1021 - Unusual Postoperative Complication: Pruritus Following Lumbar Laminectomy

Case Diagnosis: Lower extremity pruritus following L2-L4 laminectomy.

Case Description: A 59-year-old female with multiple comorbidities, including HIV, type 2 diabetes, hypertension, osteoarthritis, and a history of L4-L5 laminectomy, presented with severe lower back pain, described as burning and stabbing, along with associated numbness and bilateral leg pain, more pronounced on the right. She could walk only one block due to pain. MRI showed mild grade 1 spondylolisthesis at L4-L5 and moderate to severe stenosis at L3-L4. Despite treatment with duloxetine, pregabalin, six weeks of physical therapy, and multiple steroid injections, pain persisted. She underwent L2-L4 laminectomy for lumbar stenosis and neurogenic claudication. Post-surgery, leg pain improved, and she could walk 2-3 blocks, though mild lower back pain remained. Eight weeks later, she developed pruritus in both legs without skin changes. Dermatology suspected dermatitis and prescribed triamcinolone cream with limited relief. Increasing the pregabalin dosage ultimately resolved the pruritus.

Discussions:

This patient's postoperative course was notably complicated by lower extremity pruritus, a rare but significant complication. While laminectomy complications commonly involve persistent low back pain, the presentation of pruritus is less typical and can suggest neurogenic origins. The pruritus may be attributed to neurogenic mechanisms following spinal cord damage, such as alloknesis (itch from non-pruritic stimuli) and hyperknesis (intensified itch response). These symptoms can be indicative of neuropathic itch, often managed with medications like gabapentin or pregabalin, which have proven effective in this case.

Conclusions: Neuropathic pruritus should be considered in patients developing new-onset itching after laminectomy, particularly when dermatologic evaluations do not reveal primary skin conditions. Early recognition and appropriate management of neuropathic itch are essential for effective treatment.