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Getting’ to The point
- 1. Part II GETTING’ TO THE POINT
- 2. SIGNALMENT Shaka 14 year old Male castrated Border Collie mix
- 3. HISTORY 3 month history Progressive loss of pelvic limb function Shifting non weight bearing hind-limb lameness Restless at night Increased anxiety Spontaneous vocalization Painful
- 4. PRESENTATION AT THE Atlantic veterinary College
- 5. Physical Exam • Grade IV/VI systolic heart murmur Orthopedic Exam • Stiff hind-limb gait, with circumduction bilaterally • Left hind-limb weight bearing lameness • Increased patella reflex • Decreased sciatic reflex • Decreased tail and anal tone • Pain was elicited on lumbosacral palpation PRESENTATION
- 6. DIAGNOSTICS Complete blood count Serum biochemical profile Urinalysis Lymph node fine needle aspirate Radiographs
- 9. Working diagnosis was Degenerative Lumbosacral Stenosis 1.Clinical Signs/Exam Findings 2.Experience 3.Normal Diagnostics 4.Prevalence DIAGNOSIS
- 10. Arthritis of coxofemoral joint Arthritis of stifle joint, cruciate ligament dz Spondylosis of lumbar spine Discospondylitis Degenerative myelopathy Neuromuscular disease Myopathies Neoplasia DIFFERENTIAL DIAGNOSIS
- 12. • Mostly confined to medium and large breed dogs • Possible overrepresentation in German Shepards • Working dogs • 2:1 Male to Female Ratio • Middle aged to older. • Long term history of pelvic limb weakness (may be intermittent) • Progressive • Pain at the Lumbosacral junction • Paraparesis • Root signature (pelvic limb held off ground) SIGNALMENT /HISTORY
- 13. • Shortened choppy stride • Knuckling over • Difficulty rising, jumping • Climbing stairs • Exercise intolerance • Urinary incontinence • Fecal incontinence • Posture change • Tail paresis HISTORY/CLINICAL SIGNS
- 14. Narrowing of the vertebral canal & osteophyte formation PATHOPHYSIOLOGY Malformation of LS vertebrae or SI joint; Biomechanical factors; Age; Osteochondrosis Degeneration of L7 S1 Disc Loss of Stability Subluxation
- 15. Eventually leads to nerve root compression or ischemia, leading to Neurological signs. Disc degeneration also leads to Nociceptors in the annulus fibrosus, ligaments, periosteum, & joint capsule Nerve root compression or ischemia are the causes for pain. PATH CONT.
- 16. • L7 spinal cord segment is located at the L4 or L5 vertebrae, and travels extradurally until it leaves the vertebral canal through the intervertrebral foramen of L7 S1. • The nerves that pass the L7 S1 joint are as follows: Sciatic, Pudendal, Pelvic, Sacral, & Caudal. NERVES
- 17. • Thorough History • Physical Exam • Orthopedic Exam • Neurological Exam • Electromyography • Survey Radiographs • Myelography • Discography • Epidurography • MRI • CT scan DIAGNOSIS
- 18. • Confinement/ Exercise restriction • NSAID’s or Steroids • Epidural injection • Acupuncture • Dorsal Laminectomy, with or without diskectomy, stabilization, fenestration Medical Surgical TREATMENT
- 19. THE MEDICAL APPROACH Nsaids, Epidural, and Acupuncture
- 20. Meloxicam 1.5 mg/ml at a dose of 0.1 mg/kg BW orally once daily Minimum of two weeks of restricted activity Acupuncture was repeated weekly for three sessions and then every other month. The epidural space was infiltrated with methylprednisolone acetate 40 mg/ml at a dose of 1 mg/ kg BW MEDICAL MANAGEMENT
- 21. ACUPUNCTURE
- 22. CUN
- 23. GOVERNING VESSEL 20 Bai-hui Provides sedation for acupuncture therapy. It is located on the dorsal midline on a line drawn from the tips of the ears, level with the ear canals.
- 24. BLADDER 10 Tian-zhu • Reduces cervical and shoulder pain, as well as pain associated with intervertebral disc disease. • Located on the dorsolateral aspect of the cervical spine, in a depression just caudal to the wings of the atlas (at the junction of C1-C2), 1.5 cun from the dorsal midline.
- 25. BLADDER 15 Xin-shu Improves cognitive function. Located on the dorsolateral aspect of the spine, 1.5 cun lateral to the caudal border of the dorsal spinous process of T5.
- 26. BLADDER 40 Wei-zhong o Reduces pain associated with thoracolumbar disc disease, coxofemoral joint pain, and pelvic limb paresis. o This point is located in the center of the popliteal crease.
- 27. BLADDER 54 Ba-shan or Zhi-bian Reduces coxofemoral joint pain, osteoarthritis, pelvic limb paresis, lameness, muscle atrophy, and perianal disorders. Located at the coxofemoral joint at the level of the sacrococcygeal hiatus, just dorsal to the greater trochanter of the femur, around the coxofemoral joint.
- 28. GALLBLADDER 29 Ju-liao Reduces pain associated with osteoarthritis of the coxofemoral joint, pelvic limb paresis, and gluteal muscle pain. Located at the coxofemoral joint, in a depression just cranial to the greater trochanter of the femur.
- 29. GALLBLADDER 30 Huan-tiao Reduces pain associated with osteoarthritis of the coxofemoral joint, pelvic limb paresis or paralysis, and gluteal muscle pain. Located in a depression midway between the greater trochanter of the femur and the tuber ischii.
- 30. GALLBLADDER 34 Yang-ling-quan Provides general pain relief, and strengthens tendons and ligaments. Located on the lateral side of the pelvic limb at the stifle, in a small depression cranial and distal to the head of the fibula.
- 31. HEART 7 Shen-men Reduces anxiety and restlessness. Located on the lateral transverse crease of the carpal joint and approached via the large depression lateral to the tendon of the flexor carpi ulnaris muscle although the point is medial to this tendon.
- 32. STOMACH 36 Hou-san-li Reduces stifle pain and hind-limb weakness. Located on the craniolateral aspect of the pelvic limb, 0.5 cun lateral to the cranial aspect of the tibial crest, in the belly of the cranial tibialis muscle.
- 33. STOMACH 45 Li-dui Ameliorates behavioral problems. Located on the lateral side of the third digit of the pelvic limb at the nail bed.
- 34. SPLEEN 6 San-yin-jiao Reduces pelvic limb paresis. Located on the medial side of the pelvic limb 3 cun proximal to the tip of the medial malleolus in a small depression on the caudal border of the tibia.
- 35. CONCLUSION
- 36. Returned to near full functionality with a marked increase to activity Pain was no longer elicited on lumbosacral palpation, or during exercise Owner was advised to continue to monitor and schedule another epidural injection of steroid if felt needed REEVALUATION/EXAMINATION
- 37. RESOURCES • Kent, Marc. Degenerative lumbosacral stenosis in dogs. DVM 360 http://veterinarymedicine.dvm360.com/vetmed/article/articleDetail.jsp?id=169902 July 1, 2005. • Xie and Preast. Xie’s Veterinary Acupuncture. Blackwell Publishing Ltd. 2007 • Daems, Beosier and Janssens. Lumbosacral degenerative stenosis in the dog-the results of epidural infiltration with methylprednisolone acetate: a retrospective study. Vet Comp Orthop Traumatol 2009; 22:486-491. • Lindley and Cummings. Essentials of Western Veterinary Acupuncture. Blackwell Publishing Ltd. 2006 • Fossum, Theresa. Small Animal Surgery. Mosby Year Book Inc. 1997 • Sharp and Wheeler. Small Animal Spinal Disorders Diagnosis and Surgery 2nd edition. Elsevier Limited 2005 • Slatter, Douglass. Textbook of Small Animal Surgery Volume 2. Saunders Co. 1985
- 38. • Advisor Dr. Ortenberger • AVC Surgery Staff • AVC Anesthesia Staff • Rotation Mates • Classmates • My dog Shaka SPECIAL THANKS
- 39. QUESTIONS ?
Editor's Notes
- Hello Im Robert Gracia and today im presenting my case of Degenerative lumbosacral stenosis, getting to the point part 2
- I would like to tell you about my patient Shaka. He is a 14 year old male castrated border collie mix.
- Shaka was losing hind limb function and collapsing during attempts at climbing stairs. Later overexertion while exercising on a walking trail led to progressive dysfunction of both hind-limbs. Episodes of shifting non-weight bearing hind-limb lameness occurred later that day resolving to bilateral weight bearing lameness a week later. Seven days after the insult, shaka was restless at night, not able to sleep for more than an hour before spontaneously vocalizing.
- presentation at the avc
- At the time of presentation to the AVC, shaka was bright, alert, responsive, and very anxious. He was slightly under conditioned and had generalized muscle atrophy. His mucous membranes were pink and moist, and a grade IV/VI systolic heart murmur was auscultated. His resting heart rate was 100 beats per minute, and a resting respiratory rate could not be determined due to panting. His pulse was strong and synchronous. There was moderate enlargement of his left popliteal lymph node. Upon orthopedic examination it was noted that he had a stiff hind-limb gait, and there was evidence of a mild to moderate left hind-limb weight bearing lameness. Circumduction of both hind-limbs was evident during walking and running. He had no signs of ataxia and a wide based hind-limb stance. He had normal range of motion on all joints. He had normal to increased patella reflexes bilaterally, and decreased sciatic reflexes bilaterally. He had decreased tail tone and a low tail carriage. He had a normal rectal exam, but decreased anal tone was noted. Pain was elicited on lumbosacral palpation.
- The results of the complete blood count, serum biochemical profile, urinalysis, and lymph node fine needle aspirates were within normal limits.
- Lateral projections of the lumbar spine, including the lumbosacral junction, were performed. A moderate amount of spondylosis deformans was noted near the thoracolumbar junction.
- There was moderate narrowing of the intervertebral disk space of L3-L4.
- The working diagnosis was Degenerative lumbosacral Stenosis. This diagnosis was supported by the clinical signs, exam findings, experience of the clinician, and diagnostic outcomes and prevalence of this disease.
- Top differentials were Arthritis of coxofemoral joint, of stifle joint, cruciate ligament dz, Spondylosis of lumbar spine, Discospondylitis, Degenerative myelopathy, Neuromuscular disease, Myopathies and Neoplasia.
- now let’s talk a little about degenerative lumbosacral stenosis
- Degenerative Lumbosacral Stenosis is mostly confined to middle aged to older, medium and large breed dogs. It is probably overrepresented in German Shepherds. Other breeds affected commonly include Great Danes, Airedale terriers, Irish setters, English springer spaniels, Boxers, Labrador retrievers, and Golden retrievers. Degenerative Lumbosacral Stenosis is more common in working dogs that undergo rigorous activity. Males are twice as likely to have Degenerative Lumbosacral Stenosis over females. Common findings for Degenerative Lumbosacral Stenosis are pain in the caudal lumbar region and pelvic limb weakness that is manifested as a reluctance to jump, climb and rise.
- The severity of Degenerative lumbosacral stenosis manifests itself in neurological deficits. These may be proprioceptive deficit, decreased hock flexion with a reduced Achilles tendon reflex, urinary or faecal incontinence, and root signature signs such as stamping, lifting of a hind-limb and lower back flea biting behavior.
- Degenerative lumbosacral stenosis is caused by degeneration of the lumbosacral disc resulting in a Hansen Type II disc protrusion. The causes for degeneration of the L7-S1 disc are malformation of lumbosacral vertebrae or the sacroiliac joint, biomechanical factors, age, and osteochondrosis. Eventually a loss of stability leads to subluxation and then to a narrowing of the vertebral canal and osteophyte formation.
- There is also a variable degree of subluxation, instability, soft tissue proliferation, and spondylosis deformans that may contribute to compressive radiculopathy of the cauda equina. This eventually leads to nerve root compression or ischemia which then leads to neurological signs.
- DLSS involves varying degrees of anatomical pathology, such as hypertrophy and ventral folding of the interarcuate ligament, osteoarthritis and subsequent joint capsule proliferation of the articular facets of L7-S1 articulation, and occasionally osteochondrosis of the cranial sacral or caudal L7 end plate may be seen. The nerves most often affected by DLSS are the sciatic, pudendal, pelvic, sacral, and caudal; leading to the neurological signs seen on presentation such as hind-limb paresis and paralysis, decreased sciatic reflexes, decreased tail tone and anal tone, and incontinence.
- Diagnosis can be made utilizing the following: Thorough History, Physical Exam, Orthopedic Exam, Neurological Exam, Electromyography, Survey Radiographs, Myelography, Discography, Epidurography, MRI, CT scan
- Treatment options for DLSS can be divided into two categories; medical management or surgical treatment. Medical therapy consists of exercise restriction for a minimum of 4 to 6 weeks. Administration of anti-inflammatories can be used to control pain and inflammation throughout the restricted exercise period. For mild cases with little neurological signs, non-steroidal anti-inflammatories can be used. For moderate cases with more pronounced neurological signs, corticosteroids can be administered at anti-inflammatory doses. Epidural infiltration with a long lasting corticosteroid can also be undertaken for more severe cases. Acupuncture can be used as an adjunct therapy to help relieve pain along with the other medical management treatments previously discussed. Reduction of anxiety during the restricted activity period is a main benefit of acupuncture therapy. Surgical treatment is a consideration for animals that have a progressive decline in function or persistent pain in spite of medical therapy. Surgical techniques for DLSS include dorsal laminectomy, +/- discectomy, and +/- lumbosacral stabilization.
- Now back to the case.
- Further diagnostic testing to confirm degenerative lumbosacral stenosis was discussed with the owner, and it was opted to try a more conservative medical management approach. The dog was placed on meloxicam 1.5 mg/ml at a dose of 0.1 mg/kg BW orally once daily for pain and inflammation for one week, and two weeks of restricted activity. After the first week passed the dog displayed mild to moderate signs of improvement. During the second week he began acupuncture therapy for lumbosacral pain. Specific acupuncture points pertaining to the dog’s affliction were used to provide analgesia and relief from anxiety. Acupuncture was repeated weekly for three sessions and then every other month. On the initial treatments electro-stimulation over bilateral acupuncture points was done in order to provide a longer lasting effect. Later, a new treatment option was discussed with the owner which was the infiltration of the epidural space with a long acting steroid. The following week the dog was sedated and then placed under general anesthesia and a 21 gauge 7 cm spinal needle was placed in the L7-S1 space by the anesthesia personnel. The epidural space was infiltrated with methylprednisolone acetate 40 mg/ml at a dose of 1 mg/ kg BW. The dog recovered uneventfully and was discharged later that day.
- Now lets discuss shakas acupuncture protocol and the points used.
- a cun is a unit of measure that is particular to the patient. As seen here on this slide. Width of persons thumb at the knuckle.
- Governing vessel (GV) 20 (Bai-hui) provides sedation for acupuncture therapy. It is located on the dorsal midline on a line drawn from the tips of the ears level with the ear canals
- BL-10 (Tian-zhu) reduces cervical and shoulder pain, as well as pain associated with intervertebral disc disease, it is located on the dorsolateral aspect of the cervical spine, in a depression just caudal to the wings of the atlas (at the junction of C1-C2), 1.5 cun from the dorsal midline
- BL-15 (Xin-shu) improves cognitive function and is located on the dorsolateral aspect of the spine, 1.5 cun lateral to the caudal border of the dorsal spinous process of T5
- Bladder (BL) 40 (Wei-zhong) reduces pain associated with thoracolumbar disc disease, coxofemoral joint pain, and pelvic limb paresis. This point is located in the center of the popliteal crease
- BL-54 (Ba-shan or Zhi-bian) reduces coxofemoral joint pain, osteoarthritis, pelvic limb paresis, lameness, muscle atrophy, and perianal disorders. This point is located at the coxofemoral joint at the level of the sacrococcygeal hiatus, just dorsal to the greater trochanter of the femur, around the coxofemoral joint
- Gallbladder (GB) 29 (Ju-liao) reduces pain associated with osteoarthritis of the coxofemoral joint, pelvic limb paresis, and gluteal muscle pain. This point is located at the coxofemoral joint, in a depression just cranial to the greater trochanter of the femur
- GB-30 (Huan-tiao) reduces pain associated with osteoarthritis of the coxofemoral joint, pelvic limb paresis or paralysis, and gluteal muscle pain. It is located in a depression midway between the greater trochanter of the femur and the tuber ischia
- GB-34 (Yang-ling-quan) provides general pain relief, and strengthens tendons and ligaments. This point is located on the lateral side of the pelvic limb at the stifle, in a small depression cranial and distal to the head of the fibula
- Heart (HT) 7 (Shen-men) reduces anxiety and restlessness and is located on the lateral transverse crease of the carpal joint and approached via the large depression lateral to the tendon of the flexor carpi ulnaris muscle although the point is medial to this tendon.
- Stomach (ST) 36 (Hou-san-li) reduces stifle pain and hind-limb weakness. It is located on the craniolateral aspect of the pelvic limb, 0.5 cun lateral to the cranial aspect of the tibial crest, in the belly of the cranial tibialis muscle
- ST-45 (Li-dui) ameliorates behavioral problems and is located on the lateral side of the third digit of the pelvic limb at the nail bed
- Spleen (SP) 6 (San-yin-jiao) reduces pelvic limb paresis and is located on the medial side of the pelvic limb 3 cun proximal to the tip of the medial malleolus in a small depression on the caudal border of the tibia
- Back to the case and its conclusion
- Several weeks after the initial presentation, Shaka returned for reevaluation and examination. He was markedly improved in pain control and functionality. He had been receiving consecutive acupuncture treatments which allowed for the discontinuation of his meloxicam. Shaka had returned to near full functionality with a marked increase to activity. Pain was no longer elicited on lumbosacral palpation, or during exercise. Owner was advised to continue to monitor and schedule another epidural injection of steroid if felt needed.
- here are my resources
- I would like to give a special thanks to my Advisor Dr. Ortenberger, AVC Surgery Staff, AVC Anesthesia Staff, Rotation Mates, Class Mates, My dog Shaka
- any questions