Anterior spinal cord infarction with permanent paralysis following endoscopic ultrasound celiac plexus neurolysis.

Celiac neurolysis is an effective adjunct for managing refractory pancreatic cancer pain. Endoscopic ultrasound (EUS) offers several potential technical advantages over the traditional percutaneous technique [1]. We report the first case of paraplegia following EUS celiac neurolysis. A 76-year-old man underwent EUS celiac neurolysis for refractory pain secondary to unresectable pancreatic cancer. The major arteries all demonstrated normal pulse Doppler imaging, using a linear echoendoscope (UC140P-AL5; Olympus America, Center Valley, Pennsylvania, USA) (●" Fig.1). Several small celiac ganglia were noted. A 22-gauge needle was advanced into the largest ganglion, and 1mL of alcohol (99%) and bupivacaine (0.25%) mixture was injected. Another 23mL was injected into the celiac plexus. No immediate complications were noted. Upon awakening from general anesthesia, the patient noted paralysis of his lower extremities. Emergent magnetic resonance imaging (MRI) of the thoracic and lumbar spine revealed an anterior spinal cord infarct from T10 to the conus medullaris in the distribution of the anterior spinal artery (●" Fig.2). Imaging also demonstrated T2 hyperintensity of the paraspinal musculature (●" Fig.3), suggesting some solution may have passed via the left T12 intercostal artery, which supplies both the spinal cord via a radiculomedullary artery and the paraspinal muscles via dorsal branches. The patient remained paraplegic until death 24 days later. Percutaneous and EUS-guided celiac neurolysis relieves pain in 80% of patients with pancreatic cancer [2,3]. Major complications develop in 1%–2% of patients, and include lower extremity paraplegia, puncture of adjacent organs, and gastroparesis [2–4]. Neurologic complications develop secondary to ischemia or direct injury to the spinal cord or somatic nerves [5]. This patient highlights a rare but clinically significant risk of EUS celiac neurolysis. Therefore, appropriate patient counseling and consent are key in moderating expectations of pain relief and conveying the risks of EUS celiac neurolysis, which include paralysis.