Intraoperative Osteopathic Manipulative Therapy Used to Manage Acute Cervical Somatic Dysfunction During Deep Brain Stimulator Implantation for Parkinson’s Disease: A Case Report

Date

2024-03-21

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0000-0003-4869-7276 (Hartley, Kristina)
0000-0003-4935-0493 (Nguyen, Michael)
0009-0007-4770-6472 (Lee, Yein)

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Abstract

Background: Parkinson’s disease (PD) is a neurodegenerative disease characterized by motor and non-motor symptoms such as bradykinesia, resting tremors, and cognitive changes. Deep brain stimulation (DBS) is a surgical procedure used to control the motor symptoms of PD, where electrodes are placed inside the patient’s basal ganglia under conscious sedation. Of the documented complications directly attributable to DBS, intraoperative and postoperative musculoskeletal pain is currently not well reported on, and management of this pain is also not well established. In this case report, we describe the intraoperative osteopathic assessment and management with osteopathic manipulative treatment (OMT) of acute cervical and occipital somatic dysfunctions in a patient with PD who underwent a DBS implant.

Case Information: A 72-year-old female with a five-year history of PD presented with worsening bradykinesia, dyskinesia, rigidity, balance issues, and bilateral lower extremity pain. The patient’s carbidopa/levodopa dosage effectively controlled her motor symptoms for 2 hours before symptoms returned. Her physical exam was unremarkable except for aspects of her neurological exam, which revealed resting tremors throughout her bilateral upper and lower extremities, a very unsteady, shuffling gait, and an inability to do tandem gait, heel, or toe walking. She could not squat or rise independently. DBS implantation was recommended as a palliative option. Preoperative brain magnetic resonance images revealed an arachnoid cyst on one side and multiple small vessels surrounding the target for her DBS lead positions, necessitating more planning and increased surgery duration than expected. During the procedure, she developed severe musculoskeletal neck pain, a rating of 8/10, that gradually worsened to involve her posterior occiput and right shoulder. An osteopathic examination of the neck region showed acute tissue texture changes in her cervical paravertebral, suboccipital, trapezius, and sternocleidomastoid (SCM) musculature with hypertonicity, bogginess to palpation, and multiple myofascial trigger points. OMT was used intraoperatively in an attempt to control the musculoskeletal pain after the implementation of traditional methods of warm compresses and extra support failed to alleviate the severity. OMT used included longitudinal soft tissue of the paravertebral, direct inhibition of myofascial trigger points, and indirect myofascial release of the suboccipital musculature and SCM, reducing pain to a reported 2/10 by the patient. OMT was well-tolerated and did not give rise to any adverse events as the DBS implant procedure proceeded and was completed successfully.

Conclusions: This case illustrates how indirect and soft tissue techniques can effectively be used in close proximity to an area of operation without compromising the sterile field or displacing the patient with augmenting positional pain tolerance. Future studies should evaluate the safety and effectiveness of OMT under conscious sedation, intraoperatively, and its application as a treatment modality to augment patient tolerance of surgical procedures.

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Research Appreciation Day Award Winner - Texas College of Osteopathic Medicine, 2024 Medical Student Government Association Best in Third Year Class
Research Appreciation Day Award Winner - Texas College of Osteopathic Medicine, 2024 Student Research Award - Best Case Study
Research Appreciation Day Award Winner - Texas College of Osteopathic Medicine, 2024 OMM-I.M. Korr, Ph.D. Memorial Research Award

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