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Celiac plexus

The celiac plexus, also known as the solar plexus, is the largest major autonomic nerve plexus in the human body, consisting of a complex network of sympathetic and parasympathetic nerve fibers and ganglia located in the upper retroperitoneum of the abdomen, surrounding the celiac trunk, superior mesenteric artery, and the origins of the renal arteries from the abdominal aorta at approximately the level of the L1 vertebra.^[1]^[2] It functions primarily as a relay station for visceral afferent signals, transmitting pain, reflex, and sensory impulses from foregut and midgut organs—including the stomach, duodenum, liver, pancreas, spleen, and adrenal glands—to the central nervous system, while also modulating autonomic control over glandular secretion, smooth muscle activity, and vasomotor functions in these structures.^[3]^[4]^[5] Composed of paired celiac ganglia connected by nerve fibers from the greater, lesser, and least splanchnic nerves (sympathetic) and the vagus nerves (parasympathetic), the plexus extends secondary plexuses such as the phrenic, renal, and superior mesenteric plexuses to innervate a broad array of abdominal viscera.^[2] Its embryological origins trace to the fusion of neural crest-derived sympathetic chain ganglia and parasympathetic fibers during foregut development, highlighting its role in coordinating digestive motility, secretion, and absorption.^[2] Clinically, the celiac plexus is significant for interventions like neurolytic blocks, which target it to alleviate intractable visceral pain from conditions such as pancreatic cancer, by injecting anesthetics or neurolytic agents (e.g., alcohol) near the ganglia under imaging guidance, though procedures carry risks including hypotension, diarrhea, and organ perforation.^[4]^[6] This structure's central position and extensive connectivity underscore its importance in abdominal neuroanatomy, influencing both physiological homeostasis and therapeutic strategies for upper gastrointestinal disorders.^[1]

Overview

Definition

The celiac plexus, also known as the solar plexus, is the largest visceral plexus within the autonomic nervous system, comprising a complex network of nerve fibers and ganglia situated in the upper abdomen at the level of the L1 vertebra.^[7]^[3] It serves as a central hub for autonomic innervation to foregut and midgut derivatives, facilitating the integration of sympathetic and parasympathetic inputs to regulate visceral functions.^[4] This plexus consists primarily of the paired celiac ganglia, interconnected with adjacent paraaortic structures including the superior mesenteric and renal plexuses, through which sympathetic fibers from the greater and lesser splanchnic nerves and parasympathetic fibers from the vagus nerve (cranial nerve X) converge and distribute.^[3] The resulting network surrounds the origins of key abdominal arteries, such as the celiac trunk, enabling targeted efferent and afferent signaling to abdominal organs.^[5] Unlike the superior mesenteric plexus, which primarily innervates midgut derivatives like the distal duodenum and jejunum, or the renal plexus, which focuses on the kidneys and adrenals, the celiac plexus provides broader coverage encompassing the stomach, liver, pancreas, spleen, and proximal small intestine.^[3]

Terminology

The celiac plexus is the primary term used in contemporary anatomical nomenclature to denote the complex autonomic nerve network in the upper abdomen. The term "celiac" derives from the Greek word koilia, meaning "abdomen" or "belly," reflecting its position within the abdominal cavity.^[8] Modern anatomy textbooks, such as those referenced in standard medical resources, consistently adopt "celiac plexus" for precision in describing its role as a visceral nerve hub.^[4] Common synonyms include "solar plexus," a colloquial name arising from the radiating pattern of its nerve fibers, which resemble the sun's rays emanating from a central point. This term first appeared in English anatomical literature around 1765–1775, emphasizing the plexus's star-like arborization.^[9] The Latin equivalent, "plexus coeliacus," is also employed in scientific contexts to align with classical terminology traditions.^[3] Historically, the structure was referred to as the "epigastric plexus" in earlier anatomical descriptions, particularly in 18th- and 19th-century texts, where it was synonymous with the celiac plexus and highlighted its position in the epigastric region. Anatomist Jacob B. Winslow contributed to its early characterization in 1733, integrating it into broader discussions of abdominal innervation, while later figures like Jules Cloquet in 1816 equated it explicitly with the "solar plexus." In medical literature, "solar plexus" is often avoided in favor of "celiac plexus" to prevent ambiguity with non-anatomical usages, such as the vulnerable abdominal target in martial arts.

Anatomy

Location and Relations

The celiac plexus is a retroperitoneal autonomic nerve network situated at the level of the first lumbar vertebra (L1), where it surrounds the origin of the celiac trunk from the abdominal aorta.^[4] This positioning places it in the upper abdomen, spanning approximately from the T12 to L1 vertebral levels and extending laterally around the origins of the superior mesenteric and renal arteries.^[2] In terms of its anatomical relations, the celiac plexus lies anterior to the abdominal aorta and the crura of the diaphragm, while anteriorly it is in close proximity to the lesser sac, stomach, and pancreas.^[10] Laterally, the paired celiac ganglia are positioned medial to the adrenal glands, and superiorly the plexus is related to the renal arteries, which originate slightly inferior to the celiac trunk at the L1-L2 interspace.^[2] The celiac plexus overlies the celiac artery and lies in proximity to the superior mesenteric artery origin.^[4] On imaging, it appears as a delicate network of nerve fibers encircling the celiac axis, best visualized on contrast-enhanced CT or MRI scans, where it manifests as soft-tissue attenuation structures anterior to the aorta.^[11]

Components and Branches

The celiac plexus is primarily composed of paired celiac ganglia, which are the main neural hubs within this autonomic network, interconnected by a dense web of nerve fibers. These ganglia are typically two in number—a right and a left—each measuring approximately 1-2 cm in average diameter, though sizes can range from 0.5 to 4.5 cm.^[2] ^[12] The ganglia receive preganglionic sympathetic fibers primarily from the greater and lesser splanchnic nerves, originating from the thoracic sympathetic chain at levels T5-T12, which synapse within the ganglia before postganglionic fibers distribute to abdominal viscera.^[3] ^[13] Parasympathetic contributions to the plexus arise from the anterior and posterior vagal trunks, providing preganglionic fibers that pass through without synapsing in the celiac ganglia and continue to target organs via the postganglionic sympathetic pathways.^[3] From the celiac ganglia and surrounding plexus, several key branches emerge, forming secondary plexuses that accompany major arterial distributions. These include the superior and inferior celiac branches, which distribute fibers along the celiac trunk and its initial divisions.^[3] Contributions from the phrenic plexus integrate diaphragmatic innervation elements into the celiac network.^[3] Extensions of the plexus give rise to the hepatic plexus, which follows the hepatic artery to innervate the liver and gallbladder; the splenic plexus, accompanying the splenic artery to the spleen; the gastric plexuses (superior and inferior), supplying the stomach along the gastric arteries; and the pancreatic plexus, targeting the pancreas via branches near the common hepatic and splenic arteries.^[5] ^[3] Anatomical variations in the celiac plexus are common, affecting both the number and configuration of the ganglia. While the typical bilateral arrangement predominates, a single fused ganglion occurs in some individuals, and the total number of ganglia can range from one to five.^[2] ^[12] Absent ganglia are rare but reported in certain cases, potentially influencing the plexus's overall interconnectivity.^[2] These variations highlight the need for individualized consideration in anatomical studies, as they arise from developmental differences in neural crest migration and sympathetic chain formation.^[2]

Physiology

Innervation Patterns

The celiac plexus primarily receives sympathetic innervation through preganglionic fibers originating from the intermediolateral cell column of the spinal cord segments T5 to T12. These fibers exit the spinal cord via the ventral roots, pass through the white rami communicantes to enter the sympathetic chain, and then travel as preganglionic axons without synapsing in the paravertebral ganglia.^[13] They form the greater splanchnic nerves (from T5-T9), lesser splanchnic nerves (from T10-T11), and least splanchnic nerves (from T12), which pierce the diaphragm to reach the celiac ganglia within the plexus.^[14] The greater splanchnic nerves primarily synapse in the celiac ganglia—typically two in number, located anterolateral to the aorta—while the lesser and least splanchnic nerves may synapse there or pass to nearby ganglia such as the aorticorenal or superior mesenteric ganglia. Synaptic transmission releases postganglionic sympathetic fibers that distribute to the upper abdominal viscera, including the stomach, liver, pancreas, spleen, and proximal intestines, to modulate vasomotor tone, glandular secretion, and smooth muscle activity.^[2]^[4] Parasympathetic innervation of the celiac plexus arises from preganglionic fibers of the vagus nerve (cranial nerve X), specifically from the anterior and posterior vagal trunks that descend through the esophageal hiatus. These fibers traverse the celiac plexus and its ganglia without synapsing, as the primary parasympathetic synapses occur in intramural or terminal ganglia located near or within the target organs.^[15]^[16] This passage allows vagal efferents to provide excitatory cholinergic input to abdominal viscera, promoting functions such as increased gastrointestinal motility and secretion, in contrast to the inhibitory effects of sympathetic postganglionics.^[12] The integration of these non-synapsing parasympathetic fibers with the synaptic sympathetic components within the plexus facilitates a balanced autonomic regulation.^[17] Afferent fibers within the celiac plexus convey sensory information from the abdominal viscera, including visceral pain, distension, and reflex signals, forming a critical component of the sensory limb of the autonomic nervous system. These unmyelinated or lightly myelinated fibers primarily travel centripetally via the same splanchnic nerves and sympathetic chains as the efferent sympathetics, originating from nociceptors and mechanoreceptors in the gut wall and associated organs.^[13]^[18] Upon reaching the spinal cord, they synapse in the dorsal horn (for pain) or via vagal pathways to the nucleus tractus solitarius (for reflexes), contributing to both somatic awareness of deep abdominal discomfort and autonomic reflex arcs.^[19] Some vagal afferents also pass through the plexus to provide low-threshold sensory feedback, though the majority of pain-transmitting afferents follow sympathetic routes.^[12] As a central autonomic hub, the celiac plexus functions as a relay and integration station, blending preganglionic sympathetic inputs with traversing parasympathetic and afferent fibers to orchestrate coordinated neural control over upper abdominal physiology. This convergence enables dynamic adjustments in organ responses to physiological demands, such as digestion or stress, by allowing crosstalk between excitatory parasympathetic and modulatory sympathetic signals at the level of postganglionic distribution.^[20] The plexiform arrangement around the celiac trunk further supports this integrative role, distributing mixed fiber bundles along arterial pathways to ensure efficient innervation of foregut derivatives.^[2]

Physiological Roles

The celiac plexus serves as a critical hub for autonomic regulation of upper abdominal viscera, integrating sympathetic inputs from greater, lesser, and least splanchnic nerves with parasympathetic fibers primarily from the vagus nerve to modulate organ function.^[3] These neural pathways enable coordinated responses to maintain homeostasis in the gastrointestinal tract, liver, spleen, and pancreas.^[2] Sympathetic fibers within the celiac plexus provide vasomotor control through vasoconstriction of blood vessels supplying the gastrointestinal tract, liver, spleen, and pancreas, thereby adjusting regional blood flow in response to physiological stressors such as exercise or hemorrhage. This vasoconstrictive effect helps redirect blood to prioritize essential functions, reducing perfusion to splanchnic organs when systemic demands increase.^[3]^[21] Parasympathetic influences via the celiac plexus enhance visceral motility by stimulating peristalsis and glandular secretion in the foregut and midgut, facilitating efficient propulsion of contents through the stomach and small intestine while promoting digestive enzyme release.^[3] In contrast, sympathetic activation inhibits these processes to conserve energy during non-feeding states.^[3] The celiac plexus plays a pivotal role in pain transmission by conveying visceral afferent signals from abdominal organs to the central nervous system, often resulting in referred pain patterns, such as mid-abdominal discomfort originating from pancreatic inflammation or gastric distension.^[4] Additionally, it contributes to reflex integration in autonomic pathways, including the gastroileal reflex that coordinates ileal motility with gastric filling and vasovagal responses triggered by visceral stimuli, which can elicit bradycardia and hypotension.^[22]

Clinical Significance

Therapeutic Interventions

The celiac plexus block (CPB) is an interventional procedure involving the injection of local anesthetics, often combined with neurolytic agents like alcohol, to interrupt pain transmission through the celiac plexus nerves. It serves both diagnostic and therapeutic purposes, primarily targeting chronic abdominal pain refractory to conservative management, with neurolytic variants providing longer-lasting relief by destroying nerve fibers. This technique is most commonly applied in patients with advanced pancreatic cancer, where visceral pain arises from tumor invasion of the retroperitoneal structures innervated by the plexus.^[4] Several approaches exist for performing CPB, each tailored to patient anatomy and clinical context. The percutaneous posterior approach, typically conducted under fluoroscopic or CT guidance, involves placing the patient prone and advancing needles bilaterally through the posterior paravertebral space at the T12-L1 level to target the retrocrural space of the plexus. The endoscopic ultrasound-guided (EUS-CPB) method, which became a standard technique in the early 2000s, uses real-time endosonographic imaging via a gastrointestinal endoscope to inject agents directly into or around the celiac ganglia, offering precise visualization and reduced risk to adjacent structures. The anterior transaortic approach, performed in the supine position, directs a needle anteriorly through the aorta to reach the plexus, though it is less favored due to potential vascular trauma.^[4]^[23]^[24] Indications for CPB center on intractable visceral pain from upper gastrointestinal malignancies, particularly unresectable pancreatic adenocarcinoma, where it serves as an adjunct to opioid therapy to minimize narcotic side effects and improve quality of life. It is also considered for other upper abdominal cancers involving the stomach, liver, or duodenum when pain is mediated by celiac innervation. Efficacy studies, including meta-analyses up to 2025, report pain reduction in 60-80% of patients, with significant decreases in opioid requirements and enhanced patient satisfaction observed for 4-12 weeks post-procedure, though long-term benefits vary by tumor stage and technique.^[25]^[26]^[27] Common complications of CPB include transient diarrhea due to unopposed parasympathetic activity and orthostatic hypotension from sympathetic blockade, affecting up to 40% of patients but typically resolving within days. Rare but serious risks encompass vascular injury, such as aortic puncture or ischemia, and neurological deficits like lower extremity weakness, with an overall major complication rate below 1%. Post-2020 advancements, including hybrid ultrasound-fluoroscopy guidance for percutaneous routes and refined EUS techniques with color Doppler, have enhanced procedural precision and lowered these risks by improving needle trajectory accuracy and real-time monitoring of vascular structures.^[4]^[28]^[29]

Pathological and Surgical Considerations

The celiac plexus is frequently involved in the visceral pain associated with pancreatic cancer due to tumor invasion and compression of the neural structures surrounding the celiac trunk, leading to severe upper abdominal and back pain that is often refractory to opioids.^[30] This pain arises from nociceptive fibers within the plexus transmitting signals from the inflamed or infiltrated pancreas.^[31] Rare pathologies include schwannomas originating from the peripancreatic nerve plexus, which can mimic pancreatic masses and cause abdominal discomfort or obstructive symptoms, comprising less than 1% of all schwannomas.^[32] Additionally, the celiac plexus contributes to autonomic dysreflexia episodes in patients with spinal cord injuries above T6, where visceral stimuli trigger exaggerated sympathetic responses via mesenteric projecting neurons, exacerbating hemodynamic instability.^[33] Anatomical variations in the celiac plexus occur in a significant proportion of cases based on cadaveric dissections. These variations, including unilateral or bilateral configurations of the ganglia, can lead to incomplete analgesia if standard bilateral approaches are used without preoperative imaging confirmation.^[34] During pancreaticoduodenectomy (Whipple procedure), the celiac plexus is mobilized through careful dissection of the retroperitoneal tissues around the celiac trunk and superior mesenteric artery to access the pancreatic head while minimizing autonomic disruption.^[35] Intraoperative identification relies on the celiac trunk as a primary landmark, with the plexus located anterior to the aorta at the T12-L1 level, allowing surgeons to palpate and visualize neural fibers for preservation or resection as needed.^[4] Nerve damage during these procedures carries risks of postoperative diarrhea due to sympathetic denervation, affecting gastrointestinal motility and occurring in approximately 40% of cases, though typically transient.^[36] Post-2020 advancements include the use of robotic-assisted surgery for enhanced precision in celiac plexus preservation during pancreatic resections, enabling magnified visualization and reduced trauma to autonomic structures compared to open approaches.^[37] Emerging research also links celiac plexus dysfunction to chronic abdominal discomfort syndrome, where neurolytic interventions provide sustained pain relief in non-malignant cases like chronic pancreatitis.^[38]

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