Spinal hypertension-like syndrome with metabolic acidosis during percutaneous endoscopic lumbar discectomy：a case report

Study Design. Case-report and literature review. Objective. This report presents a rare case of spinal cord hypertension-like syndrome following percutaneous transforaminal endoscopic lumbar discectomy (PTELD). We reviewed the existing literature to elucidate potential causes, emphasizing the need for meticulous technique and early detection of neurological deficits to improve safety in this procedure. Summary of Background Data: PTELD is a minimally invasive procedure that effectively achieves neural decompression by removing the herniated nucleus pulposus via a posterolateral approach. The incidence of perioperative complications associated with PTELD is exceptionally low, as extensively documented. However, although rare, patients undergoing PTELD may occasionally experience symptoms suggestive of spinal cord hypertension-like syndrome. Methods: A 47-year-old male presented with severe lower back pain and underwent PTELD under general anesthesia. Intraoperatively, the patient developed persistent hypertension and tachycardia. During the recovery phase from general anesthesia, he exhibited extreme agitation, generalized muscle rigidity, increased RR, tachycardia, and elevated BP. Midazolam, propofol, and sufentanil were administered to manage agitation, while urapidil and esmolol were sequentially used to control BP. Hydrocortisone (100 mg) was given to provide neuroprotection. Results: The patient exhibited no further symptoms of spinal cord hypertension syndrome and is recovering satisfactorily. Conclusion: We hypothesize that the sudden intraoperative increase in BP and HR may be associated with a dural sac rupture during tissue clamping near the dural sac, allowing irrigation fluid to enter and perfuse inward, thereby elevating intracranial pressure. To mitigate this risk, surgical maneuvers should be performed with precision and efficiency to avoid dural tears. In cases where symptoms suggestive of spinal cord hypertension syndrome arise intraoperatively, prompt administration of osmotic agents such as mannitol and diuretics like furosemide is recommended to reduce intracranial pressure. Additionally, elevating the head of the bed and implementing protective measures, such as brain ice packing, should be considered. Anesthesiologists must be well-versed in managing perioperative complications related to elevated intracranial pressure to ensure optimal patient outcomes.