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Open Access 01-12-2023 | Amnesia | Case Report

Inadvertent intrathecal drug injection while treating low back pain: a case report and review of the literature

Authors: Alessandro Ferrieri, Donatella Bosco, Ennio Polilli, Raffaella Ciulli, Lina Visocchi, Lucrezia Mincione, Rosa Iacoe, Rosamaria Zocaro, Antonella Frattari

Published in: Journal of Medical Case Reports | Issue 1/2023

Abstract

Background

Undesired intrathecal injections represent an important subset of medical errors, albeit rare. Clinical effects depend on the type and concentration of drug(s) injected. Here we report on the case of a healthy woman with persistent low back pain, treated with a paravertebral injection of lidocaine, thiocolchicoside, and l-acetylcarnitine at an orthopedic practice.

Case report

A 42-year-old Caucasian woman, with no relevant past medical history, received a lumbar paravertebral injection of lidocaine, thiocolchicoside, and l-acetylcarnitine for persistent low back pain. Approximately 30 minutes after injection, she experienced quick neurological worsening. Upon arrival at the Emergency Department, she was comatose, with fixed bilateral mydriasis, trismus, and mixed acidosis; seizures ensued in the first hours; slow progressive amelioration was observed by day 6; retrograde amnesia was the only clinical relevant remaining symptom by 6 months.

Conclusions

To our knowledge, this is the first reported case of inadvertent intrathecal thiocolchicoside injection in an adult patient, as well as the first in the neurosurgical literature. Our experience suggests that injection therapy for low back pain should be administered in adequate settings, where possible complications may be promptly treated.

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Title: Inadvertent intrathecal drug injection while treating low back pain: a case report and review of the literature
Authors: Alessandro Ferrieri
Donatella Bosco
Ennio Polilli
Raffaella Ciulli
Lina Visocchi
Lucrezia Mincione
Rosa Iacoe
Rosamaria Zocaro
Antonella Frattari
Publication date: 01-12-2023
Publisher: BioMed Central
Keywords: Amnesia
Encephalitis
Back Pain
Back Pain
Back Pain
Published in: Journal of Medical Case Reports / Issue 1/2023
Electronic ISSN: 1752-1947
DOI: https://doi.org/10.1186/s13256-023-03754-y

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Inadvertent intrathecal drug injection while treating low back pain: a case report and review of the literature

Abstract

Background

Case report

Conclusions

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Case report

Conclusions

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