Delayed postoperative spinal epidural hematoma after one-hole split endoscope discectomy: a case report and literature review.

Background: One-Hole Split Endoscopic (OSE) discectomy is an emerging minimally invasive technique for lumbar degenerative disease. While OSE offers advantages such as reduced tissue dissection, it is not exempt from complications inherent to spinal surgery. Postoperative spinal epidural hematoma (POSEH), though rare, is a serious complication that can lead to significant neurological deterioration if not managed promptly. Although POSEH has been documented with other endoscopic lumbar procedures, no cases of delayed POSEH (DPOSEH) following OSE have been reported in the literature to date. Case presentation: A 69-year-old male underwent OSE discectomy at L4-L5 for symptomatic disc herniation. The initial postoperative course was uneventful, with improvement in radicular symptoms and intact neurological function. However, on postoperative day 5, he developed acute back pain, bilateral lower limb weakness, saddle anesthesia, and fecal incontinence. Emergency MRI confirmed a compressive epidural hematoma extending from L4 to L5. During the urgent surgical evacuation, multiple organized blood clots of varying sizes were identified and removed. Through postoperative rehabilitation therapy, the patient's left lower limb muscle strength gradually improved, though bowel and bladder dysfunction persisted. Conclusions: The present case highlights that, despite the absence of prior literature on this complication in OSE, the risk of symptomatic epidural hematoma exists similarly to other endoscopic spinal techniques. Early recognition, prompt imaging, and immediate surgical intervention are critical to optimizing neurological recovery. Surgeons should maintain a high index of suspicion for POSEH in OSE patients presenting with acute neurological decline, even beyond the typical 72-h postoperative window.