Improvement in sagittal alignment and mechanical low-back pain following deep brain stimulation for Parkinson’s disease: illustrative case

Abstract

BACKGROUND Parkinson’s disease (PD) is a common neurogenerative disease marked by the characteristic triad of bradykinesia, rigidity, and tremor. A significant percentage of patients with PD also demonstrate postural abnormalities (camptocormia) that limit ambulation and accelerate degenerative pathologies of the spine. Although deep brain stimulation (DBS) is a well-established treatment for the motor fluctuations and tremor seen in PD, the efficacy of DBS on postural abnormalities in these patients is less clear. OBSERVATIONS The authors present a patient with a history of PD and prior lumbosacral fusion who underwent bilateral subthalamic nucleus DBS and experienced immediate improvement in sagittal alignment and subjective relief of mechanical low-back pain. LESSONS DBS may improve postural abnormalities seen in PD and potentially delay or reduce the need for spinal deformity surgery.

Treatment of axial postural abnormalities in parkinsonism disorders: A systematic review of pharmacological, rehabilitative and surgical interventions

“…of participants (no. of females) PD duration (years) -H&Y stage if reported DBS target and settings -Research question Type of PA – PA Duration Study outcomes measures Main results Follow-up QA-LE Guerrero et al 2022 [64] Case report 1 (M) 5 -NA Bilateral STN DBS-Efficacy on low back pain and sagittal balance Not explicated (“Sagittal imbalance”) Prior to PD Clinical evaluationPain status: anamnestic Cognitive status: NR Improvement of low back pain (with bilateral lower extremity radiculopathy) and sagittal balance 3 months NA Anderson et al 2019 [65] Case report 1 (M) 7-NA Bilateral GPi-Long term efficacy of GPi DBS on PS PS (clinical)-24 months Lateral bending anglePain status: anamnestic Cognitive status: NR Improvement from 45 to 25 degrees, significant reduction of severe back pain 48 months NA Pandey S. 2017 [66] Case report 1 (F) 7 y-NA Bilateral STN DBS-Efficacy on UCC UCC (clinical)-24 months Clinical evaluationPain status: anamnestic Cognitive status: NR After DBS there was resolution of CC and back pain 3 months NA Akiyama et al 2017 [67] Case report 1 (F) 12 at DBS16 at Spinal cord stimulation-NA Bilateral STN-DBS; 4 years later, Spinal cord stimulation (SCS)DBS: Amplitude (V) R 3.5 (bipolar configuration)/L 3.2, Pw (usec) L 60, R 60, Frequency (Hz) R 60, L 60-To evaluate efficacy of Spinal cord stimulation for painful CC with OS CC and PS (clinical)-2 y from DBS6 y from SCS Clinical evaluationPain status: anamnestic (VAS is reported only after SCS)Cognitive status: NR Painful CC and PS initially improved with STN DBS but reappeared after 2 years. Painful CC and PS improved also after SCS 6 months after SCS NA Ekmekci and Kaptan 2016 [68] Case report 1 (F) 11––3 Bilateral STN-DBS-Effects on CC CC (clinical)-1 y (but with low back pain from 7 years) Trunk bendingPain status: S‑LANNS pain scale Cognitive status: MMSE Improvement from 60° to < 10°Best improvement achieved in low back pain (≥7/10 in S‑LANNS pain scale)MMSE 26/30 (28/30 at 1 year) …”

“…We found 32 studies on the effect of DBS on PA in PD, including 723 patients. 37.5 % (n = 12) were retrospective observational before-after studies [52] , [53] , [54] , [55] , [56] , [57] , [58] , [59] , [60] , [61] , [62] , [63] , 40.6 % (n = 13) were Case Reports [64] , [65] , [66] , [67] , [68] , [69] , [70] , [71] , [72] , [73] , [74] , [75] , [76] , 18.75 % (n = 6) were Case Series [77] , [78] , [79] , [80] , [81] , [82] , and 1 was a Case-control study [83] . Twenty-seven studies evaluated the effect of bilateral subthalamic DBS (STN-DBS) [52] , [70] , [71] , [54] , [55] , [56] , [57] , [58] , [59] , [61] , [62] , [63] , [64] , [66] , [67] , [68] , [73] , [74] , [75] , [77] , [78] , [79] , [80] , [81] , [82] , [83] , [84] , six studies the effect of bilateral globus pallidus par interna DBS (GPi-DBS) [53] , [65] , …”

“…The studies included 200 patients with CC, 24 patients with PS, and 3 cases of AC; in 4 studies, CC patients were divided according to a higher (i.e., thoracic) or lower (i.e., lumbar) spine flexion [52] , [53] , [55] , [56] . In 4 studies, we had an unspecific referral to abnormal posture, a score >0 on item 28 of the UPDRS, or sagittal imbalance to define the PA [57] , [58] , [62] , [64] . The median duration of PD and of PA at DBS (not including two studies in which PA occurred after DBS) was 11.8 years (range 5–25 years) and 2 years (range 0.5–19 years), respectively.…”

“…The cognitive status at baseline was reported as exclusion criteria in 5 studies, and in 2 studies, there was a report of MMSE. Outcome measures differed across studies, with 16 studies using the angle of spine flexion [59] , [61] , [63] , [65] , [68] , [69] , [71] , [74] , [77] , [78] , [81] , [52] , [53] , [54] , [55] , [56] , 13 using a clinical evaluation [64] , [66] , [67] , [70] , [72] , [73] , [75] , [76] , [77] , [80] , [83] , [84] , [85] , 10 using the UPDRS score [52] , [54] , [58] , [62] , [63] , [69] , [75] , [77] , [79] , [81] , 1 using the BFMDRS score [79] , and 1 using the Cobb angle and the C7SVA (C7 sagittal vertical axis) [57] . In 81.25 % of studies (n = 26), an improvement in PA was reported.…”