Images in Anesthesiology

Abstract

A 52-YR-OLD female with end-stage pancreatic adenocarcinoma presented to our center with uncontrolled severe abdominal pain. Our plan was to repeat a celiac plexus block, because the previous one provided significant pain relief. Retrocrural approach of the celiac plexus block with bilateral needle technique was attempted. Blood return was encountered when the second needle (approaching from the left) was 1 cm anterior to the L1 vertebral body. The needle was withdrawn in a few mm increments until no blood return was observed. A total of 5 ml iohexol contrast (180 mg/ml) was then injected after negative aspiration. The patient started complaining of spasmodic lower extremity pain and general weakness. She was unable to flex her knees upon request. Simultaneously, the fluoroscopic image showed contrast spread in the lumbar artery (see fig., crosshair in the center). The procedure was immediately aborted without injection of the neurolytic agent. By the time the patient was transferred to the recovery area, all symptoms had resolved. The entire episode lasted approximately 5 min. The patient was discharged from the center without neurologic deficits. The patient clearly experienced transient anterior spinal artery syndrome. As demonstrated on the image, the contrast had gone into the lumbar artery that led to the artery of Adamkiewicz. Vasospasm, caused by the contrast and/or local needle disturbance, along the path to the artery was the cause of the syndrome. 1 The image presented in this case facilitates the recognition of this rare but potentially serious complication of celiac plexus block. 2