A rare and severe complication in a patient who underwent percutaneous endoscopic lumbar discectomy: A case report

RATIONALE: Percutaneous endoscopic lumbar discectomy is widely performed under general anesthesia. Acute intracranial hypertension caused by massive cerebrospinal fluid loading via an unrecognized dural tear is an under-reported, potentially fatal complication that may be masked by anesthesia. PATIENT CONCERNS: A 64-year-old woman underwent elective L3-L4 endoscopic discectomy. Intraoperatively, she developed refractory hypertension, followed by generalized tonic-clonic seizures and altered consciousness shortly after extubation. DIAGNOSES: Intraoperative dural tear with retrograde irrigation-fluid influx causing acute intracranial hypertension. INTERVENTIONS: Immediate cessation of irrigation, 20° head-up positioning, mannitol 20% 200 mL intravenous (IV), dexmedetomidine 0.7 µg kg-1 h-1, propofol 100 mg IV, and methylprednisolone 80 mg IV. OUTCOMES: Irrigation-related intracranial hypertension was promptly managed; seizures stopped within 45 minutes, and full consciousness (Glasgow Coma Scale 15) was restored by 4 hours. Hemodynamics and arterial blood gas normalized without extra antihypertensives. No further sedation or antiepileptics were needed. At 24 hours, the National Institutes of Health Stroke Scale was 0, the Mini-Mental State Examination score was 29/30, and no meningeal signs. Assisted mobilization on postoperative day (POD) 2 and independent ambulation on POD 5. Discharged on POD 7 with modified Rankin Scale 0 and no symptoms; 30-day follow-up confirmed modified Rankin Scale 0 and no neurological sequelae. LESSONS: Refractory hypertension during percutaneous endoscopic lumbar discectomy should prompt immediate consideration of cerebrospinal fluid hypertension due to dural breach. Early recognition and prompt intervention are critical to prevent permanent neurological damage.