A novel approach to transnasal sphenopalatine ganglion injection.

BACKGROUND: Sphenopalatine ganglion block is used to treat headache and facial pain. There are transnasal, transoral and lateral approaches to establish the blockade. The transnasal application of topical anesthetic is the simplest and most common technique among the three. However, the diffusion of topical anesthetic to the ganglion is unpredictable and the blockade is not durable. OBJECTIVE: To describe a novel transnasal injection technique to block sphenopalatine ganglion. METHODS: The technique includes topical anesthesia to the nasal mucosa between the middle and inferior turbinates from nares to the nasopharynx, followed by a needle insertion in the same tract guided by its tailored plastic cover-sheath for blocking agent injection to the ganglion. RESULTS: Fluoroscopy revealed that with this technique the needle tip located near the medial pterygoid plate at the level of the middle concha and contrast flowed superoposteriorly to the maxilla without vascular uptake. Pain relief for this patient was prolonged from one day with topical technique to four weeks with this technique. The subsequent blocks without fluoroscopy provided similar prolonged pain relief. CONCLUSION: This method preserves the technical simplicity of the original transnasal approach and includes the predictability and durability of the blockade from needle injection.

Classic transcrural celiac plexus block simulated on 100 computed tomography images.

STUDY OBJECTIVE: To evaluate intra-abdominal needle trajectories of the classic transcrural celiac plexus block (tCPB) with a simulation technique. DESIGN: Classic tCPB technique cited from 10 latest authoritative textbooks were simulated on abdominal computed tomography images retrospectively. SETTING: University-affiliated community hospital. MEASUREMENTS: One hundred axial computed tomography images across the celiac trunk were retrieved. Three lines simulating classic tCPB were executed on each image. The organs traversed by each line were noted and analyzed. The frequencies of organ traverse were compared with the incidences described in the literature. MAIN RESULTS: All 3 lines traversed various organs with different frequencies. The right side line frequently traversed the right kidney (36%). The left side line always traversed the aorta (100%). The modified line on the right side frequently traversed the inferior vena cava (32%). The highest kidney traverse percentage on both sides and the highest aorta traverse percentage on the right side were observed in pancreatic cancer patients. CONCLUSIONS: Despite uncommon clinical complications, classic tCPB needle placement frequently traversed through several key organs in this simulation series. Organ penetrations could be avoided by needle trajectory adjustment.

A modified approach to transcrural celiac plexus block.

OBJECTIVES: Transcrural celiac block using the needle "walking off" the L1 vertebra technique may cause complications. We used patient-specific computed tomography (CT) images as a roadmap to perform the block under fluoroscopy. We present 1 case to describe the technique. CASE REPORT: The patient is a 63-year-old woman with refractory pain from pancreatic cancer. Her CT showed the celiac trunk at the upper L1 vertebra and 2 cm left to the midline. Needle trajectories were drawn on that film. The line representing the classic "walking off" the bone technique on the left side crossed the aorta. Two lines targeting the base of the celiac trunk were modified, thereby avoiding both the L1 vertebra and the surrounding organs. The following were measured: the distance from the midline to the left needle entry (2.5 cm), the angle for the left needle insertion (90 degrees), the distance (6 cm) and the angle (65 degrees) for the right needle entry, and the distance from the anterior margin of the L1 to the celiac trunk (2.6 cm). During the procedure, 2 needles were placed according to these measurements in a plane superior to the transverse process of the L1. No bony contact or needle redirection was made. Both needles reached 3 cm anterior to the anterior margin of the L1. X-ray contrast crossed the midline and silhouetted the target vasculature. Five milliliters of 0.2% ropivacaine followed by 10 mL of 6% phenol were injected on each side. The patient's pain level improved to 0 to 1/10 on a visual analog scale. CONCLUSIONS: The modified technique avoided painful needle contact on the bone, reduced needle redirections, and decreased the possibility of vital organ puncture.

Computed tomography celiac trunk topography relating to celiac plexus block.

BACKGROUND AND OBJECTIVES: The celiac plexus is a dense autonomic network surrounding the celiac trunk. To block this plexus, the celiac trunk is a landmark for needle placement. Needles inserted at a distance from the midline, "walking off" the vertebra, may penetrate surrounding organs. We reviewed 200 computed tomography images to investigate the celiac trunk topography relating to the block. METHODS: Two hundred computed tomography images across the celiac trunk were displayed. The celiac emergence level and celiac-aortic-vertebral anatomies were examined. On each image, 2 needle trajectories imitating walking-off technique were placed tangential to the vertebral body passing through the crus of the diaphragm on both sides: L-9s and L-4.5s (9 and 4.5 cm from the midline, respectively). The vital organs traversed by these lines were noted and analyzed. RESULTS: Celiac emergence levels: T11-12, 6.5%; T12, 34%; T12-L1, 31%; L1, 28.5%. Aortic locations: 70% were anterior-left to and 29% were anterior-middle to the vertebra. Celiac runoffs: 63.5% from the aorta anterolaterally on the left, 36% from the midportion. Celiac-aortic-vertebral correlations showed a various distribution in groups; 88% L-9s and 64% L-4.5s on the right side, and 96% L-9s and 88% L-4.5s on the left side traversed different vital organs with various frequencies. CONCLUSIONS: The celiac trunk anatomy varies. Blocking needles walking off the vertebra from a fixed distance frequently traverse vital organs. Previewing celiac-aortic-vertebral topography with a simulating block on individual patient's computed tomography (CT) image for accordant needle placement subsequently is warranted.