A celiac plexus block is a specialized interventional pain procedure that targets the celiac plexus — a dense network of sympathetic nerve fibers and ganglia located in the retroperitoneal space at the level of the T12-L1 vertebral bodies, posterior to the stomach and anterior to the diaphragmatic crura and aorta. The celiac plexus transmits nociceptive (pain) signals from virtually all of the upper abdominal viscera, including the pancreas, liver, gallbladder, stomach, spleen, kidneys, and proximal small intestine. By delivering local anesthetic and corticosteroid — or in appropriate cases, neurolytic agents such as absolute ethanol or phenol — directly to this plexus, the procedure effectively interrupts the transmission of visceral pain signals before they reach the spinal cord and central nervous system.
The celiac plexus block is one of the most well-established and evidence-supported interventional procedures for the management of upper abdominal cancer pain, particularly pain originating from pancreatic adenocarcinoma. Pancreatic cancer pain, which affects approximately 80-90% of patients during the course of their disease, is often severe, refractory to oral opioid analgesics, and associated with significant functional impairment and reduced quality of life. Celiac plexus neurolysis (CPN) — the version of the procedure employing neurolytic agents — has been shown in multiple randomized controlled trials and meta-analyses to provide superior pain relief compared to systemic analgesic therapy alone, while simultaneously reducing opioid consumption, opioid-related side effects (nausea, constipation, sedation, and cognitive impairment), and the need for dose escalation over time.
Beyond oncologic applications, celiac plexus block with local anesthetic and steroid is an important therapeutic option for patients with painful chronic pancreatitis, particularly those with chronic abdominal pain of visceral origin that has not responded to conservative management, endoscopic interventions, or surgical drainage procedures. At Interventional Pain Consultants, our board-certified, fellowship-trained interventional pain specialists perform these procedures using state-of-the-art fluoroscopic imaging with or without CT guidance, ensuring the highest level of accuracy and safety for every patient.
The patient is positioned prone on the procedure table, and the skin overlying the upper lumbar spine is prepared and draped in sterile fashion. Under anteroposterior fluoroscopic imaging, the T12 and L1 vertebral bodies are identified. The classic retrocrural approach involves advancing two 20- or 22-gauge, 5- to 7-inch spinal needles from paramedian entry points at the level of the T12-L1 interspace, directing the needles toward the anterolateral aspect of the T12 vertebral body. Each needle is advanced until bony contact is made, then carefully walked off the vertebral body anteriorly while the loss-of-resistance technique is used to identify passage through the diaphragmatic crus and into the retrocrural space housing the celiac plexus.
Once both needles are properly positioned, negative aspiration is performed to rule out intravascular or intrathecal placement, and a small volume of non-ionic contrast medium is injected under live fluoroscopy. On the anteroposterior view, appropriate contrast spread appears as a bilateral, linear, paravertebral column covering the T12-L1 vertebral bodies. On the lateral view, contrast should be seen spreading anterior to the vertebral bodies within the retrocrural space. In a transcrural approach, the needle traverses the diaphragmatic crus to position the tip in the more anterior (preaortic) compartment. After confirming safe needle placement, the therapeutic injectate is administered — typically 10-20 mL of 0.25% bupivacaine combined with 40-80 mg of triamcinolone or methylprednisolone, or for neurolysis, a total of 20-40 mL of 50-100% ethanol or 6-10% phenol in glycerin.
The procedure is performed on an outpatient basis or as part of a planned hospital admission for patients with advanced malignancy, and typically requires 20-40 minutes of procedure time. Patients are positioned prone and may receive moderate sedation (midazolam and fentanyl) for comfort. During injection, patients typically experience a sensation of warmth or pressure in the upper abdomen and back that lasts 1-2 minutes. For patients receiving neurolytic agents, there may be a transient sensation of intense burning or pressure during the injection, followed by a profound sense of warmth and relief as the neurolysis takes effect.
Following the procedure, patients are monitored for 30-60 minutes and are typically observed for postural hypotension — a common expected side effect resulting from splanchnic vasodilation and reduced sympathetic tone to the mesenteric circulation. Patients are instructed to maintain adequate oral hydration and to change positions slowly to minimize the risk of orthostatic symptoms. Most patients can return home the same day after appropriate monitoring, though some patients with advanced cancer may require short-stay admission for optimization.
In the hours following the procedure, patients commonly experience orthostatic hypotension, diarrhea (due to unopposed parasympathetic activity in the gastrointestinal tract), and transient increased back or abdominal pain. These effects typically resolve within 24-72 hours. Patients are advised to avoid driving, operating heavy machinery, or making important decisions for 24 hours following sedation. Most patients can resume their normal daily activities within 1-2 days, with the exception of heavy lifting (more than 10-15 pounds) and strenuous exercise for one week.
For patients undergoing neurolysis, the analgesic effect typically develops progressively over 24-72 hours as the neurolytic agent achieves complete nerve fiber destruction. The full therapeutic effect is usually apparent within one week. In patients receiving anesthetic-steroid blocks for chronic pancreatitis, the anti-inflammatory and membrane-stabilizing effects of the corticosteroid peak within 3-7 days, and the therapeutic window can be assessed at the two-week mark.
Celiac plexus blocks are most appropriate for patients whose abdominal pain has a clear visceral component — typically described as deep, gnawing, pressure-like, poorly localized, and often referred to the mid-back or epigastrium. The presence of predominantly somatic pain (well-localized, sharp, pleuritic, or movement-related) suggests parietal peritoneal involvement and reduces the likelihood of benefit from a visceral-targeted block. Pre-procedural imaging (CT or MRI) is essential to evaluate the anatomy of the celiac region and to detect any tumor infiltration, lymphadenopathy, or anatomic distortion that might alter the technical approach or increase procedural risk.
Contraindications include coagulopathy or therapeutic anticoagulation that cannot be safely interrupted, active systemic infection, known allergy to contrast media or injectate components, severe uncorrected hypovolemia, and patient inability to tolerate the prone position. At Interventional Pain Consultants, all celiac plexus procedures are performed with meticulous attention to anatomic precision, sterile technique, and contrast confirmation. Our commitment to evidence-based interventional pain medicine ensures that every patient receives the most appropriate procedure for their specific clinical circumstances, with the goal of maximizing pain relief and quality of life while minimizing procedural risk.
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