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Practical NeurologyPains in the Neckand Back 3
Wendy Blount, DVM
Intervertebral Disc Disease
Prognosis – Type I Disc Dz• Very few outcome studies on medically
managed dogs• No deep pain
– 40-50% will walk again with medical treatment (stats before rehab)
– 60-80% will walk again with surgery– 33% of those that walk again will have
intermittent incontinence– Recovery of deep pain within 2 weeks
carries a good prognosis
• Length of time between loss of deep pain and surgery– Surgery sooner is better than later– 48 hour rule – no longer widely accepted
Intervertebral Disc Disease
Prognosis – Type I Disc Dz• Non-ambulatory with pain sensation
– 80-95% success with surgery
• Mean time from surgery to ambulation– 10-13 days for small dogs
– Much longer for large dogs
• Mean 7 weeks to ambulation
• 62% walking in 4 weeks
• 92% walking within 12 weeks
• Longer for older, heavier patients
• Back pain alone without neuro deficits– 24 of 25 of dogs improved with surgery
Intervertebral Disc Disease
Prognosis - Type I Disc Dz• More acute paralysis carries worse
prognosis– Those that go from walking to paralyzed in
less than one hour don’t do as well
– Those who go down gradually (1-2 days) have better prognosis
• Respiratory compromise– (Prognosis same with a ventilator)
– Prognosis grave without ventilator
• Dogs non-ambulatory from type II disease over weeks to months have worse prognosis than type I
Intervertebral Disc Disease
Prognosis - Type I Disc Dz• 20% of dogs who have back surgery
will have another episode of back pain with neuro deficits– Most do not require surgery
– Re-operate rate is <10%
– 40% recurrence when treated medically
• Dogs with 5 or more mineralized discs at surgery have 50% recurrence rate
Intervertebral Disc Disease
Prognosis - Type I Disc Dz• Ambulatory patients – Severe Cervical
Pain– 50-70% respond to medical therapy
– 30% will relapse within 2 years
– 15-20% will need surgery
• Ambulatory patients – Severe TL Pain– Nearly 100% respond to medical therapy
– 30-50% relapse within 2 years
– Relapse more common with prednisone than with NSAIDs or high dose MPSS
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Intervertebral Disc Disease
Prognosis - Type II Disc Dz• Typically managed medically
– Injection of proteolytic enzymes into the disc holds promise (chymopapain)
• No outcome studies on surgical intervention– 10-15% success
Intervertebral Disc Disease
Progressive Myelomalacia• 5-10% of dog who lose deep pain
• Hemorrhagic necrosis and melting of the spinal cord
• Ascends and descends through the spinal cord (first sign?)
• HINT: cranial migration of panniculus
• Flaccid abdominal muscles
• Migrating flaccid paralysis
• Eventual respiratory paralysis
• Grave prognosis
Toby
• 3 yr M English bulldog– Owner seeks a second opinion for
difficulty breathing– Her regular vet did not refer her, and
in fact told me to be “very careful” with her when I called him
– Owner shows “high dollar” English Bulldogs and is a practicing attorney at 78 years of age
– Work-up for respiratory disease shows chronic aspiration pneumonia, which we are treating
– One his evening walk on Friday evening, Toby cannot rise to go outside
Toby
• Neurologic exam– Elevated respiratory rate and
hunched posture– Able to stand with assistance, but
not walk– Lower Lumbar Back pain– Normal front legs– 3+ patellar reflexes, crossed
extensor reflexes, minimal vol motor• Lesion localization: TL spinal cord• Radiographs
Toby
• Neurologic exam– Elevated respiratory rate and
hunched posture– Able to stand with assistance, but
not walk– Lower Lumbar Back pain– Normal front legs– 3+ patellar reflexes, crossed
extensor reflexes, minimal vol. motor• Lesion localization: TL spinal cord• Radiographs – hemivertebrae, butterfly
vertebrae• Dr. Mike Herron is the surgeon on call
– “I would not touch this surgery with a 10 foot pole”
Toby
• Toby does well with cage rest and analgesics– Respirations return to normal as
pain is controlled• He goes home walking in 2 weeks• Owner had just gotten off probation for
selling children– https://www.nytimes.com/1992/05/21/us/wo
man-gets-60-years-in-bid-to-sell-children.html
• Two years later, she had her own Justice Files episode
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Congenital Spinal Malformation
Hemivertebrae
• wedge shaped – lateral, dorsal, ventral
Congenital Spinal Malformation
Butterfly vertebrae
• Central vertebral body fails to form
Congenital Spinal Malformation
Block vertebrae
• Fusion of two or more vertebrae
Congenital Spinal Malformation
Stenotic vertebral canal
Transitional vertebrae
• vertebrae of one spinal segment take on characteristics of another
• Thoracic vertebrae normally have ribs
• Sacral vertebrae normally are fused
• C, L and Co vertebrae are neither
• Results in different number of C, T, L or S vertebrae than usual
Congenital Spinal Malformation
• Common in “Screwtail breeds”– English Bulldogs, French Bulldogs
– Boston terriers, Pugs
• Some malformations are incidental findings – correlate with the neuro exam
• Much like Type II Disc Disease or Wobbler– If symptomatic, usually progressive
– Occasional acute decompensation
Congenital Spinal Malformation
Treatment
• Medical treatment if pain only or ambulatory with mild to moderate neuro deficits
• Surgery if non-ambulatory
• Because of abnormal anatomy of hemivertebrae, some surgeons think that surgery carries increased risk of destabilization
• Some surgeons won’t cut as long as there is voluntary motor, unless medical therapy has failed for a really long time
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Chief
7 yr M GSD• Has gradually developed difficulty
rising in the rear limbs• Has gotten worse over the past year,
despite NSAIDs and joint supplements• CBC, GHP, UA, HW – NSAF• Exam – hair worn off the tops of the
toes on the rear feet, scabs, worn nails• Neuro Exam:
Chief
7 yr M GSD• Has gradually developed difficulty
rising in the rear limbs• Has gotten worse over the past year,
despite NSAIDs and joint supplements• CBC, GHP, UA, HW – NSAF• Exam – hair worn off the tops of the
toes on the rear feet, scabs, worn nails• Neuro Exam: gait
Chief
7 yr M GSD• Has gradually developed difficulty
rising in the rear limbs• Has gotten worse over the past year,
despite NSAIDs and joint supplements• CBC, GHP, UA, HW – NSAF• Exam – hair worn off the tops of the
toes on the rear feet, scabs, worn nails• Neuro Exam: gait
– Front limbs normal– Weak, swaying, stumbling gait in the
rear, short swing phase– Hops with rear legs at a run– Muscle atrophy in the rear limbs
Chief
• Neuro Exam: – Normal hopping on front legs– Short, weak hops on rear legs– CP deficits rear limbs– Cranial nerve and front limb reflexes
normal– Cutaneous trunci normal– Rear limb reflexes 0-1– No urinary or fecal incontinence
• Lesion Localization: lower SC• Spinal Rads: normal• Working Dx: Degenerative Myelopathy
Degenerative Myelopathy• Ascending axon and myelin
degeneration of the spinal cord
• Unknown initial cause - heritable
• GSDs and Boxer most commonly affected
• Postural tremor is common
• Paraparesis progresses to paraplegia, then incontinence
• DNA Test based on SOD1 mutation is available from a number of labs– U of Missouri
– OFA
– Optigen
– www.vetdnacenter.com – not for Bernese Mt Dogs
Degenerative Myelopathy
• Treatment – mixed results in clinical trials
– Aminocaproic acid 15 mg/kg or 500 mg/dog PO TID
– N-acetylcysteine 25 mg/kg PO q8h x 2 wks, then q8h QOD. The 20% solution should be diluted to 5% with chicken broth or suitable diluent
– (Prednisone 0.5-1 mg/lb/day x 10d, then QOD)
– Vitamins B, C (1g PO BID) and E (1000 IU PO BID)
• Aggressive PT can delay muscle atrophy and extend mobility
• Definitive Dx is necropsy histopath
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Causes of Progressive Rear End Weakness without Pain
• LMN Reflexes– Degenerative Myelopathy
– Hypothyroidism Polyneuropathy
– Diabetic neuropathy
– Botulism
– Coonhound paralysis
– Tick paralysis
– End stage myasthenia gravis
• UMN Reflexes– Rottweiler Leukoencaphalomyelopathy
– Hereditary Ataxia of Jack Russell Terriers
– Afghan Hound Myelopathy
Petunia
• Sig – 4 year old SF DMH cat, outdoor• CC – can no longer jump up to reach
food bowl, seems wobbly• PE and Neuro
Dr. Girard Beekman
Petunia
• Sig – 4 year old SF DMH cat, outdoor• CC – can no longer jump up to reach
food bowl, seems wobbly• PE and Neuro
– Normal front limbs– Increase stride in the rear limbs w/ ataxia– Hyperreflexive patellar and ischiatic reflexes– Drags toes in the rear limbs – CP deficits– She bites you hard when you palpate TL
spine – neuro exam over
• Dx Plan – TL films
Petunia
• Sig – 4 year old SF DMH cat, outdoor• CC – can no longer jump up to reach
food bowl, seems wobbly• PE and Neuro
– Normal front limbs– Increase stride in the rear limbs w/ ataxia– Hyperreflexive patellar and ischiatic reflexes– Drags toes in the rear limbs – CP deficits– She bites you hard when you palpate TL
spine – neuro exam over
• Dx Plan – TL films normal
Petunia
• Owner declines referral, but approves lumbar CSF tap & FeLV Test– Increased microprotein, normal cell counts
– CSF Culture negative, FeLV Ag Negative
• Dx – likely neoplasia– LSA most likely
• Tx– Prednisone 10 mg daily
– Declines chemo or oncology referral
• Asymptomatic for one month– Then symptoms return, and progress to
paraplegia
– euthanized
– Necropsy confirms SC lymphoma
NeoplasiaPrimary Spinal Cord Neoplasia• Glioma
• Meningioma
• Nerve sheath tumors– Hemangiopericytoma, Schwannoma
– nephroblastoma - rare
• Lymphoma (most common in cats)
• PUSS (MFH)
Metastatic Spinal Cord Neoplasia• Lymphoma
• Carcinoma (mammary, prostate, TCC)
• Epidural mets – OSA, HSA
• Melanoma
• Lipoma, liposarcoma, myelolipoma
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Neoplasia
Spinal Cord Neoplasia
• Dx
– Radiographs usually normal
• Unless tumor is mineralized
• Or invades bone
• Or is a nerve sheath rumor, enlarging the IV foramen
Suzy
• Sig – 10 year old SF Chi-MinPin mix• CC – coughing again• Hx – chronic bronchitis
–
• PE – TL spinal pain• Neuro – CP deficits rear legs• Dx plan
– CBC, GHP, lytes, UA – normal– TL spine radiographs
Suzy
• Sig – 10 year old SF Chi-MinPin mix• CC – coughing again• Hx – chronic bronchitis
–
• PE – TL spinal pain• Neuro – CP deficits rear legs• Dx plan
– CBC, GHP, lytes, UA – normal– TL spine radiographs
• DDx – osteomyelitis, neoplasia– Thoracic radiographs
Suzy
• Sig – 10 year old SF Chi-MinPin mix• CC – coughing again• Hx – chronic bronchitis
– PDA coil placed 10 years ago
• PE – TL spinal pain• Neuro – CP deficits rear legs• Dx plan
– CBC, GHP, lytes, UA – normal– TL spine radiographs
• DDx – osteomyelitis, neoplasia– Thoracic radiographs
• Large Solitary lung mass• PDA coil
Suzy
• Dx Plan– US guided aspirate of lung mass
– Cytology + culture
– Squamous cell carcinoma
– No need for culture
The same symptoms can develop a new cause
Always take 2 views
Neoplasia
Primary Vertebral neoplasia
• Osteosarcoma
• Chondrosarcoma
• Myeloma (plasma cell tumor)
Metastatic Vertebral Neoplasia
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Neoplasia
Primary Vertebral neoplasia – less common
• Osteosarcoma**
• Chondrosarcoma
• Myeloma (plasma cell tumor)
• Fibrosarcoma
• hemangiosarcoma
Metastatic Vertebral Neoplasia – more common
• Distant metastasis– Carcinoma (prostate, mammary, lung)**
• Local invasion from sublumbar LN– Bladder carcinoma
– Anal sac tumor, perianal gland tumor
Neoplasia
Primary Vertebral Neoplasia – more common
• Osteosarcoma**
• Chondrosarcoma
• Myeloma (plasma cell tumor)
• Fibrosarcoma
• hemangiosarcoma
Metastatic Vertebral Neoplasia - less common
• Distant metastasis– Carcinoma (prostate, mammary, lung)**
• Local invasion from sublumbar LN– Bladder carcinoma
– Anal sac tumor, perianal gland tumor
Neoplasia
Presentation
• Usually middle aged to older
• Young dogs or cats– Lymphoma (median age 2-3 year)
– Nephroblastoma (6 months to 3 years)
– GSD
– Labrador Retrievers
• Onset usually progressive– Lymphoma sometimes acute
• Severe pain precedes motor deficits for cord tumors
• Neuro deficits come earlier for vertebral tumors
NeoplasiaDiagnosis
• Signalment– Cats with severe TL pain progressing to
neuro deficits - LSA
• Hyperglobulinemia and proteinuria with myeloma
• Bony tumors seen on survey rads
• CSF tap– Very rarely see neoplastic cells
– Increased protein without increased cells
– for LSA – send to CSU for flow and PARR
• SC tumors often require advanced imaging– (Myelogram, epidurogram), CT, MRI
Neoplasia
Treatment
• Anti-inflammatories for cord edema– Prednisone 0.5 mg/kg PO BID, taper
• Analgesics
• Chemotherapy for LSA or myeloma– Palliative piroxicam for carcinomas
• Decompressive surgery ????
• Palliative radiation
Neoplasia
Prognosis
• Grave for bony neoplasia
• Poor for cord neoplasias treated supportively– Short term can be good
• Days to weeks to months
– Grave long term
• Long term remissions sometimes possible with meningioma in some cats – Prognosis may not be determined without
histopath
• Most euthanized within weeks to months
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Neoplasia
Monoparesis – Left Front, possible bilateral rear limb weakness
Dr. Amelia Foster
Neoplasia
Nerve Sheath Tumor
Curtis Dewey, DVM
Belle
Sig – 3 year old female Pit Bull Terrier
CC – laying around, eating fine, owner has $150
PE & neuro exam – mid-thoracic pain
Dx Plan – 1 lateral radiograph thoracic spine without sedation - normal
Tx Plan 1 –
• Deramaxx SID x 7 days and cage rest x 2 weeks
Belle
3 day follow-up call – back to normal, still doing cage rest
10 days after first visit – laying around again refuses to move, won’t eat
PE & neuro – pain at same spot is worse
Dx Plan – T spine films with sedation
Belle
3 day follow-up call – back to normal, still doing cage rest
10 days after first visit – laying around again refuses to move, won’t eat
PE & neuro – pain at same spot is worse
Dx Plan – T spine films with sedation
Dx – discospondylitis
Radiographs can be normal early in the course of discospondylitis
They don’t always have a fever
Belle
• Tx Plan 2 –– Baytril 5 mg/kg PO BID x 3 weeks
• Follow-up call in 2 weeks – Belle back to normal
• 3 months later – Belle won’t move again
• PE & Neuro – Temp 104oF, LS pain
• Dx Plan – lumbosacral radiograph with sedation, Brucella titer, urine culture
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Belle
• Tx Plan 3 –– Baytril 5 mg/kg PO BID x 3 weeks
• Follow-up call in 2 weeks – Belle back to normal
• 3 months later – Belle won’t move again
• PE & Neuro – Temp 104oF, LS pain
• Dx Plan – lumbosacral radiograph with sedation, Brucella titer, urine culture– Brucella card test, IFA, TA all +
– Urine Culture no growth
• Ames, IA for culture confirmation & speciation (TVMDL will forward)
Belle
• Tx Plan 4
– OHE
– Streptomycin and tetracycline x 30 days, then recheck spinal rads
• Recheck spinal rads normal
• Many relapses – never could clear the infection, infection would move from IVS to IVS
• Belle was eventually euthanized
Belle
• Tx Plan 4
– OHE
– Streptomycin and tetracycline x 30 days, then recheck spinal rads
• Recheck spinal rads normal
• Many relapses – never could clear the infection, infection would move from IVS to IVS
• Belle was eventually euthanized
Discospondylitis
Infection of the Intervertebral discs & vertebral end plates
• Bacterial– Staphylococcus spp.– Brucella canis– Many others
• Less commonly Fungal• L7-S1 most common• If ambulatory, prognosis good for all
but Brucella– relapsing, chronic discospondylitis
• Diagnosis – radiographs, urine culture, Brucella serology, CSF culture, LS aspiration cytology & culture
Marti – “Doc’s Spicy Martini”
• Sig – 4 month old female golden retriever
• Stiffness, sore, was fine yesterday
• PE & Neuro – neck pain – rest of neuro exam normal, possible muscular pain, possible joint pain
• CBC – grans 20,600/ul, monos 2,000/ul, HCT 30%
• GHP/Lytes – phos 8.1
• UA – USG 1.003
• DDx– myositis, polyarthritis, meningitis, unnoticed
trauma, neoplasia
Marti – “Doc’s Spicy Martini”
• Dx Plan 2– Cervical rads with sedation – normal
– CPK – normal
• DDx– Meningitis, polyarthritis, neoplasia
• Rickettsial disease
• immune mediated
• Bacterial
• Fungal
• Neospora/Toxoplasma
• Lymphoma
• (Hepatozoon)
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Marti – “Doc’s Spicy Martini”
• Tx Plan– Doxycycline 10 mg/kg divided BID x 3 weeks
– Clindamycin 15 mg/kg PO BID x 3 weeks
– Deramaxx 1 mg/lb PO SID
– Tramadol 3 mg/lg q 8hrs PRN for pain
3 days later….
• Marti is laterally recumbent & unwilling to move, but neuro exam normal, Temp 103.5oF– Immobility due to pain, neck pain suspected
– Joint pain can not be ruled out
• CBC, GHP, lytes, UA – no change
Marti – “Doc’s Spicy Martini”
• Dx Plan– CSF Tap
• Grossly normal
• Culture negative
Marti – “Doc’s Spicy Martini”• Dx Plan
– CSF Tap
• Grossly normal
• Culture negative
• Cytology – neutrophilic pleocytosis, hypersegmented segs, increased protein
• Fungal Ag (Histoplasma spp, Cryptococcus spp, Aspergillus spp, Blastomyces spp) - neg
– Joint Taps of stifles and elbows
– Urine culture – negative
– Hepatozoon PCR – negative
– Tick Panel – RMSF, Lyme, Ehrlichia – neg
– Toxoplasma/Neospora Titers – negative (Dx?)
• Diagnosis – Steroid Responsive Meningitis-Arteritis
Marti – “Doc’s Spicy Martini”
• Tx Plan– Prednisone 1 mg/lb (30 mg) PO divided BID x 2
weeks– Prednisone 10 mg PO BID x 4 weeks– Prednisone 10 mg PO SID x 4 weeks– Prednisone 10 mg PO QOD x 4 weeks– Prednisone 5 mg PO QOD x 2 weeks– If only partial response to 1 mg/lb divided
BID, go to 1 mg/lb PO BID x 1-2 weeks– Wean off pred very slowly over 4+ months– If any relapse of symptoms, inc. to previous
dose, repeat interval and try again to reduce– 50% will need lifelong pred at some dose, or
intermittently– If incomplete response to pred, can try
azathioprine, cyclosporine or other immunosuppressives
Immune Mediated Meningitis
Similar CSF results
• Culture negative
• Neutrophilic pleocytosis
• Elevated protein
All respond to immunosuppression
Different histopath on necropsy
Steroid Responsive Meningitis-Arteritis (SRMA)
Aka Aseptic Meningitis
• Nova Scotia Duck Tolling Retrievers (“Tollers”)
Immune Mediated Meningitis
• Nova Scotia Duck Tolling Retrievers (“Tollers”)
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Immune Mediated Meningitis
Necrotizing vasculitis• Prognosis not as good as SRMA• Bernese Mt Dog, Beagle, GSP• “Beagle Pain Syndrome”Pyogranulomatous ME• Rapidly progressive, neck pain, brain
stem lesions, seizures, vomiting• PointersAseptic meningitis/polyarthritis of Akitas
Osteomyelitis
DDx• bacterial• FungalDx – FNA – cytology, C&S
Dr. Gary Old
Summary
PowerPoints• .pptx• .pdf – 1 slide per page• .pdf – 6 slides per page
Laboratory Information• CSU – Advanced Lymphoma
Diagnostics Submission Form
Summary
Client Handouts• Degenerative Myelopathy• Discospondylitis• Intervertebral Disc Disease• Nerve Sheath Tumors• Steroid Responsive Meningitis
Summary
Client Drug Handouts• Acetaminophen• Amantadine• Aminocaproic Acid• Amitriptyline• Bethenachol• Carprofen• Clopidogrel• Deracoxib• Dexamethasone• Doxycycline• Enrofloxacin • Famotidine• Firocoxib
• Fish Oil• Gabapentin
• Joint Supplements• Meloxicam• Methocarbamol• Omeprazole• Phenoxybenzamine• Prazosin• Prednisone• Sucralfate• Tramadol
• Tetracycline
Acknowledgements
Curtis Dewey, ACVIM (Neurology)Ronaldo C de Costa• Practical Guide to Canine and Feline
Neurology, 3rd ed. 2016.
Michael Connolly, DVM• Nacogdoches TX
Ann Katherman, ACVIM (Neurology)• Feline Neurology – VIN 2019
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Acknowledgements
Amelia Foster, DVM• Naples FL
Girard Beekman, DVM• York ME