Surgical management of camptocormia in Parkinson’s disease: systematic review and meta-analysis

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OBJECTIVE

Camptocormia is a potentially debilitating condition in the progression of Parkinson’s disease (PD). It is described as an abnormal forward flexion while standing that resolves when lying supine. Although the condition is relatively common, the underlying pathophysiology and optimal treatment strategy are unclear. In this study, the authors systematically reviewed the current surgical management strategies for camptocormia.

METHODS

PubMed was queried for primary studies involving surgical intervention for camptocormia in PD patients. Studies were excluded if they described nonsurgical interventions, provided only descriptive data, or were case reports. Secondarily, data from studies describing deep brain stimulation (DBS) to the subthalamic nuclei were extracted for potential meta-analysis. Variables showing correlation to improvement in sagittal plane bending angle (i.e., the vertical angle caused by excessive kyphosis) were subjected to formal meta-analysis.

RESULTS

The query resulted in 9 studies detailing treatment of camptocormia: 1 study described repetitive trans-spinal magnetic stimulation (rTSMS), 7 studies described DBS, and 1 study described deformity surgery. Five studies were included for meta-analysis. The total number of patients was 66. The percentage of patients with over 50% decrease in sagittal plane imbalance with DBS was 36.4%. A duration of camptocormia of 2 years or less was predictive of better outcomes (OR 4.15).

CONCLUSIONS

Surgical options include transient, external spinal stimulation; DBS targeting the subthalamic nuclei; and spinal deformity surgery. Benefit from DBS stimulation was inconsistent. Spine surgery corrected spinal imbalance but was associated with a high complication rate.

ABBREVIATIONS DBS = deep brain stimulation; GPi = globus pallidus interna; PD = Parkinson’s disease; rTSMS = repetitive trans-spinal magnetic stimulation; STN = subthalamic nucleus.

Article Information

Correspondence Andrew K. Chan: University of California, San Francisco, CA. andrew.chan@ucsf.edu.

INCLUDE WHEN CITING Published online September 14, 2018; DOI: 10.3171/2018.4.JNS173032.

Disclosures Dr. Larson reports receipt of honoraria from Medtronic and support of non–study-related clinical or research effort from Voyager Therapeutics and serving as a consultant for Abbott. Dr. Mummaneni reports a consultant relationship with DePuy Spine, Globus, and Stryker; direct stock ownership in Spinicity/ISD; support of non–study-related clinical or research effort from NREF and ISSG; royalties from DePuy Spine, Thieme, and Springer; and honoraria from AO Spine.

© AANS, except where prohibited by US copyright law.

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Figures

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    Flowchart summarizing the study selection.

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    Meta-analyses examining factors associated with improvement of camptocormia. A: ≤ 2 years over > 2 years camptocormia duration with respect to over 15° thoracolumbar (TL) angle decrease. B: ≤ 2 years over > 2 years camptocormia duration with respect to > 50% TL angle decrease. C: ≤ 60 years old over > 60 years old with respect to > 50% TL angle decrease. A significant predictor of > 15° TL angle decrease (p < 0.05) after meta-analysis was ≤ 2 years over > 2 years camptocormia duration (A). df = degrees of freedom; M-H = Mantel-Haenszel. Figure is available in color online only.

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    Left: Preoperative photograph of a 59-year-old man with advanced idiopathic PD and severe camptocormia who underwent placement of bilateral STN deep brain stimulators and a right chest dual channel pulse generator. Right: Photograph of the patient at 2 years’ follow-up. His gait and ambulation had improved, but there was no significant improvement in his camptocormia posture. From Upadhyaya et al: Spinal deformity and Parkinson disease: a treatment algorithm. Neurosurg Focus 28(3):E5, 2010. Used with permission. Figure is available in color online only.

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