A Tribute to Milo

For those not familiar with my cat Milo, please check out my prior blog post about him here. https://drbrunke.wordpress.com/2013/07/28/matters-of-the-heart/

Milo turned 14 earlier this year, but had been slowly declining in health over the last few months. I had noticed he was drinking more and urinating more. He began to lose body weight, but was still happy, interactive, and eating. He also would have sneezing fits of 10-50 sneezes at a time.

In the last 4 weeks, he began to have trouble breathing, and would make a sound close to a snore when awake. I debated taking him to work for tests, but he would stress out about it. I also knew that he could not undergo anesthesia for a CT scan or biopsy due to his heart. Additionally, he could not be medicated, since any attempt to do so in the past was too much stress for his heart condition.

Given his signs, I was suspicious of a nasal tumor.

So, I waited. I kept his food bowl full and he would interact happily with Adelaide and Penny.

I was away last week for training, and he stayed at home with my pet sitter. We had previously discussed that if he went into acute crisis that he would be euthanized without me there. I did this for one reason, Milo’s best interest.

Shortly after arriving home Sunday, I found Milo having trouble breathing. I tried to relax him, but he was struggling. I dropped everything and took him to the hospital where I sedated him. Once he relaxed, I could appreciate a mass invading his skull.

I then humanely euthanized him, letting him be at peace.

While letting him go was difficult, it was absolutely the right decision for him and me. Diagnosing or treating his tumor would be near impossible given his heart condition, and it would not be fair to Milo to put him through that.

I am very thankful for all the lessons I learned from him. To take a chance, to give things time, and that not all the patients read the books nor follow rules. Milo lived thirteen years longer than he should have. Those years were full of fun, eating, playing, and hunting. In the end, his heart was still strong and that is the message I appreciate most of all.

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Options for Canine Chronic Back Pain

If you have read some of my other posts, you are familiar with my multimodal approach to managing pain and mobility. For those of you new to this blog, this is where we use a combination of therapies to achieve a good outcome. In some cases, this is combining an oral medication with therapeutic exercises, or a surgical procedure with photobiomodulation (laser) therapy.

Using this approach, we can usually get better outcomes with less side effects. I also use this approach when an ideal treatment is not an option for a patient. This can be due to financial limitations, health of the pet (perhaps anesthesia is not an option), other options are not working, or any number of factors.

With this background, I would like to walk through some challenging cases I’ve had over the past few years. All of these dogs are German Shepherds, some male, some female, all between 7-15 years of age. While this disease can happen to many breeds, we do see it more in German Shepherds. Sometimes the spinal canal, through which the spinal cord and nerves pass, narrows and compresses the nerves.  The most common spot for this narrowing to occur is at the lumbosacral joint, where the spine meets the pelvis. Spinal canal narrowing at the lumbosacral joint is referred to as lumbosacral stenosis, and the condition resulting from the compression of these spinal nerve roots is called cauda equina syndrome.

The narrowing is most often caused by arthritic degeneration or intervertebral disc herniation, but traumatic injury, congenital malformation (born with it), or tumor growth can also be involved.

The most common symptom of lumbosacral stenosis is pain. In the beginning, you may also notice stiffness leading to difficulty in walking, climbing stairs, getting on furniture, wagging the tail, positioning to defecate, or getting into a car. One or both back legs may become weak. Some dogs will cry out in pain when trying to move. In severe cases, the nerve roots can become so compressed that urinary and fecal incontinence will result.

This can be diagnosed through a combination of physical exam, blood and urine tests, radiographs, but it needs a CT scan or MRI to be definitively diagnosed. This is because radiographs (x-rays) do not show the discs and spinal cord, which can be seen on CT scans and MRIs.

The initial pain usually responds well to NSAIDS or Non-Steroidal Anti-Inflammatory Drugs. I will combine this with weight loss (if indicated), muscle building (to strengthen the body), pain relievers (such as gabapentin) and other modalities (joint mobilizations, LASER, underwater treadmill workouts) to help keep the patient in good shape and moving.

Since it is most often caused by arthritis or disc herniation, setbacks, flare ups, and progression of the disease can happen even with the best of management. In those cases, we can add in other medications, or seek a consult with a boarded veterinary surgeon or neurosurgeon. Relieving the pressure through surgery can be very helpful in improving mobility and decreasing pain. After surgery, physical rehabilitation is needed to build upon what the surgeon has improved.

But what if a several thousand dollar CT scan or MRI isn’t in the cards? Or the scan shows the specialist that surgery is not a good option in this case? Are we out of options? Will your dog have to live in chronic pain?

I would hope you repeat readers know by now that this is not the case. So, let’s talk about options.

Studies have been done on both human and animal patients, and there is good evidence in the literature for epidural injection of cortisone. You may have heard of an epidural or spinal before. This is placing a needle or catheter in the space between two vertebrae and around the spinal cord itself. A more common place for this is childbirth, as a local anesthetic (lidocaine) can be injected into the space and block the body from perceiving pain. This is just like going to the dentist. They use novocaine so that you don’t feel them working in your mouth.

In veterinary medicine, we will use a local anesthetic (sometimes along with other pain relieving medications) for surgery (c-section, fracture repair) or for helping to relax an animal that is in labor and help to manually deliver the offspring.

Can we combine these two ideas? Absolutely. An epidural can be done for these lumbosacral patients with cortisone to provide anti-inflammatory action and pain relief. We need to rule out infection first, and ideally have a CT scan or MRI to rule out cancer or other causes. Where do I use this? When my oral medications are maxed out, the pet is still in pain, or for any number of reasons a pet cannot take certain oral medications.

For those of you thinking “wait, I had an epidural and I was awake for it, will my dog be awake?” The answer is no. While some dogs are excellent about holding still, it is not safe to do this procedure awake. It may require general anesthesia, but often can be done under heavy sedation. Their fur in the area will need to be clipped away, and a long needle is placed between the last lumbar vertebrae and the first sacral vertebrae. The cortisone is then injected around the spinal cord in the epidural space.

In my practice, we do this on an outpatient basis with the dog going home the same day. I use either triamcinolone or methylprednisolone, both of which are long acting steroids, as these have been shown to be most effective in the human literature. The dog goes home with specific instructions and restrictions and I see them back in one week. We then institute a combination of home exercises and outpatient rehab sessions to build muscle and strength.

90% of the dogs I have done this for improved in 7 days, and 100% are improved in 2 weeks. Some we are doing just for pain relief and others because they have trouble moving their legs.

How long will this last? This depends on the type of cortisone used. I had one dog that needed a repeat injection at 6 months. The others are doing well on one injection (approaching or exceeding one year).

Are there side effects/risks? With any procedure, there is always risk, but I do my best to minimize that. Blood and urine tests help to rule out other causes. Sedation is short and reversible, so that minimizes risk there. Infection is always a risk, but we do this under a sterile environment. The cortisone is confined to the epidural space, but some can get systemically absorbed. For those cases the dog may drink or urinate more for a few days, and will need to be off their NSAID for a period before and after their procedure.

So, what about those patients I talked about at the beginning? All but two are still alive and doing well. Fritz and Bailey were both over 13 years when I did their injections, and while they improved, their other mobility and health issues ultimately caught up with them. But during the time they had left, they were very comfortable. So, I’m pleased with that outcome. Yosh had an epidural and then months later herniated a disk in a different area that required surgery, I am pleased to report he is doing very well. The other patients are up and moving, and I hope that continues to be their story.

If you have questions, or think your pet may benefit from this or other procedures, please discuss it with your veterinarian or contact me.

Skeeter’s Vomiting

This story refers back to a previous post “Quality over Quantity”. In that story, my own dog, Skeeter, was going through chemotherapy for stage 3 hemangiosarcoma. You can read the full post here: https://drbrunke.wordpress.com/2015/10/27/quality-over-quantity/

During the chemotherapy she developed a slight cough and began having intermittent vomiting. Prior to starting chemo, we had established (via x-rays and ultrasound) that there was no cancer in her lungs, stomach, or the rest of her GI tract.

In some cases, coughing can be associated with cancer that spreads into the lung known as a lung metastases. Metastases will be solid and not allow air to move in that part of the lung .In some cases vomiting can be associated with different types of chemotherapy. However, in Skeeter’s case this wasn’t true. We took special precautions around the one drug in her regiment that could possibly cause vomiting and she never vomited during that medication. This would be random vomiting weeks after that drug was given.

Disclosure: During this time I was not completely objective. As a veterinarian, I wanted to know what was causing the problems. As a caregiver, I didn’t. I wanted to ignore it because I didn’t want to have to face the possibility that this was a possible sign that her cancer was spreading elsewhere.

During her follow-up ultrasound exams (looking at the cancer in her liver as it shrunk from chemo) we did not see any problems with her stomach. This was an appeasement to myself, I had looked (a bit) and that sufficed for now.

One Friday, while working at the emergency room, Skeeter’s coughing got worse. At that point, I took x-rays of her chest. I stared over them and peered from different angles trying to find a reason for her cough. I didn’t see anything obviously wrong with her lungs or heart.

I’m lucky to have great friends. My classmates and I keep in touch via smart phone and social media. We all bounce cases off of each other looking for ideas and insights to problems that baffle us. I sent out photos of Skeeter’s x-rays to the group and asked for opinions.

Amy wrote back a moment later, “Yeah, lungs look ok, but what’s that in her stomach?” Then, two other classmates chimed in and said the same thing. I took another look. Just at the edge of the x-rays was part of Skeeter’s stomach. And sure enough it looked like something was in there. (She had not eaten yet that morning) I took another set of x-rays, focusing on her abdomen. And sure enough it looked like there was a foreign object in her stomach.

I sent all the radiographs to another friend for verification. Sean, a boarded veterinary radiologist, took a closer look as I needed to be as close to 100% sure that this was an actual problem in her stomach. Being on chemotherapy and therefore suppressing her immune system did not make her a fantastic candidate for surgery and anesthesia.

Sean wrote back saying that he didn’t know what it was exactly, but it definitely did not belong there. I explained to him her current condition but his thoughts didn’t change: Whatever it was, it needed to come out.

I had two options here: The first was that I could get Skeeter to a specialist to try and remove this via endoscopy. This is where they put the animal under anesthesia and pass a scope down their esophagus with a mini-grappling hook to grab the object and pull them back out. This is called minimally invasive since it doesn’t require surgery and having to heal from an incision. In some cases it is very successful. Sometimes it does not work (object too big, can’t latch on, etc.).

Since it was a Friday, I would have to drive to Cornell for this procedure, unless I wanted to wait until Monday. At the time there was no weekend option for endoscopy in our region.

The second choice was to go in surgically myself and check it out. Anesthesia is a minimal risk for both cases. The hesitation I had was being wrong and not actually having an object to remove as well as having Skeeter need to heal from two incisions: one in her stomach, the other her abdominal wall.

Second disclaimer: Skeeter had never been a chewer and never really played with toys. So, there wasn’t anything that I knew of that could cause the obstruction. This fact contributed to my hesitation. But there was definitely something there. I just didn’t know what it was.

Ultimately, with support from Sean, Amy, and others, I went forward with surgery that afternoon. Skeeter did great through anesthesia and I found a small “U” shaped piece of flexible rubber in her stomach.

She recovered very well and didn’t have any further vomiting, coughing (likely the rubber getting stuck in her esophagus) or other problems during her chemotherapy.

I have no idea where the piece of rubber came from, or why she chose to eat it.

It can be daunting to face your fears. I was scared of what I would find with Skeeter’s vomiting and coughing. Facing my fear and finding the support of good friends helped me get through a difficult time and I am lucky that it had a good outcome.