Use of modified knee-chest position for fluoroscopy-guided celiac plexus block: A novel technique in patients with discomfort in prone position

Abstract

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.