Authors: Shankar V et al.
Cureus, June 17, 2026.
Summary
This case report describes the perioperative management of a man in his mid-60s who required elective lumbar spine surgery shortly after sustaining a monkey scratch and beginning rabies post-exposure prophylaxis.
The patient had chronic lower back pain, bilateral radiculopathy, and severe limitation in walking. Imaging demonstrated an L5-S1 prolapsed intervertebral disc with lumbar canal stenosis. After six weeks of unsuccessful conservative treatment, he was scheduled for L5-S1 decompression and transforaminal lumbar interbody fusion.
One day before the scheduled operation, the patient sustained a Grade III monkey scratch to his right flank. The wound was immediately washed and disinfected. Human rabies immunoglobulin was infiltrated around and into the wound, with the remaining dose administered intramuscularly. He also began a four-dose intradermal rabies vaccination schedule on days 0, 3, 7, and 28.
Because the spinal operation was elective, surgery was postponed until the rabies post-exposure prophylaxis regimen was completed. The patient underwent surgery approximately one month after the monkey scratch and one week after his final vaccine dose.
The L5-S1 fusion lasted three hours and involved approximately 250 mL of blood loss. No intraoperative complications occurred. The patient was mobilized on postoperative day 1, the wound was healthy on postoperative day 2, and he was discharged on postoperative day 3.
At follow-up, the patient remained symptom-free and clinically well at 3, 6, and 12 months.
The authors emphasized that evidence regarding anesthesia and surgery during active rabies prophylaxis is extremely limited. Surgical stress and certain anesthetic medications may theoretically suppress immune function and interfere with vaccine effectiveness, but direct clinical evidence demonstrating this effect is lacking.
Emergency surgery has previously been performed successfully in patients receiving rabies prophylaxis. However, elective surgery should generally be delayed when clinically reasonable so that the vaccination schedule can continue without interruption and the immune response can develop adequately.
The authors noted that some expert recommendations suggest postponing elective surgery for at least one week following an inactivated vaccine. Rabies vaccines are inactivated vaccines.
Regional anesthesia may theoretically preserve immune function by reducing the systemic surgical stress response. However, neuraxial anesthesia could complicate neurologic assessment if a patient developed the paralytic form of rabies, because weakness or neurologic deficits might initially be attributed to the regional anesthetic.
General anesthesia may also produce immunosuppressive effects, and isolated reports have raised concern regarding ketamine during rabies prophylaxis. However, these concerns are based on extremely limited evidence and do not establish a causal relationship.
What You Should Know
Elective surgery is not absolutely contraindicated during rabies post-exposure prophylaxis.
When possible, elective surgery should be postponed until the rabies vaccination schedule is completed or until at least one week after an inactivated vaccine dose.
The rabies vaccination schedule should never be interrupted or delayed because of surgery.
Human rabies immunoglobulin and vaccination should be administered promptly after a qualifying animal exposure.
When surgery cannot be delayed, the anesthetic technique should be individualized according to the patient’s condition, surgical requirements, and potential immunologic and neurologic concerns.
Unnecessary perioperative immunosuppressive medications should be avoided.
Careful neurologic examination and documentation should be completed before and after surgery, particularly when neuraxial anesthesia is used.
The successful outcome in this patient is reassuring but cannot establish general clinical guidelines because this was a single case report.
Larger studies are needed to determine the safest timing of surgery and the optimal anesthetic technique for patients receiving rabies post-exposure prophylaxis.
Thank you to Cureus for allowing us to summarize this article.