Life-Threatening Upper Airway Obstruction as a Complication of Corrective Spinal Surgery in a Patient with Parkinson’s Disease: A Case Report

A 74-year-old female with a 10-year history of Parkinson’s disease visited our hospital complaining of severe kyphoscoliosis deformity. Corrective spinal surgery was performed through a posterior approach. Oral anti-Parkinson medication was continued until the day of surgery, when continuous intravenous dopamine infusion was initiated; dopamine was discontinued and oral medication restarted on the day after surgery. Four weeks after surgery, the patient developed dyspnea. Laryngeal examination revealed rigidity of the neck muscles causing upper airway obstruction. Emergency tracheotomy was performed and the patient’s respiratory condition improved immediately. Because of difficulty of swallowing, gastrostomy was performed 2 weeks after tracheotomy. After tracheotomy and gastrostomy, the patient’s respiratory condition improved. Life-threatening upper airway obstruction can occur after corrective spine surgery in patients with Parkinson’s disease. It is important to ensure the oral administration of antiParkinson medication after surgery. *Corresponding author: Takashi Kobayashi, Department of Orthopedic Surgery, Akita Kousei Medical Center, 1-1-1 Iijima-Nishifukuro, Akita 011-0948, Japan, Tel: +81-18-880-3000; Fax: +81-18-880-3040; E-mail: takakoba825@hotmail.com Received November 18, 2016; Accepted December 06, 2016; Published December 08, 2016 Citation: Kobayashi T, Miyakoshi N, Abe T, Kikuchi K, Abe E, et al. (2016) LifeThreatening Upper Airway Obstruction as a Complication of Corrective Spinal Surgery in a Patient with Parkinson’s Disease: A Case Report. J Spine 5: 348. doi: 10.4172/2165-7939.1000348 Copyright: © 2016 Kobayashi T, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
Patients with Parkinson's disease have a higher risk of complications following spine surgery than other patients. There are two categories of complications related to spine surgery in patients with Parkinson's disease. The first includes spine surgery-related complications, such as bleeding, surgical site infection, neurovascular injury, epidural hematoma, dura mater injury, and instrumentation failure [1][2][3]. The second includes complications related to Parkinson's itself, such as urinary tract infection, aspiration pneumonia, bacterial infection, postoperative delirium, and hypotension [4].
We report a rare case of life-threatening upper airway obstruction after corrective spinal surgery in a patient with Parkinson's disease and discuss its cause.

Case Report
A 74-year-old female with a pathologic fracture at L2 presented with gradually progressive kyphoscoliosis without trauma. The patient had a 10-year history of Parkinson's disease, which was Stage 5 at presentation [5]. Camptocormia was seen on standing. She could stand only briefly with support, had difficulty with transfer from bed to wheelchair, and was unstable even when sitting. She had no signs of airway obstruction or mouth-opening restriction before surgery and could feed herself. Her medications consisted of oral levodopa/benserazide (100 mg/10 mg five times daily), amantadine hydrochloride (50 mg five times daily), ropinirole (2 mg five times daily), and selegiline hydrochloride (2.5 mg three times daily). The patient's preoperative blood pressure was 100/60 mmHg with medication. Radiological examination revealed severe kyphoscoliosis deformity (Figures 1a and 1b) with vertebral compression fracture of L2 (Figures 1c and 1d).
The L2 vertebra was resected and replaced with two rectangular cages through a posterior approach. Instrumentation with pedicle screws and alar-iliac screws was placed from T4 to the pelvis (Figures 2a  and 2b). Oral anti-Parkinson medication was continued until the day of surgery, when continuous intravenous dopamine was initiated and continued until the day after surgery. Operation time was 6 hours 30 minutes; total blood loss was 750 mL. After 5 hours of surgery, arterial systolic blood pressure suddenly elevated to 190 mmHg. The patient's blood pressure did not decrease with intravenous injection of 5 mg of diltiazem. After oral administration of hypertension medication, the patient's systolic blood pressure decreased to 120 to 150 mmHg. The patient received her regular dose of levodopa/benserazide and other oral medications on the morning after surgery.
After surgery, the patient experienced swallowing disturbance. Although she could be ingested a meal somehow on her own, dysphasia had worsened. Although we decided that she could take medicine exactly, anti-Parkinson medication was occasionally aspirated from the trachea during suctioning via an aspirator.
Four weeks after surgery, the patient developed dyspnea. Lifting her chin improved her dyspnea. Without her chin up, the patient could not breathe smoothly because of upper airway obstruction, and her systolic blood pressure fell to 30 mmHg. Laryngeal examination revealed neck muscle rigidity causing upper airway obstruction. Supine X-ray of cervical spine showed that the airway was closed ( Figure 3). Emergency tracheotomy was performed and the patient's respiratory condition improved immediately. Because of difficulty of swallowing, gastrostomy was performed 2 weeks after tracheotomy. muscle rigidity. A swallowing test showed no accidental aspiration. The patient started oral intake, and 1 year after surgery could again feed herself; her respiratory condition also improved. The patient was able to maintain a sitting position in her wheelchair, and could walk with walker support.

Discussion
Camptocormia in Parkinson's disease can be a great source of disability. Patients benefit from corrective surgery, despite the high complication rate [6]. Although many complications related to spine surgery have been reported in patients with Parkinson's disease [1][2][3][4], life-threatening upper airway obstruction has rarely been reported [7,8].
If patients are unable to take oral anti-Parkinson medication easily after surgery, upper airway obstruction can occur. Patients with Parkinson's disease are at greater risk for specific complications after abdominal or spine surgery, including urinary-tract infection, aspiration pneumonia, bacterial infection [4], and blood pressure instability [9]. Post-operative laryngospasm, sialorrhea, dysphagia, and esophageal dysmotility increase the risk of aspiration pneumonia [10]. There are only two reports of upper airway obstruction in a patient with Parkinson's disease [7,8]. One case experienced upper airway obstruction immediately after extubation caused by laryngospasm [7]. The patient required tracheal intubation for over 12 hours because of respiratory arrest caused by side effect of medicine. Her postextubation laryngospasm was thought to be related to Parkinson's disease. Another case experienced upper airway obstruction caused by withdrawal of L-dopa in a patient with Parkinson's disease who was fasted before surgery [8]. The patient omitted anti-Parkinson medication for 2days before surgery, and had an obstructed upper airway. In the present case, the cause of upper airway obstruction was suspected due to worsening of Parkinson's disease itself because this patient had not taken anti-Parkinson drugs properly until the occurrence of the current complication (during 4 weeks after surgery). Not only the post-operative sagittal alignment must have been fine but also cervical spine had never been fixed, therefore, the corrective surgery of the thoracolumbar spine seemed to have an insignificant effect.

Conclusion
In conclusion, life-threatening upper airway obstruction can occur after corrective spine surgery in patients with Parkinson's   disease. It is important to ensure oral administration of anti-Parkinson medication after surgery. If post-operative oral administration is difficult, a nasogastric tube can be considered to ensure medication administration.