Resident Physician Stony Brook Medicine/University Hospital PM&R Program Commack, New York
Case Diagnosis: Quadriplegia status-post C6 vertebral body fracture with C4-T1 Open Reduction and Internal Fixation
Case Description or Program Description: 61-year-old male presented after a fall with C6 vertebral body fracture resulting in incomplete spinal cord injury. He underwent C4-T1 posterior laminectomy, bilateral foraminectomies, and posterior lateral fusion prior to admission to inpatient rehabilitation. Patient was previously prescribed sertraline 50mg daily for anxiety, which was continued throughout admission. Pain was initially addressed with acetaminophen before transitioning to tramadol 50mg every 6 hours as needed for added relief; tramadol was increased to 100mg every 6 hours as needed due to continued pain.
Setting: After 1 week of this medication regimen, patient exhibited rigidity, generalized spasms, leg tremors, and a contiguous, beefy red facial rash. Patient was febrile to 101.8°F and oxygen saturation dropped to 86% on room air. CTA chest was negative. Patient reported right hip pain with generalized myalgias.
Assessment/Results: Due to the constellation of these symptoms, Serotonin Syndrome was suspected. Tramadol and sertraline were immediately discontinued. Overnight there was complete resolution of all symptoms, however patient remained on 3L oxygen with 96% saturation.
Discussion (relevance): This case demonstrates features suggestive of serotonin syndrome due to increased tramadol with concomitant sertraline treatment. It is critical to be vigilant and mindful of the serotonergic effects of tramadol, especially in patients with long-term treatment of SSRIs and/or SNRIs; even in those taking relatively lower doses, such as in this case. The patients' pain was subsequently managed with hydrocodone without side effects, further indicating that his symptoms were likely due to serotonin syndrome.
Conclusions: Rehabilitation patients commonly present with spasticity and/or infections as sequalae to spinal cord trauma. Therefore it is critically important to perform thorough medication reconciliation while identifying the underlying etiology.
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