department of Anaesthesia and Critical Care, Al-Sabah Hospital, Ministry of Health
Source of Support: None, Conflict of Interest: None
Celiac plexus block (CPB) for chronic upper abdominal pain, particularly cancer pain, can be given in both supine and prone positions, using anterior and posterior approaches, respectively. Both approaches suffer from their own demerits. In ultrasonography (USG)-guided anterior approach, the needle has to pass through the liver, intestine, stomach, pancreas, and vessels, exposing the patient to the risk of infection, hemorrhage, and fistula formation. Moreover, in the presence of ascites and large lymph nodes, retroperitoneal area cannot be visualized clearly using USG. In the posterior approach, the patient lies prone with a pillow underneath the abdomen to alleviate lumbar lordosis, and the block is given under fluoroscopic or computed tomography (CT) guidance. Terminally ill patients have difficulty in tolerating prone position because of pain and discomfort due to abdominal distension. To the best of my knowledge, no position other than the supine, prone and rarely lateral, have been described for giving CPB in patients. We present three cases with carcinoma head of pancreas, where CPB was given under fluoroscopic guidance. As all three patients could not tolerate the prone position because of pain and ascites, we modified the position to a knee-chest position [Figure 1]. The patients found the position comfortable to maintain, and they were cooperative during the block. We encountered no problems in imaging the vertebral bodies in anteroposterior (AP) and lateral view. No pillow was required, as the lumbar lordosis was already abolished in this position. In each patient, bilateral block was given using 15-20 mL of 50% alcohol in 0.25% bupivacaine, on either side using a 15-cm Chiba needle. Subsequent follow-up showed successful blockade in all three patients. The use of a modified knee-chest position has not been described earlier for this procedure, but may be a suitable, convenient, and comfortable alternative for terminally ill patients who are unable to lie prone.
Keywords: Celiac plexus, knee-chest position, neurolysis
|How to cite this article:|
Aggarwal A, Girdhar KK, Suresh V. Use of modified knee-chest position for fluoroscopy-guided celiac plexus block: A novel technique in patients with discomfort in prone position. Indian J Pain 2016;30:55-7
|How to cite this URL:|
Aggarwal A, Girdhar KK, Suresh V. Use of modified knee-chest position for fluoroscopy-guided celiac plexus block: A novel technique in patients with discomfort in prone position. Indian J Pain [serial online] 2016 [cited 2020 May 31];30:55-7. Available from: http://www.indianjpain.org/text.asp?2016/30/1/55/173479
| Introduction|| |
Pancreatic cancer and chronic pancreatitis produce intractable abdominal pain that is difficult to control. Nonpharmacologic therapies, such as celiac plexus neurolysis (CPN), are often given with the goal of alleviating pain and improving quality of life, while minimizing the risk of drug-related side effects. Since its introduction in 1914 by Kappis,  percutaneous technique for splanchnic nerve and celiac plexus block (CPB) has evolved as one of the standard modalities in providing pain relief for intractable abdominal pain of various etiologies. Various approaches to the block have been described in literature, each associated with its own merits and demerits. CPN provides long-lasting relief to 70-90% of the patients with pancreatic and other intra-abdominal cancers, regardless of the technique used. Adverse effects of the procedure, though common, are generally transient and mild.  Classically, prone position has been considered as the gold standard for fluoroscopy or computed tomography (CT)-guided CPB. But prone position is not tolerated well by patients who are obese, have ascites or in patients where the pain gets aggravated in the prone position. We encountered three such patients in the last 6 months, where the patients expressed inability to lie prone. We innovated our technique and used a modified knee-chest position while doing CPN/CPB in the patients. The appreciable comfort perceived by the patients prompts us to advocate its consideration as an acceptable alternative for such patients.
| Case Report|| |
We report the management of three patients who required CPN/block and who were unable to lie prone due to various reasons but could tolerate the modified knee-chest position comfortably. The first case was of a 46-year-old male patient with metastatic carcinoma- head of pancreas (patient A), who was on oral morphine 240 mg/day, and was planned for CPN to improve pain control and quality of life. His numerical pain score (NPS) was 6-7 on a scale of 10. He routinely assumed the knee-chest position to relieve the intensity of his pain. The second case was of a 52-year-old female patient with pancreatic carcinoma and metastasis to the liver (patient B). Gross ascites, generalized pain and tenderness contributed to significant discomfort the patient experienced in the supine position. The third case was of a 58-year-old male patient with alcoholic liver disease and chronic pancreatitis, who was having severe abdominal pain (patient C). Gross ascites made assuming prone position uncomfortable. The patients underwent a thorough preanesthetic evaluation preoperatively with stress on allergies and use of anticoagulants. Informed and written consent was obtained, with detailed explanation of the complications associated with CPN/CPB. In the preoperative room, all patients were infused with 20 mL/kg of normal saline solution to minimize the risk of hypotension. Inside the operation theatre, the patients were first positioned in the supine position, standard noninvasive monitors were attached, and baseline readings were taken. The patients were subsequently placed in the knee-chest position, and vital signs were recorded again. Change in vital signs within ± 20% of the baseline was considered acceptable and anything beyond this was investigated and remedied prior to starting the procedure. The classical knee-chest position was modified by abducting the thighs and legs at the hip, so that the abdomen hung freely in between the thighs [Figure 1]. All the patients were provided conscious sedation using intravenous midazolam (10-20 μg/kg). Pain scores were assessed perioperatively using a standardized 10-point NPS. All blocks were given under C-arm guidance. Patient A was given 15 mL of 50% alcohol in 0.25% bupivacaine bilaterally for CPN [Figure 2] and [Figure 3]. NPS scores, both static and dynamic, after 24 h and 2 weeks were 1-2/10, which is independent of morphine and adjuvant therapy. Patient B received 15 mL of 50% alcohol in 0.25% bupivacaine. Patient C was given CPB with 20 mL of 0.25% bupivacaine along with 40 mg depo-medrol, bilaterally. After the procedure, patient's NPS score after 24 h was 1-2/10. The overall pain scores were significantly lower 2 weeks after the procedure, independent of morphine use, or adjuvant therapy.
| Discussion|| |
CPN is an important tool to manage intractable abdominal cancer and noncancer pain. CPN is given commonly in prone position under fluoroscopic or CT guidance. Alternatively, it can also be given by anterior approach, under ultrasonography (USG) guidance. The various techniques mentioned in the literature are as follows.
This approach is especially beneficial when patients have advanced disease with severe lymph nodes around celiac plexus. In these patients administering neurolytic agent retrocrurally blocks predominantly the splanchnic nerves which are feeders to celiac plexus.
Transcrural or antecrural approach
CPN can be given via precrural approach under C-arm or CT guidance. The drug is deposited close to the celiac plexus. Lesser volume of neurolytic agent is required.
USG-guided CPB in supine position
Here the needle is inserted under USG guidance immediately adjacent and anterior to the lateral aspect of the aorta, at the level of the celiac trunk.
Although this technique circumvents the discomfort associated with prone position, it has the potential risk of damage to all the structures that the needle passes through, i.e., the liver, stomach, bowel and pancreas, to reach the celiac ganglia and, thus, there is a risk of infection, hemorrhage, and fistula formation.  Occasionally, altered anatomy resulting from significant lymphadenopathy and/or bulky tumors may hinder accurate visualization and placement of needle. 
To mitigate the problems associated with both the anterior and prone position, we propose a modified knee-chest position as a viable and comfortable option. The patient lies in knee-chest position with thighs wide apart so that legs do not come in front of abdomen. Apart from relieving the pressure to the abdomen, it also prevents the bones of the lower limbs from coming in the visual field [Figure 1].
Advantages of this position are as follows:
- Patients are able to tolerate this position better, and intensity of pain is less in this position compared to prone position. 
- In prone patients, a pillow is inserted beneath the abdomen to obliterate the lumbar curve, which adds to the discomfort of the subset of patients in question. In the codified knee-chest position, lumbar lordosis is automatically obliterated, and there is no need to put the pillow under the abdomen.
- In patients with advanced pancreatic cancer, lymphadenopathy around celiac plexus and ascites alter the anatomy and make needle placement difficult with USG-guided anterior approach. This is not the case with CPB by posterior approach in modified knee-chest position.
- Patients with ascites can be given block in this position with no need to do a prior ascitic tap, which is otherwise necessary sometimes in USG-guided blocks.
| Conclusion|| |
Modified knee-chest position is useful in patients unable to lie prone for fluoroscopically guided CPB/neurolysis. This could be a useful adjunct in the armamentarium of interventional pain physician.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kappis M. Experience with local anesthetic for abdominal surgery. Verhandl D German F Gesellsch Cir 1914;43: 87.
Eisenberg E, Carr DB, Chalmers TC. Neurolytic celiac plexus block for treatment of cancer pain: A meta-analysis. Anesth Analg 1995;80:290-5.
Navarro-Martinez J, Montes A, Comps O, Sitges-Serra A. Retroperitoneal abscess after neurolytic celiac plexus block from the anterior approach. Reg Anesth Pain Med 2003;28:528-30.
Levy MJ, Wiersema MJ. EUS-guided celiac plexus neurolysis and celiac plexus block. Gastrointest Endosc 2003;57: 923-30.
Carroll JK, Herrick B, Gipson T, Lee SP. Acute pancreatitis: Diagnosis, prognosis and treatment. Am Fam Physician 2007; 75:1513-20.
[Figure 1], [Figure 2], [Figure 3]