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.

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.