Spinal surgery, severe comorbidities

Gabrielle Morris

56yo female. Large disc bulge at L3/4. Radiculopathy. Nil cauda equina

Background

  • BMI 47
  • IHD – prev CABG (angio ’22 graft to OM occluded, moderate disease otherwise) w/ occaisional angina for medical management due to challenging angiography (patient intolerance)
  • T2DM on insulin, poorly controlled
  • Graves Dx
  • CKD eGFR ~ 45
  • CVA – balance and slurred speech remain
  • Depression
  • Legally blind
  • PTSD
  • Chronic thrombocytopenia, plt ~100
  • Full assistance w/ ADLs, living in group home, consent for self
  • Labile BP control – hypotension/hypertension, polypharmacy
  • Vapes, ex-smoker, distant asthma 

Issues

  • ? surgery indicated – main complaint in clinic and with carer was of back pain
  • ? able to physically prehabilitate
  • Goals of surgery? – pain v. functional improvement, likelihood of either?
  • Multiple unoptimized comorbidities
    • ? OHS (HCO3 mildly elevated, previously “slow to wake” after GA in 2021)
    • Poor diabetes control
    • Ongoing vaping
    • BMI 47

Discussion

  • Perioperative risk prediction can be challenging in patients like this whereby risk scoring tools may under-estimate risk
  • Would benefit from a physician to provide oversite of multiple organ systems and rationalize medications, rather than clinicians acting in silos. 
  • ? can have a “rehab” direct admission from an outpatient setting
  • Shared decision making  challenging when patient expectations around surgery outcomes are very concrete
  • Our traditional prehab models would not be appropriate due to this patient’s existing severe disabilities and needs.

Plan

  • Discuss with neurosurgeon – ? surgery indicated, ? risk if surgery postponed/cancelled
  • Ideally physician holistic management – will d/w endocrinologist
  • Explore rehab or cardiac rehab options
  • Investigation and management of ? OHS/severe OSA
  • Discuss with GP