Background: Postoperative neurological disturbance after endoscopic lumbar discectomy is rare. Proposed mechanisms include dural breach, irrigation-pressure transmission into the cerebrospinal fluid (CSF) space, pneumocephalus, and chemical or inflammatory irritation. As utilization of uniportal systems with continuous irrigation increases, recognizing these interactions is increasingly important. Case Description: A 29-year-old man underwent uniportal endoscopic L5/S1 discectomy for left S1 radiculopathy. No durotomy was identified intraoperatively, and irrigation pressures were maintained between 25 and 40 mmHg. Four hours postoperatively, he developed acute confusion and a generalized tonic-clonic seizure. Computed tomography brain demonstrated intracranial pneumocephalus without hemorrhage, consistent with retrograde air entry through an unrecognized dural defect facilitated by pressure fluctuations and operative gas production. He was managed with supportive care, head elevation, supplemental oxygen, and a single loading dose of levetiracetam, with no further seizures. Cognition normalized within 24 h, and radicular symptoms resolved. Persistent postural headaches prompted re-intervention on day 7, where a small, contained durotomy adjacent to the traversing nerve root was identified and repaired endoscopically, resulting in complete symptom resolution. Conclusion: Although uncommon, acute confusion, seizure, and pneumocephalus may occur following endoscopic lumbar discectomy when dural injury allows pressure transmission or air ingress into the CSF compartment. Prompt neurological assessment, urgent imaging, and short-term monitored care support excellent outcomes. As endoscopic spine surgery continues to expand, understanding the interaction between irrigation dynamics, dural integrity, and intracranial physiology is essential for early recognition and prevention of this complication.
Huang et al. (2026) studied this question.