Managing Disorders of the Canine Spine: Difference between revisions
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== Introduction == | == Introduction == | ||
Spinal pain is a common presenting complaint in canine patients, but many disorders of the spine have similar clinical signs and histories.<ref>Cardy TJ, De Decker S, Kenny PJ, Volk HA. Clinical reasoning in canine spinal disease: what combination of clinical information is useful? Vet Rec. 2015;177(7):171.</ref> | Spinal pain is a common presenting complaint in canine patients, but many disorders of the spine have similar clinical signs and histories.<ref>Cardy TJ, De Decker S, Kenny PJ, Volk HA. Clinical reasoning in canine spinal disease: what combination of clinical information is useful? Vet Rec. 2015;177(7):171.</ref> This page discusses some of the more common causes of spinal dysfunction in dogs. The following points are important to consider whenever a canine patient presents with apparent spine-related pain:<ref name=":0">Van der Walt A. Managing Disorders of the Canine Spine Course. Physioplus, 2021.</ref> | ||
This page discusses some of the more common causes of spinal dysfunction in dogs. The following points are important to consider whenever a canine patient presents with apparent spine-related pain:<ref name=":0" /> | |||
* Severe cervical pain is one of the few conditions that will cause “screaming or crying” pain in the dog | * Severe cervical pain is one of the few conditions that will cause “screaming or crying” pain in the dog | ||
* Dogs with spinal pain may display numerous postural abnormalities such as a hunched back, low carriage of the head and torticollis | * Dogs with spinal pain may display numerous postural abnormalities such as a hunched back, low carriage of the head and torticollis | ||
| Line 163: | Line 149: | ||
==== Cervical Spine<ref name=":0" /> ==== | ==== Cervical Spine<ref name=":0" /> ==== | ||
* Commonly produces only neck pain without major loss of nerve function to the limbs - this may be | * Commonly produces only neck pain without major loss of nerve function to the limbs - this may be because the cervical vertebral column has a larger vertebral canal / spinal cord ratio<ref name=":4" /> | ||
* Unilateral or bilateral lameness (caused by lower cervical nerve root compression) | * Unilateral or bilateral lameness (caused by lower cervical nerve root compression) is reported in 15 to 50 percent of cases<ref name=":4" /> | ||
* | * One of the few conditions that will often cause dogs to vocalise pain during sudden movements or when they are picked up | ||
* Patients adopt a stiff gait | * Patients adopt a stiff gait | ||
* They often refuse to flex or extend their neck to eat | * They often refuse to flex or extend their neck to eat | ||
* | * In severe case, ataxia (front and / or hind limbs) and loss of ambulation can occur. Ataxia with tetraparesis or tetraplegia can develop<ref name=":4" /> | ||
==== Thoracolumbar Spine<ref name=":0" /> ==== | ==== Thoracolumbar Spine<ref name=":0" /> ==== | ||
Revision as of 19:36, 2 March 2021
Introduction[edit | edit source]
Spinal pain is a common presenting complaint in canine patients, but many disorders of the spine have similar clinical signs and histories.[1] This page discusses some of the more common causes of spinal dysfunction in dogs. The following points are important to consider whenever a canine patient presents with apparent spine-related pain:[2]
- Severe cervical pain is one of the few conditions that will cause “screaming or crying” pain in the dog
- Dogs with spinal pain may display numerous postural abnormalities such as a hunched back, low carriage of the head and torticollis
- Nerve root signs indicate that there is irritation of the nerve root, resulting in unilateral limb lameness
- Spinal compression or degeneration may cause limb paresis / paralysis with associated ataxia. However, it is important to note that these changes can also be due to pathologies outside of the spine, such as brain tumors and mid thoracic pathology
- Dogs with acute and / or progressive potential spinal pain must always be referred to the veterinarian as a matter of urgency
Atlantoaxial Instability[edit | edit source]
Atlantoaxial (AA) instability occurs after the subluxation or dislocation of the atlantoaxial joint. This can be congenital (often due to the abnormal formation of ligaments in the animal’s vertebrae) or occur after an accident.[2][3] This is especially true for smaller dogs who get injured jumping from tall structures.[2]
AA instability can cause:[2]
- Spinal cord compression
- Pain and disability
AA instability can occur in dogs and cats, but in canine patients, it is common in young, toy- or small-breed dogs[4][5] (e.g.Yorkshire Terriers).
Key Features[edit | edit source]
AA instability should be suspected in any young, toy-breed dog who presents with signs of a C1 to C5 myelopathy.[2]
- Neck pain, with mild ataxia in 24.9 percent of cases
- Ambulatory with moderate to severe ataxia or paresis in 34.1 percent of cases
- Non-ambulatory paraparetic in 34.5 percent of cases
- 6.5 percent of cases are tetraplegic
Diagnosis of AA instability can typically be made on survey radiographs.[5]
Treatment[edit | edit source]
Treatment may be conservative or surgical. It is important to note that manual manipulation of the neck should be avoided if AA instability is suspected.
Conservative[edit | edit source]
Conservative management is indicated in the following instances:[2]
- An acute history of neurological signs
- Immature bones for which surgery may not provide adequate stabilisation
- Financial considerations
The goal of conservative management is to encourage fibrous tissue that can stabilise the AA joint to form, and to prevent further subluxation. Treatments include:[2]
- Cervical splints
- Pain management
- Strict exercise restriction for around 8 weeks
It has been found that the use of a cervical splint is a viable treatment option for young dogs who experience an acute-onset of AA instability with clinical signs, regardless of the severity of the neurological deficits on presentation.[8]
Surgical[edit | edit source]
The goal of surgical management of AA instability is to achieve reduction of the subluxation. It is recommended for patients who have neurological deficits or neck pain that is not responding to conservative management.[5]
Both dorsal and ventral approaches have been described. The prognosis for patients following surgery is usually good.[5]
Physiotherapy Management[edit | edit source]
As both conservatively and surgically managed patients are likely to be in a splint initially, the treatment approaches will be similar. Patients are not often referred for physiotherapy in the initial stages of recovery (i.e. the splinted stage).
Owners should be advised to perform exercises that focus on maintaining strength and function in the rest of the body. For example:[2]
- Static proprioceptive and balance training
- Rhythmic stabs
- 3-legged stand/diagonal stand (supported so that patient does not fall if balance is lost)
- Non-habitual movements such as walking backwards (depending on patient compliance)
- Functional mobility exercises such as sit-stand / down-stand (depending on patient compliance)
- Once the patient is out of its splint, progressive restoration of cervical active range of motion (ROM), as well as rehabilitation of the strength and proprioception of cervical spine can commence
- It is important to ensure the dog has good stability and motor control of the thoracic sling
Caudal Cervical Spondylomyelopathy[edit | edit source]
Caudal cervical spondylomyelopathy (CCSM), also known as Wobblers syndrome and cervical vertebra instability, is a degenerative, progressive disorder of the intervertebral disc, ligaments, and facet joints of the cervical spine that, ultimately, results in compression of the spinal cord and nerve roots.[9]
It can affect any dog breed, but younger Great Danes and older Dobermanns are more likely to be affected.[10] Disc‐associated CCSM is often found in Doberman pinschers and other large‐breed dogs.[9]
The pathological abnormalities associated with CCSM can be roughly divided into two groups based on the age of the animal at presentation:[2]
- Young dogs (e.g. Great Danes less than two years of age) typically have vertebral malformation with accompanying secondary soft tissue changes that cause spinal cord compression
- Middle-aged dogs (typically large- and giant-breeds) have spinal cord compression as a result of hypertrophy of the dorsal annulus fibrosis or Hansen type 2 disc rupture
Most dogs with CCSM will be presented with a history of a slow, progressive onset of symptoms that gradually worsen with time. It is, however, important to note that acute exacerbations are possible. CCSM most commonly occurs at C5/6 and/or C6/7.[2]
Key Features[edit | edit source]
Key characteristics of CCSM include a “wobbling” gait, paresis and cervical pain:[11][2]
- Symptoms range from mild ataxia of the rear legs to non-ambulatory tetraparesis
- The owner will report the dog has a wobbly, unsteady gait in the hind legs, and “knuckling over” on the hind feet
- Affected dogs will generally have a low head and neck posture and resist extension of the cervical spine
- Cervical pain is typically not present in these dogs, but a small number will exhibit mild cervical pain on neck manipulation
- Dogs with CCSM tend to walk with a stiff, stilted gait in the front legs
- Deficits of the hind legs are typically present - these are made worse with neck extension
- Neurological abnormalities in the front legs will be absent or less severe than in the hind legs apart from in dogs who are more severely affected
- Definitive diagnosis can only be made with myelography
Treatment[edit | edit source]
Conservative Management[edit | edit source]
Conservative management tends to be indicated only when there are financial constraints, or the animal has comorbidities that would prevent surgery.[2] De Decker and colleagues found that conservative management of CCSM is associated with a “guarded prognosis”.[13]
Treatment usually consists of:[9]
- Restricted activity
- Using a body harness
- Analgesia and / or steroids
Surgical Management[edit | edit source]
Surgical techniques include:[2]
- Dorsal laminectomy
- Ventral cervical decompression
- Modified distraction-stabilisation technique
Post-operative care depends on the animal’s neurological status, but a dog will require a harness instead of a collar for the rest of its life.[2]
Physiotherapy Management[edit | edit source]
In the case of surgery, activity limitations will be determined by the surgeon. It will be important to maintain and improve the dog’s general strength, mobility and exercise tolerance. Progressions will depend on the patient’s tolerance and the surgeon’s guidelines.
Treatment will focus on:[2]
- Managing pain
- Enhancing cervical strength, proprioception / sensorimotor function
- Active ROM (avoiding hyperextension)
- Static strengthening of cervical muscles - this can start during the first week post- surgery
- If the dog has retrieving skills - progressive loading of the cervical extensors in mid-range can be achieved by getting the dog to retrieve articles
Sensorimotor rehabilitation may include:[2]
- Eye movements - initially with neck in neutral before moving to progressive lateral flexion
- Foraging activities
- Dog touching a target with its nose
Intervertebral Disc Disease[edit | edit source]
Intervertebral disc disease (IVDD) is the most common spinal condition in canine patients.[14] It occurs most often in the thoracolumbar region (T3-L3 in particular). There is no gender predisposition, but certain dogs are more predisposed to IVDD, particularly chondrodystrophic breeds (i.e. short-legged phenotype).[15]
The most common presenting breeds are:[2]
- Dachshund
- Pug
- Bull dog
- Bassett
- Pekinese
- Lhasa apso
- Shih tzu
- Beagle
- Poodle
- Cavalier King Charles spaniel
- Boston terrier
Dogs are usually affected when aged between three and six years. If a predisposed breed presents with spinal pain, IVDD must be considered in a differential diagnosis.[2] The overall prevalence of disc herniation in dogs is two percent, but between 19 and 24 percent of dachshunds present with clinical signs of IVDD during their lifetime. They account for between 45 and 73 percent of all acute cases of disc extrusion in dogs.[16]
There are two types of IVDD:[17]
- Hansen Type I: Intervertebral disc extrusion[2]
- This is an acute disease process caused by the extrusion of disc material (i.e. the nucleus pulposus) through a tear in the annulus and into the vertebral canal. This causes cord and / or nerve root compression. It is usually associated with chondroid degeneration[16] and is more common in young and middle-aged chondrodystrophic breeds[17]
- Hansen Type II: Intervertebral disc protrusion[2]
- This chronic process occurs secondary to tearing of the annulus fibrosus, which results in bulging of the disc dorsally and compression of the spinal cord. It is usually associated with fibroid degeneration.[16] In contrast to Type I, it tends to occur in older non-chondrodystrophic dogs (i.e. aged over 7 years).[17] Commonly affected breeds include labrador retrievers and german shepherds
Various imaging techniques have been used to identify IVDD in dogs including survey radiographs, myelography, CT, and MRI.[18]
- Radiographs, while unable to identify disc prolapses or disc extrusions, can identify disc calcifications and spondylitic changes around the vertebra. They can also exclude other potential causes of disc pain[2][18]
- Narrowing of disc spaces may be associated with acute disc extrusions but this may often be misleading due to incorrect positioning
- Myelography allows evaluation of compressive lesions of the spinal cord and can be used to evaluate and identify disc extrusions and protrusions. It has, however, largely been replaced by cross-sectional imaging in areas where CT and MRI are available[18]
- MRI is a more advanced imaging technique that allows better evaluation of areas of disc pathology and is able to evaluate the spinal cord itself. It is considered the gold standard IVDD imaging[18]
Key Features[edit | edit source]
Thoracolumbar intervertebral disc herniation occurs in 66 to 87 percent of dogs with intervertebral disc herniation. Cervical disc herniation is reported in 12.9 to 25.4 percent of canine patients who have intervertebral disc herniation.[16] Older dogs have a higher incidence of cervical disc disease.
Cervical Spine[2][edit | edit source]
- Commonly produces only neck pain without major loss of nerve function to the limbs - this may be because the cervical vertebral column has a larger vertebral canal / spinal cord ratio[16]
- Unilateral or bilateral lameness (caused by lower cervical nerve root compression) is reported in 15 to 50 percent of cases[16]
- One of the few conditions that will often cause dogs to vocalise pain during sudden movements or when they are picked up
- Patients adopt a stiff gait
- They often refuse to flex or extend their neck to eat
- In severe case, ataxia (front and / or hind limbs) and loss of ambulation can occur. Ataxia with tetraparesis or tetraplegia can develop[16]
Thoracolumbar Spine[2][edit | edit source]
- Thoracolumbar IVDD causes varying degrees of pain and neurological deficits (mild paraparesis to paraplegia)[16]
- Characteristic gait abnormalities begin to develop and progress in usually predictable patterns:[2]
- Dog starts to refuse to do 'normal activities' (e.g. avoid jumping onto couch, avoid walks, usual games)
- Dog develops an ataxic gait (has variable weakness, and refuses or is unable to walk or stand)
- Dog has complete loss of motor function (bladder and bowel function usually also lost)
- Dog has a loss of deep pain
Treatment[edit | edit source]
Conservative management of IVDD can be considered if:[2]
- There is no neurological fall-out
- Cord compression is mild
- Nerve root compression is the primary finding
Treatment will focus on pain management combined with cage rest or strict confinement at home to help prevent further disc extrusion.[16]
A multi-drug approach is typically used:[2]
- Muscle relaxants such as diazepam, anti-inflammatory medications (non–steroidal) and an NADMA receptor antagonist such as gabapentin has been found to be effective
- Steroids may initially be used to reduce inflammation, but their use should be limited to the initial 2-4 days before being replaced by non-steroidal medications
Treatment should be continued for a month after all pain has been controlled. If conservative management fails, or if there is neurological fall-out, then surgery is warranted (ventral slot decompression cervical IVDD; hemilaminectomy with fenestration for thoracolumbar decompression).[2]
Supportive Care for Neurological Patients[edit | edit source]
A key treatment objective is to prevent or mitigate secondary complications. It is imperative that decubitus ulcers, urine scalding, and infection are prevented / managed.[19]
Bedding[2][edit | edit source]
- Immobile and non-ambulatory patients must be provided with adequate bedding.
- Ideally, bedding should be smooth, stable, nonporous (or easily cleaned and replaced), and deformable
- It should be checked frequently (sometimes as often as hourly) for soiling. Bedding that is wet with water, urine, faeces, or serous and purulent discharge needs to be replaced immediately
Because the patient’s skin may require frequent cleaning, detergents and materials used for cleaning should be gentle products that will not disrupt the protective epidermal layer.
Patients that are not yet able to hold themselves in a sternal position, or who lay preferentially on one side or the other should be turned every 4 to 6 hours[19]
Harnesses[2][edit | edit source]
Harnesses assist in lifting heavy patients and support mobility until the patient regains sufficient strength and coordination to be independently ambulatory. They should be constructed of a durable yet soft, lightweight, and breathable material. Edges should be smooth or padded to prevent rubbing / pinching of the skin and catching of the fur.
Booties[edit | edit source]
Patients with reduced / absent proprioception and sensory capacity are more likely to develop skin lesions. These range from hair loss and abrasions to full thickness wounds on the digits and bony prominences of the lower limbs. They may be caused by pressure necrosis, scuffing on the ground, or self-mutilation. As with pressure necrosis lesions, abrasions on the extremities can quickly progress to full thickness lesions and may become infected.[2]
The toes and distal limbs can be protected from trauma with the use of bandages or commercial booties. These should fit securely but not constrict the thin, soft tissue layers of the extremities.
The use of booties can be problematic, however, because booties that provide adequate protection to the skin may also limit sensory input to the distal limb. This can potentially hinder any emerging proprioceptive signalling. Moreover, the weight of the bootie may complicate locomotion in dogs with weakness (e.g. weak hock flexion secondary to sciatic neuropathy or weak carpal extension secondary to radial nerve palsy). Many patients will object to the feel of the booties or be inclined to chew at the unfamiliar article. It is, therefore, important to consider these issues when selecting a bootie.[2]
Bladder Management[edit | edit source]
Many patients with spinal cord disease also have bladder and urethral dysfunction.[20][21] There should be continuous monitoring for signs of urinary tract injury or compromise. When the patient is completely unable to initiate or complete micturition, the bladder needs to be manually expressed. Bladder management may also be facilitated with the use of medications.[2]
Owners of patients managed as outpatients should be advised to watch for any change in the frequency or amount of urine production, changes in colour or odour, and the presence of blood, fibrin, or mucus. Even when there are no outward signs of infection, and especially when dogs are participating in hydrotherapy sessions, routine monitoring is recommended (i.e urine cultures every 4 weeks to 3 months for as long as the dog remains non-ambulatory).[2]
Faecal Incontinence[edit | edit source]
Faecal incontinence is a frequent challenge, but medical management options are limited. Appropriate sanitation and nursing care as described above are the primary management goals. Commercially available dog nappies can be used. Neonatal nappies can often also be adapted for use.[2]
Physiotherapy Management[edit | edit source]
The goals of physiotherapy management are to:
- Prevent secondary complications
- Promote neurorecovery
- Maximise function by maintaining and strengthening all innervated muscle groups and facilitating functional patterns of activity
- Support and educate the patient, carers, family and staff
Physiotherapy should start as soon as patients are medically stable and can tolerate the required treatment intensity. There are no evidence-based guidelines for IVDD rehabilitation protocols in dogs. Management has, therefore, been adapted from human clinical guidelines.[2]
References[edit | edit source]
- ↑ Cardy TJ, De Decker S, Kenny PJ, Volk HA. Clinical reasoning in canine spinal disease: what combination of clinical information is useful? Vet Rec. 2015;177(7):171.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 2.26 2.27 2.28 2.29 2.30 2.31 2.32 2.33 2.34 Van der Walt A. Managing Disorders of the Canine Spine Course. Physioplus, 2021.
- ↑ Takahashi F, Hakozaki T, Kouno S, Suzuki S, Sato A, Kanno N et al. Atlantooccipital overlapping and its effect on outcomes after ventral fixation in dogs with atlantoaxial instability. The Journal of veterinary medical science. 2018;80(3):526–31.
- ↑ Planchamp B, Bluteau J, Stoffel MH, Precht C, Schmidli F, Forterre F. Morphometric and functional study of the canine atlantoaxial joint. Research in Veterinary Science. 2020;128:76-85.
- ↑ 5.0 5.1 5.2 5.3 Slanina MC. Atlantoaxial Instability. Vet Clin North Am Small Anim Pract. 2016;46(2):265-75.
- ↑ Southeast Veterinary Neurology. What is Atlantoaxial Instability in Dogs? || Southeast Veterinary Neurology. Available from: https://www.youtube.com/watch?v=q2Q9d_jHznY [last accessed 1/3/21]
- ↑ MercolaHealthyPets. Dr. Becker Discusses Atlantoaxial Instability in Dogs. Available from: https://www.youtube.com/watch?v=mpaIZdJWBgg [last accessed 1/3/21]
- ↑ Havig ME, Cornell KK, Hawthorne JC, McDonnell JJ, Selcer BA. Evaluation of nonsurgical treatment of atlantoaxial subluxation in dogs: 19 cases (1992-2001). J Am Vet Med Assoc. 2005;227(2):257-62.
- ↑ 9.0 9.1 9.2 Reints Bok TE, Willemsen K, van Rijen MHP, Grinwis GCM, Tryfonidou MA, Meij BP. Instrumented cervical fusion in nine dogs with caudal cervical spondylomyelopathy. Vet Surg. 2019;48(7):1287-98.
- ↑ Plessas J. Treating neck pain in dogs – neurological five-step approach [Internet]. Vet Times. 2016 [cited 1 March 2021]. Available from: https://www.vettimes.co.uk/app/uploads/wp-post-to-pdf-enhanced-cache/1/treating-neck-pain-in-dogs-neurological-five-step-approach.pdf
- ↑ Shekhar P, Singh GD, Kumar S, Singh AK, Choudhury S, Shukla A. Wobbler's syndrome in labrador and rotweiller pups: an emerging concern in canines: a review. International Journal of Science, Environment and Technology. 2018;7(1):361-4.
- ↑ MercolaHealthyPets. Wobbler's Syndrome in Dogs. Available from: https://www.youtube.com/watch?v=teYOyBn9xCY [last accessed 1/3/2021]
- ↑ De Decker S, Bhatti SF, Duchateau L, Martlé VA, Van Soens I, Van Meervenne SA, Saunders JH, Van Ham LM. Clinical evaluation of 51 dogs treated conservatively for disc-associated wobbler syndrome. J Small Anim Pract. 2009;50(3):136-42.
- ↑ Rusbridge C. Canine chondrodystrophic intervertebral disc disease (Hansen type I disc disease). BMC Musculoskelet Disord. 2015;16(Suppl 1):S11.
- ↑ Baumhardt R, Ripplinger A, Aiello G, Schwab M, Ferrarin D, Wrzesinski MR et al. Clinical management of dogs with presumptive diagnosis of thoracolumbar intervertebral disc disease: 164 cases (2006-2017). Pesquisa Veterinária Brasileira. 2020;40(1):55-60.
- ↑ 16.0 16.1 16.2 16.3 16.4 16.5 16.6 16.7 16.8 Brisson BA. Intervertebral disc disease in dogs. Vet Clin North Am Small Anim Pract. 2010;40(5):829-58.
- ↑ 17.0 17.1 17.2 Fenn J, Olby NJ; Canine Spinal Cord Injury Consortium (CANSORT-SCI). Classification of Intervertebral Disc Disease. Front Vet Sci. 2020;7:579025.
- ↑ 18.0 18.1 18.2 18.3 da Costa RC, De Decker S, Lewis MJ, Volk H; Canine Spinal Cord Injury Consortium (CANSORT-SCI). Diagnostic Imaging in Intervertebral Disc Disease. Front Vet Sci. 2020;7:588338.
- ↑ 19.0 19.1 Drum M, Werbe B, McLucas K, Millis D. Nursing care of the rehabilitation patient. In Millis DL, Levine D, editors. Canine Rehabilitation and Physical Therapy. 2nd Edition. Elsevier Saunders, 2014. p.277-304.
- ↑ Laitinen OM, Puerto DA. Surgical Decompression in Dogs with Thoracolumbar Intervertebral Disc Disease and Loss of Deep Pain Perception: A Retrospective Study of 46 Cases. Acta Vet Scand. 2005;46:79.
- ↑ Barnes KH, Aulakh KS, Liu C. Retrospective evaluation of prazosin and diazepam after thoracolumbar hemilaminectomy in dogs. Vet J. 2019;253:105377.
