What is the management approach for a patient with a herniated disc and leukocytosis (elevated White Blood Cell count)?

Management of Herniated Disc with Elevated WBC Count

When a patient presents with a herniated disc and elevated white blood cell count (leukocytosis), a thorough investigation for underlying infection should be performed before proceeding with standard herniated disc management.

Evaluation of Elevated WBC Count

• An elevated WBC count (>14,000 cells/mm³) or a left shift (percentage of band neutrophils >16% or total band neutrophil count >1,500 cells/mm³) warrants careful assessment for bacterial infection, with or without fever 1
• Leukocytosis with a WBC count >14,000 cells/mm³ has a likelihood ratio of 3.7 for detecting bacterial infection 1
• A complete blood count with differential (preferably a manual differential to assess bands and other immature forms) should be performed to evaluate the elevated WBC count 1

Infection Workup

• Consider potential sources of infection that may be causing the elevated WBC count:
  • Urinary tract infection - evaluate with urinalysis and urine culture if symptoms present 1
  • Respiratory infection - consider appropriate respiratory evaluation 1
  • Discitis or vertebral osteomyelitis - may present with back pain similar to disc herniation 1
• Additional diagnostic tests should be guided by clinical presentation and may include:
  • Blood cultures if systemic infection is suspected 1
  • MRI with contrast to evaluate for discitis/osteomyelitis if infection of the spine is suspected 1

Management Algorithm

1. First, determine if infection is present:

   • If signs of systemic infection (fever, chills, hypotension) are present, prioritize infection workup and treatment 1
   • If localized infection is suspected in the spine (discitis, osteomyelitis), obtain appropriate imaging and infectious disease consultation 1

2. If infection is identified:

   • Treat the underlying infection with appropriate antimicrobial therapy before addressing the herniated disc 1
   • Avoid invasive procedures related to disc management until infection is controlled 1

3. If no infection is identified and WBC elevation is unexplained:

   • Monitor WBC count while proceeding with herniated disc management 1
   • Consider other causes of leukocytosis (stress response, inflammation, medication effect) 1

4. For herniated disc management (once infection is ruled out or treated):

   • Begin with non-surgical approaches which have moderate evidence (Level B) of effectiveness 2:
     • Patient education and self-management
     • McKenzie method exercises
     • Mobilization and manipulation
     • Exercise therapy
     • Neural mobilization
   • Consider epidural injections if conservative measures fail 2
   • Surgical intervention is indicated if there is severe neurological deficit, cauda equina syndrome, or failure of conservative treatment 3, 4

Special Considerations

• Avoid invasive procedures such as central venous catheterization, lumbar puncture, and surgical interventions while active infection is present 1
• Most patients with lumbar disc herniation can experience relief with non-surgical measures 4
• The type of disc herniation (contained vs. non-contained) may influence the clinical course - non-contained herniations often have a shorter clinical course but may respond to conservative treatment if managed for at least 2 months 5
• For thoracic disc herniation, which is less common, surgical approach selection is essential if conservative management fails 6

Monitoring and Follow-up

• Monitor WBC count to ensure resolution if infection was identified 1
• Follow neurological status closely to detect any worsening that would necessitate urgent surgical intervention 4
• Continue conservative management for at least 2 months before considering surgery in the absence of progressive neurological deficits 5