Revised: September 16, 2026
Accepted: October 21, 2026
Published online: October 28, 2026
Processing time: 96 Days and 20.4 Hours
Computed tomography (CT)-guided neurolytic splanchnic nerve block (NSNB) is used to treat pain in unresectable pancreatic cancers. Whether outcomes differ according to tumor site remains uncertain.
To evaluate the efficacy and safety of CT-guided NSNB in unresectable pancreatic cancer and explore differences by tumor site.
This single-center retrospective cohort study included 22 patients who underwent initial CT-guided NSNB at the Oita Red Cross Hospital between 2007 and 2023. Clinical success comprised recorded pain relief or opioid reduction within 1 week; standardized pain scores were not routinely recorded. Technical success required bilateral retrocrural distribution. Adverse events were graded using the Common Terminology Criteria for Adverse Events (CTCAE). Proportions were reported with 95% confidence intervals (95%CIs); comparisons used Fisher’s exact and exact permutation Mann-Whitney U tests.
Technical and clinical success occurred in 17/22 (77.3%; 95%CI: 56.6%-89.9%) and 18/22 (81.8%; 95%CI: 61.5%-92.7%), respectively. The recorded duration was available for 13 clinical responders, with a median of 40 days (interquartile range: 19-144 days); four transfers and one death lacked an evaluable duration. The clinical success rates were 6/9 for head tumors and 12/13 for body/tail tumors. The available duration medians were 29.5 days and 117 days, respectively. Adverse events occurred in 6/22 (27.3%; 95%CI: 13.2%-48.2%), with no CTCAE grade ≥ 3 events.
CT-guided NSNB is associated with encouraging clinical responses at both tumor sites in this small retrospective cohort. Prospective studies should confirm these findings and clarify potential tumor-site differences.
Core Tip: This retrospective study evaluated outcomes after the initial computed tomography-guided neurolytic splanchnic nerve block in 22 patients with unresectable pancreatic cancer. Clinical success was achieved in 81.8%, with responses observed in both pancreatic head and body/tail tumors. No grade ≥ 3 adverse events were observed. These encouraging findings support further investigation of this approach for pancreatic cancer pain management. Larger prospective studies with standardized outcome assessments are needed to confirm the findings and clarify potential differences by tumor site.
- Citation: Baba H, Takaki H, Yamada Y, Nakayama T, Iwaki K, Fukuzawa K, Motomura M, Asayama Y. Computed tomography-guided splanchnic nerve neurolysis outcomes by tumor site in unresectable pancreatic cancer: A single-center retrospective cohort study. World J Radiol 2026; 18(10): 126066
- URL: https://www.wjgnet.com/1949-8470/full/v18/i10/126066.htm
- DOI: https://dx.doi.org/10.4329/wjr.126066
Pain management remains a significant challenge in patients with advanced cancer[1]. Pancreatic cancer frequently causes severe abdominal pain, impairs the quality of life, and complicates treatment[2]. Pancreatic cancer remains associated with a poor prognosis, with a 5-year relative survival rate of only 13% in the United States[3]. This highlights the importance of effective supportive and palliative care, including pain management.
The celiac plexus block (CPB) and neurolytic splanchnic nerve block (NSNB) are interventional options for refractory cancer pain. Randomized trials have evaluated neurolytic CPB and splanchnic nerve neurolysis in unresectable pancreatic cancer[4,5]. Given the differences in the anatomical targets and guidance techniques, further evaluation of computed tomography (CT)-guided NSNB may help clarify its role in pain management. Variations in treatment responses also highlight the importance of exploring factors associated with clinical outcomes.
Previous studies suggested that CPB may provide less pain relief for pancreatic body or tail cancers than for pancreatic head cancer[6]. Whether outcomes after NSNB show a similar association with tumor site remains uncertain.
Reported adverse events associated with CPB and NSNB include orthostatic hypotension, diarrhea, vascular injury, alcohol intoxication, and in rare cases, anterior spinal artery syndrome[7,8]. Fluoroscopy- and CT-guided approaches for CPB have been described[9-13]. Further reports have addressed needle-tip positioning and endoscopic ultrasound guidance[14,15]. Although reports have been made on image-guided approaches, few studies have focused on CT-guided NSNB.
Thus, this study aimed to investigate the clinical outcomes and adverse events of CT-guided NSNB for pain management in unresectable pancreatic cancer and, in an exploratory analysis, compare the outcomes according to the pancreatic tumor site.
This single-center retrospective cohort study identified 24 consecutive patients who underwent CT-guided NSNB for pancreatic cancer pain at the Oita Red Cross Hospital, Oita, Japan, between June 2007 and October 2023, using procedure records retrieved from the radiology information system. After excluding two patients treated for postoperative re
Clinical records were retrospectively reviewed by one radiologist for patient demographics, tumor site (head or body/tail), extrapancreatic nerve plexus (PL) involvement, metastatic or locally invasive disease, procedural details, clinical outcomes, efficacy duration, and adverse events. The extracted data were checked for consistency in procedure dates, outcome classifications, and recorded durations. Clinical outcomes and adverse events were verified against the clinical records, and unavailable information was recorded as missing. The baseline characteristics are summarized in Table 1. Unresectability and PL involvement were based on diagnoses documented in the clinical records without a new imaging-based reassessment. For PL involvement, PL I was defined as the nerve plexus extending from the right celiac ganglion to the posterior pancreatic head, and PL II as the nerve plexus connecting the superior mesenteric nerve plexus with the uncinate process. Involvement was recorded as PL I only, PL II only, or both, based on the clinical records.
| Characteristic | All patients (n = 22) | Head (n = 9) | Body/tail (n = 13) | Technical success | Technical failure |
| Age (years) | 60.5 (56.5-64.5) | 61 (53-63) | 60 (58-65) | 60 (58-63) | 63 (44-70) |
| Male sex | 16 (72.7) | 6 (66.7) | 10 (76.9) | 11 (64.7) | 5 (100.0) |
| PL I only | 5 (22.7) | 1 (11.1) | 4 (30.8) | 3 (17.6) | 2 (40.0) |
| PL II only | 3 (13.6) | 3 (33.3) | 0 (0.0) | 2 (11.8) | 1 (20.0) |
| Both PL I and PL II | 14 (63.6) | 5 (55.6) | 9 (69.2) | 12 (70.6) | 2 (40.0) |
| Recorded metastatic or locally invasive disease | 17 (77.3) | 7 (77.8) | 10 (76.9) | 15 (88.2) | 2 (40.0) |
| 90% alcohol mixture volume (mL) | 10.6 ± 3.5 | 9.0 ± 1.7 | 11.7 ± 4.1 | 11.5 ± 3.3 | 7.4 ± 2.5 |
All patients were assessed by the same radiologist experienced in interventional procedures, who determined the indication for NSNB individually based on pain and imaging findings. All patients had pain inadequately controlled by their existing analgesic regimens.
This study was approved by the Ethics Committee of the Oita Red Cross Hospital on April 16, 2024. The requirement for written informed consent was waived for this retrospective study.
All procedures were performed using a posterior approach, with the patient in the prone position. Among the 36 recorded needle access routes used during the 22 initial procedures, the approaches were paravertebral in 22 (61.1%; Figure 1A), transdiscal in 13 (36.1%; Figure 1B and C), and retroperitoneal in one (2.8%; Figure 1D). Following CT imaging in the prone position, the puncture route was planned, and local anesthesia was administered. A 21-gauge percutaneous transhepatic cholangiography needle was advanced into the retrocrural space under CT guidance (Figure 2A).
A small volume of 2% lidocaine and contrast agent mixture was injected to confirm its distribution. After careful monitoring for potential complications (e.g., vascular injury, pain, and dysesthesia), a 9:1 mixture of anhydrous alcohol and contrast agent (90% alcohol) was slowly injected, and CT imaging was performed to visualize its distribution. The injection was discontinued once sufficient coverage was achieved (Figure 2B). The intended procedural endpoint was sufficient distribution of the neurolytic agent within both retrocrural spaces. If unilateral injection achieved sufficient bilateral distribution, the procedure was concluded (Figure 2C).
After the procedure, patients were kept on bed rest and underwent regular blood pressure monitoring until the following morning.
For the main patient-level analysis, the following parameters were assessed using the initial procedure for each patient: (1) Technical success rate; (2) Injected drug volume (90% alcohol); (3) Adverse events; (4) Clinical success rate; and (5) Efficacy duration. The clinical success rate and efficacy duration were also compared according to tumor site as explo
Technical success was defined as the CT confirmation of sufficient distribution of the contrast-containing neurolytic agent within both retrocrural spaces, irrespective of unilateral or bilateral needle placement. Technical failure means that sufficient bilateral distribution could not be achieved because of incomplete access or inadequate spreading. Thus, procedures concluded with neurolytic agent delivery to only one retrocrural space, rather than both, were classified as technically unsuccessful, but could still achieve clinical success. Adverse events were graded using the Common Terminology Criteria for Adverse Events (CTCAE), version 5.0.
Clinical success was defined in the chart review as documented pain relief or a reduction in opioid dose within one week after treatment; standardized pain scores were not routinely recorded. Opioid reduction was assessed relative to preprocedural use with oral morphine-equivalent conversion based on the 2020 Guidelines for Pharmacotherapy of Cancer Pain[16]. Clinical records through at least postprocedure day 7 were available for all patients and were reviewed to assess clinical success within the first week. Opioid reduction included documented decreases in scheduled doses or rescue opioid use; no minimum absolute or percentage reduction was prespecified.
The recorded efficacy duration was defined as the number of days until the opioid dosage returned to the preprocedural level. The numerical duration was unavailable after four transfers and one death.
The primary outcomes were technical success and pain-related clinical outcomes (clinical success and duration of efficacy) after the initial procedure.
Secondary outcomes were adverse-event incidence and exploratory comparisons by tumor site.
The analyses included only initial procedures for each patient. Continuous variables were summarized as mean ± SD or median with interquartile range (IQR), and categorical variables as counts and percentages. Proportions were reported using Wilson’s 95% confidence intervals (95%CIs). The 95%CI for the difference in clinical success rates between tumor sites was calculated using Newcombe’s method without continuity correction. Clinical success was compared between the tumor sites using Fisher’s exact test. Efficacy duration was compared according to tumor site and technical success using two-sided exact permutation tests based on the Mann-Whitney U statistic, accounting for tied observations. Distribution-free confidence intervals (CIs) for the medians were calculated using order statistics to provide at least 95% coverage where estimable.
Primary duration analyses included only clinically successful patients with available duration data; missing durations were not imputed. A supplementary bounded analysis evaluated pain-control duration while alive among all clinical responders. The 13 recorded durations were retained, transfer times were treated as lower bounds without specified upper limits, and death at day 11 ended the period of pain control during life. Lower and upper bounds for the sample median were calculated under these assumptions (Supplementary Tables 1 and 2). All comparisons were exploratory; statistical significance was defined as a two-sided P < 0.05. Analyses were performed using Python versions 3.12.13 and 3.12.14, NumPy version 2.3.5, and SciPy version 1.17.0.
Among the 22 patients, 16 were male, and six were female; median age was 60.5 (IQR: 56.5-64.5) years. Nine patients had head tumors, and 13 had body/tail tumors. The recorded plexus involvement comprised PL I alone in five, PL II alone in three, and both in 14 patients; 17 patients had recorded metastatic or locally invasive disease (Table 1). Technical success was achieved in 17/22 (77.3%; 95%CI: 56.6%-89.9%) and clinical success in 18/22 (81.8%; 95%CI: 61.5%-92.7%). Clinical success comprised documented pain relief alone in five patients, opioid reduction alone in six, and both in seven. Efficacy duration was available for 13 clinically successful patients, with a median of 40 (IQR: 19-144; distribution-free 95%CI: 19-173; observed range: 8-243) days. Duration was unavailable for the remaining five patients because of transfer (n = 4) or death (n = 1); these patients were excluded from the duration summary (Table 2). Pain control was confirmed through days 74, 10, 84, and 14 in the four transferred patients and through death on day 11 in one patient. In the supplementary analysis of all 18 clinical responders, the median duration of pain control while alive was bounded between 36.5 days and 105 days (Supplementary Tables 1 and 2).
| Outcome | All patients (n = 22) | Head (n = 9) | Body/tail (n = 13) |
| Technical success | 17/22 (77.3); 56.6%-89.9% | 7/9 (77.8); 45.3%-93.7% | 10/13 (76.9); 49.7%-91.8% |
| Clinical success | 18/22 (81.8); 61.5%-92.7% | 6/9 (66.7); 35.4%-87.9% | 12/13 (92.3); 66.7%-98.6% |
| Any adverse event | 6/22 (27.3); 13.2%-48.2% | 0/9 (0.0); 0.0%-29.9% | 6/13 (46.2); 23.2%-70.9% |
| Grade ≥ 3 adverse events | 0/22 (0.0); 0.0%-14.9% | 0/9 (0.0); 0.0%-29.9% | 0/13 (0.0); 0.0%-22.8% |
| Evaluable duration/clinical successes | 13/18 | 6/6 | 7/12 |
| Recorded efficacy duration (days) | 40 (19-144); 19-173 | 29.5 (20.8-38.3); 18-181 | 117 (56-158.5); 8-243 |
| Duration unavailable after transfer | 4 | 0 | 4 |
| Duration unavailable after death | 1 | 0 | 1 |
Among patients with evaluable duration, the median was 105 days after technically successful procedures (n = 10; IQR: 34.8-165.8 days; distribution-free 95%CI: 19-181) and 19 days after technically unsuccessful procedures (n = 3; IQR: 13.5-22.5 days). The difference between the observed medians was 86 days (technical success minus failure), whereas the rank-based exact permutation comparison did not show statistical significance (P = 0.056; Figure 3). Three observations were insufficient for a finite distribution-free 95%CI for the technical failure median.
For the 22 procedures, the mean injected volume of the 90% alcohol mixture was 10.6 ± 3.5 (median: 10.0; IQR: 8.0-13.5) mL, corresponding to a mean pure-alcohol equivalent of 9.5 mL. The mean volume was 11.5 ± 3.3 (pure-alcohol equivalent: 10.4) mL after technically successful procedures and 7.4 ± 2.5 (pure-alcohol equivalent: 6.7) mL after technically unsuccessful procedures.
Adverse events were recorded after 6/22 initial procedures (27.3%; 95%CI: 13.2%-48.2%): Grade 2 hypotension in three patients, diarrhea in two (one grade 1 and one grade 2), and grade 1 alcohol intoxication in one. No grade ≥ 3 events were observed (0/22; Wilson 95%CI: 0%-14.9%).
Clinical success occurred in 6/9 patients (66.7%) with head tumors and in 12/13 patients (92.3%) with body/tail tumors (Fisher’s exact test, P = 0.264). The difference in clinical success rates was -25.6 percentage points (head minus body/tail; 95%CI: -57.5 to 7.7). Duration was available for all six clinically successful head tumor patients, but only seven of the 12 clinically successful body/tail patients; all four transfers and the single death occurred in the body/tail group. Median durations were 29.5 (IQR: 20.8-38.3; distribution-free 95%CI: 18-181) days and 117 (IQR: 56.0-158.5; distribution-free 95%CI: 8-243) days, respectively (exact permutation P = 0.387; Table 2 and Figure 4). The observed median difference was -87.5 days (head minus body/tail).
This retrospective observational study evaluated the outcomes after the initial CT-guided NSNB procedure in 22 patients with unresectable pancreatic cancer. Technical success was achieved in 77.3% and clinical success in 81.8%. The median efficacy duration among the 13 clinically successful patients was 40 days, and the mean injected volume of the 90% alcohol mixture was 10.6 mL. Adverse events occurred after 27.3% of the initial procedures, and no grade ≥ 3 events were observed. Clinical responses were recorded in both pancreatic head and body/tail tumors, although the exploratory comparison was inconclusive regarding the differences between tumor sites.
The technical success rate in this study was 77.3%. The five unsuccessful initial procedures were attributed to failure to avoid the nerve root (n = 2) or difficulty accessing the retrocrural space because of anatomical limitations (n = 3). Previous studies have described CT-guided NSNB for upper abdominal cancer pain[17,18]. Our findings similarly illustrate its clinical application, while highlighting the difficulty in achieving bilateral retrocrural distribution in some patients. Clinical success was recorded in 81.8% of the patients. Yanaizumi et al[7] reported a clinical success rate of 74.8% after fluoroscopy-guided NSNB, although they required at least a 50% reduction in the numerical rating scale score without opioid escalation within 14 days. Differences in patient populations, assessment timing, and outcome definitions limit a direct comparison with our chart-based composite endpoint.
The median efficacy duration was 40 days among the 13 clinically successful patients with available duration data. The duration was numerically longer after technically successful initial procedures than after unsuccessful initial procedures (105 days vs 19 days; exact permutation, P = 0.056). This exploratory pattern warrants further investigation of the association between bilateral retrocrural distribution and treatment durability. Long-term NSNB studies assessed pain scores and opioid consumption over several months[19], whereas our study used the recorded time until the opioid doses returned to baseline, providing a complementary perspective on treatment durability.
Adverse events occurred after 27.3% of the initial procedures and included hypotension, diarrhea, and alcohol intoxication. No grade ≥ 3 adverse events were observed according to CTCAE version 5.0 in this small cohort. Alcohol intoxication occurred in one patient (4.5%), compared with 13.6% (14/103) in the fluoroscopy-guided NSNB series reported by Yanaizumi et al[7]. Among technically successful initial procedures, the mean pure-alcohol-equivalent volume was 10.4 (median: 9.9) mL, lower than the volumes reported by Fujita[17] (28 mL) and Dong et al[5] (12-18 mL). CT provides cross-sectional visualization of retrocrural anatomy and injectate distribution, whereas fluoroscopy shows needle position and contrast spread on projection images[7,17]. This cross-sectional information may help guide the injection endpoint and tailor the injection volume to individual patients. However, injection volume was not protocolized and depended on anatomy, access, and the observed distribution of the injectate. Differences in patient selection, techniques, and adverse event ascertainment also limit comparisons across studies. These observations are hypothesis-generating and may inform prospective dose-finding studies; larger studies are needed to determine the optimal alcohol volume and assess whether CT guidance affects adverse-event risk.
The clinical success rates for pancreatic head and body/tail tumors were 66.7% and 92.3%, respectively (P = 0.264). The median efficacy durations were 29.5 days and 117 days, respectively (exact permutation, P = 0.387). These results document the clinical responses at both tumor sites. However, the small sample size limited the precision of the comparison, and clinically important differences between tumor sites cannot be excluded. In addition, all five clinically successful patients with unavailable duration data had body/tail tumors. Thus, the absence of statistical significance cannot establish equivalent efficacy or independence of the tumor site. In contrast, Rykowski and Hilgier[6] reported lower CPB success rates for body and tail tumors than for head tumors (28.6% vs 91.7%). Differences in treatment target, case mix, and assessment methods limit direct comparisons; however, their findings provide a rationale for further investigation of tumor location and plexus involvement.
The clinical responses observed in patients with body/tail tumors may also be considered in the context of the anatomical distinctions between CPB and NSNB. Both procedures interrupt the neural pathways that transmit upper abdominal visceral pain; however, they target different structures. The celiac plexus forms a relatively diffuse network, whereas the splanchnic nerves lie within a semi-enclosed retrocrural space (Figure 5). When tumor involvement distorts the celiac plexus, targeting the preserved retrocrural space may facilitate neurolytic distribution. This anatomical rationale supports further studies of NSNB in patients with advanced plexus involvement.
However, direct comparative evidence requires careful interpretation. Shwita et al[20] randomized 79 patients with upper gastrointestinal malignancies to the celiac plexus or splanchnic nerve neurolysis groups, with 60 patients included in the analysis. The pain scores were comparable from 1 week onward, while some subsequent analgesic use and quality-of-life measures favored splanchnic nerve neurolysis. A recent systematic review also supports neurolytic interventions for pancreatic cancer pain but highlights heterogeneity in approaches and imaging guidance[21]. Given this heterogeneity and the inclusion of several cancer types in the comparative trial, further studies focusing on pancreatic cancer are needed to determine whether differences in neurolytic approaches and imaging guidance affect pain relief, treatment durability, or adverse events.
This study had several limitations. First, this small, uncontrolled, single-center, retrospective cohort was susceptible to selection and documentation biases. The sample comprised available eligible cases without a formal sample size calculation, and the exploratory tumor-site comparison was not powered to establish equivalence. Second, standardized numerical pain scores were not routinely recorded. Clinical success was based on retrospective documentation of pain relief or opioid dose reduction within one week, without a prespecified minimum opioid reduction threshold. Therefore, subjective assessment and analgesic changes unrelated to NSNB may affect the outcome classification. Third, the duration was summarized only for clinically successful patients with available data, excluding non-responders and five patients with unavailable durations. Death and transfer may be related to the prognosis or care needs, making these omissions potentially informative. Long-term follow-up was not standardized, and its duration could not be consistently determined from the clinical records. The observed median was conditional on clinical success and available duration data. The supplementary bounds illustrate uncertainty from incomplete follow-up and do not establish comparative superiority. Given the small number of evaluable responders, particularly in the technical failure group (n = 3), the duration comparisons were descriptive and exploratory, and the CIs for between-group differences in medians were not reported. Fourth, the indications and injection endpoints were individualized. Baseline pain intensity, oral morphine-equivalent doses, analgesic co-medications, performance status, formal disease stage, and concurrent oncologic treatment were not consistently available, limiting assessment of potential confounding. Fifth, the long study period may have included changes in CT technology, operator experience, patient selection, and procedural and supportive care. Finally, the absence of a control group limited our conclusions regarding the comparative efficacy. Larger prospective studies with standardized pain and opioid assessments and complete follow-ups are required to validate these findings.
CT-guided NSNB showed encouraging clinical outcomes for pain management in 22 patients with unresectable pancreatic cancer, with clinical success achieved in 81.8% (95%CI: 61.5%-92.7%) after the initial procedure. Adverse events occurred in 27.3% (95%CI: 13.2%-48.2%), with no CTCAE grade ≥ 3 events observed in this small cohort. The median efficacy duration was 40 days among the 13 clinically successful patients with available duration data. Clinical responses were observed in both pancreatic head and body/tail tumors, supporting further investigation of NSNB at both tumor sites. However, the small sample size precludes firm conclusions regarding differences between sites. Larger prospective studies with standardized pain and opioid assessments and complete follow-ups are warranted to confirm these findings.
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