Severe PD, spinal surgery

75-year-old lady for L4 and L5 laminectomy for bilateral leg pain

Background

  • Retired Anaesthetist
  • IHD – AMI 1997, recent angiogram normal, echo shows posterior RWMA and normal LVEF
  • Paroxysmal AF – apixaban and diltiazem
  • PE 2020 
  • Peripheral neuropathy – chronic, affecting both feet.
  • BMI 33

Issues:

  • Parkinson’s – non-tremor dominant. Decreased mobility with rigidity, constipation, depression, and urinary incontinence. On Apomorphine infusion.
  • Bulbar symptoms? Quiet voice and slurred speech on telephone. Denies dysphagia but describes frequent choking episodes, particularly at night.
  • Recent aspiration pneumonia:
    • Awoke from sleep in middle of the night ‘choking’ 
    • 1-week hospital stay, requiring IV antibiotics. 
    • Treated for fluid overload. 
    • Commenced on Domperidone with nil further choking episodes.
  • TKR – 09/21. Uneventful spinal. Had been discharged a week when developed aspiration. Unable to complete rehabilitation due to pneumonia.
  • Frailty – significant decline in functional capacity over recent months. Requires care with all ADL’s, currently unable to stand unaided, housebound. CFS = 7
  • C1/C2 arthropathy – severe neck pain, referred for regional block

Discussion

Optimisation

  • Frailty and immobility – these are multi-factorial issues. Uncertain if optimisable based on telephone consult.
  • Currently re-engaging with physiotherapist to perform rehabilitation for TKR
  • Cardiologist review and echo pending

Perioperative risk

  • Risks discussed with patient including death, serious complications, and discharge to nursing home. Understands and is keen to proceed. 
  • Previously unaware of perioperative risks and thought surgery could be done under local/regional.
  • Suggestion of possible early cognitive decline?
  • Patient feels that a nursing home admission is inevitable and if she can delay that then she has nothing to lose
  • Immobility and urinary incontinence are main factors affecting QoL – these are unlikely to be resolved by lumbar spine surgery. 
  • Very difficult to make a decision without clinical assessment. 

Timing of procedure

  • Recent major surgery and readmission to hospital – choking episode related to Parkinson’s/opioids/both?
  • Discuss with neurologist regarding disease severity and contribution of Parkinson’s to current immobility
  • Discussed with neurosurgeon:
    • Laminectomy will only help with back pain/sciatica in this case. 
    • He anticipates no improvement in mobility or urinary incontinence.
    • Happy to review in clinic and revisit indications and expected surgical outcomes

Plan:

  • Liaise with neurologist regarding frailty/immobility
  • Face to face or video-conference appointment at perioperative clinic
  • Neurosurgical review preoperatively