Paraplegia After Intraoperative Celiac Plexus Block (1997)

Celiac plexus block during laparotomy (intraoperative celiac plexus block), as well as that by the posterior approach, are widely used techniques for the management of upper abdominal cancer pain in Japan, and are considered to be simple and safe methods [1-3]. While paraplegia after the posterior approach to celiac plexus block has rarely been reported [4-7], there have been no reports of its association with intraoperative celiac plexus block. We describe a case of paraplegia that occurred after intraoperative celiac plexus block with alcohol. Case Report A 72-yr-old man with the clinical diagnosis of advanced gastric cancer and left iliac bone metastasis complained of moderate upper abdominal and left lumbar pain. He had been treated for hypertension for 10 yr. Direct invasion of the celiac plexus by the carcinoma was considered a possible cause of the abdominal pain. The patient was scheduled for total gastrectomy, partial resection of left iliac bone, and intraoperative celiac plexus block. Anesthesia was induced intravenously with 100 micro g of fentanyl, 250 mg of thiopental, and 16 mg of vecuronium and maintained with isoflurane and nitrous oxide in oxygen. After resection of the stomach, celiac plexus block was performed by the anesthesiologist. A 22-gauge needle was inserted under direct vision between the abdominal aorta and the inferior vena cava and advanced until its tip was anterior to the body of the first lumbar vertebra. A test dose of 15 mL of 2% mepivacaine was injected. A 10% decrease in arterial blood pressure was confirmed after 5 min. Ten min after mepivacaine injection, 20 mL of 99.5% alcohol was injected slowly. During the procedure, multiple aspirations were negative for blood or cerebrospinal fluid. Fifteen min after the alcohol injection, intravenous dopamine (3-5 micro g [center dot] kg-1 [center dot] min-1) was initiated to maintain systolic blood pressure more than 100 mm Hg until the end of the operation. On arrival in the recovery ward, the patient was pain free, and his cardiovascular and respiratory condition was stable. However, he noticed weakness in his lower extremities and complained of numbness of the legs and abdominal wall just below the umbilicus. Neurological examination disclosed bilateral total loss of hip, knee, and foot flexion and extension. Although pain, vibration, and temperature sensation below the level of T-11 were lost, sensation to light touch was partially preserved. Bladder and anal sphincter control were absent. The findings on magnetic resonance (MR) imaging performed the next day were normal. Three days after the paralytic episode, light touch was absent, resulting in total sensory and motor loss. After 3 wk, spinal cord infarction below the T-11 level was demonstrated on MR imaging. There was no improvement in neurologic status, and the patient died 5 mo after the block due to recurrence of the carcinoma. Permission for autopsy could not be obtained. Discussion The blood supply of the human spinal cord is provided by a single anterior spinal artery, which supplies most of the cord, and a pair of posterior spinal arteries. Six to eight radicular arteries arise from the posterior wall of the aorta and anastomose with the anterior spinal artery at several levels. The most caudad artery, the major anterior radicular artery of Adamkewicz may be found anywhere between the level of T-7 and L-4; although it usually occurs at T-11. This artery may supply the lower two thirds of the spinal cord [8]. The importance of the major radicular artery relative to the blood supply of the cord varies considerably and depends on the degree of the collateral circulation. In general, even if the artery is occluded, the spinal cord receives adequate collateral blood supply [5,7-9]. In this case, spinal cord infarction was identified by MR imaging. Ischemic damage to the cord has been postulated to cause neurological impairment after celiac plexus block [4-7]. Our patient's history of hypertension suggests the presence of generalized arteriosclerosis, which may have compromised collateral blood flow. The spinal cord infarction was likely caused by arteriosclerotic narrowing of the collaterals, which could not maintain sufficient spinal cord perfusion when the major radicular artery was damaged during celiac plexus block. Occlusion of the major radicular artery may result from either spasm or thrombosis provoked by the procedure. The irritation induced by alcohol injection in close proximity to the artery or mechanical damage by the needle might be causative factors. Another possibility is the induction of thrombosis by alcohol injection into the wall of the artery [5,7]. This complication has also been reported during the technique of needle placement using radiologic control with contrast medium in the posterior approach to celiac plexus block [6,7]. Compared with the traditional posterior approach, the intraoperative celiac plexus block is considered to be a more reliable and safer method because it is performed under direct vision and the needle passes through less tissue in this approach [1-3]. Despite the use of this method, paraplegia after celiac plexus block occurred. Although this serious complication of the celiac plexus block is fortunately rare, it is a potential problem with the intraoperative as well as the posterior approach to the celiac plexus block.