Title : High dose tramadol-associated neurotoxicity in an elderly patient following hip arthroplasty: A case report
Abstract:
Tramadol is widely used for moderate postoperative pain but carries a risk of neurotoxicity, particularly in elderly patients. We report a case highlighting tramadol-associated neurologic complications in a very elderly postoperative patient, with emphasis on diagnostic challenges and the effects of continuous infusion in extreme age.
A 91-year-old hypertensive female was admitted for a slightly displaced fracture of the femoral neck following a fall. She received tramadol for analgesia preoperatively and was subsequently placed on a postoperative continuous tramadol infusion following partial hip arthroplasty. Six hours postoperatively, she developed acute altered sensorium with tonic posturing, hyperreflexia, and a positive Babinski sign, while vital signs remained stable. Cranial computed tomography revealed no acute intracranial pathology. The episode was assessed as a generalized tonic seizure likely secondary to tramadol-induced neuroexcitation. Tramadol was discontinued, and treatment was shifted to alternative analgesia and levetiracetam, resulting in resolution of symptoms and no recurrence of seizures.
This case underscores two key issues: the increased vulnerability of geriatric patients to neurotoxicity from continuous tramadol infusion due to age-related pharmacokinetic changes, and the diagnostic complexity of distinguishing drug-induced neuroexcitation from acute neurologic emergencies such as stroke or primary seizure disorders in the postoperative seting.
Early recognition of tramadol-associated neurotoxicity is essential in elderly patients presenting with acute neurologic deterioration, particularly in the context of opioid escalation. Careful opioid selection and close neurologic monitoring are warranted in this high-risk population.
