2013.03.28. 1 Common Spinal Common Spinal Disorders Disorders Péter Csébi DVM éter Csébi DVM Veterinary University Veterinary University Surgical Department Surgical Department Hungary Hungary Spinal disorder? Spinal disorder? Transvers Transversal al myelopathy myelopathy: Alteration caudal to the lesion: Alteration caudal to the lesion: ► Postural deficits Postural deficits ► Ataxia Ataxia ► Paresis Paresis ► Abnormal spinal reflexes (Hypo Abnormal spinal reflexes (Hypo-, , hyperreflexia hyperreflexia) ► Micturation Micturation abnormalities (UMN and LMN bladder) abnormalities (UMN and LMN bladder) ► (Pain) (Pain) (See the detailed explanation in pathophysiology lecture!) Severity Severity – Grading Grading 1-5 5 scale scale ►Grade Grade 1: only only hyperaesthesia hyperaesthesia ►Grade Grade 2: mild mild paraparesis paraparesis and and ataxia ataxia ►Grade Grade 3: 3: severe severe paraparesis paraparesis and and ataxia ataxia ►Grade Grade 4: 4: non non-ambulatory ambulatory paraparesis paraparesis with with intact deep pain perception intact deep pain perception ►Grade Grade 5: 5: paraplegi paraplegia without deep pain a without deep pain perception perception This scoring is used in most of the neurological textboooks. Severity Severity – Grading Grading Modified Modified Frankel Frankel Score Score (MFS) (MFS) ►0: 0: non non-ambulatory ambulatory para para/tetraplegia tetraplegia, , lack lack of of superficial superficial and and deep deep nociception nociception ►1: 1: non non-ambulatory ambulatory para para/tetraplegia tetraplegia, , lack lack of of superficial superficial but but retained retained deep deep nociception nociception ►2: 2: non non-ambulatory ambulatory para para/tetraplegia tetraplegia, , retained retained superficial superficial and and deep deep nociception nociception ►3: 3: non non-ambulatory ambulatory para para/tetraparesis tetraparesis ►4: 4: ambulatory ambulatory para para/tetraparesis tetraparesis (ataxia ataxia) ►5: 5: segmental segmental hyperaesthesia hyperaesthesia This is the preferred scoring in some surgery literature. Diagnostic work up in suspected Diagnostic work up in suspected spinal diseases spinal diseases ► Signalment Signalment ► History History ► Neurologic examination Neurologic examination Localization Localization Assesment Assesment of severity of severity - grading grading ► Ancillary tests Ancillary tests Blood work Blood work, , urine urine analysis analysis Radiography Radiography Advanced imaging: MRI, CT Advanced imaging: MRI, CT CSF analysis CSF analysis ► Differential diagnosis, diagnosis Differential diagnosis, diagnosis ► Prognosis Prognosis ► Therapeutic plan Therapeutic plan
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2013.03.28.
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Common Spinal Common Spinal Disorders Disorders
PPéter Csébi DVMéter Csébi DVMVeterinary UniversityVeterinary University
Surgical Department Surgical Department
HungaryHungary
Spinal disorder?Spinal disorder?
TransversTransversalal myelopathymyelopathy::
Alteration caudal to the lesion:Alteration caudal to the lesion:
►►Described in Described in chondrodystrophoid chondrodystrophoid dogsdogs
►► Peak incidence: 3 Peak incidence: 3 –– 6 y6 y
►► 75% TL herniations 75% TL herniations between T11between T11/12 and /12 and L1/2L1/2
TypeType--II. disk herniationsII. disk herniations
►►Often multipleOften multiple
►►Occur at points of greatest Occur at points of greatest mobilitymobility
►►Dehydration and fibrosis of Dehydration and fibrosis of the nucleus results in the nucleus results in transference of load to the transference of load to the annulusannulus
►►Annulus bulges and Annulus bulges and fragmentsfragments
►►Acute herniation of dehydrated, fibrotic Acute herniation of dehydrated, fibrotic nucleus: old dachshund, large breedsnucleus: old dachshund, large breeds�� Undergone chondroid metaplasia but not Undergone chondroid metaplasia but not
degeneration and calcificationdegeneration and calcification
►►Acute herniation of hydrated nucleusAcute herniation of hydrated nucleus�� Most common in the cervical spine Most common in the cervical spine
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Breed predispositionBreed predisposition The DachshundThe Dachshund
►► Occurrence of 19% across Occurrence of 19% across dachshunds, some families dachshunds, some families as high as 75% (Ball et al., as high as 75% (Ball et al., 1982)1982)
►►SurgicalSurgical::decompressiondecompression, , fenestrationfenestration--SevereSevere neurologicneurologic signssigns--FailureFailure of of nonsurgicalnonsurgical therapytherapy
►►+ Physiotherapy+ Physiotherapy
Decision making in therapyDecision making in therapy
►►Acute or chronic?Acute or chronic?
►►Severity?Severity?
►►Grading!Grading!
�� Grade Grade 55: surgical: surgical
�� Grade Grade 44: surgical, may be conservative: surgical, may be conservative
�� Grade Grade 2, 32, 3: surgical or conservative: surgical or conservative
�� Grade Grade 55: conservative: conservative
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Succes of cSucces of conservative vs. onservative vs. ssurgical urgical treatmenttreatment
*It mainly depends on the time of the surgical decompression!
Chance of relapse in case of Chance of relapse in case of conservative managementconservative management
►►ThoracolumbalThoracolumbal: 3: 300.9%.9%
►►CervicalCervical: 33%: 33%
Levin et al. Evaluation of the Success of Medical Management for Presumptive Thoracolumbar Intervertebral Disk Herniation in Dogs.
Veterinary Surgery. 2007
Levin et al. Evaluation of the Success of Medical Management for Presumptive Cervical Intervertebral Disk Herniation in Dogs.
Veterinary Surgery. 2007
When should be performed the When should be performed the surgical decompression?surgical decompression?
►►As soon as possible!As soon as possible!
►►Prevent secondary damage caused by the Prevent secondary damage caused by the prolonged compression and loss of prolonged compression and loss of circulationcirculation
►►What if there is no more deep pain What if there is no more deep pain sensation?sensation?
�� Does it make sense to do surgery in 12Does it make sense to do surgery in 12--2424--48 48 hours or even later?hours or even later?
►► LoughinLoughin (VCOT 2005)(VCOT 2005)�� In In 12 12 hh→→ 6600% % recoveredrecovered
�� More then More then 48 48 hh →→ 6.7%6.7%
►► Laitinien Laitinien (Acta Vet Scan, 2005)(Acta Vet Scan, 2005)
�� In 24 h 41.3% recovered in avarage In 24 h 41.3% recovered in avarage 12.5 12.5 monthmonth
�� More then More then 24 24 h no recovery!h no recovery!
�� In cases when deep pain sensation recovered in 2 weeks the In cases when deep pain sensation recovered in 2 weeks the recovery rate was recovery rate was 66.7%, 66.7%, when only later the rate waswhen only later the rate was 110%0%
►► Olby Olby (JAVMA 2003)(JAVMA 2003)
�� 58% recovered if treated in 48 h58% recovered if treated in 48 h
�� 78% 78% regained deep pain sensation in the first 2 weeksregained deep pain sensation in the first 2 weeks
�� 19% 19% in the second two weeksin the second two weeks
�� 3%3% laterlater
�� 41% 41% was incontinent laterwas incontinent later
�� Progressive hemorrhagic myelomalacia occurs in up to 11% of dogs Progressive hemorrhagic myelomalacia occurs in up to 11% of dogs that have lost nociception!that have lost nociception!
What is the prognosis in general?What is the prognosis in general?
►►Intact deep pain s.Intact deep pain s.: : favourablefavourable
►►No deep pain s.No deep pain s.: : gravegrave –– poorpoor
►►If deep pain s. regains in 2 weeksIf deep pain s. regains in 2 weeks: : favourablefavourable
Current surgical treatment of Current surgical treatment of IVDDIVDD
Aim is to decompress the spinal cordAim is to decompress the spinal cord
►►Bladder care Bladder care (evacuation 3 times (evacuation 3 times daily!)daily!)
►►Mental stimulationMental stimulation
Take home messagesTake home messages►► Most commonly the Th11Most commonly the Th11--L2 sites are involved in TL2 sites are involved in T--L disk L disk
extrusion extrusion
►► It is extremely important that deep pain be properly It is extremely important that deep pain be properly assessed. The withdrawal reflex does not verify the assessed. The withdrawal reflex does not verify the presence of deep pain. The animal should vocalize or presence of deep pain. The animal should vocalize or otherwise indicate that pain was feltotherwise indicate that pain was felt..
►► Control of adequate bladder function is very importantControl of adequate bladder function is very important
►► The most common mistake made in managing animals The most common mistake made in managing animals with disk extrusions is administration of corticosteroids with disk extrusions is administration of corticosteroids and analgesics without appropriate concurrent and analgesics without appropriate concurrent confinement. Strict cage rest is mandatory in these confinement. Strict cage rest is mandatory in these patientspatients..
►► It is generally accepted that patients with paresis should It is generally accepted that patients with paresis should be treated by early decompressionbe treated by early decompression..
►► Patients without deep pain s. should be operated on Patients without deep pain s. should be operated on within 24 (within 24 (–– 48) hours of disk extrusion48) hours of disk extrusion..
►► It is not sufficient to remove lamina, facets and It is not sufficient to remove lamina, facets and pediculespedicules alone without the compressive disk materialalone without the compressive disk material..
►► The role of prophylactic fenestration remains unclear.The role of prophylactic fenestration remains unclear.
►► LLumboumbo--sacralsacral painpain!!►►Difficult to stand up or jump Difficult to stand up or jump ►►Dragging the toes on the groundDragging the toes on the ground►►Hind limb paresisHind limb paresis►►Muscle atrophy except m. quadricepsMuscle atrophy except m. quadriceps►► Low carriage of the tailLow carriage of the tail►► FecalFecal and urinary incontinenceand urinary incontinence►►Decreased anal reflexDecreased anal reflex►►Hyperaesthesia, Hyperaesthesia, prurituspruritus, , automutilationautomutilation is is
possiblepossible
Ancillary testsAncillary tests
►►RadiographyRadiography
►►MyelographyMyelography
►►EpidurographyEpidurography
►►DiscographyDiscography
►►CTCT
►►MRIMRI
►►ElectrophysiologyElectrophysiology
LS stenosis can be seen
MyelographyMyelographyDisk protusion Disk protusion -- CECCEC
C.E.C. epidurogrC.E.C. epidurographyaphy
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CTCT
Sacrum OCD és CEC
MRI
TherapyTherapy
►►Conservative Conservative �� In mild casesIn mild cases
►► Cervical vertebral malformation or malarticulation results in Cervical vertebral malformation or malarticulation results in compression of the cervical spinal cord segmentscompression of the cervical spinal cord segments
►► Most common in middle aged Dobermans (3Most common in middle aged Dobermans (3--9 y) and 9 y) and young Great Danes (2)young Great Danes (2)
►► C5C5--6 and C66 and C6--7 is the most common7 is the most common
The most common causes of WobblerThe most common causes of Wobbler--syndromesyndrome
►►Narrowing of the Narrowing of the vertebralvertebral canal because of canal because of osseus malformation osseus malformation (Great Danes)(Great Danes)
►►Hypertrophy of the Hypertrophy of the lig. lig. flavum and joint capsulesflavum and joint capsules
►►Annulus hypertrophy and Annulus hypertrophy and dorsal longitudinal dorsal longitudinal ligament pathologyligament pathology
Clinical signsClinical signschronic compression of the cervical spinal cordchronic compression of the cervical spinal cord
►► Stiff neckStiff neck
►► AtaxiAtaxiaa
►► ParesisParesis
►► „Two engine dog”„Two engine dog”
►► LMN signs on the front LMN signs on the front limbslimbs
►► UMN signs on the hind UMN signs on the hind limbslimbs
►► First signs on the hind First signs on the hind limbslimbs
Wobbler therapyWobbler therapy
►►Conservative Conservative �� In mild casesIn mild cases
�� Exercise restrictionExercise restriction
�� NSAIDs, NSAIDs, corticosteroidscorticosteroids
�� PhysiotherapyPhysiotherapy
►►Surgical Surgical �� High potential for morbidity High potential for morbidity
and postop. complications!and postop. complications!
�� In case of gait abnormalitiesIn case of gait abnormalities
�� In case of failure of the cons. In case of failure of the cons. treatmenttreatment►►Dorsal laminectomyDorsal laminectomy
►► Slowly progressive axonal degeneration and Slowly progressive axonal degeneration and demyelindemyelinisisationation
►► Older German shepherdOlder German shepherd (>8 y)(>8 y) and mixes, boxer and mixes, boxer etc., rarely in catsetc., rarely in cats
►► Hind limb ataxia and paresis, Hind limb ataxia and paresis, nonpainfulnonpainful!!►► Imaging: spinal cord atrophyImaging: spinal cord atrophy►► Genetic test is availableGenetic test is available►► No curative treatment, poor prognosisNo curative treatment, poor prognosis►► PhysiotherapyPhysiotherapy
►► Direct trauma to the spinal cord results primary Direct trauma to the spinal cord results primary and secondary injuries and secondary injuries (See in closed (See in closed mechanical injuries lecture!)mechanical injuries lecture!)
►► Emergency initial examination and stabilizationEmergency initial examination and stabilization
�� Immobilize the spine to prevent further Immobilize the spine to prevent further damage!damage!
�� Durotomy (in case of Durotomy (in case of severe swelling)severe swelling)
►►Stabilization:Stabilization:�� Pins, screws and Pins, screws and
polymethylmethacrylatepolymethylmethacrylate
�� Vertebral body plates Vertebral body plates
C5 fracture
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Post op.
►►Tumors can affect the vertebrae, Tumors can affect the vertebrae, meningesmeninges and and spinal cordspinal cord
►►NeoplasiaNeoplasia can be classified as can be classified as extraduralextradural, , intraduralintradural--extramedullaryextramedullary, or , or intramedullaryintramedullary�� ExtraduralExtradural tutummors can be primary or secondary.ors can be primary or secondary.
►► Mainly in middleMainly in middle--aged large breed dogsaged large breed dogs
►► Single or multiple sitesSingle or multiple sites
►► Clinical signs reflect the location, pain is the most common!Clinical signs reflect the location, pain is the most common!
►► Other infection or systemic disease can be in the Other infection or systemic disease can be in the background!background!
►► Therapy: long term antibiotic treatment (6Therapy: long term antibiotic treatment (6--8 weeks), 8 weeks), NSAIDNSAID’s’s
XX--rayray:: osteolysis osteolysis surrounded by sclerosis on the vertebral surrounded by sclerosis on the vertebral endplatesendplatesCave:Cave: radiographic signs only after the first 2 weeksradiographic signs only after the first 2 weeks
OsteomyelitisOsteomyelitis MeningitisMeningitis
►►Most common form is the immuneMost common form is the immune--mediated mediated ((„„beaglebeagle--painpain””, , „„steroid responsive meningitissteroid responsive meningitis””))
�� Typically in young (7Typically in young (7--18 month) dogs18 month) dogs
�� Most common in beagle, bernese, boxer, vizslaMost common in beagle, bernese, boxer, vizsla
�� Severe neck pain and feverSevere neck pain and fever
�� CSF cytology is the definitive diagnostic testCSF cytology is the definitive diagnostic test
�� Treatment is longTreatment is long--term (min. 6 month) term (min. 6 month) immunosuppression with tapering dosage of immunosuppression with tapering dosage of prednisolonprednisolon
�� Prednisolon can be combined with other Prednisolon can be combined with other immunsuppresants (azathioprin, cyclosporin)immunsuppresants (azathioprin, cyclosporin)
►►Viral, bacterial, protozoal or fungal Viral, bacterial, protozoal or fungal
�� Cats: FIP, FeLVCats: FIP, FeLV, toxoplasmosis etc., toxoplasmosis etc.
�� Dogs: distemper, toxoplasmosis, neosporosis, Dogs: distemper, toxoplasmosis, neosporosis, cryptococcosis etc. cryptococcosis etc.
►►Multifocal neurological signs, can iclude Multifocal neurological signs, can iclude paresis and ataxiaparesis and ataxia
►►Often systemic signs tooOften systemic signs too
►►CSF test is the basis of the diagnosticsCSF test is the basis of the diagnostics
►►Vascular compromise of the spinal cord that often Vascular compromise of the spinal cord that often progresses to local infarctionprogresses to local infarction
►► Fibrocartilaginous embolic myelopathy (FCEM) or Fibrocartilaginous embolic myelopathy (FCEM) or spinal cord infarct or ischemic myelopathyspinal cord infarct or ischemic myelopathy
►► Peracute onset, nonprogressive, nonpainful, often Peracute onset, nonprogressive, nonpainful, often asymmetricalasymmetrical
►►Transverse myelopathy (ataxia, paresis)Transverse myelopathy (ataxia, paresis)►►Most common in large breed dogs, miniature Most common in large breed dogs, miniature
schnauzers and catsschnauzers and cats►► Imaging: MRI is definitiveImaging: MRI is definitive►►Treatment: physiotherapyTreatment: physiotherapy
AtlantoAtlanto--axial luxationaxial luxation►► Instability or malformation of the atlantoaxial joint Instability or malformation of the atlantoaxial joint
allows excessive flexion of the cervical 1allows excessive flexion of the cervical 1--2 joint2 joint
►► Subsequent ventral cord compression occurs from the Subsequent ventral cord compression occurs from the cranial aspect of the body of the axiscranial aspect of the body of the axis
►► Most common in young toy breedsMost common in young toy breeds
ChiariChiari--like malformation and like malformation and syringomyeliasyringomyelia and and
hydromyeliahydromyelia
►► HydromyeliaHydromyelia is a fluid dilatation of the central canalis a fluid dilatation of the central canal
►► SyringomyeliaSyringomyelia is a fluid dilatation in the spinal cord that is a fluid dilatation in the spinal cord that may communicate with the central canalmay communicate with the central canal
►► Any condition that causes obstruction of normal CSF flow Any condition that causes obstruction of normal CSF flow along the spinal cord can cause italong the spinal cord can cause it
►► Most common in cervical regionMost common in cervical region
►► Cervical Cervical syringohydromyeliasyringohydromyelia occurs as a component of occurs as a component of congenital anomalies associated with caudal occipital congenital anomalies associated with caudal occipital malformation syndrome (malformation syndrome (ChiariChiari), which is most common in ), which is most common in Cavalier King Charles spanielCavalier King Charles spaniel
HemivertebraeHemivertebrae►►Wedge shaped malformation, with the apex Wedge shaped malformation, with the apex
dorsally, ventrally, or medially across the midline dorsally, ventrally, or medially across the midline which often results in angulation of the v. columnwhich often results in angulation of the v. column
►►Spinal cord compression can occurSpinal cord compression can occur
►►Most common: bulldog, pug, yorkie, boston Most common: bulldog, pug, yorkie, boston terrier, german shorthair pointerterrier, german shorthair pointer
►►Treatment: Treatment: �� Conservative in mild cases: NSAIDs, steroidsConservative in mild cases: NSAIDs, steroids
�� In severe cases surgical decompression, partial excision In severe cases surgical decompression, partial excision and marsupalisation of the dura is recommendedand marsupalisation of the dura is recommended
Subarachnoideal cyst
Thank you for your attention!Thank you for your attention!
Literature
•BSAVA Manual of Canine and Feline Neurology•Handbook of Veterinary Neurology•Small Animal Spinal Disorders•Veterinary Neuroanatomy and Clinical Neurology•Small Animal Surgery