Celiac plexus<unk>  Celiac plexus<unk>  (CPN) is the chemical ablation of the celiac plexus. This type of<unk>  is mainly used to treat pain associated with advanced pancreatic cancer. Traditional opioid medications used to treat pancreatic cancer patients may yield inadequate pain relief in the most advanced stages of pancreatic cancer, so the goal of CPN is to increase the efficiency of the medication. This in turn may lead to a decreased dosage, thereby decreasing the severity of the side effects. CPN is also used to decrease the chances of a patient developing an addiction for opioid medications due to the large doses commonly used in treatment. Traditional CPN approaches and nerve blocks CPN can be performed by percutaneous injection either anterior or posterior to the celiac plexus. CPN is generally performed complementary to nerve blocks, due to the severe pain associated with the injection itself.<unk>  is commonly performed only after a successful celiac plexus block. CPN and celiac plexus block (CPB) are different in that CPN is permanent ablation whereas CPB is temporal pain inhibition. There are multiple posterior percutaneous approaches, but no clinical evidence suggests that any one technique is more efficient than the rest. The posterior approaches generally utilize two needles, one at each side of the L1 vertebral body pointing towards the T12 vertebral body. Increasing the spread of the injection may increase the efficacy of the<unk> . Endoscopic ultrasound-guided<unk>  Endoscopic ultrasound (EUS)-guided<unk>  is a technique that performs<unk>  using a linear-array echoendoscope. The EUS technique is minimally invasive and is believed to be safer than the traditional percutaneous approaches. EUS-guided<unk>  technique can be used to target the celiac plexus, the celiac ganglion, or the broad plexus in the treatment of pancreatic cancer-associated pain. EUS-guided celiac plexus<unk>  (EUS-CPN) is performed with either an oblique-viewing or forward-viewing echoendoscope and is passed through the mouth into the esophagus. From the gastroesophageal junction, EUS imaging allows the doctor to visualize the aorta, which can then be traced to the origin of the celiac artery. The celiac plexus itself cannot be identified, but is located relative to the celiac artery. The<unk>  is then performed with a spray needle that disperses a neurolytic agent, such as alcohol or phenol, into the celiac plexus. EUS-CPN can be performed unilaterally (centrally) or bilaterally, however, there is no clinical evidence supporting the superiority of one over the other. EUS-guided<unk>  can also be performed on the celiac ganglion and the broad plexus in a similar fashion to the EUS-CPN. The celiac ganglion<unk>  (EUS-CGN) is more effective than EUS-CPN and broad plexus<unk>  (EUS-BPN) is more effective than EUS-CGN. Lumbar sympathetic<unk>  Lumbar sympathetic<unk>  is typically used on patients with ischemic rest pain, generally associated with nonreconstructable arterial occlusive disease. Although the disease is the basis for this type of<unk> , other diseases such as peripheral neuralgia or vasospastic disorders can receive lumbar sympathetic<unk>  for pain treatment. Magnetic Resonance Image of Lumbar Spine courtesy of Nevit Dilmen Lumbar sympathetic<unk>  is performed between the L1-L4 vertebrae with separate injections at each vertebra junction. The chemicals used for<unk>  of the nerves cause destructive fibrosis and cause a disruption of the sympathetic ganglia. The vasomotor tone is decreased in the area affected by the<unk> , which in addition to arteriovenous shunting, create a light pink appearance within the affected area. Lumbar sympathetic<unk>  alters the ischemic rest pain transmission by changing norepinephrine and catecholamine levels or by disturbing afferent fibers. This procedure is mainly used only when other feasible approaches to pain management are unable to be used. Lumbar sympathetic<unk>  is performed by using absolute alcohol, but other chemicals such as phenol, or other techniques such as radiofrequency or laser ablation have been studied. To aid in the procedure, fluoroscopy or CT guidance is used. Fluoroscopic guidance is the most frequent, giving better real-time monitoring of the needle. The general technique of administering lumbar sympathetic<unk>  involves using three separate needles rather than one because it allows for better longitudinal spread of the chemicals. Complications can arise from this procedure such as nerve root injury, bleeding, paralysis, and more. Complications have been seen to be diminished when using the aforementioned radiofrequency or laser ablation techniques in comparison to the injection of alcohol or phenol. Generally, approximately two-thirds of patients can expect a favorable outcome (pain relief with minimal complications). Overall, the minimally invasive technique of lumbar sympathetic<unk>  is important in the relief of ischemic rest pain. Chemodenervation Chemodenervation is a process used to manage focal muscle overactivity through the use of either phenol, alcohol, or one of the more recently discovered botulinum toxins (BoNTs). Chemodenervation is used as a complement to<unk> . The agent of choice is injected into the muscle fibers as opposed to nerve tissue and the two work together to dull the neuronal signaling within the muscles. Nerve block of cervical spine courtesy of PainDoctorUSA The use of alcohol and phenol injections have different effects than the use of BoNTs.<unk>  mediates the effects of alcohol and phenol injections but does not mediate the effects of BoNT injections. Phenol and alcohol are less expensive, faster acting, can treat larger areas and can be readministered or boostered in less than three months, however, those injections also require the patient to be sedated cause muscle scarring and can lead to muscle fibrosis. BoNT injections are easier to inject, better accepted by patients, and have reversible effects on muscles, however, they are more expensive, act very slowly, and the body can develop a resistance to them.
Neurolysis
Neurotomy
Astragalectomy
Neurectomy
Depot injection
Cranioplasty
Equianalgesic
Laminotomy