Update – Severe PD, spinal surgery

Gabrielle Morris

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

Retired anaesthetist

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. 
  • TKR – 09/21. Uneventful spinal. Had been discharged a week when developed aspiration pneumonia.
  • Frailty – significant decline in functional capacity over recent months. Requires care with all ADL’s, housebound. CFS = 7
  • C1/C2 arthropathy – severe neck pain, referred for regional block. Pending.
  • Distance patient
  • Difficult to perform adequate clinical assessment via phone consult.

Update

  • Discussed with neurologist: 
    • Disease severity and contribution of Parkinson’s to current immobility
    • Recent major surgery and readmission to hospital – choking episode related to Parkinson’s/opioids/both?
    • Suggestion of possible early cognitive decline?
    • Neurologist feels that pain is a significant issue but is certain that she has significantly deteriorated from a Parkinson’s perspective.
    • No documented any bulbar symptoms or cognitive decline but feels that these would be realistic symptoms of this type of Parkinson’s
    • He has organised a preoperative review
  • 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
  • Video consult 
    • Very helpful
    • Patient did not appear as frail as she sounded 
    • Updated patient and husband on neurosurgical and neurologist conversations
    • Husband expressing frustration at current level of immobility and encouraging patient to proceed with surgery when she was concerned regarding risks

Discussion

Timing of procedure

  • 8 weeks post TKR – concerning regarding risk for DVT post TKR 
  • Previous PE
  • Discussed with neurosurgical team – they are not concerned. Predicting a non-instrumented, quick procedure with Clexane recommenced within 24 hours.
  • Patients current level of immobility emphasised.

OSA?

  • Describes regular ‘choking episodes’ at night
  • BMI 33, no previous investigations for OSA. 
  • STOPBANG – 5 ESS 7, HCO3 normal

Plan:

  • Await input from neurologist regarding Parkinson’s progression.