Paraplegia after celiac plexus neurolysis in a patient with pancreatic cancer - A case report and literature review -

Possible Transient Anterior Spinal Artery Syndrome After a Celiac Plexus Neurolytic Block

Celiac plexus blocks have been utilized to treat chronic abdominal pain of various etiologies that are refractory to medication management. This procedure is considered relatively safe; however, one rare complication is anterior spinal artery syndrome, which can result in temporary or permanent paralysis of the lower extremities. A 67-year-old male with a history of metastatic esophageal adenocarcinoma and chronic pain refractory to high doses of opioids presented for a celiac plexus neurolytic block. The block was performed successfully with a test block containing 2% lidocaine and 0.5% bupivacaine, after which neurolysis with alcohol was completed. The patient had a syncopal episode in the post-anesthesia care unit (PACU), which resolved with fluid resuscitation without requiring advanced cardiovascular life support (ACLS). He was then discharged. On the evening of discharge, the patient had progressive lower extremity weakness to the point where he was unable to walk even with significant assistance from a family member. He went to the emergency department where a complete spine MRI was done which did not show any spinal cord defect. His physical exam showed preserved proprioception and vibration sensation with upper motor neuron exam signs. The remainder of his sensory exam was inconsistent with both reported intact sensation to pinprick and temperature with intermittently reported hyperalgesia in his lower extremities. Over the next day of admission, his weakness slowly improved. Unfortunately, the patient developed a bowel perforation during hospitalization that was non-operable, and he passed away on hospital day five. This patient likely had anterior spinal artery vasospasm causing temporary lower extremity weakness. Given his overall debility, his physical exam was difficult, although he had intact proprioception and vibration sensation with upper motor neuron exam findings suggestive of an anterior cord process. Vasospasm could be secondary to needle placement near the artery of Adamkiewicz, alcohol, or epinephrine. This case emphasizes the importance of recognizing anterior spinal artery syndrome despite its rarity in patients undergoing celiac plexus neurolysis. Regardless of the rarity of various complications, it is imperative that physicians discuss potential devastating complications of procedures with patients to allow for individualized decision-making. Additionally, there should be a low threshold for overnight admission after celiac plexus neurolytic blocks in patients with severe underlying systemic disease processes.