Computed Tomography-Guided Versus Fluoroscopy-Guided Celiac Plexus Neurolysis for Pancreatic Cancer Pain: A Novel Comparative Study Integrating Pain Phenotyping and Functional Outcomes

INTRODUCTION

Pancreatic cancer remains one of the most lethal malignancies worldwide, often diagnosed at an advanced stage and associated with a dismal 5-year survival rate of <10%.^[1] Among its many clinical manifestations, abdominal pain stands out as one of the most distressing symptoms, affecting up to 80% of patients with unresectable disease.^[2] This pain is typically complex and multifactorial, resulting from tumour infiltration of the celiac plexus, splanchnic nerves and surrounding visceral and somatic structures, rendering it refractory to conventional pharmacological treatments.^[3]

While the World Health Organisation (WHO) analgesic ladder remains the cornerstone of cancer pain management, it often proves inadequate in the context of pancreatic cancer, especially in advanced stages.^[4] Moreover, high-dose opioid therapy – frequently required in these patients – is associated with adverse effects such as sedation, constipation, tolerance and dependency, all of which significantly impair quality of life in palliative care settings.^[5] As a result, celiac plexus neurolysis (CPN) has emerged as a valuable minimally invasive intervention that interrupts afferent nociceptive transmission by chemically ablating the celiac plexus using neurolytic agents such as absolute alcohol or phenol.^[6]

Over the past two decades, advancements in image-guided interventions have enhanced the precision and safety of CPN. Fluoroscopy-guided CPN, though traditionally employed, offers limited soft-tissue resolution and is highly operator-dependent. In contrast, CT-guided CPN provides superior anatomical visualisation, particularly in cases with distorted retroperitoneal anatomy due to tumour burden, lymphadenopathy or prior surgical interventions.^[7,8] This improved visualisation facilitates optimal needle placement, minimises inadvertent injury to adjacent vascular and neural structures and promotes symmetric spread of the neurolytic agent.^[9]

Despite widespread clinical adoption of both imaging modalities, direct comparative data on their efficacy – particularly regarding pain phenotype, functional improvement and complication profiles – remain scarce, especially in the Indian population. Notably, pancreatic cancer pain often includes a neuropathic component, which can influence the therapeutic response to neurolysis. Assessment tools such as the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) enable identification of neuropathic pain components, thus supporting more personalised pain management strategies.^[10]

While previous studies, including randomised controlled trials and observational cohorts, have demonstrated the analgesic efficacy of CPN in pancreatic cancer^[11,12] few have concurrently compared fluoroscopy and CT-guided techniques while integrating pain phenotyping and functional outcomes. To address this gap, the present study was designed as an ambispective comparative analysis to evaluate and contrast the efficacy, safety and functional impact of CT-guided versus fluoroscopy-guided CPN in pancreatic cancer patients, with a specific focus on neuropathic pain features and patient-centric outcomes.

MATERIALS AND METHODS

RESULTS

A total of 60 patients were enrolled in the study and divided equally into two groups: CT-guided CPN (n = 30) and fluoroscopy-guided CPN (n = 30). Both groups were comparable in terms of age, sex, baseline pain scores and disease staging, ensuring a balanced cohort for comparative analysis [Table 1].

Pain relief (VAS scores)

Pain intensity was measured using the VAS at 5 time points: Baseline, immediate post-procedure, 1 week, 1 month and 3 months.

At baseline, mean VAS scores were similar across the groups (CT: 8.91 ± 1.12 vs. Fluoroscopy: 8.88 ± 1.10; P = 0.86). Pain reduction was evident in both groups over time. However, the CT group consistently demonstrated lower mean VAS scores at each follow-up, with statistically significant differences noted at 1 month (P = 0.045) and 3 months (P = 0.038), favouring CT-guided intervention. This suggests more sustained pain control with CT guidance [Figure 1].

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Figure 1:

Trend of pain intensity over time as measured by visual analogue scale (VAS). CT: Computed tomography

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Neuropathic pain (LANSS scores)

Neuropathic pain was assessed using the LANSS scale. Both groups had comparable baseline LANSS scores (CT: 13.87 ± 1.31 vs. Fluoro: 13.81 ± 1.35; P = 0.84).

At 3 months, the CT group showed a more substantial reduction in LANSS scores (mean 8.27 ± 2.12) compared to the fluoroscopy group (9.65 ± 2.41), with the difference reaching statistical significance (P = 0.011). This finding underscores the enhanced efficacy of CT-guided CPN in alleviating neuropathic components of pancreatic cancer pain [Figure 2].

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Figure 2:

Changes in neuropathic pain scores over time using Leeds Assessment of Neuropathic Symptoms and Signs Scale (LANSS). CT: Computed tomography

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DISCUSSION

This study evaluated and compared the efficacy, functional outcomes and safety of CT-guided versus fluoroscopy-guided CPN in patients with pancreatic cancer. Our findings demonstrated significant pain relief in both groups, with CT-guided procedures showing superior results in terms of neuropathic pain reduction, lower complication rates and improved functional outcomes.

Pancreatic cancer is notoriously associated with severe abdominal pain due to the infiltration of the celiac and splanchnic plexuses.^[1] Despite advancements in multimodal analgesia, pain control remains suboptimal in a substantial proportion of patients.^[2,3] The WHO analgesic ladder, while foundational in cancer pain management, is often inadequate in advanced pancreatic malignancies.^[4,5]

CPN has emerged as an effective intervention for managing pain refractory to pharmacological regimens.^[6,7] CT-guided CPN allows for precise needle placement and real-time visualisation of neurolytic spread, thereby enhancing both efficacy and safety.^[8] In our study, patients undergoing CT-guided CPN demonstrated significantly greater reductions in LANSS scores and a lower rate of complications compared to those treated with fluoroscopy guidance. These findings are consistent with the retrospective analysis by Bogdanovic et al., which similarly showed improved pain outcomes with CT-guided approaches.^[9] The LANSS scale was employed to phenotype pain and identify neuropathic components. Its use allowed us to stratify patients more likely to benefit from targeted neurolytic intervention.^[10] Arcidiacono et al. also reported significant reductions in pain and opioid consumption following CPN, which corroborates our observations.^[11]

While our study did not evaluate ultrasound-guided techniques, prior work by Amr and Makharita has shown that such approaches can also provide effective analgesia in upper abdominal malignancy.^[12] Anatomical strategies, such as bilateral versus unilateral injections, have been explored by Sahai et al., who concluded that bilateral approaches offer superior coverage and pain relief.^[13]

The improvement in functional outcomes, as reflected by higher Karnofsky Performance Scores and SF-36 scores in the CT-guided group, highlights the clinical relevance of more accurate imaging techniques. These findings are supported by Jain et al. and Wong et al., who emphasised the link between technical precision and quality-of-life outcomes in palliative care.^[14,15]

An important consideration in interpreting the duration and consistency of pain relief in CPN is the neurolytic technique itself. Adequate spread of alcohol and accurate bilateral retrocrural needle placement are key contributors to long-term analgesia. While CT guidance offers superior anatomical detail and safety, it may be associated with increased procedural cost and radiation exposure. As reported by Lazarus et al., CT guidance carries approximately 0.9 higher relative value units than fluoroscopic guidance (3.32 vs. 2.41), reflecting increased resource use and time.^[16] Nevertheless, in our government tertiary care setting, both imaging modalities were economically viable and available without additional burden to patients.

Beyond procedural technique, the knowledge and attitudes of healthcare providers significantly influence pain management outcomes. Lebovits et al. stressed that inadequate provider training and opioid-related misconceptions can compromise palliative care delivery.^[17] Our findings indirectly affirm this: Better opioid tapering and functional recovery in the CT group may reflect higher procedural confidence and institutional prioritisation of pain control.

CT imaging has also been increasingly used to assess the extent of neurolytic spread post-procedure, offering valuable feedback for quality assurance.^[18] Seminal contributions by Kastler et al. and Gangi et al. established the utility of CT-guided interventional pain procedures, particularly in abdominal malignancies.^[19,20]

In summary, our findings suggest that CT-guided CPN results in superior pain phenotyping, greater neuropathic pain relief, improved functional outcomes and a more favourable safety profile compared to fluoroscopy-guided techniques. These advantages advocate for the broader adoption of CT-guided CPN as a component of personalised palliative care strategies in pancreatic cancer.

CONCLUSION

CT-guided CPN demonstrates a superior clinical profile compared to fluoroscopy-guided techniques in the management of pancreatic cancer pain. Patients undergoing CT-guided CPN experienced better pain relief, particularly in neuropathic phenotypes, greater functional improvement and significantly fewer complications. While both modalities offer meaningful palliative benefits, the precision and safety associated with CT-guidance support its preferential use, especially in anatomically complex or high-risk cases. Our study underscores the value of integrating pain phenotyping (LANSS) into procedural selection and highlights the importance of functional and opioid-related outcomes in evaluating pain interventions. Further prospective multicentric studies with longer follow-up are warranted to validate these findings and guide standardised pain care pathways in oncology.