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

Abstract

Only a few reports exist concerning biomechanical challenges spine surgeons face when treating Parkinson's disease (PD) patients with spinal deformity. We recognized patients suffering from spinal deformity aggravated by the burden of PD to stress the principles of sagittal balance in surgical treatment. Treatment of sagittal imbalance in PD is difficult due to brittle bone and (the neuromuscular disorder) with postural dysfunction. We performed a retrospective review of 23 PD patients treated surgically for spinal disorders. Mean ASA score was 2.3 (2-3). Outcome analysis included review of medical records focusing on failure characteristics, complications, and radiographic analysis of balance parameters to characterize special risk factors or precautions to be considered in PD patients. The sample included 15 female and 8 male PD patients with mean age of 66.3 years (57-76) at index surgery and 67.9 years (59-76) at follow-up. 10 patients (43.5%) presented with the sequels of failed previous surgery. 18 patients (78.3%) underwent multilevel fusion (C3 level) with 16 patients (69.6%) having fusion to S1, S2 or the Ilium. At a mean follow-up of 14.5 months (1-59) we noted medical complications in 7 patients (30.4%) and surgical complications in 12 patients (52.2%). C7-sagittal center vertical line was 12.2 cm (8-57) preoperatively, 6.9 cm postoperatively, and 7.6 cm at follow-up. Detailed analysis of radiographs, sagittal spinal, and spino-pelvic balance, stressed a positive C7 off-set of 10 cm on average in 25% of patients at follow-up requiring revision surgery in 4 of them. Statistical analysis revealed that patients with a postoperative or follow-up sagittal imbalance (C7-SVL [10 cm) had a significantly increased rate of revision done or scheduled (p = 0.03). Patients with revision surgery as index procedure also were found more likely to suffer postoperative or final sagittal imbalance (C7-SPL, 10 cm; p = 0.008). At all, 33% of patients had any early or late revision performed. Nevertheless, 78% of patients were satisfied or very satisfied with their clinical outcome, while 22% were either not satisfied or uncertain regarding their outcome. The surgical history of PD patients treated for spinal disorders and the reasons necessitating redo surgery for recalcitrant global sagittal imbalance in our sample stressed the mainstays of spinal surgery in Parkinson's: If spinal surgery is indicated, the reconstruction of spinopelvic balance with focus on lumbar lordosis and global sagittal alignment is required.

Pedicle subtraction osteotomies (PSO) in the lumbar spine for sagittal deformities

“…This is especially true in case of a concomitant osteoporosis. Fusion to the higher thoracic spine is usually necessary in deformities with high SVA (more than 10-15 cm), in the presence of Parkinson's disease [21,22], osteoporosis and in patients who do not compensate with active extension of the thoracic spine [11] ( Table 2).…”

Spinopelvic balance: new biomechanical insights with clinical implications for Parkinson’s disease

“…In Parkinson's disease, the surgical correction of spinal deformities is featured by a high risk of short-and long-term complications [7]. As recently shown by Koller et al [7] post-surgical follow-up of PD spinal surgery presents medical and surgical complications, respectively, in 22 and 52 % of the cases, while 33 % of the patients have the possibility to receive further surgical procedures. According to these data, the achievement of a better understanding of pathological adaptation in PD patients' spine would be of interest in the prospective view of improving the conservative management including orthosis, exercise and behavioral treatments.…”

“…The understanding of the regulatory principles of sagittal balance is useful to achieve good outcomes when treating different spinal disorders in the field of orthopedic rehabilitation and spine surgery, especially when treating major deformities [3,7,8]. Indeed, the influence of sacropelvic balance and morphology has been widely evaluated in the literature concerning adult spinal deformity [12], adolescent idiopathic scoliosis [1,9], spondylolisthesis [14], and low back pain [13].…”

“…Compared to the amount of data regarding spinal deformities in patients not affected by neurological disease, scientific papers focusing on sacropelvic morphology and sagittal balance in patients affected by Parkinson's disease (PD) are represented by few case studies [11] or cohorts [7]. Nevertheless, the study of sacropelvic and sagittal balance in this population can be of particular interest because of their intrinsic correlation with postural modulation and the ongoing compensatory mechanisms involving lower limbs [1,3].…”

“…Nevertheless, the study of sacropelvic and sagittal balance in this population can be of particular interest because of their intrinsic correlation with postural modulation and the ongoing compensatory mechanisms involving lower limbs [1,3]. In Parkinson's disease, the surgical correction of spinal deformities is featured by a high risk of short-and long-term complications [7]. As recently shown by Koller et al [7] post-surgical follow-up of PD spinal surgery presents medical and surgical complications, respectively, in 22 and 52 % of the cases, while 33 % of the patients have the possibility to receive further surgical procedures.…”