75-year-old lady for L4 and L5 laminectomy for bilateral leg pain.
- 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.
- 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
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.
- Describes regular ‘choking episodes’ at night
- BMI 33, no previous investigations for OSA.
- STOPBANG – 5 ESS 7, HCO3 normal
- Await input from neurologist regarding Parkinson’s progression.