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Bergamotte

How to Rule Out Parkinson's Coexisting with CM?

4 posts in this topic

Dear Dr. Okun:

My 84-year-old husband has been treated for presumed Parkinson’s for the last two years with levodopa/benserazide. He has bradykinesia, rigidity, on-and-off right hand tremor, and increasing weakness in the right arm and right leg. Both legs are increasingly spastic; he’s very bouncy on rising from a chair.

He has a poor response to medication (it never helped him much with movement even on 600 mg of levodopa per day). Dose increases simply exacerbate the sleepiness and dizziness, making it harder for him to exercise.

Recently I took him to be seen for a second opinion on his medical therapy. An experienced neurologist examined him, he thought he saw hints of spinal pathology in the gait, he didn’t see a parkinsonian gait at all; and he informed us that possibly my husband does not have Parkinson’s. He ordered cervical spine MRI which was consistent with spinal cord compression and compression of a nerve root on the right, with probable cervical myelopathy. Two electrophysiologic tests confirmed the CM diagnosis. The neurologist told us that this pathology accounts for all my husband’s movement-related symptoms.

We accept the new diagnosis of cervical myelopathy. We want to discontinue the levodopa (a slow taper would be our preference); but is there a way to confirm first that he does not have Parkinson’s in addition to CM? The second-opinion neurologist felt safe in instructing us to completely stop the levodopa therapy for two days at home “to see what happens”, a sort of stress test; but I am reluctant to do that because I fear the possibility of malignant syndrome. My husband is chronically under-hydrated despite all my efforts to get him to drink.

Thank you for your thoughts, Dr. Okun.

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You should be cautious.  It is still possible you have Parkinson's disease as well as the spinal stenosis/compression.  Whenever we wean medications we do it low and slow over a few weeks.  One approach may be to do one thing at a time.  Fix the spine and see how you recover and then slowly wean the PD medications.  In general you should be able to figure this out without a DAT scan, but if there is confusion that may be a potential approach.

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Thank you so much, Dr. Okun.

Theoretically, in a patient who has both CM and Parkinson's, is it possible that the spinal pathology may limit the amount of symptomatic improvement achievable with anti-Parkinson's medications?

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Tough question, but usually no...except when the other condition is affecting similar symptoms as PD.....very tough to disentangle...

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