A pain in the rear

Joey is a cranky old man. Actually a cranky old dog. A Corgi, he believes that any one objecting to his concept of life is the enemy. I experienced this first hand when I took for granted that a 12 year old dog that moved poorly couldn’t bite me when I touched his lower back. I was wrong.

Walking into the exam room, I had misread him completely. He had been lying on the yoga mat I use for my rehab exams when I walked in, and I assumed because he was old that he was slow. There was no growl, no snarl, just teeth on my hand. No break in the skin, but he made his point.

As I evaluated the damage to my hand, I flipped through Joey’s fairly thick chart. 12 years of medical records. Everything was in there, his first set of vaccines, being neutered, a few ear infections, and a battle with fleas. And of course, his most recent issue, the six month battle with a bulging disc in his lower back.

It had initially started on a Friday night. Ms. Cartwright had gotten home from work and Joey did not greet her at the door. She found him on his bed, and while his front legs pushed him up, his back legs were not cooperating. She took him straight to the local veterinary emergency clinic.

An examination there showed that he could use his back legs, but his coordination was not very good. With assistance however, he could walk about ten steps. Mom declined doing an MRI on him, and started with cage rest and steroids to curtail the inflammation. *(Side note, MRI in dogs requires general anesthesia, and while it would have confirmed the diagnosis, Joey was not seen as needing surgery at this time).

Joey had responded well to conservative therapy. He was on cage rest for 4 weeks, muscle relaxants for 5 days, oral steroids for 3 weeks. He regained almost 90% of the use of his legs over 2 months. Ms. Cartwright had been extremely diligent in her care with him, and was happy to have her buddy up and walking. He also enjoyed lounging around with the other two dogs at home.

Starting about three months ago, Mom noticed that Joey started to scuff his back feet when he walked. She had him re-evaluated and he was started back on medication and rest. Another month of inactivity and he seemed back to normal.

Two weeks ago, Joey began spending more time by himself and didn’t want to lay with the other dogs. He also didn’t enjoy going on the short walks with his Mom. However, he was walking pretty well. Again, he went back to his primary vet, but there was no decrease in his neurological function. She was told he was just getting old. Mom didn’t like that answer and came to see me.

When a disc between our vertebrae bulges, it creates inflammation. The steroids (specifically cortico-steroids, like cortisone or prednisone) are used to decrease the inflammation. This then allows the body to come in and clean up the bulging tissue. While this can work very well, steroids can cause other problems, such as muscle loss, a ravenous appetite, insatiable thirst and the necessity to urinate.

If a disc is bulging enough to compress the spinal cord severely, we lose our ability to walk. It is these cases that make up the vast majority of the cases that go to surgery. Decompressing the area and removing the bulging disc material at surgery is a lot faster than asking steroids and the body to do it over a few weeks. This is needed in cases where the spinal cord is “pinched” so much that we are concerned about permanent paralysis.

As I evaluated Joey, he made it perfectly clear he was not happy to be there. After trying to bite me a few more times, I placed a muzzle on him. I was able to complete my neurologic and orthopedic evaluation, but getting him to try and walk with the muzzle on was not happening. He just slunk into the mat. When I took off the muzzle, the teeth came.

As I was pondering my next move, I flipped through his chart again. That’s when it struck me. At our hospital we mark aggressive dogs’ charts with a “W” for watch and the date. Joey’s “W” was placed 4 months ago. 11 years of happy dog. 4 months of teeth. Something did not add up. A severe, painful ear infection three years ago? No aggression. An impacted anal gland infection a year ago? Same thing. I help him to walk 10 steps and he is acting like Jaws. Time for an experiment.

I asked Ms. Cartwright to pet Joey’s head. No issues. I touched his head, no problem. Not wanting anyone to get injured, I put an Elizabethan collar on Joey.DSC_6047

Now he couldn’t whip around and bite. I had Mom touch his toes, again no issue. Same response when I did it. When I gently palpated his lower back, Joey tried to roll and snap at me. Got it buddy.

Joey’s lower back hurt. He wasn’t aggressive; he was protecting himself. That is why the “W” popped up just recently. And while his ability to walk hadn’t changed much in the last few months after his initial recovery, he still had a problem.

I discussed this with Mom, and we came up with a plan. Pain happens for different reasons, and is best attacked by different pathways. I prescribed a low dose three-week course of steroids for Joey to reduce any inflammation, but also started him on a cocktail of a muscle relaxant (methocarbomol), an opiod (Tramadol) and gabapentin.

Gabapentin was originally designed to treat seizures, but in low doses has been found to be a great medication for chronic nerve pain. It was used in people for fibromyalgia before Lyrica was developed. It takes about 2-4 weeks to start taking effect though. That is why Joey was on the other medications, because they would take effect sooner.

Not wanting to cause him discomfort, and not wanting him to anticipate pain from me, we did not start rehabilitation that day. I saw Joey back in 10 days, and he was much more comfortable. He still tried to bite, but with less enthusiasm, and I was able to start laser therapy and electrical stimulation. These modalities also allowed me to attack Joey’s chronic pain and help to strengthen him. Over the next few weeks we tapered off the muscle relaxant, and then the steroid. We kept up with the Tramadol and the gabapentin.

Two weeks after stopping the steroid, Joey was biting more again. I increased his Tramadol dose for short term and the gabapentin for long term. Not much improvement. Ms. Cartwright was hesitant to go to steroids again, but we needed to try them. After a week he was still walking well, but still painful.

This bulging disc was a problem. While he had made great improvement, it kept causing enough discomfort that we had to keep going back to steroids, and now it wasn’t responding to that. I could increase the steroids to a higher dose, but recent research has shown that is not as beneficial as we once thought.

We had a few options. Medically we could add in flextime. This is the generic for Prozac. At a basic level, pain is depressing. Anti-depressant may relieve the pain. One of the analogs for fluoextine, duloxetine, received FDA approval for the treatment of chronic arthritis pain in people recently. I had been using fluoxetine for chronic pain for a few years now. I’ve had promising results, but again it can take 2-4 weeks to see an effect.

We were now almost 10 months out from Joey’s initial back problem. While we were improved, Mom was getting a bit frustrated and I couldn’t blame her. I recommended seeing one of the specialty surgeons in the area. Considering a CT scan or an MRI to give us more information, and allow us to see if surgery could help. Due to his age I could not 100% rule out a spinal cord tumor, but those usually progress much faster than this case.

Joey saw the surgeon a few days later and had a CT scan. Thankfully there was no tumor, but there was a chronically herniated disc and spinal cord compression with a little atrophy of the cord itself. Mom elected to have it surgically addressed. Joey did well under anesthesia, and the procedure went well.

I saw him two weeks later. He seemed comfortable, but was having difficulty walking because of two weeks on inactivity following surgery. He also was hesitant to having his surgical area touched.  He was no longer on medication, so we started with rehabilitation exercises to strengthen his muscles and improve his walking.

Three weeks later he was moving better, but he still didn’t like having his back touched. He had a recheck with his surgeon, and no problems with the surgical site were found. I started Joey back on Tramadol and gabapentin, and we continued his rehabilitation. Two weeks later he was tolerant of having his back supported, and over the next three weeks Joey got stronger, but was still hesitant to being touched. We stopped the gabapentin, continued the Tramadol, and added in fluoextine.

Over the next two months, Joey improved in tremendous strides. He was able to move well, and we tapered off the Tramadol. He stayed on the fluoxetine and was very comfortable. On occasion, he would try and bite if he was touched along his back, but it was not consistent or repeatable.

I wanted to remove the “W” from his chart, but I think he had learned to anticipate a bit of discomfort after nearly a year-long battle with a bulging disc. Joey continued to do well for nearly three more years; he had regular rehab sessions to keep moving, and continued to enjoy his senior years.

Joey’s case was a success, even though he still continued to have problems. Surgery did help where conservative therapy had plateaued. Due to the long period of time his spinal cord was compressed, he had some residual pain even after surgery. The combination of medical and surgical treatment in this case shows that each case is truly unique, and we should not expect to treat them as such.