GOING UNDER THE KNIFE

Surgery and Parkinson's Disease

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Although undergoing surgery can be complicated for any individual, it may be particularly challenging for those with Parkinson’s disease, in terms of the surgical procedure itself as well as the recovery and rehabilitation period following. Here are twelve potential challenges that may arise and that you need to consider if you have Parkinson’s disease and are undergoing surgery.

(1) Pre-Operative Assessment:

If your procedure is elective and not done on an emergency basis, you should consider asking for an appointment known as a Pre-Operative Assessment, which is a time to meet with the anesthetist before your surgical day. This is helpful for both you and the clinicians involved in your anesthesia and surgery. At this meeting you have the opportunity to discuss other health problems including your Parkinson’s and the medications you have been prescribed by other health care providers that may affect your surgical process. It is also a time to discuss whether local anesthesia instead of general anesthesia is an option for your particular procedure as local anesthetics usually lead to a quicker and easier recovery. And if the surgery must be done under general anesthesia, there are certain recommended medications that should be used in Parkinson’s patients so it is helpful for your anesthetist to be aware of your condition.

(2) Your Parkinson’s Medications:

There are some caveats when considering your Parkinson’s medications and it is helpful to discuss them with your movement disorder specialist or other health care provider and your surgeon prior to surgery. It is of great importance that you receive your meds at your scheduled time - up to the point of surgery and as soon after your surgery as possible and throughout your stay in hospital. First you should clarify with your surgeon whether or not you can take your dose of regular PD meds with a sip of water prior to surgery and what plans are in place for taking your PD meds after surgery. For example, in the case of abdominal procedures, where it may not be possible for you to take your medications orally, alternate routes may be possible – for example intravenously or via a nasogastric tube. Or perhaps in that situation your MDS may opt to prescribe medications that may be given subcutaneously or trans dermally via a patch.

If you are able to take your medications as normal after surgery during your hospital stay, then you may want to take your own supply and ask if you can take your pills yourself at your normal times. Because in hospital, meds are usually administered by the nursing staff at specific intervals which may not coincide with your timings. And as you all know, not getting your meds on time can be a real issue. Post-surgery, your recovery can become more challenging if your PD symptoms are aggravated because of delayed treatment.

(3) Medication Interactions:

With regards to the medications you receive in hospital post-operatively and during your recovery, you need to be aware that they may interact with the medications you take for your PD. For example, if you are on a MAO-B Inhibitor such as rasagaline or Azilect, there are a number of medications that may dangerously interact with it such as Meperidine (Demerol) or Tramadol, both commonly prescribed for pain control. You don’t necessarily have to know about all potential drug interactions, but you should at least be aware that there may be some issues and there is no harm in making sure your surgical team is aware.

(4) Medications That Worsen PD Specifically

There are also certain medications commonly given in hospital that may worsen your PD symptoms specifically. Metoclopromide, a medication given for nausea for example, also blocks dopamine receptors making your PD motor symptoms worse as do some typical antipsychotics such as haloperidol (or Haldol).

(5) Medications Accentuating PD Symptoms

There are also some medications that may aggravate your post-operative course such as pills that help with sleep and anxiety, for example benzodiazepines, but worsen your balance, making you at an increased risk for falls. Other medications can lower your blood pressure as a side effect which can be risky if you already have trouble with orthostatic hypotension (a symptom of Parkinson’s where blood pressure drops with changes in position such as sitting to standing).

(6) Poor Mobility

When you have Parkinson’s disease, you are often faced with a longer post-surgical recovery. This may be due to a variety of reasons including slow mobilization. It may take longer to get moving and doing so safely without falling, is a concern. In-hospital physiotherapy or occupational therapy may be necessary and beneficial early in your post-operative course to help with this issue.

(7) Delirium

Delirium can occur after surgery and manifests as acute confusion which may include hallucinations, agitation and delusions. This type of complication is more common in those with PD especially there are any pre-existing cognitive issues. Having someone familiar with you to reassure and orient you may be helpful as are certain medications but those must be chosen carefully in the context of your PD.

(8) Higher Aspiration Risk

Those with Parkinson’s may be at higher risk for aspiration because the majority of individuals affected have some degree of swallowing dysfunction (dysphagia) which may be made worse by anesthesia. With dysphagia, you are less able to protect your airway when eating or drinking. Awareness of this potential problem, getting a dietician or speech language pathologist consultation to advance your diet carefully after surgery may be helpful.

(9) Pneumonia Risk

Because of potential aspiration and also because in PD there can be rigidity or abnormal movements in the voluntary muscles in the chest wall as well as the upper airway muscles, there is an increased risk for not being able to breathe deeply, clear your secretions putting you at increased risk for pneumonia. Seeing a respiratory therapist to help with deep breathing after surgery may be helpful.

(10) Blood Pressure Fluctuations

Your blood pressure may fluctuate after surgery and more severe episodes of low blood pressure can occur. Therefore, if you get up too quickly and without support, you may be at increased risk for falls. So always, especially early on, have someone around as you try and go from lying down to standing.

(11) Urinary Tract Infection

Another thing to be aware of is your bladder. Urinary dysfunction is a common problem in PD and this may make you prone to urinary tract infections, especially if you have a catheter, which in turn may result in a worsening of your Parkinson’s symptoms.

(12) Constipation

And the last one I’d like to mention is constipation. Constipation, getting your bowels moving is often a challenge for most people after surgery and this is particularly aggravated in those of us with PD. Therefore, activating a plan in terms of bowel meds to address potential constipation issues post-operatively is very important.

As you can see, there are a number of potential issues when it comes to having surgery in the context of your Parkinson’s disease. If you know about your surgery ahead of time, then personally I would recommend that you see your neurologist or movement disorder specialist to discuss potential issues that may arise depending on the surgery you will be undergoing and your personal PD situation. Formulate a game plan with them and then have them communicate (preferably in writing) with your surgical team.

Knowledge is power and being aware of potential issues and planning ahead, can really help avoid or minimize any potential complications.