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:

Perioperative Talk