Introduction: Coexisting Parkinson’s disease (PD) and cervical spondylotic myelopathy (CSM) presents a diagnostic and therapeutic challenge due to symptomatic similarities. While CSM is routinely treated with surgery, PD patients face poorer outcomes following spine surgery. No study has reported clinical outcomes following decompression in patients with PD and CSM. The purpose of this study was to report clinical outcomes following cervical decompression for patients with coexisting PD and CSM.
Methods: A matched cohort study of all patients with coexisting PD and CSM undergoing cervical decompression at a single tertiary-care center between 1996 and 2014 were included. These patients were matched to controls with CSM alone by age, gender, ASA, and operative parameters. The primary outcome measure was clinical outcomes assessed by change in the Nurick scale and the modified Japanese Orthopaedic Association (mJOA) classification of disability. Achievement of the minimal clinically important difference (MCID) in the mJOA scale was secondary. Multivariable linear regression was used to model the effect of PD on mJOA.
Results: Twenty-one matched pairs were included. PD patients experienced poorer improvement in Nurick (0.0 vs. -1.0, p<0.01) and mJOA (0.9 vs. 2.5, p<0.01) composite scores. Additionally, only 29% of PD patients achieved an mJOA MCID at LFU compared to 57% of controls (p=0.12). However, no significant changes in absolute improvement in the upper extremity motor, sensory, or sphincter mJOA components were observed. Multivariable linear regression identified PD as a predictor of decreased improvement in mJOA (ß=-0.89, p<0.01) and failure to achieve an MCID in mJOA (OR 0.18, p=0.03).
Conclusions: 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.
Patient Care: The results presented here suggest that PD represents a significant risk factor for poorer overall postoperative outcomes, which may influence clinical decision-making and the choice to proceed with decompression. However, it is important to recognize that the diminished overall improvement in myelopathy as measured by the Nurick and mJOA scales is heavily driven by inferior lower extremity motor symptoms, as this component of the mJOA scale actually worsened over follow-up among the PD cohort. In contrast, cervical decompression appears to offer a significant clinical benefit with respect to upper extremity motor and sensory symptoms. Thus, when considering surgery to treat coexisting PD and CSM, it is especially critical to identify specific symptoms to assess for feasibility of significant clinical benefit.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Describe the importance of cervical decompression to treat cervical spondylotic myelopathy in both typical patients and patients with coexisting Parkinson’s disease.
2) Discuss, in small groups, the role of cervical decompression in treating upper extremity motor, sensory, and sphincter-related symptoms associated with cervical spondylotic myelopathy in patients with Parkinson’s disease.
3) Identify an effective treatment of coexisting cervical spondylotic myelopathy and Parkinson’s disease, including cervical decompression to treat upper extremity motor, sensory, and sphincter-related symptoms.
References: 1. Matz PG, Anderson PA, Holly LT, et al. The natural history of cervical spondylotic myelopathy. J Neurosurg Spine. 2009;11(2):104-111.
2. Babat LB, McLain RF, Bingaman W, Kalfas I, Young P, Rufo-Smith C. Spinal surgery in patients with Parkinson’s disease: construct failure and progressive deformity. Spine (Phila Pa 1976). 2004;29(18):2006-2012.
3. Koller H, Acosta F, Zenner J, et al. Spinal surgery in patients with Parkinson’s disease: Experiences with the challenges posed by sagittal imbalance and the Parkinson's spine. Eur Spine J. 2010;19(10):1785-1794.