BACKGROUND: The proconvulsive properties of tramadol, bupropion, and nortriptyline have been well documented. Spinal fractures secondary to drug-induced seizures have been rarely reported. CASE REPORT: A 39-year-old female presented with a chief complaint of back pain. She went to bed feeling well in a separate room from her husband. During the previous night, he heard a noise and went into her room, finding her confused and twisted in an awkward position on her bed. Later she complained to him of severe back pain, prompting transport to a hospital. Shortly after arrival in the emergency department, staff witnessed a generalized convulsion. Following a one-hour post-ictal period, she complained of worsened back pain. Lab studies were normal, including a urine tox screen for drugs of abuse. No alcohol was implicated. ECG showed sinus rhythm, HR 113 beats/min, QRS 108 ms, QTc 389 ms. Brain magnetic resonance imaging (MRI) was normal. X-ray and an MRI of the thoracic spine confirmed four contiguous vertebral compression fractures, from T2 through T5. EEG showed diffuse changes consistent with a metabolic or toxicologic process. She denied taking any drugs other than prescribed doses of her medications, which included tramadol, bupropion, and nortriptyline. She had no previous history of seizures, head injury, or CVA. Bupropion and tramadol were discontinued, and seizures did not recur. CASE DISCUSSION: This patient's history, EEG findings, and brain imaging all point to a metabolic or toxic cause. It is likely that her three proconvulsant medications--even at therapeutic doses--synergistically lowered her seizure threshold or even precipitated her seizures. Retrospective studies and case reports portray these drugs as potentially offending agents. CONCLUSIONS: Sudden onset of back pain during sleep can be an important clue to a seizure complicated by vertebral compression fractures, even in the absence of trauma. Toxicology consultation in seizures of unclear etiology can help discern drugs that offend even in therapeutic doses.
