84yo lady for cervical laminectomy. 

Background 

• Spinal canal stenosis – severe, numbness and weakness all 4 limbs, gait and balance affected, incontinence issues. 
• IHD – NSTEMI 2019, medically mx 
• HOCM – apical hypertrophy, nil LVOT, EF 65% 
• Dyslipidaemia 
• 4WW, assistance with ADLs 
• DASI 3.3 METS 

Issues: 

• Unexplained weight loss
  • 20% over 8 months 
  • Anorexia, decreased intake 
  • Concerning for occult malignancy 
• Surgeons + gastro consulted -> recommended CT/PET scan, endoscopies if anaemic 

Discussion: 

Should surgery proceed? 

• Non-elective procedure given imaging and clinical e/o myelopathy 
• Surgeon notes specify that improvement unlikely. Goal is to prevent further decline. 
• Timing of surgery relative to investigations? 
• Where possible, Ix should all be undertaken prior to surgery, as a palliative diagnosis may be made which would likely negate surgery 
• BMJ Best Practice guidelines have a summary regarding the patient with unintentional weight loss – See attached article 

Plan: 

• Add on TSH, HbA1c 
• Await imaging 
• Postpone surgical date 
• Liaise with surgeons regarding the above 
• Liaise with gastro team if anaemia identified – availability for urgent endoscopies