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.

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Cage’s Rehab: Part One

Being a paralyzed dog is hard. Being that dog’s parents can be just as challenging. It’s scary, there are a lot of unknowns and it can get expensive quickly. I don’t deny any of these. From a patient’s perspective they can get frustrated very quickly. Imagine if 99% of what you did today you couldn’t do tomorrow.

Think how you would feel in the pet’s position: To be dependent on others to sit you up, feed you, clean you; To not have the independence to stand up and walk, or to simply sit up. This is why we my team and I look to achieve a comfortable and stable atmosphere for the patient through empathy. We are objective and analytical throughout our treatment, this guides us as we make small, incremental steps in the right direction or re-assess when and where progress slows and stalls.

I met Cage on July 1st, 2015. On my initial physical exam, aside form his neurological deficits and elbow arthritis he had muscle soreness of his shoulders, front legs, neck and back muscles. This is common in paralyzed dogs because they are using tremendous amounts of effort to get themselves up and drag their hind end.

After discussing options and prognosis with the owners, they elected to take him home that night and return the next day to begin rehab. After initial evaluations I break rehabilitation down into three segments:

1) Pain Management – Reducing the pain load on the patient

2) Strength Building – Working muscles to regain motor control and coordination

3) Maintenance – Sustaining gains after treatment

 

It is the third part that incorporates proper nutrition and regular exercise as ways to protect the body or minimize progression of diseases. A commitment is needed to maintain the hard earned gains from treatment. I also ask for a commitment to get through the first two phases, no matter how dark and dismal they may seem. My patients (and clients) require patience.

Cage had an excellent neurosurgical team in Boston. They worked hard to do mechanical aspects and provide multimodal pain management. Cage had taken meloxicam (an NSAID) for his arthritis for years along with amantadine to provide pain relief. After surgery, they added in gabapentin and tramadol to alleviate the post-surgical pain and the pain from his compressed disc and subsequent infection.

I started acupuncture on Cage the first day. Acupuncture helps to release the body’s natural endorphins (what morphine is made from essentially). This, in conjunction with TENS (transcutaneous electric nerve stimulation), would help alleviate the pain in his muscles. He also received daily treatments with our therapy laser. This would target sore muscles and help release cytokines to promote muscle healing and an anti-inflammatory action. After a few days, Cage was more comfortable. His muscles didn’t jerk and spasm in his neck and shoulders.

Each day he was with us, Cage received hot packs applied to his sore muscles to warm them up. Then he was stretched out, massaged gently and all of his joints were put through cycles of normal range of motion. When a body is not weight bearing muscles atrophy quickly. If normal pressure isn’t applied to our joints, they can become stiff from inactivity.

After being warmed up, Cage was placed in either the underwater treadmill or our overhead hoist. This allowed him to stand in a normal position and see the world. It also gave his body feedback (the joints, nerves and muscles all need gravity input to function normally). He would then have electrical stimulation applied to his rear legs to “teach” his muscles how to contract again. After that, he would rest lying down with ice packs on his muscles and joints. A week later, I was able to discontinue tramadol, one of the pain medications he was on.

Each day, we were expressing his bladder and bowels 3-4 times a day. We needed to teach those nerves and muscles to do their job just like the rest of his body. On July 10th, I noticed that his urine had a foul odor to it. A test showed that he had developed a urinary tract infection. These can occur in paralyzed dogs because they are not always emptying their bladder fully. We cultured it hoping that we could just increase the antibiotic he was on for the spinal cord infection, or at least get both infections with one antibiotic. This wasn’t the case as his particular infection was resistant to many drugs. We added in another oral antibiotic to his regiment and carried on.

After the first two weeks, Cage showed improvement. In the underwater treadmill he could pull his rear limbs forward. When suspended on the overhead hoist he could stand and pull himself forward. When I placed acupuncture needles at different points, I saw progress in how the messages were being conducted along his nerves.

During this time, he became very attached to me. He would follow me around the room with his eyes and would take his pills or eat for me when he wouldn’t do it for others. I was a little worried about this but was also glad to have him engaging and participating. After daily updates and then a reassessment after 3 weeks, I recommended we continue with rehab. His parents agreed. They saw he was more comfortable. Our goal now would be to make him stronger.

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Dealing with the cards we are dealt

This case is from a few years ago but I have been re-telling the story again lately and wanted to share it with you.

When I met Gus, he was a two-year old male French Mastiff who couldn’t use his hind legs and had no control of his bladder or bowels. The first time I examined him he urinated all over me. It wasn’t his fault but I knew we had a long road ahead of us.

Gus lived in Albany with his owners and their three small children. His dad was called back to active duty in the Army and left overseas. While Gus loved his mom and the kids, dad was the center of his universe. The day after his dad deployed, Gus kept looking for him at the front door; pacing and whining he kept searching for him. His mom would call him back to the living room to be with the family but as soon as he was there, he would head back to the front door to look for his dad.

After the third day, Gus started jumping at the door. One time he hit the handle just right and the door opened. Gus took off into the street. His mom yelled and ran after him, only to see Gus run over by a truck in the road. He was rushed to the local animal emergency room and was treated for shock and pain.

The truck had fractured a vertebrae in his lower back and caused a disc to herniate against his spinal cord. It also broke many of the bones in his tail. The damage was severe. He had no function in his back legs or tail.

The only two options were to pursue a neurosurgery specialist or euthanize him. Surgery would stabilize his fracture and take the pressure off his spinal cord. At the time, his mom could not reach her husband to let him know what had happened. Knowing how much he loved Gus, she made the decision to go forward with surgery.

The closest specialist was in Boston. So, mom, the kids and Gus drove out there. Dr. Stephanie Kube operated on Gus, amputating his tail, stabilizing the fracture and removing the herniated disc. After surgery, Gus could feel his legs but did not gain much function back. This can happen in spinal cord surgery. Sometimes function comes back quickly, other times very slowly, and, in rare cases, not at all.

Gus stayed in Boston for about 2 weeks after his surgery and began fundamental rehab there. But due to the distance away from home and the need for a formal rehab center he was transferred to my care.

After changing into dry pants, I admitted Gus for a week of rehab. I had advised caution with his mom and could not make guarantees that he would recover. We agreed to take it one week at a time and look for steady improvements. Gus had weighed 90 pounds before his accident and was down to 75 pounds. This was caused by muscle atrophy in his hindquarters.

Unfortunately, Gus was still too big to manage at home and was incontinent. He was being catheterized 3-4 times a day if he wasn’t urinating on his own. I did not keep a permanent catheter in him for three reasons. First, with a catheter in, I wouldn’t know if he had the ability to urinate on his own. Second, a catheter can put the patient at risk for infections and third, his bodyweight would compress it and occlude the line.

His front legs worked perfectly and he would lift himself up in the run to move around. He would also get fed up with his rehab and try to walk away. While most of the time he laid still for his rehab he would get frustrated some days.

Gus’s rehab was an all day affair. He was living at the hospital, so we worked with him for 15-20 minutes at a time 3-4 times a day instead of the typical 90 minutes straight. This gave him time to rest and also added variety to his day. Some days we had to change our plan if he had urinated or defecated on himself.

Gus had electrical stimulation to work the muscle groups in his back legs. He also had range of motion exercises, standing exercises and therapeutic laser treatments for his hind legs. His front legs were working hard supporting all of his weight, so we worked on those and his back muscles to keep him comfortable.

His mom and the kids came to visit him after a few days and we agreed to continue on for two more weeks. Gus became attached to my rehab technician, Rebecca, and I as much as we became attached to him. He enjoyed the interactions and always wanted to see what we were doing. After a few weeks, he started living in the rehab room permanently instead of the ICU. This allowed him more mental stimulation and actually made our lives easier. By having him there, we could do short exercises with him without taking the 20 minutes to get him up from the cage, over to rehab and back to his cage.

Each week Gus would make progress. We had to catheterize him less often as he gained sensation and the ability to urinate on his own. It was far from perfect but he made steps. I had him on medications to help stimulate bladder contraction and antibiotics since he had developed a urinary tract infection.

After a month or so, he could move his legs but wasn’t strong enough to stand to walk. The owner wasn’t sure she could continue on with rehab and was considering euthanizing him. We worked it out that he would stay with us for another few weeks but if he didn’t make more progress we would stop.

I completely understood and respected her concerns. Managing Gus was a full time job for Rebecca and I and we had the help of other staff at the hospital. Trying to do that and raise three kids would be impossible. There were still days Gus would either urinate or defecate on himself and require a bath. There was also the financial aspect to consider.

We had a cart from a previous patient that we started to use for Gus. Carts are great tools as part of rehab. They allow the pet to be upright and can be set either as a “walker” or a wheelchair depending on the ability the pet has. With his front legs working well, Gus could pull himself around the room in the cart. This minimized his chances of injuries and getting pressure sores on his back legs.

Gus also used a harness to keep his back legs up. Doing this on a land treadmill we could exercise his front half and two of us could move his back legs for him. One of us would hold the harness and the other would place his feet in time with his front legs. This was done to mimic walking and get input up his spinal cord that his legs could do this.

While he had made progress, the owner decided she could not keep going. Instead of euthanasia he would be placed in a foster home through a French Mastiff Rescue group. I had spoken with the owner about this and the group leader. Unfortunately they could not take Gus for a few more weeks. The owner could not afford to keep paying us, so we agreed that Gus could stay with us at no charge until the rescue group could take him.

During his time with us, we became very attached to Gus. He was a happy two year old who just wanted to play and didn’t understand why his legs didn’t work. He would get “jealous” of us working with other dogs and bark or whine. If we weren’t working with patients, he would bark at the door to have someone play with him.

His favorite toy was a soccer ball. He would nudge it back to you if you rolled it to him. He even learned to bump it back to you using his head. I would lob the ball at him and he could head butt it back. This game could last hours if you let him have his way.

We kept working with Gus each day. Although he had shown some motor function, he hadn’t walked using his back legs on his own. While it was still early, this troubled me because he would be very hard to place in a home with all of his conditions. And while he enjoyed his time in the cart, it made him twice as wide due to the wheels. This would make using it inside a normal house difficult.

About a week before the rescue group was coming to pick him up, I was working at the desk in the rehab room. My back was to Gus as I finished some paperwork. I was also racking my brain trying to figure out why he wasn’t walking. There were no other patients there and I was reviewing my notes again on him to see what I had missed.

Being in the room meant I was there to play with Gus. Well, that’s what he thought at least. He was laying at the opposite end of the room and would roll the ball to my feet. I could work and gently kick it backwards to him at the same time. This was the only way to get any work done, otherwise he would whine or bark for attention.

As the ball came rolling back to me it slid under the desk. I couldn’t find it with my foot and stopped reading his chart. As I bent down to find the ball, I felt Gus lick my hand. As I turned to nudge him away, I saw him STANDING on all four feet. I stepped back and he WALKED to me. Not his half-walk, half-drag but a choppy walk using all four feet.

I shouted in joy and got down to hug him. Gus of course walked right past me and got the ball. I had taken too long in his opinion.

Sometimes you just have to wait for the right time. Gus had waited and walked when he was good and ready.

I let his mom know that he was walking and she started crying over the phone. She was happy he had recovered but it didn’t change her situation. Gus faced a lifetime of medical problems ahead and she couldn’t provide the care he needed.

A week later, Gus left with the French Mastiff Rescue foster family. I made sure they had plenty of soccer balls to keep him motivated. I received updates from the rescue group the first year that Gus was doing well. After that we lost touch.

Patience, time and dedication can improve outcomes. Sometimes the changes in lifestyle or financial concerns change the outcome as well. Gus and his family may not have gotten what they wanted, but they got what they needed.

Making a Case for Acupuncture

Shortly after my acupuncture final exam, I was asked to consult on a case at a local veterinary hospital. Molly was a 5-year-old Bassett Hound mix who had no function in her hind legs. She was brought to her primary care veterinarian a week before Christmas for back pain, but could walk normally. She was started on pain relievers and was placed on restricted activity.

Two days after Christmas, she could not use her back legs at all. There was no trauma or incident that they could identify as a cause. She was re-examined and baseline blood tests were overall unremarkable. Radiographs of her spine showed a narrow space between two vertebrae. At this point, a consult with a veterinary neurologist for potential surgery was recommended. This was not an option for the owner since the consult and surgical estimate was $5,000-$7,000 and this was beyond their capabilities. She was started on cortisone and antibiotics to prevent infections, tumors or anything that could be placing pressure on her spinal cord.

When there is inappropriate pressure on the spinal cord function can be impaired. The most common cause of pressure is a bulging or herniated intervertebral disc. Other causes can be infections, tumors, fractures or fibrocartilaginous emboli (FCE). Without a CT scan or MRI exam these can be very challenging to tell apart, but survey radiographs can be helpful.

As the pressure builds on the spinal cord, the patient will usually start with back pain and it may stop there. It can also progress slowly or rapidly to impair the spinal cord. The job of the spinal cord is to relay the message from the legs to the brain for interpretation like a cell phone signal. When the cord is impaired it’s like trying to talk on the phone with less than 5 bars of service, the message can be choppy or incomplete.

As the “signal” gets weaker the back pain can lead to a wobbly or ataxic gait because the patient doesn’t know where their feet are. This can progress to losing the ability to walk entirely and even the ability to perceive pain. The loss of pain for an extended period of time is a very poor prognosis.

If the pressure can be relieved the spinal cord regains its function in the reverse order that it lost it. Pain comes back first and then, hopefully, the ability to walk followed by the fine motor skills. Urination and defecation can be anywhere in between pain and fine motor as it depends on where the cord is damaged.

When I met Molly on January 2nd, she had lost the ability to feel pain 6 days prior. Ideally, she would have had surgery to relieve the pressure within 24-48 hours of losing that ability, but that was not an option for her family.

Although an MRI exam and spinal surgery were not an option, Molly’s family did not want to give up. I was asked to consult and see if anything else could be done. After examining Molly and discussing my thoughts and prognosis with them, I treated Molly with acupuncture and adjusted some of her medications. I placed her on low doses of cortisone, along with muscle relaxants and continued her on gabapentin to reduce any neuropathic pain.

Given her age, breed and progression of her signs, I was suspecting that a herniated disc was the cause of her problems. I recommended treating Molly three times to see if we could regain pain perception. If we could, then we could continue to treat her. If not, we would talk about the ability for the owners to provide long term care for a paralyzed, incontinent Molly.

When I saw her 3 days later, she had regained pain perception. This was excellent but we were still not out of the woods. I didn’t know if Molly would regain the ability to walk. I treated her again with acupuncture, including electro acupuncture and aqua acupuncture with Vitamin B12. This combination approach would provide different levels of stimulation to her body for varying lengths of time.

On her third treatment three days later, I repeated those acupuncture points and had a frank discussion with her owners. Molly weighed 50 pounds and can be challenging to move around. Her front legs were working perfectly and they had a harness to support her chest and back legs so that she did not scrape her body on the ground. At 50 pounds, she is not a dog they could pick up and carry around. We discussed using a cart (from Eddie’s Wheels) as a potential to assist in her mobility and also as part of her rehab. The cart could also support her long term if she did not make a full recovery. The owners would think about it and let me know.

At this time, I had given her family detailed instructions on doing range of motion exercises and other therapeutic exercises to help with Molly’s rehab. They were doing these every day along with providing her nursing care. In other cases, I have hospitalized patients to do this but given all the circumstances for this case this option was most feasible for Molly’s owners.

I saw Molly a week after her third treatment and now she could consistently wag her tail. She also had very weak but present motor function in her back legs. The owners were trying to figure out finances of a cart. With her improvement I recommended starting her on a Chinese herbal compound to assist her spinal cord healing. This would reinforce the acupuncture treatments she was receiving.

The following week, I measured Molly her for her cart and started the herbal treatment with her. Again, I repeated her acupuncture treatment and also started to taper off some of her other medications.

Due to some outside factors, I did not see Molly again for almost three weeks. I was surprised to see her WALKING into the treatment room! Molly had regained 80% of her motor function in 6 weeks. The average time for this type of recovery is usually 2-3 months. I was very pleased and we agreed to hold on having her cart shipped since she had done so well so quickly. I continued to treat her with acupuncture and scheduled to see her again three weeks later.

At this time, she had 95% of her function back and was in excellent spirits. We had weaned her off most of her pain meds but continued her herbal treatment. I will see Molly in another 3 weeks and then only as needed. I expect her to make a full recovery.

Each individual case is just that, an individual. I am always hopeful when I work with challenging cases, but, I have to admit, Molly’s recovery exceeded my expectations. I hope to be able to repeat this outcome with other patients through a combined approach of Western and Eastern treatment.

If you have any questions about spinal injuries and your pet that are NOT urgent, please contact me.

For more information on herniated discs please check out this website. http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=2373

For information on FCE check out this site. http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=1663