Spinal Cord Disease appearance and differentials. MG Young DVM,MS, DACVIM

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1 Spinal Cord Disease appearance and differentials MG Young DVM,MS, DACVIM

2 Localization There are four localizations: these are derived from the changes to UMN or LMN signs to either thoracic or pelvic limbs. C1-C5 UMN signs to all four limbs, cervical pain, +/- vestibular and reticular activating system dysfunction C6-T2 LMN to TL, UMN to PL, low cervical pain, +/- Horner's, +/- cutaneous trunci changes T3-L3 UMN to the PL, altered cutaneous trunci, +/- UMN bladder, cutaneous trunci changes L4-S1 LMN to the PL, LMN bladder, low tail carriage, loss of anal tone

3 Localization

4 DAMNIT list for differentials Degenerative - disk disease, DM, osteoarthritis, spondylosis deformans, malformations, breed specific degenerations, Anomalous - malformations, spondylomyelopathy, stenosis, synovial cysts, progressive malformations, storage disease, arachnoid diverticula Metabolic - Calcinosis circumscripta, hypervitaminosis A, cellular metabolic/storage disease Neoplasia primary (nerve sheath, meningioma, glioma, lymphoma); secondary (hemangiosarcoma, sarcoma s, and carcinoma s, and round cell) and paraneoplastic myelopathy Inflammatory - diskospondylitis, joint disease, infection, immune disease, SRMA, Para spinal abscess, foreign body migration, rabies, parasite migration, algae, fungus, protozoal Vascular - FCE, infarction, hemorrhage, myelomalacia, feline ischemic myelopathy Trauma HBC as the most common

5 Bea 7yr Frenchie presents for seizures, taking PHB and KBr

6 Bea

7 Localization C1-C5 UMN signs to all four limbs cervical pain, +/- vestibular system dysfunction Spinal reticular system dysfunction Horner s syndrome (partial vs complete) Respiratory dysfunction (phrenic nerve) Cervical muscle loss/and altered sensation

8 Other signs Pain consider manifestations of pain Fainting/passing out Altered blood pressure, heart and respiratory rate Loss of appetite Muscle spasm and altered posture Avoidance of movement

9 Bea MRI

10 Outcome across all locations and grades of Type I disk disease Medical Surgical Cervical 60% (pain alone) 92% (pain or/and weak) Recurrence 40% 10% TL Grade 3 90% 100% TL Grade 4 45% 90% TL Grade 5 5% 60% Recurrence 40% 10% (with fenestration) Davies JV, et al. J Small Anim Pract. 1983; 24: Funquist B. Acta Vet Scand. 1962; 3:

11 Bell Athletic breed, young, trauma, Schnauzer Acute, maybe progressive over 24hrs Asymmetric exam Either non-painful or quickly resolving Both dogs and cats

12 Bell Video

13 Fibrocartilaginous Emboli Definition Nucleus pulposus enters arteriole occluding blood flow to spinal cord Or other ischemic myelopathy

strikes the spinal cord, dissipates or crosses the dura and enters spinal

14 ANNPE Acute non-compressive nucleus pulposus extrusion (ANNPE) Small volume of nucleus pulposus rapidly extrudes through a small tear in the annulus, strikes the spinal cord, dissipates or crosses the dura and enters spinal cord resulting in edema, inflammation, necrosis, hemorrhage (high signal on T2)

15 FCE/ANNPE treatment Physical therapy Manage the bladder diazepam 3-7 days of NSAID TIME AND NURSING CARE these can take months to resolve

16 2y F(N) Cavalier King Charles Spaniel Presented for 16 month history of: Phantom scratching of the head Rubbing of the face Intermittent vocalization Lily

17 MRI Results

18 MRI Results

19 Video lily

20 Beagle 8yr Beagle presents for recurrent cervical pain

21 Immune ganglioradiculoneuritis

22 Immune mediated disease SRMA (beagles, boxer, Bernese) young athletic type dogs, Meningomyelitis (GME, or MUE) generic immune response, Ganglioradiculoneuritis nerve root immune disease Feline polioencephalomyelitis: - grey matter disease Feline hyperesthesia syndrome unknown

23 Craniocervical junction Other stuff

24 Arachnoid diverticula 1. Pugs, French bulldogs, Rottweillers 2. May be congenital or underlying cause 3. More in males 4. Age 2.5m to 11.5 yrs 5. Cervical most common 6. Surgical management curative

26 Neoplasia Primary CNS tumors meningioma, lymphoma, glioma and nerve sheath tumors. These can all have an apparent acute onset do not be misled. Early diagnosis provides more TX options Secondary tumors metastatic tumors (hemangiosarcoma, lymphoma) Invasive tumors sarcomas and carcinomas of the surrounding tissue that invade the vertebral column, and spinal cord. Neoplasia frequently presents as an acute onset of significant neurologic deficits. Lameness and other older patient signs may have been blamed and therefore signs may have been missed earlier.

27 Neoplasia radiographs Job

28 MRI Job

29 Neoplasia radiographs/mri Yoshi

30 Neoplasia radiographs Remember 70% change to the bone to see changes Masses need to be about 1cm or greater to be seen. 3 view radiographs of the thorax

31 Trauma HBC, caught in doors, physical assault, puncture wounds. Be very careful with handling, avoid extension/flexion or rotational forces Sedated radiographs to avoid struggles

32 Penny MRI

33 Penny post-op video

34 Diagnostics CBC/Chemistry/urine analysis Sedate, well positioned, and localized radiographs (primary area of interest at the center of the beam and narrow field of view). Accuracy of radiographs for disk disease reported to be between 50-60% Ideally multiple signs of disk disease not just narrowed space mineralized disk material in situ is okay, in the canal is abnormal Spondylosis does not equal disk disease Points to remember 70% change in the bone required to identify on radiographs must be perfectly straight overlap should be seen of all symmetric structure to make statements of narrowing. Wedges, sand bags, and tape can be used for this purpose. C2 dorsal process should be adjacent to or overlap C1, enlargement of the canal over the intumescences, narrowed disk space at C7-T1, T10-11, T11-12, loss of detail of ventral L4 body

35 Treatments Pain tramadol, gabapentin, codeine with or without Tylenol, amantadine Anti-inflammatory NSAID of choice Bladder management diazepam, +/- phenoxybenzamine vs prazosin The mainstay of medical management is absolute strict exercise restriction. The goal is to allow the disk with a rent to scar and prevent further extrusion. The disk material extruded will remain and fibrous to the spinal cord. Medications will improve comfort and inflammation, but not reduce the volume of compression. Antibiotics to treat infections based on clinical signs, and positive titer s remember a positive titer does not necessitate active infection. Surgery is indicated when the patient fails to improve or declines or due to significant neurologic dysfunction

36 NSAIDS > Steroids NSAID therapy associated with higher (better pain control, fewer side effects) via questionnaire (Levine) Administration of steroid is associated with higher rate of GI and urinary complications causing increased hospital stay and expense NSAIDS lower recurrence rate than prednisone (Mann) Levine JM, et. al. Vet Surg.2007; 36: Mann FA, et. al. J Emer Crit Care. 2007; 17:

37 Steroids Steroids have detrimental effect - suppression of the immune system (bladder), weaken ligaments, weight gain, gastric ulceration (increased with TL disks) Increased risk of recurrence when treating disk disease compared with non-steroidal Not shown to have a significant benefit over other treatments in a large controlled prospective study Unpublished data large controlled study showed MP to be equivalent to PEG and saline in deep pain negative patients. Can significantly delay diagnosis and more appropriate treatment and worsen prognosis

38 Key points Consider the breed and the age Not only disk disease If not improving consider another potential cause or worsening disease process Sedate, perfectly positioned and localized radiographs Steroids can negatively impact the diagnosis, future treatments, and prognosis Early diagnosis of neoplasia allows for more and less radical treatment options Disk disease frequently recurs with medical management, the recurrence rate is increased in dogs treated with full course prednisone Cats get disk disease, neoplasia, and infections as most common causes of spinal cord signs

39 Questions

SPINAL CORD DISEASE IN DOGS PART TWO: MOST LIKELY CAUSES

Vet Times The website for the veterinary profession https://www.vettimes.co.uk SPINAL CORD DISEASE IN DOGS PART TWO: MOST LIKELY CAUSES Author : RITA GONÇALVES Categories : Vets Date : April 7, 2014 RITA