A Rare Complication of Sepsis Following L4–l5 Microdiscectomy for Prolapsed Intervertebral Disc With Radiculopathy

Technical Summary: A Rare Complication of Sepsis Following L4–L5 Microdiscectomy

Problem Statement
Prolapsed intervertebral disc (PIVD) at the L4–L5 level is a prevalent condition in India, often precipitated by trauma, twisting, and heavy lifting. While microdiscectomy is an established and effective surgical intervention for PIVD with radiculopathy when conservative management fails, postoperative wound infections, although uncommon, remain a significant risk. Such infections can lead to severe morbidity, delayed recovery, and complex secondary complications. This case report addresses the clinical trajectory of a patient who developed a Staphylococcus aureus wound infection following an L4–L5 microdiscectomy, highlighting the critical need for rigorous postoperative surveillance and management.

Methodology and Case Presentation
This study presents a single-case report of a 34-year-old female admitted with severe lower back pain, radiating shooting pain, and tingling sensations in the right leg, attributed to heavy lifting. Initial conservative management (medication, bed rest, physiotherapy) failed to alleviate symptoms. Radiological investigation (MRI) confirmed an L4–L5 PIVD with spinal canal narrowing (8.5mm diameter) and radiculopathy.

The patient underwent an uneventful L4–L5 microdiscectomy. Postoperatively, she was managed in the Neuro ICU with standard supportive care, antibiotics, and analgesics. However, seven days post-surgery, the patient presented with fever (38°C), pain at the suture site, and yellowish purulent discharge.

Diagnostic workup included:

• Laboratory Analysis: Elevated CRP (43.141 mg/L), leukocytosis (WBC 13,000/cumm), and anemia (Hb 8.5%).
• Microbiology: Pus swab culture isolated Staphylococcus aureus, which demonstrated sensitivity to Amoxicillin+clavulanic acid, Amikacin, Cephalexin, and Vancomycin.
• Imaging: Contrast MRI revealed a small postoperative fluid collection around the L4 spinous process and patchy enhancement, consistent with infection but without evidence of discitis.

Intervention and Results
Due to the recurrence of infection and pus formation, the patient underwent a second surgical procedure: wound exploration and re-suturing with drain placement. The patient received a unit of Packed Red Cells (PRC) for anemia and was treated with a broad-spectrum antibiotic regimen (including Levofloxacin, Metrogyl, Amikacin, and Linezolid) alongside nutritional support (high protein diet, albumin powder).

Following the second intervention, the drain was removed, the wound healed, and inflammatory markers (CRP) improved. The patient was discharged in a stable condition with a regimen of oral antibiotics (Amoxyclav), pain management, and iron/folic acid supplementation.

Key Contributions and Claims
The primary contribution of this report is the documentation of a post-microdiscectomy wound infection requiring re-exploration and aggressive antimicrobial therapy. The paper emphasizes several critical clinical points:

1. Etiology: The infection was caused by Staphylococcus aureus, necessitating specific culture-guided antibiotic therapy.
2. Management Protocol: Successful resolution required a multi-modal approach including wound exploration, drainage, blood transfusion for anemia, and a tailored antibiotic course.
3. Preventive Necessity: The authors assert that while microdiscectomy is effective, preventing postoperative complications relies on strict surgical asepsis, meticulous wound care, early identification of infection signs (fever, discharge), and patient education regarding activity restrictions (specifically avoiding heavy lifting).

Significance
The paper concludes that early intervention and appropriate antibiotic therapy are pivotal in achieving favorable outcomes in cases of postoperative wound infection following spinal surgery. It underscores that even in effective procedures like microdiscectomy, the potential for severe complications exists, making postoperative monitoring and rapid response to infection signs essential components of surgical care. The authors note that while literature on intradural lumbar disc herniation is limited, timely diagnosis and skilled management remain the preferred course for ensuring positive outcomes and minimizing postoperative complications.