Contralateral needle entry to perform transdiscal coeliac plexus neurolysis: is it effective? a case report

Coeliac plexus neurolysis is a well-established interventional technique for the management of intractable visceral pain originating from the upper abdominal organs, particularly in patients with pancreatic malignancy. Several approaches have been described to deliver the neurolytic agent into the preaortic space, including the posterior transdiscal technique. A unilateral approach is often sufficient; however, a bilateral approach may be required to achieve adequate spread when contrast distribution is unsatisfactory. Typically, the needle tip is positioned on the ipsilateral side relative to the point of entry. A 73 year-old Arab woman with a history of hypertension and recurrent metastatic pancreatic carcinoma following surgical treatment presented with severe upper abdominal pain of pancreatic origin. Her pain was refractory to multiple analgesic modalities, including a fentanyl transdermal patch at a dose of 300 µg/h. During coeliac plexus neurolysis using a posterior splanchnic approach, the needle was unintentionally advanced along the curvature of the annulus fibrosus to the contralateral side of the T12–L1 intervertebral disc, opposite the entry point. This needle’s tip position is typically achieved intentionally using a different technique. Despite this deviation from the planned approach, the procedure was completed without modification. Injection of local anesthetic resulted in a reduction of the patient’s pain, and subsequent neurolysis with ethanol effectively relieved the upper abdominal visceral pain. However, opioid requirements remained unchanged due to persistent generalized body and abdominal pain. This case highlights the importance of detailed anatomical knowledge and technical adaptability in different circumstances when performing coeliac plexus neurolysis. Familiarity with multiple approaches allows clinicians to recognize acceptable non-standard but safe needle positions, potentially avoiding unnecessary repositioning while still achieving therapeutic goals. Awareness of potential deviations in needle trajectory may be particularly valuable when managing challenging conditions.