Delayed remote cerebellar hemorrhage after unilateral biportal endoscopic lumbar decompression: a case report and literature review
This case report describes a rare instance of delayed remote cerebellar hemorrhage following unilateral biportal endoscopic lumbar decompression, highlighting the critical need to monitor for unexplained agitation, hypertension, and excessive wound drainage as early indicators of occult cerebrospinal fluid leakage and subsequent intracranial complications, even when initial postoperative imaging is normal.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Spinal surgery has evolved into a highly refined art, where surgeons use small cameras and specialized tools to fix problems deep inside the back without making large incisions. One popular method, known as unilateral biportal endoscopy, involves creating two tiny openings to remove pressure from pinched nerves. To keep the surgeon's view clear, the procedure relies on a steady stream of fluid that washes away blood and debris, much like a garden hose clearing a muddy path. While this technique is generally safe and effective, the human body is a complex, interconnected system. The spine and the brain are linked by a continuous channel of fluid that cushions the nervous system. When surgeons work in the lower back, they are essentially working on the same fluid system that surrounds the brain. If too much fluid escapes or if pressure builds up in the wrong place, the consequences can travel upward, affecting the brain in ways that are difficult to predict. Understanding how a routine back operation might trigger a rare brain complication is vital for keeping patients safe, as it helps doctors recognize subtle warning signs before a situation becomes critical.
A team of surgeons and researchers from Chengdu University of Traditional Chinese Medicine recently documented a striking case that highlights this hidden connection. They treated a 55-year-old man suffering from severe narrowing of the spinal canal in his lower back, a condition that caused pain and weakness in his legs. The patient underwent the standard two-opening endoscopic procedure to relieve the pressure. During the operation, the surgeons saw no tears in the protective covering of the spinal cord, and no fluid appeared to be leaking out. The surgery seemed to go exactly as planned. However, as the patient woke up from anesthesia, something unusual happened. Instead of waking up calmly, he became extremely agitated, his heart raced, and his blood pressure spiked to dangerous levels. When doctors immediately scanned his brain with a computerized tomography machine, the images looked normal. There was no sign of bleeding or swelling.
The situation changed rapidly over the next day. The drain placed in the patient's lower back, which usually collects a small amount of fluid, began to release a massive volume of bloody liquid—550 milliliters in just one night. Shortly after the drain was removed, the patient's condition deteriorated sharply. He began to struggle for air, his neck became stiff, and he developed weakness on the right side of his body. A second brain scan revealed the true cause of his distress: a rare and dangerous condition known as remote cerebellar hemorrhage. This meant that bleeding had occurred in the lower part of the brain, the cerebellum, which controls balance and coordination, even though the surgery had taken place far away in the lower back. The scan also showed that the bleeding had blocked the normal flow of fluid in the brain, causing a dangerous buildup of pressure known as hydrocephalus.
The medical team acted quickly to save the patient's life. They inserted a temporary tube into the brain to drain the excess fluid and relieve the pressure. While the patient was in the intensive care unit, doctors also looked for a broken blood vessel or a weak spot in an artery that might have burst on its own. Advanced imaging showed no such structural defects, ruling out a spontaneous aneurysm rupture. Instead, the evidence pointed toward the surgery itself. The researchers suspect that the continuous stream of fluid used during the operation, combined with a tiny, unseen tear in the spinal covering, allowed pressure to travel up the fluid channel to the brain. This pressure disturbance likely pulled on the delicate veins in the cerebellum, causing them to rupture. The massive amount of fluid draining from the back wound suggested that the body was losing fluid at a rate that further destabilized the pressure balance inside the skull.
Over the following weeks, the patient's condition slowly improved. The bleeding in the brain began to clear, and the pressure subsided. By the time he was two months post-surgery, the patient could walk on his own and his leg pain had completely vanished. He did, however, retain some weakness in his right arm and leg, a lasting reminder of the brain injury he suffered. This case is significant because it shows that serious brain complications can happen even when the initial brain scan looks perfect and no obvious tear is seen during the operation. The patient's sudden agitation and high blood pressure right after waking up were the first clues that something was wrong, appearing long before the bleeding showed up on the scan.
The authors of this report suggest that when patients undergoing this type of endoscopic spine surgery wake up with unexplained agitation, high blood pressure, or a racing heart, doctors should consider the possibility of a pressure problem traveling from the spine to the brain. If these signs are accompanied by an unexpectedly large amount of fluid draining from the surgical wound, it may indicate a hidden leak of the spinal fluid. The lesson from this case is that a normal brain scan immediately after surgery does not guarantee safety. If a patient's condition worsens or new symptoms appear, repeating the scan is essential. By paying close attention to these early warning signs and managing the drainage tubes carefully, medical teams can catch these rare complications early and provide the life-saving treatment needed to help patients recover.
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