Outcome Of Posterior Thoracolumbar Surgery In Patients With Parkinson Disease

Objiective:Little data are available to identify clinical outcomes in Parkinson's patients who undergo posterior thoracolumbar surgery.The study is to preliminarily investigate clinical outcome of the posterior thoracolumbar sugery in patients with Parkinson disease(PD)and anlyze the effect of surgical strategy on the paravertebral muscles of PD patients.Methods:24 patients with PD undergoing posterior thoracolumbar sugery with complete clinical data and follow-up between 2008.1.1 and 2017.6.31 were picked.According to whether to open the paraspinal muscles,they were divided into minimally invasive group and opening group.A total of 72 non-PD patients were screened by age,sex,operative segment and surgical method.Patients' charts,imaging data,the time of sugery and postoperative hospitalization,sugery-related questionnaires were reviewed.We utilize Hoehn and Yahr staging scale to assess the severity of Parkinson disease.The Lumbar Lordosis angle and the height of the anterior and posterior edge of the vertebral body were measured before and after the operation,and calculated the sagittal index.Image J2x was used to measure the cross sectional area and the degree of fat infiltration in the L5 paraspinal muscles,and to evaluate the paravertebral muscle atrophy by imaging evaluation.The SPPSS 20.0 system was used to analyze and summarize the follow-up data.Result:There are 24 PD and 72 non-PD patients who underwent posterior thoracolumbar surgery.The average age of 11 PD patients with minimally invasive surgery was 71.5±9.9 years old and 72.4±6.3 years old in the non-PD patients.The average age of opening surgery patients was 69.3±8.4 years old with PD patients and 68.7±7.3 years old in the non-PD patients.And the average age in PD patients and non-PD patients was no difference(P>0.05).The average follow-up time was 38.7 months.11 patients with Parkinson disease and 33 non-PD patients underwent percutaneous kyphoplasty(PKP)for thoracolumbar vertebral compression fractures,and the Parkinson H-Y was classified as 3 and 4 in 4 patients,and the remaining patients were less than grade2.In PD patients,the average time of operation was 67.8 ± 34.1 minutes,and the average in-hospital days after operation were 4.8 ± 2.1 days.In non-PD patients,the average time of operation was 54.6 ± 26.7 minutes,and the average in-hospital days after operation were 3.9 ± 2.7 days.Operative time and postoperative in-hospital days in PD patients with PKP were more than those of non-PD patients(P<0.05).Opening surgery of bilateral paraspinal muscles was performed in 13 patients with PD.2 patients underwent lumbar posterior internal fixation for lumbar fracture,and 3 patients underwent posterior lumbar interbody fusion(PLIF)for lumbar disc herniation,and 7 patients also underwent PLIF for lumbar spinal canal stenosis or lumbar spondylolisthesis,and 1 patients underwent spinal posterior correction surgery because of scoliosis.All patients were stripped of L5 vertebral paraspinal muscles.The Parkinson H-Y grade in all patients was less than grade 2.In PD patients,the average operative time was 176 ± 43.6 minutes,and the average postoperative hospital stay was 12.2 ±3.1 days.In non-PD patients,the average time of operation was 163.3 ± 56.4 minutes,and the average in-hospital days after operation were 10.3 ± 4.7 days.Postoperative in-hospital days in PD patients with opening surgery were more than those of non-PD patients(P=0.029),and the operative time was not significantly different in PD and non-PD patients(P=0.063).Preoperative lumbar lordosis angle in minimally invasive group with PD patients was 28.55°± 12.47°,and recovered to 31.45°±11.88°(P<0.001)after surgery.During the recent follow-up,the lumbar lordosis angle was 27.55°± 12.53°,lower than one month after sugery(P=0.001).Preoperative lumbar lordosis angle in minimally invasive group with non-PD patients was 31.97°± 16.83°,and recovered to 39.73°±17.21°(P=0.003)after surgery.During the recent follow-up,the lumbar lordosis angle was 37.06° ±14.64°,no significant changes after sugery(P=0.078).The corresponding sagittal index(SI)of the compressed fractures with PD patients recovered from 69%(48%to 92%)before surgery to 86%(68%to 95%)after operation(P<0.001),and the short-term follow-up was 74%(62%to 93%),which was lower than that of one month after suegery(P=0.013).And in non-PD patients,the SI recovered from 63%(43%to 79%)before surgery to 77%(64%to 89%)after operation(P=0.013),and the short-term follow-up was 76%(59%to 88%),which was no significant changes after sugery(P=0.241).In opening group,the lumbar lordosis angle was 16.69° ± 12.13° before operation with PD patients,and recovered to 25.08° ± 6.29°after surgery(P<0.001).During the recent follow-up,the lumbar lordosis angle was 24.69°±5.95°,which was no significant difference compared to one month after surgery(P=0.274).And in non-PD patients,the lumbar lordosis angle was 20.08° ±13.68° before operation with PD patients,and recovered to 27.26°±10.16° after surgery(P<0.01).During the recent follow-up,the lumbar lordosis angle was 26.54° ±11.29°,which was no significant difference compared to one month after surgery(P=0.142).The VAS score of preoperative lumbar pain in PD patients was 6.18 ± 0.75 in minimally invasive group and reduced to 1.72 ± 0.64 after surgery(P<0.001).During the last follow-up,the VAS score of the lumbar spine was 2.91 ± 0.83,higher than one month after sugery(P=0.027).The VAS score of preoperative lumbar pain in non-PD patients was 6.24 ± 1.73 in minimally invasive group and reduced to 1.70 ± 0.92 after surgery(P<0.001).During the last follow-up,the VAS score of the lumbar spine was 2.16 ± 1.07,higher than one month after sugery(P=0.067).In PD patients,the VAS pain score of the lumbar spine in opening gruop decreased from 5.50 ± 1.87 before surgery to 2.00 ± 0.63(P<0.001)after operation,and 2.17 ± 0.75 in the recent follow-up,which was no difference compared to one month after surgery(P=0.101).The VAS pain score of non-PD patients in opening gruop decreased from 5.08 ± 2.54 before operation to 2.15 ± 0.77(P<0.001)after operation,and the short-term follow-up was further reduced to 2.36 ± 0.69,which was no difference compared to one month after surgery(P=0.081).There was significant difference in the cross sectional area and fat infiltration of the multifidus muscle and psoas muscle of the upper and lower margins of L5 vertebral body compared with PD patients and non-PD patients in minimally invasive group(P<0.05).According to the imaging evaluation method,3 patients had mild atrophy of multifidus muscle,6 patients were moderate atrophy,2 patients had severe atrophy in PD patients;1 patients had moderate atrophy in the psoas muscle and 10 patients were mild atrophy.In non-PD patients,19 patients had mild atrophy of multifidus muscle,13 patients were moderate atrophy,1 patients had severe atrophy in PD patients;26 patients had moderate atrophy in the psoas muscle and 7 patients were mild atrophy.The cross-sectional area of the multifidus muscle and psoas muscle of the upper and lower edge of the L5 vertebrae in the opening surgery PD patients was significantly lower than that in non-PD patients(P<0.01).The proportion of fat infiltration of multifidus muscle in PD patients was significantly higher than that in non-PD patients(P<0.05),and no difference in psoas muscle(P>0.05).According to the imaging evaluation method,2 patients had mild atrophy of multifidus muscle,8 patients were moderate atrophy,3 patients had severe atrophy in PD patients and 1 patients had moderate atrophy in the psoas muscle before operation,10 patients were mild atrophy.In non-PD patients,21 patients had mild atrophy of multifidus muscle,16 patients were moderate atrophy,2 patients had severe atrophy in PD patients;31 patients had mild atrophy in the psoas muscle and 8 patients were moderate atrophy.Conclusion:The degree of atrophy of the multifidus muscle and the psoas muscle in PD patients is heavier than that of non-PD patients and the opening surgery may lead to the aggravation of the degenerative muscle.Posterior lumbar surgery can significantly improve the symptoms of pain in the lumbar and back of Parkinson patients.The overall outcome of posterior thoracolumbar surgery in patients with Parkinson's disease is good.PD patients undergoing PKP are more likely to form a recurrence of verterbral collapse and back pain than those in non-PD patients.Openging surgery for PD and non-PD patients can get a good effect in the far near future.