Managing Disorders of the Canine Spine: Difference between revisions

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* Foraging activities
* Foraging activities
* Dog touching a target with its nose
* Dog touching a target with its nose
== Intervertebral Disc Disease ==
Intervertebral disc disease (IVDD) is the most common spinal condition in canine patients.<ref name=":3">Rusbridge C. Canine chondrodystrophic intervertebral disc disease (Hansen type I disc disease). BMC Musculoskelet Disord. 2015;16(Suppl 1):S11. </ref> 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).<ref>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.</ref>
The most common presenting breeds are:<ref name=":0" />
* 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.<ref name=":0" /> 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.<ref name=":4">Brisson BA. Intervertebral disc disease in dogs. Vet Clin North Am Small Anim Pract. 2010;40(5):829-58. </ref>
{{#ev:youtube|rKdzVL9XDSo}}<ref>MercolaHealthyPets. Dr. Becker on Intervertebral Disc Disease (IVDD). Available from: https://www.youtube.com/watch?v=rKdzVL9XDSo [last accessed 3/3/21]</ref>
There are two types of IVDD:<ref name=":5">Fenn J, Olby NJ; Canine Spinal Cord Injury Consortium (CANSORT-SCI). Classification of Intervertebral Disc Disease. Front Vet Sci. 2020;7:579025. </ref>
* Hansen Type I: Intervertebral disc extrusion<ref name=":0" />
** 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<ref name=":4" /> and is more common in young and middle-aged chondrodystrophic breeds<ref name=":5" />
* Hansen Type II: Intervertebral disc protrusion<ref name=":0" />
** 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.<ref name=":4" /> In contrast to Type I, it tends to occur in older non-chondrodystrophic dogs  (i.e. aged over 7 years).<ref name=":5" />  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.<ref name=":6">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.</ref>
* 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<ref name=":0" /><ref name=":6" />
* 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<ref name=":6" />
* 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<ref name=":6" />
=== Key Features ===
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.<ref name=":4" /> Older dogs have a higher incidence of cervical disc disease.
==== Cervical Spine<ref name=":0" /> ====
* 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) 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
* 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
==== Thoracolumbar Spine<ref name=":0" /> ====
* Thoracolumbar IVDD causes varying degrees of pain and neurological deficits (mild paraparesis to paraplegia)<ref name=":4" />
* Characteristic gait abnormalities begin to develop and progress in usually predictable patterns. The dog:<ref name=":0" />
*# Starts to refuse to do 'normal activities' (e.g. avoid jumping onto couch, avoid walks and usual games)
*# Develops an ataxic gait (has variable weakness, refuses / is unable to walk or stand)
*# Has complete loss of motor function (bladder and bowel function usually also lost)
*# Has a loss of deep pain
{{#ev:youtube|AXOXzBMtPoQ}}<ref>Southeast Veterinary Neurology. Intervertebral Disk Disease(IVDD) in Dogs - Causes, Diagnosis and Treatment. Available from: https://www.youtube.com/watch?v=AXOXzBMtPoQ [last accessed 3/3/21]</ref>
=== Treatment ===
Conservative management of IVDD can be considered if:<ref name=":0" />
* There is no neurological fallout
* 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.<ref name=":4" />
A multi-drug approach is typically used:<ref name=":0" />
* Muscle relaxants such as diazepam, anti-inflammatory medications (non–steroidal) and an NDMA 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 between 2 and 4 days before they are replaced with 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 fallout, then surgery is warranted (ventral slot decompression for cervical IVDD; hemilaminectomy with fenestration for thoracolumbar decompression).<ref name=":0" />
==== Supportive Care for Neurological Patients ====
A key treatment objective is to prevent or mitigate secondary complications. It is imperative that decubitus ulcers, urine scalding, and infection are prevented / managed.<ref name=":7">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.</ref>
===== Bedding<ref name=":0" /> =====
* 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, gentle products that will not disrupt the protective epidermal layer. should be used. 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.<ref name=":7" />
===== Harnesses<ref name=":0" /> =====
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 =====
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. Abrasions can quickly progress to full thickness lesions and may become infected.<ref name=":0" />
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. It is, however, important to note that the use of booties can be problematic. Booties that provide adequate protection to the skin may also limit sensory input to the distal limb, which can potentially hinder 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.<ref name=":0" />
===== Bladder Management =====
Many patients with spinal cord disease also have bladder and urethral dysfunction.<ref>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. </ref><ref>Barnes KH, Aulakh KS, Liu C. Retrospective evaluation of prazosin and diazepam after thoracolumbar hemilaminectomy in dogs. Vet J. 2019;253:105377.</ref> There should be continuous monitoring for signs of urinary tract compromise. If the patient is unable to initiate or complete micturition, the bladder needs to be manually expressed. Bladder management may also be facilitated with the use of medications.<ref name=":0" />
Owners of canine 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 routine monitoring is recommended (i.e  urine cultures every 4 weeks to 3 months for as long as the dog remains non-ambulatory). This is especially important for dogs participating in hydrotherapy.<ref name=":0" />
===== Faecal Incontinence =====
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 also be adapted for use.<ref name=":0" />
==== Physiotherapy Management ====
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:<ref name=":0" />
* Standing
** Soft Tissue Effects : Standing has been found to result in reduced muscle tone and improved range of motion or muscle length.<ref name=":8">Spinal Cord Injury Centre Physiotherapy Lead Clinicians. [https://www.mascip.co.uk/wp-content/uploads/2015/05/Clinical-Guidelines-for-Standing-Adults-Following-Spinal-Cord-Injury.pdf Clinical Guideline for Standing Following Spinal Cord Injury]. Multidisciplinary Association for Spinal Cord Injury Professionals. 2013. 44 p.</ref> This is probably mostly valuable for canine patients presenting with hip flexor or adductor spasticity<ref name=":0" />
** Bone Health Effects: High frequency standing that is introduced soon after injury and maintained can significantly reduce bone demineralisation in human patients with spinal cord injury
** Exercise Effects:  Exercise is associated with improved postural control, strengthening the antigravity muscles, better balance reactions and the maintenance of functional range of movement. It can also help to enhance skill acquisition during gait retraining.<ref name=":8" /> This is most easily achieved by getting the client to support the dog in standing with its hind limbs placed in a functional position, at practical times of the day (i.e. while the dog is eating). This can be progressed to more challenging positions as the dog’s strength increases, such as placing the dog’s front feet on a slightly raised surface<ref name=":0" />
* Gait training should include conventional overground walking, supported by body weight–supported treadmill training (or underwater treadmill training) where possible<ref name=":0" />
* Functional electrical stimulation
When the patient has pain, any diagnosis of neuropathic pain must be informed by the patient's complete patient history, as well as a physical examination using the International Spinal Cord Injury Pain (ISCIP) Classification System.<ref name=":9">Bryce TN, Biering-Sørensen F, Finnerup NB, Cardenas DD, Defrin R, Lundeberg T et al. International spinal cord injury pain classification: part I. Background and description. March 6-7, 2009. Spinal Cord. 2012 Jun;50(6):413-7.</ref> It is essential to screen for Red Flags to help identify any serious underlying conditions that may cause, aggravate or mimic neuropathic pain.
* Acute or chronic nociceptive pain can be visceral or musculoskeletal (or other nociceptive pain):<ref name=":9" />
** Visceral pain may arise from trauma, disease or inflammation of the viscera
** Musculoskeletal pain may arise from trauma, disease or inflammation of the musculoskeletal system
* Neuropathic pain can occur above, at, or below the level of injury:<ref name=":0" />
** Above-level neuropathic pain is not exclusive to SCI and may occur secondary to complex regional pain syndromes or peripheral nerve injury
** At-level neuropathic pain may occur secondary to trauma to the spinal cord or nerve roots
** Below-level neuropathic pain also occurs secondary to trauma to the spinal cord
==== Therapeutic Interventions for IVDD ====
===== Spasticity and Contracture Management =====
* Manual Stretching
* Weight Bearing (standing)
* Vibration (low frequency—5—50Hz)
===== Gait Training =====
The major requirements for successful walking include:<ref name=":0" />
* Support of the body by lower limbs
* Propulsion of the body in the intended direction
* The production of a basic locomotor rhythm
* Dynamic balance control of the moving body
Whole body vibration increases tone in functional positions (50 - 100Hz). It appears to be safe and well-tolerated. It may also improve muscle oxygenation and the patient’s body awareness during treatment.<ref>Felter C. Whole Body Vibration for People with Spinal Cord Injury: a review. ''Curr Phys Med Rehabil Rep.'' 2017;5:99-107.</ref>
Treadmill training (including underwater treadmill training) provides an opportunity for dogs to repetitively practise missing gait components. It has been found that the repeated activation of sensorimotor pathways by task-specific training may reinforce the circuits and synapses used to successfully complete the task or movement.<ref>Hubli M, Dietz V. The physiological basis of neurorehabilitation--locomotor training after spinal cord injury. J Neuroeng Rehabil. 2013;10:5.</ref>
* A harness can be used for individuals who have significant functional limitations. Harnesses provide the opportunity to grade the amount of body weight support provided. In the case of underwater treadmill walking, this body weight support is facilitated by buoyancy in the water
* Therapists help to facilitate alternating stepping and weight-bearing<ref name=":0" />
===== Balance Training =====
Progressively provide more challenging positions and surfaces.
===== Pain Management<ref name=":0" /> =====
* Physical modalities such as TENS, heat, and cold
* Soft tissue techniques such as massage
* Specific strengthening and stretching exercises
* Graded exercise or activity programmes
* Hydrotherapy
* Education on activity pacing
===== Exercise Guidelines =====
It has been found that adults with SCI should engage in:<ref>National Centre for Sports and Exercise Medicine. SCI guidelines: United Kingdom. Available from: https://www.ncsem-em.org.uk/sciguidelinesuk/ (accessed 3 March 2021).</ref>
* 20 minutes of moderate to vigorous intensity aerobic exercise 2 x per week AND 3 sets of strength training exercises for each major functional group at a moderate to vigorous intensity 2 x per week to achieve cardiorespiratory and muscle strength benefits
* 30 minutes of moderate to vigorous intensity aerobic exercise 3 x per week for cardiometabolic health
Fitting patients with a wheelchair helps them to achieve these exercise goals:<ref name=":0" />
* Canine wheelchairs can only be worn for short periods at a time - 20 - 40minutes, so are not a solution for all-day mobility
* Wheelchairs can only be used under supervision
* Wheelchairs should be well-fitting to reduce pressure areas and musculoskeletal strain
Hydrotherapy is also a practical way of maintaining cardiovascular fitness in non-ambulant of poorly-ambulating patients.<ref name=":0" />


== References ==
== References ==

Revision as of 21:05, 2 March 2021

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (2/03/2021)
Original Editor - Ansi van der Walt Top Contributors - Jess Bell, Kim Jackson, Lucinda hampton and Tarina van der Stockt

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]

[6]
[7]

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]

  1. 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
  2. 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

[12]

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

References[edit | edit source]

  1. ↑ 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. ↑ 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 Van der Walt A. Managing Disorders of the Canine Spine Course. Physioplus, 2021.
  3. ↑ 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.
  4. ↑ 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. ↑ 5.0 5.1 5.2 5.3 Slanina MC. Atlantoaxial Instability. Vet Clin North Am Small Anim Pract. 2016;46(2):265-75.
  6. ↑ 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]
  7. ↑ MercolaHealthyPets. Dr. Becker Discusses Atlantoaxial Instability in Dogs. Available from: https://www.youtube.com/watch?v=mpaIZdJWBgg [last accessed 1/3/21]
  8. ↑ 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. ↑ 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.
  10. ↑ 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
  11. ↑ 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.
  12. ↑ MercolaHealthyPets. Wobbler's Syndrome in Dogs. Available from: https://www.youtube.com/watch?v=teYOyBn9xCY [last accessed 1/3/2021]
  13. ↑ 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.
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