An Intrathecal Pump Misadventure in Two Acts: An Unrecognized Partial Pocket Fill Followed by an Unusual Withdrawal Syndrome Two Months Later

Objective: We present a case of a patient with an intrathecal pump who experienced an unrecognized partial pocket fill, leading to an atypical opioid withdrawal characterized by akathisia. Case Report: A 57-year-old female with multiple myeloma presented to an emergency department with new-onset akathisia requiring admission. Eight weeks prior, her intrathecal pump was refilled with morphine, bupivacaine, and ziconotide. After a thorough evaluation, her pump reservoir was found to be empty despite an expected residual volume of 10 mL. Furthermore, she reported sedation following her last pump refill, all consistent with an unrecognized partial pocket fill followed by an unusual opioid withdrawal presentation. Conclusions: This case represents an example of both an unrecognized partial pocket fill and an atypical presentation of opioid withdrawal manifesting as akathisia. Furthermore, this patient's case may be considered a medical error given the serious morbidity that can be associated with inadvertent pocket fills.