75-year-old lady for L4 and L5 laminectomy for bilateral leg pain
- 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
- 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
- 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
- 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
- Liaise with neurologist regarding frailty/immobility
- Face to face or video-conference appointment at perioperative clinic
- Neurosurgical review preoperatively