Severe COPD, Lumbar Laminectomy

Gabrielle Morris

78year old lady with L4/5 canal stenosis causing radiculopathy (pain and numbness) without motor weakness or signs of upper motor neurone compromise. Requiring opioids and neuropathic agents. Significant impact on QoL. Some relief from steroid injects one side but not the other ?proceduralist inexperience.

Background

  • Severe COPD 
    • Exacerbations x4 in last year requiring stress steroids and Abx  
    • Spiro: FEV1 34% 
    • SPO2 90% clinic with quiet air entry 
    • Heavy smoker
    • Appeared breathless at rest
  • CVS: PPM for bradycardia
  • Attended appointment in wheelchair due to leg pain + SOBOE
  • MCOG 3/5 

Issues

  • Perioperative risks
    • NSQIP – high risk of functional decline 30% severe, 8% death, 24% delirium post op
    • BODE index suggests 80% mortality within 4 years (see Eur Respir J 2008; 32: 1269–1274 DOI: 10.1183/09031936.00138507)
    • Patient expressed that the periop risks were too great for her. Goals are to be at home with her growing family.
  • Appropriateness of surgery?
  • Alternatives to surgery?

Discussion

  • What is natural history of disease? Will it progress to cauda equina syndrome or motor weakness?
  • Comment from pain team: symptoms sound like nerve root irritation which has potential for functional rehabilitation, core strengthening, to improve pain and function.
  • Non-relief of back pain from surgery is common

Plan

  • Discuss with surgeons – natural history of disease?
  • Consider surgical path if surgery is inevitable.
  • GP to refer to respiratory physician (regardless of surgery) – can possibly optimise exacerbations although improvement/engagement may be limited if ongoing smoking
  • Suggest referral for physical therapy
  • Support for patient’s decision to decline surgery at this stage