Spinal surgery in patients with Parkinson's disease: experiences with the challenges posed by sagittal imbalance and the Parkinson's spine

A guide to selecting upper thoracic versus lower thoracic uppermost instrumented vertebra in adult spinal deformity correction

PURPOSE

Operative treatment of adult spinal deformity (ASD) has been shown to improve patient health-related quality of life (HRQOL). Selection of the uppermost instrumented vertebra (UIV) in either the upper thoracic (UT) or lower thoracic (LT) spine is a pivotal decision with effects on operative and postoperative outcomes. This review overviews the multifaceted decision-making process for UIV selection in ASD correction.

METHODS

PubMed was queried for articles using the keywords "uppermost instrumented vertebra", "upper thoracic", "lower thoracic", and "adult spinal deformity".

RESULTS

Optimization of UIV selection may lead to superior deformity correction, better patient-reported outcomes, and lower risk of proximal junctional kyphosis (PJK) and failure (PJF). Patient alignment characteristics, including preoperative thoracic kyphosis, coronal deformity, and the magnitude of sagittal correction influence surgical decision-making when selecting a UIV, while comorbidities such as poor body mass index, osteoporosis, and neuromuscular pathology should also be taken in to account. Additionally, surgeon experience and resources available to the hospital may also play a role in this decision. Currently, it is incompletely understood whether postoperative HRQOLs, functional and radiographic outcomes, and complications after surgery differ between selection of the UIV in either the UT or LT spine.

CONCLUSION

The correct selection of the UIV in surgical planning is a challenging task, which requires attention to preoperative alignment, patient comorbidities, clinical characteristics, available resources, and surgeon-specific factors such as experience.

Treatment of axial postural abnormalities in parkinsonism disorders: A systematic review of pharmacological, rehabilitative and surgical interventions

Axial postural abnormalities (PA) are frequent, highly disabling, and drug-refractory motor complications affecting patients with Parkinson's disease (PD) or atypical parkinsonism. Over the past few years, advances have been reached across diagnosis, assessment, and pathophysiological mechanisms of PA. Nonetheless, their management remains a challenge, and these disturbances are generally overlooked by healthcare professionals, potentially resulting in their worsening and impact on patients' disabilities. From shared consensus-based assessment and diagnostic criteria, PA calls for interdisciplinary management based on the complexity and multifactorial pathogenesis. In this context, we conducted a systematic literature review to analyze the available pharmacological and non-pharmacological treatment options for PA in PD according to the new expert-based classification of axial PA in Parkinsonism. Different multidisciplinary approaches, including dopaminergic therapy adjustment, physiotherapy, botulinum toxin injection, and deep brain stimulation, can improve PA depending on its type and severity. An early, interdisciplinary approach is recommended in PD patients to manage PA.

Impact of deep brain stimulation therapy on the vertebral sagittal balance in Parkinson's disease patients

Parkinson's disease (PD) is characterized by cardinal motor signs: 4-6 Hz resting tremor, rigidity, and bradykinesia. In addition, 3-18% of PD patients have camptocormia, an abnormal forward flexion of the thoracolumbar spine, which may have a negative impact on patients' quality of life. Different possible treatments have been suggested for such a condition, but no one is resolutive. This study aims to define the possible impact of DBS, with selective targeting on the dorsal-lateral region of the STN, on the sagittal balance of patients affected by PD. Among all patients that have undergone DBS procedures in our institution, we selected eight subjects, four females and four males, with selective targeting on the dorsal-lateral region of the subthalamic nucleus (STN) because of camptocormia and other severe postural changes. Radiological assessments of spinal balance parameters before surgery and at 6 and 12 months postoperatively were carried out. Comparison of preoperative and postoperative spine X-ray data showed a statistically significant improvement in dorsal kyphosis angle (D-Cobb) 12 months after the operation. Deep brain stimulation with selective targeting of the dorsal lateral part of the STN may induce changes of the posture in patients with Parkinson's disease 12 months after the operation, which appears to improve in this small sample size, but larger observational and controlled trials would be required to confirm this observation.

Patient Optimization for the Prevention of Proximal Junctional Kyphosis

Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are well-recognized challenges of surgery for adult spinal deformity (ASD). Multiple risk factors have been identified for PJK/PJF, including osteoporosis, frailty, neurodegenerative disease, obesity, and smoking. Several surgical techniques to mitigate risk of PJK/PJF have been identified; however, patient optimization is also critical. This review summarizes the data behind these 5 risk factors (osteoporosis, frailty, neurodegenerative disease, obesity, and smoking) and details the related recommendations for patients undergoing surgery for ASD.

Adult Spinal Deformity Correction in Patients with Parkinson Disease: Assessment of Surgical Complications, Reoperation, and Cost

BACKGROUND

Parkinson disease (PD) is a neurodegenerative disorder that manifests with postural instability and gait imbalance. Correction of spinal deformity in patients with PD presents unique challenges.

METHODS

The PearlDiver database was queried between 2010 and 2020 to identify adult patients with spinal deformity before undergoing deformity correction with posterior spinal fusion. Two cohorts were created representing patients with and without a preoperative diagnosis of PD. Outcome measures included reoperation rates, surgical technique, cost, surgical complications, and medical complications. Multivariable logistic regression adjusting for Charlson Comorbidity Index, age, gender, 3-column osteotomy, pelvic fixation, and number of levels fused was used to assess rates of reoperation and complications.

RESULTS

In total, 26,984 patients met the inclusion criteria and were retained for analysis. Of these patients, 725 had a diagnosis of PD before deformity correction. Patients with PD underwent higher rates of pelvic fixation (odds ratio [OR], 1.33; P < 0.001) and 3-column osteotomies (OR, 1.53; P < 0.001). On adjusted regression, patients with PD showed increased rates of reoperation at 1 year (OR, 1.37; P < 0.001), 5 years (OR, 1.32; P < 0.001), and overall (OR, 1.33; P < 0.001). Patients with PD also experienced an increased rate of medical complications within 30 days after deformity correction including deep venous thrombosis (OR, 1.60; P = 0.021), pneumonia (OR, 1.44; P = 0.039), and urinary tract infections (OR, 1.54; P < 0.001). Deformity correction in patients with PD was associated with higher 90-day cost (P = 0.007).

CONCLUSIONS

Patients with PD undergoing long fusion for deformity correction are at significantly increased risk of 30-day medical complications and revision procedures after 1 year, controlling for comorbidities, age, and invasiveness. Surgeons should consider the risk of complications, subsequent revision procedures, and increased cost.

Postural deformities in Parkinson's disease: A bibliometric analysis based on web of science

Objective

Postural deformities are common debilitating conditions during the progression of Parkinson's disease (PD). However, the underlying pathophysiology and optimal treatment strategy are unclear. In this study, we aimed to identify primary research fields, important achievements and emerging trends in postural deformities in PD.

Methods

Web of Science Core Collection database was searched to retrieve all literature related to postural deformities in PD over the past 20 years. Data such as annual numbers of publications, countries of origin, publication journals, cooperation between countries, citation index and keywords were retrieved from the selected publications. Bibliometrix Package in R software were used for bibliometric analysis and visualization.

Results

In total, 211 publications that met the criteria were collected. Analyses had shown that the annual numbers of publications increased gradually with fluctuations. Japan was the most prolific country (n = 59). Italy participated in international cooperation the most frequently. Parkinsonism & related disorders (n = 25) took a prominent lead among all journals, and the most productive institution in this area was University of Verona (n = 27). The most local cited author was Tinazzi Michele. According to the thematic map, "scoliosis", "fusion", and "balance" have rapidly become research hot spots in related fields.

Conclusions

Articles pertaining to postural deformities in PD are still being published, in which the etiology is a combination of peripheral plus central involvement. Treatment approaches include rehabilitative exercises, oral medication, botulinum toxin injection, deep brain stimulation and spine surgery, which is getting current attention and would be a hot topic of future research.

Degenerative Spine Surgery in Patients with Parkinson Disease: A Systematic Review

BACKGROUND

Parkinson disease (PD) has been recognized as responsible for concurrent spinal disorders. Surgical correction may be necessary, but the complexity of such fragile patients may require specific considerations. We systematically reviewed the literature on degenerative spine surgery in patients with PD.

METHODS

PubMed, Scopus, Web of Science, and Cochrane were searched according to the PRISMA guidelines to include studies reporting clinical data of patients with PD undergoing degenerative spine surgery. Clinical characteristics, treatment protocols, and outcomes were analyzed.

RESULTS

We included 22 articles comprising 442 patients (61.5% female). Mean age was 66.9 ± 3.5 years (range, 41-83 years). Mean PD duration and modified Hoehn and Yahr stage were 4.46 ± 2.39 years and 2.3 ± 0.8, respectively. Operation types included fusion (55.3%) and decompression (41.6%). Mean operated spine levels were 6.0 ± 5.08. A total of 377 postoperative complications occurred in 34.6% patients, categorized into mechanical failure (58.0%), infection (15.1%), or neurologic (10.7%). Of patients, 31.8% required surgical revisions, with an average of 1.88 ± 1.03 revisions per patient. The average normalized presurgery, postsurgery, and final aggregate numeric patient outcome scores were 0.37 ± 0.13, 0.63 ± 0.18, and 0.61 ± 0.19, respectively, with a score of 0 and 1 representing the worst and best possible score.

CONCLUSIONS

Degenerative spine surgery in patients with PD is challenging, with complications and revisions occurring in up to a third of treated patients. Surgery should be offered when other treatment options have proved ineffective and is typically reserved for patients with myelopathy or significant disability. Successful outcomes depend on strong interdisciplinary support to control the movement disorder before and after surgery.

A comparison of in-hospital outcomes after elective anterior cervical discectomy and fusion in cases with and without Parkinson's Disease

Background

Following orthopedic surgery, patients with Parkinson's disease (PD) have been shown to have high rates of surgical complications, and some studies suggest that PD may be associated with greater risk for postoperative medical complications. As complication rates are critical to consider for elective surgery planning, the current study aimed to describe the association of PD with medical complications following anterior cervical discectomy and fusion (ACDF), the most commonly performed procedure to treat cervical degenerative pathology.

Methods

The 2008-2018 National Inpatient Sample database was queried for cases involving elective ACDF. Demographics and comorbidities were extracted using ICD codes. Cases were propensity matched based on demographic and comorbidity burden, and logistic regression was used to compare in-hospital complications between patients with and without PD.

Results

After weighting, a total of 1,273,437 elective ACDF cases were identified, of which 3948 (0.31%) involved cases with PD. After 1:1 propensity score matching by demographic and comorbidity variables, there were no differences between the PD and non-PD cohorts. Logistic regression models constructed for the matched and unmatched populations showed that PD cases have greater odds of in-hospital minor adverse events with no differences in odds of serious adverse events or mortality.

Conclusions

After matching for demographics and comorbidity burden, PD cases undergoing elective ACDF had slightly longer length of stay and greater risk for minor adverse events but had similar rates of serious adverse events and mortality. These findings are important for surgeons and patients to consider when making decisions about surgical intervention.

Complications, Readmissions, Revisions, and Patient-reported Outcomes in Patients With Parkinson Disease Undergoing Elective Spine Surgery: A Propensity-matched Analysis

STUDY DESIGN

Retrospective analysis on prospectively collected data.

OBJECTIVE

To determine the effectiveness of elective spine surgery in patients with Parkinson disease (PD).

BACKGROUND CONTEXT

PD has become increasingly prevalent in an aging population. While surgical treatment for degenerative spine pathology is often required in this population, previous literature has provided mixed results regarding its effectiveness.

METHODS

Data from the Quality Outcomes Database (QOD) was queried between April 2013 and January 2019. Three surgical groups were identified: (1) elective lumbar surgery, (2) elective cervical surgery for myelopathy, (3) elective cervical surgery for radiculopathy. Patients without PD were propensity matched against patients with PD in a 5:1 ratio without replacement based on American Society of Anesthesiology grade, arthrodesis, surgical approach, number of operated levels, age, and baseline Oswestry Disability Index, Numerical Rating Scale (NRS) extremity pain, NRS back pain, and EuroQol 5-Dimensions (EQ-5D). The mean difference was calculated for continuous outcomes (Oswestry Disability Index, NRS leg pain, NRS back pain, and EQ-5D at 3 and 12 mo after surgery) and the risk difference was calculated for binary outcomes (patient satisfaction, complications, readmission, reoperation, and mortality).

RESULTS

For the lumbar analysis, PD patients had a higher rate of reoperation at 12 months (risk difference=0.057, P =0.015) and lower mean EQ-5D score at 12 months (mean difference=-0.053, P =0.005) when compared with patients without PD. For the cervical myelopathy cohort, PD patients had lower NRS neck pain scores at 3 months (mean difference=-0.829, P =0.005) and lower patient satisfaction at 3 months (risk difference=-0.262, P =0.041) compared with patients without PD. For the cervical radiculopathy cohort, PD patients demonstrated a lower readmission rate at 3 months (risk difference=-0.045, P =0.014) compared with patients without PD.

CONCLUSION

For the matched analysis, in general, patients with and without PD had similar patient-reported outcomes and complication, readmission, and reoperation rates. These results demonstrate that a diagnosis of PD alone should not represent a major contraindication to elective spine surgery.

Postoperative Complication Rates After One-Level Cervical Spine Surgery in Patients with Parkinson Disease: A Database Study

OBJECTIVE

Parkinson disease (PD) is a risk factor for worse surgical outcomes. The degree to which PD affects outcomes in cervical spine surgery is not well understood. Therefore, we characterize rates of postoperative complications among patients with PD who undergo cervical spine surgery.

METHODS

Using the PearlDiver database, we identified patients who underwent 1-level anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), or discectomy/decompression with concomitant PD between 2011 and 2019. Patients with PD who underwent surgery and had 1 year follow-up were included. Complications 30, 60, and 90 days after surgery were identified and aggregated into body systems (e.g., respiratory and gastrointestinal). Comparison controls without concomitant PD who received cervical spine (C-spine) surgery were matched for age, sex, and comorbidities.

RESULTS

A total of 259,443 ACDFs, 30,929 PCFs, and 29,563 decompressions were identified. Of these procedures, 1117 were performed on patients with PD (0.35%). The highest 90-day complications rates in patients with PD were pulmonary and gastrointestinal related (6.05%) in those who received ACDF, neuro related (8.51%) in those who received PCF, and genitourinary related (8.76%) in those who received a decompression. Compared with patients without PD, postoperative complications rates were similar and not significantly different.

CONCLUSIONS

Patients with PD who receive ACDF have higher rates of pulmonary (6.05%), neurologic (5.24%), and psychiatric (3.23%) complications at 90 days. The differences did not reach statistical significance. This finding suggests that patients with PD do not experience higher rates of acute postoperative complications when undergoing 1-level cervical spine surgery.

Thoracolumbar Instrumentation Surgery in Patients with Parkinson's Disease: A Case-Control Study

BACKGROUND

 With increasing prevalence of Parkinson's disease (PD), instrumentation surgery of the thoracolumbar spine of PD patients grows in importance. Poor operative results with high rates of revision surgery have been reported. The goal of this study was to compare the biomechanical complications of thoracolumbar instrumentation surgery of patients with and without PD.

METHODS

 In a retrospective case-control study, we compared 16 PD patients with a matched cohort of 104 control patients regarding the following postinstrumentation complications: (1) adjacent joint disease, (2) material failure, and (3) material loosening. Also, we compared the spinal bone density, which is the main prognostic criteria for failed instrumentation surgery, between the groups.

RESULTS

 We found the rate of material revision to be significantly higher in PD patients (43.8 vs. 13.5%, p = 0.008, odds ratio (OR) = 5.0). Furthermore, the indications for revision surgery differed between the groups, with more hardware failures in the PD group and more adjacent segment degeneration in the control group. PD patients profited from modern operation techniques (percutaneous instrumentation and CT-navigated screw implantation). Hospitalization was significantly longer for PD patients (20.2 ± 15.1 vs. 14.1 ± 8.9 days, p = 0.03).

CONCLUSION

 PD patients exhibit challenging biomechanical demands on instrumenting the spine. Besides osteoporosis, especially sagittal imbalance, gait disturbance, and altered muscle tone may be contributive. PD patients may particularly profit from navigated and less invasive surgical techniques.

Spinal Surgery after Bilateral Subthalamic Stimulation for Patients with Parkinson's Disease: A Retrospective Outcome Analysis of Pain and Functional Control

Parkinson’s disease (PD) patients often suffer from spinal diseases requiring surgeries, although the risk of complications is high. There are few reports on outcomes after spinal surgery for PD patients with deep brain stimulation (DBS). The objective of this study was to explore the data on spinal surgery for PD patients with precedent DBS. We evaluated 24 consecutive PD patients with 28 spinal surgeries from 2007 to 2017 who received at least a 2-year follow-up. The characteristics and outcomes of PD patients after spinal surgery were compared to those of 156 non-PD patients with degenerative spinal diseases treated in 2013–2017. Then, the characteristics, outcomes, and spinal alignment of PD patients receiving DBS were analyzed in degenerative spinal/lumbar diseases. The mean age at the time of spinal surgery was 68 years. The Hoehn and Yahr score regarding PD was stage 1 for 8 patients, stage 2 for 2 patients, stage 3 for 8 patients, stage 4 for 10 patients, and stage 5 for 0 patient. The median preoperative L-DOPA equivalent daily dose was 410 mg. Thirteen patients (46%) received precedent subthalamic nucleus (STN) DBS. Lumbar lesions with pain were common, and operation and anesthesia times were long in PD patients. Pain and functional improvement of PD patients persisted for 2 years after surgery with a higher complication rate than for non-PD patients. PD patients with STN DBS maintained better lumbar lordosis for 2 years after spinal surgery. STN DBS significantly maintained spinal alignment with subsequent pain and functional amelioration 2 years after surgery. The outcomes of spinal surgery for PD patients might be favorably affected by thorough treatment for PD including DBS.

Outcomes of Patients With Parkinson Disease Undergoing Cervical Spine Surgery for Radiculopathy and Myelopathy With Minimum 2-Year Follow-up

STUDY DESIGN

This was a retrospective cohort analysis.

OBJECTIVE

To identify the impact of Parkinson disease (PD) on 2-year postoperative outcomes following cervical spine surgery (CSS).

SUMMARY OF BACKGROUND DATA

(PD) patients are prone to spine malalignment and surgical interventions, yet little is known regarding outcomes of CSS among PD patients.

MATERIALS AND METHODS

All patients from the Statewide Planning and Research Cooperative System with cervical radiculopathy or myelopathy who underwent CSS were included; among these, those with PD were identified. PD and non-PD patients (n=64 each) were 1:1 propensity score-matched by age, sex, race, surgical approach, and Deyo-Charlson Comorbidity Index (DCCI). Demographics, hospital-related parameters, and adverse postoperative outcomes were compared between cohorts. Logistic regression identified predictive factors for outcomes.

RESULTS

Overall, patient demographics were comparable between cohorts, except that DCCI was higher in PD patients (1.28 vs. 0.67, P=0.028). PD patients had lengthier mean hospital stays than non-PD patients (6.4 vs. 4.1 d, P=0.046). PD patients also incurred comparable total hospital expenses ($69,565 vs. $57,388, P=0.248). Individual medical complication rates were comparable between cohorts; though PD patients had higher rates of postoperative altered mental status (4.7% vs. 0%, P=0.08) and acute renal failure (10.9% vs. 3.1%, P=0.084), these differences were not significant. Yet, PD patients experienced higher rates of overall medical complications (35.9% vs. 18.8%, P=0.029). PD patients had comparable rates of individual and overall surgical complications. The PD cohort underwent higher reoperation rates (15.6% vs. 7.8%, P=0.169) compared with non-PD patients, though this difference was not significant. Of note, PD was not a significant predictor of overall 2-year complications (odds ratio=1.57, P=0.268) or reoperations (odds ratio=2.03, P=0.251).

CONCLUSION

Overall medical complication rates were higher in patients with PD, while individual medical complications as well as surgical complication and reoperation rates after elective CSS were similar in patients with and without PD, though PD patients required longer hospital stays. Importantly, a baseline diagnosis of PD was not significantly associated with adverse two-year medical and surgical complications. This data may improve counseling and risk-stratification for PD patients before CSS.

LEVEL OF EVIDENCE

Level III.

Complications after Spinal Surgery in Patients with Parkinson’s Disease

Background:

Several studies have shown that spinal surgeries in patients who suffer from Parkinson’s Disease have a high rate of complications. These patients often need revision surgery.

Objective:

This is a retrospective study involving 21 patients with Parkinson’s Disease. This study aimed to examine the complications after spinal surgery.

Methods:

We studied 21 patients with Parkinson’s Disease retrospectively, who had undergone a previous operation by the same surgeon between 2004 to 2019. There were 11 females and 10 males. The mean age was 71.9 years (range, 52 to 85). However, the initial diagnosis and types of surgery were different. The mean time of follow-up for each patient was 3.6 years (ranging from 2 to 8 years).

Results:

Most of the patients had a post-operative complication within a period of three years. Τhe most common complication was kyphotic deformity and camptocormia. Twelve patients (57.1%) underwent revision surgery, and three patients (14.2%) denied treatment. In four patients (19.04%), kyphotic deformity or stooped posture remained. Only one patient (4.7%) presented with no complication in a follow-up of 8 years.

Conclusion:

Patients with Parkinson’s disease have a high rate of complications after spinal surgery and often need revision surgery. For this literature review, the overall number of patients was 502, and the mean revision rate was 43.6%. The surgeon must inform patients of possible complications, and a thorough post-operative observation must be implemented.

Surgery for spinal deformity in Parkinson's disease patients: What are we missing?

INTRODUCTION

Deformity associating coronal and sagittal malalignment can severely impair quality of life in Parkinson's disease (PD). Realignment using patient-specific rods (PSRs) is useful for achieving alignment goals.

METHODS

This was a retrospective single-center analysis of a prospectively maintained database of all PD patients who underwent surgery between January 2013 and January 2017. Clinical evaluation, preoperatively and at 1 year's follow-up, used the Oswestry Disability Index (ODI). Radiological evaluation used systematic preoperative and 1-year postoperative full-spine radiographs.

RESULTS

Twelve patients were included: 6 female, 6 male; mean age, 68.4 years. Mean follow-up was 40.8 months [range 12-70]. On average, 14 levels were fused [range 10-18]. Unplanned revision surgery was necessary for 8 patients at a mean 15.625 months after index surgery. Mean preoperative ODI score was 64% preoperatively [range 56-70] versus 52% [range 28-64] at 1 year's follow-up (P=0.004). Lumbar lordosis improved significantly, from -16.7° preoperatively to -41.4° at 1 year (P=0.006). Pelvic tilt was the least effectively corrected parameter, with a mean preoperative value of 31.6° vs. 27.8° at 1 year (P=0.19). Mean preoperative sagittal vertical axis was 149.7mm versus 73.6mm at 1 year (P=0.013). Mean preoperative coronal tilt was 68.2mm versus 22.9mm at 1 year (P=0.007).

CONCLUSION

Parkinson's disease is a degenerative disease frequently associated with major spine malalignment. The severity of the postural disorders in these patients needs special precautions to avoid complications.

Multimodal treatment including lumbar facet joint denervation for severe low back pain in patients with neuromuscular disorders

BACKGROUND

Severe low back pain (LBP) is an occasional complaint in patients with neuromuscular disorders (NMDs). Accurate diagnosis and treatment are required to manage LBP; however, the precise pathophysiology differs for each patient. This study aimed to evaluate the efficacy of lumbar facet joint denervation (FJD) and adjunctive modalities in the treatment of LBP in patients with NMD-associated kyphoscoliosis.

METHODS

A total of 16 patients (22 sites) with NMD (bilateral, n = 6; unilateral, n = 10) and LBP treated with lumbar FJD were evaluated. The patients were divided into two groups: those treated with FJD alone (group 1) and those treated with multimodal treatment, including FJD along with radiofrequency ablation for sacroiliac joint pain, piriform muscle block, botulinum toxin injection into the paraspinal muscles, spinal cord stimulation, or any of their combinations (group 2). All patients were followed up for 48 weeks postoperatively. The two groups were compared with respect to the duration required for improvements in LBP by more than 50% (numerical rating scale ≤ 5).

RESULTS

There was no significant difference between the groups regarding the age, duration since the onset of Parkinson's syndrome, and radiographic analysis. The effective period of improved pain was greater in group 2 than in group 1 (30.7 vs. 8.4 weeks, P < 0.01).

CONCLUSIONS

Multimodal treatment including FJD is safe and relatively effective in patients with NMD-associated kyphoscoliosis. Hence, it is a potential substitute for conventional spinal fixation surgery, which has a higher risk of complications.

Sagittal alignment changes and postoperative complications following surgery for adult spinal deformity in patients with Parkinson's disease: a multi-institutional retrospective cohort study

Background

Parkinson’s disease (PD) has been found to increase the risk of postoperative complications in patients with adult spinal deformity (ASD). However, few studies have investigated this by directly comparing patients with PD and those without PD.

Methods

In this multicenter retrospective cohort study, we reviewed all surgically treated ASD patients with at least 2 years of follow-up. Among them, 27 had PD (PD+ group). Clinical data were collected on early and late postoperative complications as well as any revision surgery. Radiographic parameters were evaluated before and immediately after surgery and at final follow-up, including sagittal vertical axis (SVA), thoracic kyphosis, lumbar lordosis, sacral slope, and pelvic tilt. We compared the surgical outcomes and radiographic parameters of PD patients with those of non-PD patients.

Results

For early complications, the PD+ group demonstrated a higher rate of delirium than the PD− group. In terms of late complications, the rate of non-union was significantly higher in the PD+ group. Rates of rod failure and revision surgery due to mechanical complications also tended to be higher, but not significantly, in the PD+ group (p = 0.17, p = 0.13, respectively). SVA at final follow-up and loss of correction in SVA were significantly higher in the PD+ group.

Conclusion

Extra attention should be paid to perioperative complications, especially delirium, in PD patients undergoing surgery for ASD. Furthermore, loss of correction and rate of non-union were greater in these patients.

Spinal Surgery for Parkinson Disease With Camptocormia: Propensity Score-Matched Cohort Study With Degenerative Sagittal Imbalance (DSI)

STUDY DESIGN

A propensity score-matched cohort study.

OBJECTIVE

The objective of this study was to compare the radiologic and clinical outcomes of camptocormia in Parkinson disease (PD) with degenerative sagittal imbalance (DSI) patients.

SUMMARY OF BACKGROUND DATA

Camptocormia in PD and DSI could be characterized by a dynamic deformity. However, no study has directly evaluated the outcomes of patients with camptocormia and DSI.

METHODS

Thirteen consecutive PD patients undergoing surgical correction for camptocormia were matched in a 1-to-2 format with 26 patients in the DSI group by propensity score-matching. Radiologic outcomes, including paravertebral muscle changes, and clinical outcomes were compared between the 2 groups. The rate of proximal junctional problems and reoperations were assessed.

RESULTS

PD patients with camptocormia had significantly greater preoperative coronal and sagittal malalignments (29.9 vs. 16.9 mm, P=0.019; 142.8 vs. 64.4 mm, P=0.0001, respectively) and weakness of paravertebral muscles compared with the DSI patients. Regarding the clinical outcomes, reoperations were significantly higher in the camptocormia group, compared with the DSI group (53.8% vs. 7.7%, P=0.001). Moreover, proximal junctional failure was developed in 8 patients in the camptocormia group, while 1 patient in the DSI group (61.5% vs. 3.8%, P=0.0001). In subgroup analysis, independent risk factors for the proximal junctional failure were the total fusion levels (hazard ratio=0.26, P=0.018) and the degree of fatty changes of the paravertebral muscles (hazard ratio=1.15, P=0.048).

CONCLUSIONS

PD patients undergoing spinal surgery for camptocormia had global malalignment and higher rates of complications compared with DSI patients. Patients should be appropriately counseled regarding the increased risk of operative complications and closely followed for incipient failure.

Minimally Invasive Scoliosis Correction in Parkinson Disease: Retrospective Case Series

BACKGROUND

Parkinson disease (PD) is the second most common neurodegenerative disease in the United States. In the context of the disability inherent to PD, the additional physical challenges and pain from scoliosis can be debilitating for these patients. However, the magnitude of surgery required to correct the deformity combined with the medical co-morbidities and frailty in this population of patients makes surgery very risky.

OBJECTIVE

To investigate clinical presentations and outcomes of patients with PD that underwent minimally invasive long-segment fusion for scoliosis correction.

METHODS

A retrospective chart review was performed over the years 2007 to 2017 for patients diagnosed with PD undergoing long-segment spinal fusion (5 or more levels) with the use of circumferential minimally invasive spine surgery techniques. Data including age, sex, race, medical co-morbidities, presenting symptoms, radiographic findings, surgical procedure, case history, and complications were collected from the medical record.

RESULTS

Retrospective chart review revealed three patients that met the inclusion criteria. They included 2 males and 1 female, with a mean age of 68.7 yr (range 63-75 yr). Ability to maintain upright posture, return to activities of daily living, and visual analog scale (VAS)-back improved in all patients at 1-yr follow-up. Results were durable at 2-yr follow-up. No medical complications were observed.

CONCLUSION

The generally positive results suggest that minimally invasive technique could have significant benefits in this high-risk group of patients.

Acute Spinal Cord Contusion in a Patient with Multiple Upper Cervical Fractures, Parkinson's Disease, and Torticollis: Surgical Management

Case Report. Spine surgery in patients with Parkinson's disease (PD) involves increased risk. We describe a case of cervical myelopathy in a patient with PD, multiple fractures involving the atlas and axis vertebrae, and spasmodic torticollis. The patient was successfully treated with an upper cervical decompression and occipital-cervical (OC) fusion surgery. Strategies for torticollis reduction and successful surgical outcome are discussed. Risks and benefits must be carefully weighed when considering occipital cervical fusion in PD patients. Conclusion. Intraoperative manual reduction of laterocollis is possible after general endotracheal anesthesia, and continuous neuromonitoring is established. Use of optimizing strategies such as perioperative botulinum injections and intraoperative O-arm navigation should be considered.

[Surgical challenges with spinal balance in adult spinal deformities-the forgotten coronal plane]

This article gives a brief overview of the importance, planning and correction of coronal spinal imbalance in patients with adult and pediatric spinal deformity.

Adult Spinal Deformity Surgery in Patients With Movement Disorders: A Propensity-matched Analysis of Outcomes and Cost

STUDY DESIGN

This was a retrospective study using national administrative data from the MarketScan database.

OBJECTIVE

To investigate the complication rates, quality outcomes, and costs in a nationwide cohort of patients with movement disorders (MD) who undergo spinal deformity surgery.

SUMMARY OF BACKGROUND DATA

Patients with MD often present with spinal deformities, but their tolerance for surgical intervention is unknown.

METHODS

The MarketScan administrative claims database was queried to identify adult patients with MD who underwent spinal deformity surgery. A propensity-score match was conducted to create two uniform cohorts and mitigate interpopulation confounders. Perioperative complication rates, 90-day postoperative outcomes, and total costs were compared between patients with MD and controls.

RESULTS

A total of 316 patients with MD (1.7%) were identified from the 18,970 undergoing spinal deformity surgery. The complication rate for MD patients was 44.6% and for the controls 35.6% (P = 0.009). The two most common perioperative complications were more likely to occur in MD patients, acute-posthemorrhagic anemia (26.9% vs. 20.8%, P < 0.05) and deficiency anemia (15.5% vs. 8.5%, P < 0.05). At 90 days, MD patients were more likely to be readmitted (17.4% vs. 13.2%, P < 0.05) and have a higher total cost ($94,672 vs. $85,190, P < 0.05). After propensity-score match, the overall complication rate remained higher in the MD group (44.6% vs. 37.6%, P < 0.05). 90-day readmissions and costs also remained significantly higher in the MD cohort. Multivariate modeling revealed MD was an independent predictor of postoperative complication and inpatient readmission. Subgroup analysis revealed that Parkinson disease was an independent predictor of inpatient readmission, reoperation, and increased length of stay.

CONCLUSION

Patients with MD who undergo spinal deformity surgery may be at risk of higher rate of perioperative complications and 90-day readmissions compared with patients without these disorders.

LEVEL OF EVIDENCE

3.

Extensive Spinal Fusion Surgery in Patients With Parkinson Disease or Atypical Parkinsonism: Time Course of Clinical Outcomes in 5 Years Progress Report

STUDY DESIGN

A retrospective case series.

OBJECTIVE

To clarify the mid-term results of extensive spinal fusion surgery in patients with Parkinson disease (PD) or atypical Parkinsonism, especially with respect to their activities of daily living (ADL) over time SUMMARY OF BACKGROUND DATA.: Postural disorders associated with PD lead to spinal imbalance and deformity, resulting in significant disabilities. Clinical outcomes of extensive fusion surgeries in patients with PD over a medium-term follow-up period are currently unknown.

METHODS

Patients with PD who underwent extensive fusion surgery more than 5 years prior were included. The patients' backgrounds, surgical and radiographic parameters, perioperative and mechanical complications, and indoor ADL over time were assessed. To assess the activities of severely disabled patients, indoor ADL was classified into four stages: independent; or cane, walker, and wheelchair use.

RESULTS

Twenty-two patients (mean age, 70.6 yrs) were included. The mean blood loss, duration of surgery, and fusion levels were 2039 mL, 424 minutes, and 11.9 levels, respectively. Sagittal vertical axis improved from 220 mm preoperatively to 95 mm postoperatively. Perioperative complications were observed in 17 cases (77%). Before surgery, 1, 5, 12, and four cases were independent in ADL, T-cane, walker, and wheelchair use, respectively, which improved to seven, four, six, and four, respectively in 1 year. Revision surgeries were performed in eight patients (36%) within 3 years of surgery. In the 3 to 5 years after the surgery, the ADL of nine patients worsened due to deterioration of PD. Fifteen cases were followed up over 5 years, at which one, two, four, and seven cases were independent in ADL, cane, walker, and wheelchair use, respectively.

CONCLUSION

Surgical intervention in PD patients with spinal deformities leads to good short-term outcomes; however, the patients' conditions deteriorated because of complications within 3 years and worsening of PD over 3 years after the surgery.

LEVEL OF EVIDENCE

4.

A National Snapshot Detailing the Impact of Parkinson's Disease on the Cost and Outcome Profiles of Fusion Procedures for Cervical Myelopathy

BACKGROUND

Studies suggest a higher prevalence of cervical deformities in Parkinson's Disease (PD) patients who predispose to cervical myelopathy (CM). Despite the profound effect of CM on function and quality of life, no study has assessed the influence of PD on costs and outcomes of fusion procedures for CM.

OBJECTIVE

To conduct the first national-level study that provides a snapshot of the current outcome and cost profiles for different fusion procedures for CM in PD and non-PD populations.

METHODS

Patients with or without PD who underwent cervical decompression and fusion anteriorly (ACDF), posteriorly (PCDF), or both (Frontback), for CM were identified from the 2013 to 2014 National Inpatient Sample using International Classification of Disease codes.

RESULTS

A total of 75 870 CM patients were identified, with 535 patients (0.71%) also having PD. Although no difference existed between in-hospital mortality rates, overall complication rates were higher in PD patients (38.32% vs 22.05%; P < .001). PD patients had higher odds of pulmonary (P = .002), circulatory (P = .020), and hematological complications (P = .035). Following ACDFs, PD patients had higher odds of complications (P = .035), extended hospitalization (P = .026), greater total charges (P = .003), and nonhome discharge (P = .006). Although PCDFs and Frontbacks produced higher overall complication rates for both populations than ACDFs, PD status did not affect complication odds for these procedures.

CONCLUSION

PD may increase risk for certain adverse outcomes depending on procedure type. This study provides data with implications in healthcare delivery, policy, and research regarding a patient population that will grow as our population ages and justifies further investigation in future prospective studies.

Patients with Parkinson Disease Experience Increased Perioperative Complications Following Cervical Decompression and Fusion: A Retrospective Review of the National Inpatient Sample

BACKGROUND

Despite improved medical management, the incidence of spinal pathology remains high in patients with Parkinson disease (PD). Several studies have investigated lumbar spine surgery in this population, but data regarding costs and perioperative complications for patients undergoing cervical decompression/fusion on a nationwide scale are lacking.

METHODS

Cases of cervical spinal decompression, fusion, or exploration in years 2008-2014 were collected via the Healthcare Cost and Utilization Project National Inpatient Sample. Demographics, complications, outcome, and total charges were compared in patients with and without PD (NPD). Confounding variables were identified for multivariate analysis.

RESULTS

Data were available for 195,341 cervical spine cases, of which PD was prevalent in 779 cases (0.4%). Cases with PD experienced greater overall complication rates (12.5 vs. 7.6%; P < 0.001). Multivariate analysis revealed longer lengths of stay for the PD cohort (mean = 1.21 days longer; P < 0.001) and decreased routine discharge (odds ratio = 0.308; P < 0.001). There was no significant difference in mean total charges between PD and NPD (-$1532; P = 0.337). Mortality rates did not significantly differ for either group.

CONCLUSIONS

Although patients with PD experience greater complication rates and non-home discharges following cervical spine surgery compared with NPD patients, the overall clinical impact of these results may be minimal relative to surgery at other spinal levels in this population.

The fate of thoracolumbar surgeries in patients with Parkinson's disease, and analysis of risk factors for revision surgeries

Background

Compared to patients without Parkinson’s disease (PD), patients with PD who underwent spinal surgeries were reported to have a relatively high complication rate. However, studies that analyze surgical risk factors for these patients are limited.

Methods

From October 2004 to April 2015, patients with PD who underwent spinal surgeries at our department were reviewed. Patients who underwent lumbar or thoracolumbar instrumented surgeries due to degeneration or deformity disease were included. Any reason for revision surgery was recorded. Risk factors including patients’ factors, surgical factors, and lumbo-pelvic radiographic parameters were analyzed. Patients’ factors included patients’ underlying diseases, body mass index (BMI), osteoporotic status, and PD’s severity using the modified Hoehn and Yahr staging scale. Surgical factors included surgical levels, extending to thoracic spine or not, corrective osteotomy, with anterior approach or not, and interbody device. Radiographic parameters included lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), coronal Cobb’s angles, and score for spino-pelvic realignment achievement.

Results

A total of 66 patients were enrolled. The mean age at surgery was 69.0 years old. The mean follow-up time was 51.2 months. Twenty-six revision surgeries were required in 19 patients (29%). Risk factors for revision surgery included modified Hoehn and Yahr stage ≥3 (p <  0.001), cancer history (p = 0.024), osteoporosis (P = 0.012) and underwent corrective osteotomy (p = 0.035). According to binary logistic regression analysis, the modified Hoehn and Yahr stage ≥3 (p <  0.001) was the only independent risk factor. The Kaplan-Meier analysis revealed patients with long instrumentation (surgical levels > 3), T-spine instrumentation, and lower score of spino-pelvic realignment achievement tended to have earlier revision.

Conclusion

For PD patients planning for elective thoracolumbar surgery, aggressive control status of PD before or after surgery is necessary to prevent surgical complications. Longer surgical levels and corrective osteotomy also tended to have earlier revision. A better score in spino-pelvic realignment achievement after surgery could reduce occurrence of revision.

Analysis of Relationships between Spinal Deformity and Walking Ability in Parkinson's Disease Patients

Introduction

This study aimed to determine impacts on walking ability of spinal deformity and imbalance as distinct from movement disorders in Parkinson's disease (PD).

Methods

Thirty-two patients (15 males, 17 females; mean age 72.5 years) were analyzed. Three, thirteen, eleven, and five were at Hoehn-Yahr stages I, II, III, and IV, respectively. In addition to various spinal imbalance and deformity classifications the following were assessed: Cobb angle (CA) for scoliosis, thoracic kyphosis (TK) at T2-12, thoracolumbar kyphosis(TLK) at T12-L2, lumbar lordosis(LL) at L1-S1, pelvic tilt(PT), pelvic incidence(PI), and sagittal vertical axis(SVA). The Timed Up and Go (TUG) test was used to measure walking ability. Patients were evaluated using the Unified Parkinson's Disease Rating Scale (UPDRS) part III, and bone mineral density (BMD) scans.

Results

Nineteen patients (59%) had spinal deformity and imbalance within the following classifications: thoracic scoliosis, 1; thoracic kyphosis, 2; lumbar scoliosis, 15; Pisa syndrome, 3; camptocormia, 2. Mean values were 20.0° CA for scoliosis, 42.3° TK, 14.8° TLK, 26.7° LL, 20.8° PT, 48.8° PI, and 66.4 mm SVA. The mean TUG score was 13.9s. The UPDRS III mean was 36.6±24.5 points. Mean BMD was 0.856 g/cm² at lumbar L2-4 and 0.585 g/cm² at the femoral neck. UPDRS part III (P<0.001), LL (P<0.05), and femoral neck BMD (P<0.05) significantly correlated to TUG test results.

Conclusions

Distinct from the movement disorders of PD (UPDRS III), loss of normal LL and loss of BMD at the femoral neck were shown to be correlated with diminished walking ability (TUG test) in PD patients. When UPDRS improved in response to L-dopa, walking ability improved. In addition to any PD-specific interventions that contribute to the maintenance of ambulation, interventions specific to the restoration of LL, as well as early treatment for osteoporosis may positively affect HRQOL in PD.

Risk Factors for Cement Loosening after Vertebroplasty for Osteoporotic Vertebral Fracture with Intravertebral Cleft: A Retrospective Analysis

STUDY DESIGN

Retrospective case-control study.

PURPOSE

To evaluate the primary outcomes and radiographic results of percutaneous vertebroplasty (PVP) in patients with singlelevel osteoporotic vertebral fracture (OVF) with intravertebral cleft (IVC) to identify the risk factors for cement loosening after PVP.

OVERVIEW OF LITERATURE

PVP is a widely accepted method for managing painful OVF; however, cement loosening occasionally occurs with poor outcomes.

METHODS

This retrospective study involved 195 patients treated with PVP for single-level OVF with IVC. Six months thereafter, the primary outcomes were evaluated using the Visual Analog Scale (VAS) for back pain and the modified Oswestry Disability Index. Computed tomography was conducted to detect cement loosening. Possible risk factors, such as age, sex, wedging angle, intravertebral instability, Parkinson's disease, spinous process fracture, ankylosing spinal hyperostosis, split vertebrae, and adjacent intervertebral vacuum, were assessed.

RESULTS

Forty-nine patients (25%) experienced cement loosening 6 months after PVP. The mean VAS scores were significantly higher in patients with cement loosening than in those without (50 vs. 26 mm, respectively; p <0.01). Cement loosening was closely associated with intravertebral instability (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.04-1.40; p =0.015), Parkinson's disease (OR, 54.31; 95% CI, 4.47-659.53; p =0.002), spinous process fracture (OR, 7.11; 95% CI, 1.65-30.60; p =0.009), and split vertebrae (OR, 11.59; 95% CI, 1.64-82.02; p =0.014).

CONCLUSIONS

Patients with cement loosening experienced worse back pain than those without cement loosening. The important risk factors that influenced cement loosening after PVP were high intravertebral instability, Parkinson's disease, spinous process fracture, and split vertebrae.

The Effect of Parkinson's Disease on Patients Undergoing Lumbar Spine Surgery

Study Design

Retrospective Database Analysis.

Objective

The purpose of this study was to assess characteristics and outcomes of patients with Parkinson's disease (PD) undergoing lumbar spine surgery for degenerative conditions.

Methods

The Nationwide Inpatient Sample was examined from 2002 to 2011. Patients were included for study based on ICD-9-CM procedural codes for lumbar spine surgery and substratified to degenerative diagnoses. Incidence and baseline patient characteristics were determined. Multivariable analysis was performed to determine independent risk factors increasing incidence of lumbar fusion revision in PD patients.

Results

PD patients account for 0.9% of all degenerative lumbar procedures. At baseline, PD patients are older (70.7 versus 58.9, p < 0.0001) and more likely to be male (58.6% male, p < 160.0001). Mean length of stay (LOS) was increased in PD patients undergoing lumbar fusion (5.1 days versus 4.0 days, p < 0.0001) and lumbar fusion revision (6.2 days versus 4.8 days, p < 180.0001). Costs were 7.9% (p < 0.0001) higher for lumbar fusion and 25.2% (p < 0.0001) higher for lumbar fusion revision in PD patients. Multivariable analysis indicates that osteoporosis, fluid/electrolyte disorders, blood loss anemia, and insurance status are significant independent predictors of lumbar fusion revision in patients with PD.

Conclusion

PD patients undergoing lumbar surgery for degenerative conditions have increased LOS and costs when compared to patients without PD.

Functional results and patient satisfaction after long fusion for spinal deformity in Parkinson's disease

BACKGROUND

Patients with Parkinson's disease often present abnormal posture or severe sagittal malalignment, causing significant disability. Surgical fusion is these cases shows high rates of complications, but may nevertheless provide functional benefit; however, this remains to be assessed.

HYPOTHESIS

Long fusion for patients with Parkinson's disease and postural disorder could alleviate disability despite the high risk of complications.

METHODS

We retrospectively reviewed 18 Parkinson patients treated by long fusion for spinal deformity. Functional results on the Oswestry Disability Index (ODI) and patient satisfaction were assessed at a minimum 2 years' follow-up. Predictive factors for good outcome were analyzed.

RESULTS

Median follow-up was 44.4 months (IQR, 36-62.4 months). ODI showed significant improvement, from 64 (IQR, 59-77) preoperatively to 49 (IQR, 40-57) at last follow-up (p=0.0014). Fifteen patients (83%) were very satisfied (n=5) or satisfied (n=10) with the procedure. On multivariate analysis, only age was significantly associated with improvement in ODI at last follow-up (estimate: -9.8; p=0.5).

DISCUSSION

Although long spinal fusion involves a high risk of complications in Parkinson's patients, the improvement in autonomy and patient satisfaction should be borne in mind before rejecting surgery, especially with motivated patients.

LEVEL OF EVIDENCE

IV.

Etiology and Management of Spinal Deformity in Patients With Parkinson's Disease

Patients with Parkinson's disease (PD) commonly develop severe spinal deformity, including scoliosis, antecollis, camptocormia, and Pisa syndrome. The etiology of PD-associated spinal deformity is not completely understood and in most cases is likely due to multiple interrelated factors, including central dystonia and focal myopathy. Once spinal deformity has occurred, surgery is often the only modality that can correct the condition, although control of the movement disorder through medication and deep brain stimulation may slow progression. Advances in spinal instrumentation and deformity correction techniques have improved the outcomes of PD spinal deformity patients, though complications and revision surgery rates remain high. Surgical intervention is reserved for individuals who are physiologically healthy and whose condition is refractory to nonoperative management and follows similar treatment principles as other causes of neuromuscular scoliosis/kyphosis. Spinal deformity patients with PD are optimally treated by spinal deformity surgeons who are familiar with the unique needs of PD patients, with vigilant preoperative and postoperative treatment of their movement disorder and bone density.

Surgical treatment of spinal disorders in Parkinson's disease

PURPOSE

Most patients suffering from Parkinson's disease (PD) exhibit alterations in the posture, which can in several cases give rise to spine deformities, both in the sagittal and the coronal plane. In addition, degenerative disorders of the spine frequently associated to PD, such as spinal stenosis and sagittal instability, can further impact the quality of life of the patient. In recent years, spine surgery has been increasingly performed, with mixed results. The aim of this narrative review is to analyze the spinal disorders associated to PD, and the current evidence about their surgical treatment.

METHODS

Narrative review.

RESULTS

Camptocormia, i.e., a pronounced flexible forward bending of the trunk with 7% prevalence, is the most reported sagittal disorder of the spine. Pisa syndrome and scoliosis are both common and frequently associated. Disorders to the spinopelvic alignment were not widely investigated, but a tendency toward a lower ability of PD patients to compensate the sagittal malalignment with respect to non-PD elderly subjects with imbalance seems to emerge. Spine surgery in PD patients showed high rates of complications and re-operations.

CONCLUSIONS

Disorders of the posture and spinal alignment, both in the sagittal and in the coronal planes, are common in PD patients, and have a major impact on the quality of life. Outcomes of spine surgery are generally not satisfactory, likely mostly due to muscle dystonia and poor bone quality. Knowledge in this field needs to be consolidated by further clinical and basic science studies. These slides can be retrieved under Electronic Supplementary Material.

Inpatient morbidity after spinal deformity surgery in patients with movement disorders

Background

To investigate the inpatient perioperative morbidity rate of patients with movement disorders (MD) after spinal deformity surgery.

Methods

The Nationwide Inpatient Sample database from 2002 to 2011 was queried to identify adult patients with MD who underwent spinal deformity surgery. Complication rates were compared between patients with MD and controls. A multiple logistic regression analysis was conducted to assess the effect of MD on outcome.

Results

A total of 365 patients with MD (3.3%) were identified among 11,043 patients undergoing surgery for spinal deformity. Patients with MD were on average 8 years older than the control group (67 vs. 59 years of age, P<0.001). The complication rate was 55.1% for patients with MD and 43.7% for patients without MD (P<0.001). The most common complication was acute post-hemorrhagic anemia, which occurred in 31.9% of all patients (41.6% in MD patients and 31.5% in the control group, P<0.001). Other complications that were more common in patients with MD included delirium (P<0.001), acute kidney injury (P=0.032), and pulmonary embolism (P=0.014). After controlling for patient age, sex, osteoporosis, complex procedures, fusion to the lumbosacral spine, use of bone morphogenetic protein, and use of blood transfusion, patients with MD were 1.3 times more likely to develop a complication compared to patients without MD [odds ratio (OR), 1.27; 95% confidence interval (CI), 1.02-1.59; P=0.032] on multiple logistic regression analysis. No significant difference in hospital stay was observed.

Conclusions

Patients with MD who undergo spinal deformity surgery may be at risk of higher rate of complications compared to patients without these disorders.

Management of Spinal Conditions in Patients With Parkinson Disease

Parkinson disease (PD) is increasingly prevalent in the aging population. Spine disorders in patients with PD may be degenerative in nature or may arise secondary to motor effects related to the parkinsonian disease process. Physicians providing care for patients with PD and spine pathologies must be aware of several factors that affect treatment, including the patterns of spinal deformity, complex drug interactions, and PD-associated osteoporosis. Following spine surgery, complication rates are higher in patients with PD than in those without the disease. Literature on spine surgery in this patient population is limited by small cohort size, the heterogeneous patient population, and variable treatment protocols. However, most studies emphasize the need for preoperative optimization of motor control with appropriate medications and deep brain stimulation, as well as consultation with a movement disorder specialist. Future studies must control for confounding variables, such as the type of surgery and PD severity, to improve understanding of spinal pathology and treatment options in this patient population.

Clinical Outcomes Following Surgical Management of Coexisting Parkinson Disease and Cervical Spondylotic Myelopathy

BACKGROUND

Distinguishing the causes of weakness and gait instability in patients with Parkinson disease (PD) and cervical spondylotic myelopathy (CSM) is a diagnostic and therapeutic challenge due to symptomatic similarities. No study has reported outcomes following decompression in patients with PD and CSM.

OBJECTIVE

To report outcomes following cervical decompression for patients with coexisting PD and CSM.

METHODS

A retrospective matched cohort study of all patients with PD and CSM undergoing cervical decompression at a tertiary-care center between January 1996 and December 2014 was conducted. PD patients were matched to patients with CSM alone by age, gender, American Society of Anesthesiologists classification, and operative parameters. Myelopathy was assessed by Nurick and modified Japanese Orthopaedic Association (mJOA) scales. The effect of PD on mJOA was modeled using multivariable regression.

RESULTS

Twenty-one matched pairs were included. PD patients experienced poorer improvement in Nurick (0.0 vs -1.0, P < .01) and mJOA (0.9 vs 2.5, P < .01) composite scores. However, no significant changes in absolute improvement in the upper extremity motor, upper extremity sensory, or sphincter mJOA components were observed. Multivariable regression identified PD as a significant predictor of decreased improvement in mJOA (β = -0.89, P < .01) and failure to achieve a minimal clinically important difference in change in mJOA (OR 0.18, P = .03).

CONCLUSION

This study is the first to characterize outcomes following cervical decompression in patients with PD and CSM. PD patients experienced symptomatic improvement but less overall improvement in myelopathy compared to controls. However, PD patients demonstrated improvement in upper extremity motor, upper extremity sensory, and sphincter symptoms no worse than control patients.

Lumbar Spinal Surgery in Patients With Parkinson Disease: A Multicenter Retrospective Study

STUDY DESIGN

A multicenter, retrospective study.

OBJECTIVE

To identify the factors that affect surgery-related complications and to clarify the surgical strategy for treating lumbar disorders in Parkinson disease (PD).

SUMMARY OF BACKGROUND DATA

Previous studies have reported a high complication rate for spinal surgery in patients with PD. Because of the limited number of studies, there are no guidelines for spinal surgery for PD patients.

METHODS

We retrospectively reviewed the records for 67 PD patients who underwent lumbar spinal surgery. The patients were divided into 3 groups: 12 patients underwent laminectomy (Laminectomy), 24 underwent fusion surgery (Fusion) for lumbar canal stenosis, and 31 underwent corrective surgery for spinal deformity (Deformity). We assessed surgery-related complications in each group. The Cox proportional hazards model was used to identify the factors that predicted surgical failure.

RESULTS

The percentages of patients who experienced failure of the initial surgery were 33.3% in the Laminectomy group, 45.8% in the Fusion group, and 67.7% in the Deformity group. The rates of implant failure were high in the Fusion and Deformity groups (33.3% and 38.7%, respectively). The Deformity group had a high rate of postoperative fracture (41.9%). These complications occurred at the most caudal site within a year after surgery and resulted in progression of kyphotic deformity. Multivariate analysis revealed that preoperative lumbar lordosis angle (LL) (per -1 degree) was associated with a failure of the initial surgery (hazard ratio, 1.024; 95% confidence interval, 1.008-1.04; P=0.003).

CONCLUSIONS

We have demonstrated that a small preoperative LL increases the risk for failure of the initial surgery. Attaining and maintaining the proper lumbar lordosis with rigid fixation may be necessary in PD patients with a small preoperative LL.

Evolution and complications after surgery for spine deformation in patients with Parkinson's disease

INTRODUCTION

Surgical treatment of spinal deformity is high risk in patients suffering from Parkinson's disease (PD). Several series have already reported a high rate of complications. However, none of these studies included more than 40 patients and none of the risk factors of complications were described. The aim of this study was to describe the rate and risk factors of revision surgery as well as the clinical outcome at the last visit in a large multicenter study of PD patients operated for spinal deformities.

METHODS

A multicenter retrospective study included arthrodesis for spinal deformity in patients with PD. Clinical and surgical data including revision surgeries were collected. Assessment of functional outcomes at last follow-up was classified in 3 grades and spinal balance was assessed on anteroposterior and lateral plain X-rays of the entire spine.

RESULTS

Forty-eight patients were included. Median age was 67 years old (range 41-80). Median follow-up was 27 months. The rate of surgical revision was 42%. Eighty per cent of revisions were performed for chronic mechanical complication. Global results were considered to be good in 17 patients (35%), doubtful in 17 patients (35%) and a failure in 14 patients (30%), for the whole series.

CONCLUSIONS

The results of surgery for spinal deformities in patients with Parkinson disease vary with a high rate of complications and revisions. Nevertheless, these results should be seen in relation to the natural progression of these spinal deformities once spinal imbalance has developed. The association between preoperative clinical balance and final outcome suggests that early surgery can probably play a role in treatment.

LEVEL OF EVIDENCE

Level IV (e.g. case series).

Is Decompressive Surgery for Cervical Spondylotic Myelopathy Effective in Patients Suffering from Concomitant Multiple Sclerosis or Parkinson's Disease?

A subset of patients with a demyelinating disease suffer from concurrent cervical spondylotic myelopathy, both of which evince similar symptomatology. Differentiating the cause of these symptoms is challenging, and little research has been done on patients with coexisting diseases. This review explores the current literature on the appropriate surgical management of patients with concurrent multiple sclerosis (MS) and cervical spondylotic myelopathy (CSM), and those with both Parkinson’s disease (PD) and CSM. MS and CSM patients may benefit from surgery to reduce pain and radiculopathy. Surgical management in PD and CSM patients has shown minimal quality-of-life improvement. Future studies are needed to better characterize demyelinating disease patients with concurrent disease and to determine ideal medical or surgical treatment.

Sagittal balance is correlated with Parkinson's Disease clinical parameters: an overview of spinopelvic alignment on 175 consecutive cases

PURPOSE

The aim of this study was to describe the disease-related sagittal balance changes in relation to the sacro-pelvic morphology of Parkinson's Disease patients with different duration of disease.

METHODS

One hundred and seventy-five consecutive Parkinson's Disease (PD) patients (102 males, 73 females; age: 55-83 years) participated in the cross-sectional study. The clinical assessment included: Hoehn Yahr (H&Y) score; Tinetti score; plumb line (PL) distance from the spinous process of C7, L3 and S1 and kyphosis apex. Lumbar lordosis (LL), thoracic kyphosis (TK), spinosacral (SSA) and spinopelvic (SPA) angles, spinal tilt, pelvic incidence (PI), sacral slope (SS) and pelvic tilt (PT) were radiographically assessed.

RESULTS

Spinosacral and spinopelvic were correlated with the duration of disease and Tinetti score, but not with age. We found a positive correlation between LL and both SSA and SPA. TK was significantly correlated with LL but not with pelvic parameters, while PI with SS and LL.

CONCLUSIONS

Female gender, high PI and high LL together with a low PL-C7 distance can be considered as protective factors for spinal imbalance and fall risk; negative factors are represented by male gender, longer disease duration, higher H&Y Class, and low PL-L3 distance. Looking at the pelvis is revealing new important insights in spinal disease management, both surgical and rehabilitative.

Characteristics of spinopelvic alignment in Parkinson's disease: Comparison with adult spinal deformity

PURPOSE

The characteristics and pathogenesis of spinopelvic alignment in Parkinsons's disease (PD) patients-including differences compared to non-PD subjects and their relationships with the severity of PD-have not been clarified. The aim of this study was to investigate the characteristics of spinopelvic alignment in patients with PD.

METHODS

Forty-eight PD patients complaining of chronic low back pain were included (PD group). The PD condition, determined using the Hoehn and Yahr (H&Y) stage and Unified Parkinson Disease Rating Scale (UPDRS) score; radiographic spinopelvic alignment; lumbar range of motion (ROM); and low back pain-related quality of life assessments were evaluated. Fifty age- and sex-matched patients with adult spinal deformities were included as controls (ASD group).

RESULTS

The spinopelvic alignments of the PD/ASD groups demonstrated sagittal vertical axes of 120.9/106.3 mm and pelvic incidences of 49.7/52.9°, with no significant differences. Conversely, there were significant differences in the thoracic kyphosis (TK; 27.6/16.7°), lumbar lordosis (-22.7/-7.9°), and pelvic tilt (25.3/34.4°) (all, p < 0.05). With regard to correlations with the PD condition, the H&Y stage demonstrated significant correlations with the sagittal vertical axis, thoracolumbar kyphosis, and lumbar ROM (all, p < 0.05), and the UPDRS score tended to correlate with the TK and thoracolumbar kyphosis (both, p < 0.01).

CONCLUSION

Characteristic spinal conditions in PD exist, with progressed PD condition causing stooped posture with increased thoracic or thoracolumbar kyphosis and decreased lumbar ROM; moreover, global sagittal malalignment progresses without sufficient compensatory mechanisms such as loss of TK and pelvic retroversion.

Multiple Spinal Revision Surgery in a Patient with Parkinson's Disease

Parkinson's disease (PD) patients frequently have several spinal deformities leading to postural instabilities including camptocormia, myopathy-induced postural deformity, Pisa syndrome, and progressive degeneration, all of which adversely affect daily life activities. To improve these postural deformities and relieve the related neurologic symptoms, patients often undergo spinal instrumentation surgery. Due to progressive degenerative changes related to PD itself and other complicating factors, patients and surgeons are faced with instrument failure-related complications, which can ultimately result in multiple revision surgeries yielding various postoperative complications and morbidities. Here, we report a representative case of a 70-year-old PD patient with flat back syndrome who had undergone several revision surgeries, including anterior and posterior decompression and fusion for a lumbosacral spinal deformity. The patient ultimately benefitted from a relatively short segment fixation and corrective fusion surgery.

Quality of life outcomes following cervical decompression for coexisting Parkinson's disease and cervical spondylotic myelopathy

BACKGROUND CONTEXT

Coexisting Parkinson's disease (PD) and cervical spondylotic myelopathy (CSM) presents a diagnostic and therapeutic challenge due to symptomatic similarities between the diseases. Whereas CSM patients are routinely treated with surgery, PD patients face poorer outcomes following spine surgery. No studies have investigated the quality of life (QOL) outcomes following decompression in coexisting PD and CSM.

PURPOSE

The purpose of the present study was to characterize QOL outcomes for patients with coexisting PD and CSM following cervical decompression.

STUDY DESIGN/SETTING

This is a matched cohort study at a single tertiary-care center.

PATIENT SAMPLE

Patients with coexisting PD and CSM undergoing cervical decompression between June 2009 and December 2014 were included. These patients were matched to controls with CSM alone by age, gender, American Society of Anesthesiologists classification, Modified Japanese Orthopaedic Association scores, and operative parameters.

OUTCOME MEASURES

The primary outcome measure was QOL outcomes assessed by change in the EuroQol 5-Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire-9 (PHQ-9) at last follow-up (LFU). Change in QOL exceeding the minimal clinically important difference (MCID) was secondary.

METHODS

QOL data were collected using the institutional prospectively collected database of patient-reported health status measures. Simple and multivariable regressions were used to assess the impact of PD upon change in QOL.

RESULTS

Eleven PD patients were matched to 44 controls. Control patients experienced QOL improvement across all three measures, whereas PD patients only improved with respect to PDQ(89.9-80.7, p=.03). Despite no significant differences in preoperative QOL, PD patients experienced poorer QOL at LFU in EQ-5D (0.526 vs. 0.707, p=.01) and PDQ (80.7 vs. 51.4, p=.03), and less frequently achieved an EQ-5D MCID (18% vs. 57%, p=.04). However, no differences in the achievement of an MCID in PDQ or PHQ-9 were observed between cohorts. Multivariable regression identified PD as a significant independent predictor of poorer improvement in EQ-5D (β=-0.09, p<.01) and failure to achieve an EQ-5D MCID (odds ratio: 0.08, p<.01).

CONCLUSIONS

This is the first study to characterize QOL outcomes following cervical decompression for patients with coexisting PD and CSM. Although myelopathy may have been less severe among PD patients, a significant reduction in pain-related disability was observed following decompression. However, PD predicted diminished improvement in overall QOL measured by the EQ-5D.

Transforaminal Percutaneous Endoscopic Discectomy in Parkinson Disease: Preliminary Results and Short Review of the Literature

Objective

To study the effectiveness of Transforaminal Percutaneous Endoscopic Discectomy (TPED) for lumbar disc herniation in patients with Parkinson disease (PD).

Methods

Fifteen patients diagnosed with PD and lumbar disc hernia were recruited to the study. All patients underwent TPED. Mean age was 61.27±6 years, with 8 male (53.3%) and 7 female patients (46.7%). Level of operation was L3-4 (33.3%), L4-5 (33.3%) and L5-S1 (33.3%). Visual analogue scale (VAS) for leg pain and Oswestry Disabillity Index (ODI) for back pain, as well as the Medical Outcomes Study Questionnaire Short-Form 36 Health Survey (SF-36) for health-related quality of life (HRQoL) were assessed right before surgery and at 6 weeks, 3, 6, and 12 months after surgery.

Results

VAS and ODI showed significant (p<0.005) reduction one year after TPED, with a percentage improvement of 83.9% and 79.4%, respectively. Similarly, all aspects of quality of life (SF-36) were significantly (p<0.005) improved 1 year after the procedure. Bodily pain and role physical demonstrated the highest increase followed by role emotional, physical function, social function, vitality, mental health, and general health. Beneficial impact of TPED on clinical outcome and HRQoL was independent of gender and operated level.

Conclusion

TPED is effective in reducing lower limb symptoms and low back pain in patients with lumbar disc hernia, suffering from PD. Positive effect of endoscopy is, also, evident in HRQoL of those patients one year after the procedure.

Elective Thoracolumbar Spine Fusion Surgery in Patients with Parkinson Disease

OBJECTIVE

Few data are available concerning clinical outcomes in patients with Parkinson disease who undergo elective thoracolumbar spine fusion surgery. The goal of this study is to elucidate complication and revision rates after posterior thoracolumbar fusion surgery in patients with Parkinson disease, with a focus on how Parkinson disease modifies these rates.

METHODS

The PearlDiver database (2005-2012) was queried for patients who underwent posterior approach thoracolumbar fusion from 2006 to 2011. Cohorts of patients with a previous diagnosis of Parkinson disease (n = 4816) and without (n = 280,702) were compared. Multivariate analysis that included various comorbidities and demographics was used to calculate effects of Parkinson disease on development of postoperative infection and major medical complications within 90 days and revision surgery within 1 year. For analyses, significance was set at P < 0.001.

RESULTS

Major medical complications were observed in 545 patients (11.3%) for 90 days after the index procedure. Postoperative infection was noted in 91 patients (1.9%) within 90 days, and revision surgeries were performed in 250 patients (5.2%) within 1 year. Multivariate analysis showed that Parkinson disease was significantly associated with an increased risk for medical complications (adjusted odds ratio, 1.22; 95% confidence interval, 1.11-1.34; P < 0.001) and revision surgery (adjusted odds ratio, 1.70; 95% confidence interval, 1.49-1.93; P < 0.001), but not postoperative infection (P = 0.02).

CONCLUSIONS

Patients with Parkinson disease are more likely to require revision surgery and have higher rates of adverse medical events postoperatively. Patients with Parkinson disease should be appropriately selected to ensure favorable clinical outcomes.

Management of Spinal Deformity in Adult Patients With Neuromuscular Disease

A wide range of neuromuscular diseases, including Parkinson disease, cerebral palsy, multiple sclerosis, and myopathy, are associated with spinal deformities. The most common postural deformities include anterocollis, Pisa syndrome (pleurothotonus), scoliosis, and camptocormia. Nonsurgical management of spinal deformity in patients with neuromuscular disease centers on maximizing the medical management of the underlying neurodegenerative pathology before surgical intervention is contemplated. Surgical management can include decompression alone, or decompression and fusion with short or long fusion constructs. Patients with neuromuscular disease are susceptible to postoperative medical complications, such as delirium, epidural hematomas, pulmonary emboli, and cardiac events. Compared with outcomes in the typical patient with spinal deformity, postoperative outcomes in patients with neuromuscular disease have higher rates of surgical complications, such as instrumentation failure, proximal junctional kyphosis, loss of correction, and the need for revision surgery, regardless of the magnitude of surgical treatment.

Transforaminal Percutaneous Endoscopic Discectomy for Lumbar Disc Herniation in Parkinson's Disease: A Case-Control Study

Study Design

A case-control study.

Purpose

To investigate the effectiveness of transforaminal percutaneous endoscopic discectomy (TPED) in Parkinson's disease (PD).

Overview of Literature

Patients with PD frequently suffer from radiculopathy and low back pain. Additionally, they demonstrate higher complication rates after open spine surgery. However, the clinical outcome of minimally invasive techniques for lumbar discectomy, such as TPED, have not been established for this population.

Methods

Patients diagnosed with lumbar disc hernia were divided into Group A (11 patients diagnosed with PD), and Group B (10 patients as the control, non-PD group). All patients underwent TPED. Indexes of visual analogue scale (VAS) for leg pain and Oswestry disability index (ODI) were assessed right before surgery and at six weeks, three months, six months and one year post-surgery.

Results

At the baseline visit, groups did not differ significantly with age (p=0.724), gender (p=0.835), level of operation (p=0.407), ODI (p=0.497) and VAS (p=0.772). Parkinson's patients had higher scores in ODI at every visit, but the outcome was statistically significant only at 3 months (p=0.004) and one year (p=0.007). Similarly, VAS measurements were higher at each time point, with the difference being significant at 3 (p<0.001), 6 (0.021), and 12 (p<0.001) months after surgery. At the end of a year of follow up, ODI was reduced by 49.6% (±16.7) in Group A and 59.2% (±8.0) in Group B (p=0.111), translating to a 79.5% (±13.0) and 91.5% (±4.1) average improvement in daily functionality (p=0.024). VAS was reduced by 59.1 mm (±11.8) in Group A and 62.2 mm (±7.4) in Group B (p=0.485), leading to an 85.3 % (±4.0) and 91.9% (±2.6) general improvement in leg pain (p<0.001).

Conclusions

Our data indicate that TPED led to satisfactory improvement in leg pain and daily living in PD patients a year after surgery.

Pisa syndrome in Parkinson's disease and parkinsonism: clinical features, pathophysiology, and treatment

Pisa syndrome is defined as a reversible lateral bending of the trunk with a tendency to lean to one side. It is a frequent and often disabling complication of Parkinson's disease, and has also been described in several atypical forms of parkinsonism and in neurodegenerative and psychiatric disorders after drug exposure and surgical procedures. Although no consistent diagnostic criteria for Pisa syndrome are available, most investigations have adopted an arbitrary cutoff of at least 10° of lateral flexion for the diagnosis of the syndrome. Pathophysiological mechanisms underlying Pisa syndrome have not been fully explained. One hypothesis emphasises central mechanisms, whereby Pisa syndrome is thought to be caused by alterations in sensory-motor integration pathways; by contrast, a peripheral hypothesis emphasises the role of anatomical changes in the musculoskeletal system. Furthermore, several drugs are reported to induce Pisa syndrome, including antiparkinsonian drugs. As Pisa syndrome might be reversible, clinicians need to be able to recognise this condition early to enable prompt management. Nevertheless, further research is needed to determine optimum treatment strategies.

Pathophysiological Concepts and Treatment of Camptocormia

Camptocormia is a disabling pathological, non-fixed, forward bending of the trunk. The clinical definition using only the bending angle is insufficient; it should include the subjectively perceived inability to stand upright, occurrence of back pain, typical individual complaints, and need for walking aids and compensatory signs (e.g. back-swept wing sign). Due to the heterogeneous etiologies of camptocormia a broad diagnostic approach is necessary. Camptocormia is most frequently encountered in movement disorders (PD and dystonia) and muscles diseases (myositis and myopathy, mainly facio-scapulo-humeral muscular dystrophy (FSHD)). The main diagnostic aim is to discover the etiology by looking for signs of the underlying disease in the neurological examination, EMG, muscle MRI and possibly biopsy. PD and probably myositic camptocormia can be divided into an acute and a chronic stage according to the duration of camptocormia and the findings in the short time inversion recovery (STIR) and T1 sequences of paravertebral muscle MRI. There is no established treatment of camptocormia resulting from any etiology. Case series suggest that deep brain stimulation (DBS) of the subthalamic nucleus (STN-DBS) is effective in the acute but not the chronic stage of PD camptocormia. In chronic stages with degenerated muscles, treatment options are limited to orthoses, walking aids, physiotherapy and pain therapy. In acute myositic camptocormia an escalation strategy with different immunosuppressive drugs is recommended. In dystonic camptocormia, as in dystonia in general, case reports have shown botulinum toxin and DBS of the globus pallidus internus (GPi-DBS) to be effective. Camptocormia in connection with primary myopathies should be treated according to the underlying illness.