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Risk Factors Associated with Progressive Myelomalacia in Dogs

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Risk Factors Associated with Progressive Myelomalacia in Dogs Castel et al. BMC Veterinary Research (2019) 15:433 https://doi.org/10.1186/s12917-019-2186-0 RESEARCH ARTICLE Open Access Risk factors associated with progressive myelomalacia in dogs with complete sensorimotor loss following intervertebral disc extrusion: a retrospective case-control study Aude Castel1, Natasha J. Olby2,3* , Hongyu Ru2, Christopher L. Mariani2,3, Karen R. Muñana2,3 and Peter J. Early2 Abstract Background: Progressive myelomalacia (PMM) is a usually fatal complication of acute intervertebral disc extrusion (IVDE) in dogs but its risk factors are poorly understood. The objective of this retrospective case-control study was to identify risk factors for PMM by comparing dogs with complete sensorimotor loss following IVDE that did and did not develop the disease after surgery. We also investigated whether any risk factors for PMM influenced return of ambulation. Medical records of client-owned dogs with paraplegia and loss of pain perception that underwent surgery for IVDE from 1998 to 2016, were reviewed. Dogs were categorized as PMM yes or no based on clinical progression or histopathology. Walking outcome at 6 months was established. Signalment, onset and duration of signs (categorized), steroids, non-steroidal anti-inflammatory drugs (yes or no), site of IVDE (lumbar intumescence or thoracolumbar) and longitudinal extent of IVDE were retrieved and their associations with PMM and walking outcome were examined using logistic regression. Results: One hundred and ninety seven dogs were included, 45 with and 152 without PMM. A 6-month-outcome was available in 178 dogs (all 45 PMM dogs and 133 control dogs); 86 recovered walking (all in the control group). Disc extrusions at the lumbar intumescence were associated with PMM (p = 0.01, OR: 3.02, CI: 1.3–7.2). Surgery performed more than 12 h after loss of ambulation was associated with PMM (OR = 3.4; CI = 1.1–10.5, p = 0.03 for 12-24 h and OR = 4.6; CI = 1.3–16.6, p = 0.02 for the > 24 h categories when compared with the ≤12 h category). Treatment with corticosteroids was negatively associated with PMM (OR: 3.1; CI: 1.3–7.6, p = 0.01). The only variable to affect walking outcome was longitudinal extent of IVDE (OR = 2.6; CI = 1.3–5.3, p = 0.006). Conclusion: Dogs with lumbar intumescence IVDE are at increased risk of PMM. Timing of surgery and corticosteroid use warrant further investigations. PMM and recovery of walking are influenced by different factors. Keywords: Ascending-descending myelomalacia, Spinal cord injury, Intervertebral disk disease, Paraplegia * Correspondence: [email protected] All work for this study was completed at North Carolina State University College of Veterinary Medicine. This work was not supported by any grant or funding agency. This work was presented as a research abstract at the 2018 ACVIM forum in Seattle. 2Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC 27607, USA 3Comparative Medicine Institute, North Carolina State University, 1060 William Moore Drive, Raleigh, NC 27607, USA Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Castel et al. BMC Veterinary Research (2019) 15:433 Page 2 of 9 Background risk factors for the development of PMM in dogs with Progressive myelomalacia (PMM) is one of the most sin- complete loss of motor function and pain perception in ister complications associated with thoracolumbar inter- the pelvic limbs and tail undergoing a hemilaminectomy vertebral disc extrusion (TL IVDE) [1, 2]. In this following thoracolumbar IVDE. The second goal was to condition, there is progressive ascending and/or de- evaluate whether risk factors for PMM also influenced scending hemorrhagic necrosis of the cord following long-term recovery of ambulation (with and without re- acute, severe thoracolumbar spinal cord injury (SCI) due covery of pain perception). to acute IVDE [2]. There is no current treatment for this devastating and typically fatal condition [2]. A definitive Results diagnosis requires post mortem evaluation of the spinal One hundred and ninety seven cases met our inclusion cord, but a presumptive diagnosis with a high clinical criteria (Additional file 1). Of these, 45 were included in suspicion can be made based upon neurologic examin- the PMM group and the rest of the dogs (152/197) were ation findings corroborated with magnetic resonance im- included in the control group. In the PMM group, 12 aging (MRI) characteristics [3–6]. The clinical signs dogs had a diagnosis of PMM confirmed at necropsy consistent with PMM are a combination of complete while the other dogs (33/45) had a presumptive diagno- sensorimotor loss in the pelvic limbs and the tail, loss of sis of PMM based on a combination of clinical signs and spinal reflexes in the pelvic limbs, loss of abdominal tone imaging findings. All but two of the 45 dogs in the and advancement of the caudal border of the cutaneous PMM group were euthanized. The two remaining dogs trunci muscle reflex (CTMR) [5, 6]. As the disease showed halting of PMM after initial progression. Both spreads to the thoracic and cervical spinal cord, progres- remained paraplegic without pain perception, and one of sion to tetraparesis, loss of reflexes in the thoracic limbs, them had progressed to develop paresis of the thoracic bilateral Horner’s syndrome and respiratory distress limbs. The clinical characteristics of the PMM dogs were often arise prior to death or humane euthanasia [5]. described in a previous study [5]. The detailed signal- Most dogs develop signs consistent with PMM within ment for both groups is reported in Table 1. The most 48 h of presentation but although the majority progress common breed in both groups was the Dachshund (19/ and are euthanized within 3 days after onset of signs, a 45 in PMM group and 87/152 in the control group). delayed progression can be observed [5]. There was no difference between breed representation, The prevalence of PMM is 2% when all dogs with TL sex and age between the two groups (Table 1). IVDE are considered [6] but it is dramatically higher in The results of the multivariate analysis of risk factors paraplegic pain perception negative dogs, ranging from 9 for development of PMM are provided in Table 2 with to 17.5% [6–10]. Breed appears to be important because additional detail on speed of onset of signs and duration a prevalence of 33% was reported in French bulldogs of signs provided in Table 3. Breed, age, sex, site, time [11]. Risk factors associated with the development PMM from onset of signs to loss of ambulation, time from loss have been reported in a relatively small cohort of PMM of ambulation to surgery, treatment with NSAIDs and dogs, and, when considered separately, include a more treatment with corticosteroids were all evaluated. Three severe neurologic status, younger age, site of disc extru- of these variables affected the risk of development of sion at L5-L6, speed of onset of less than 24 h and the PMM, location of the disc extrusion, timing of surgical ratio of the hyperintensity on T2 weighed magnetic res- decompression and use of corticosteroids (p = 0.01, p = onance image to the length of L2 [6]. However, when 0.03 and p = 0.01 respectively). More specifically, dogs considered together in a multivariate analysis, the T2 with IVDE affecting the intumescence had higher odds weighted hyperintensity ratio was the only significantly of developing PMM compared to the TL region (odd ra- significant predictor of PMM development. There is a tio (OR) = 3.0, confidence interval (CI) = 1.3–7.2). A lon- need to examine a larger population of dogs in order to ger time to surgery was also associated with higher odds confirm risk factors implicated in the previous univariate of PMM (OR = 3.4; CI = 1.1–10.5 for 12-24 h and OR = analysis [6], and to identify new risk factors that illumin- 4.6; CI = 1.3–16.6 for the > 24 h categories when com- ate the underlying pathophysiological mechanisms and pared with the ≤12 h category). Finally, dogs that had potential therapies. Given the prevalence of PMM is not received steroids had higher odds of developing highest in paraplegic pain perception negative dogs, we PMM compared to dogs that had received steroids identified this population for additional examination. (OR = 3.1, CI = 1.3–7.6). We focused on dogs undergoing surgery because, in this A post hoc analysis was performed to examine particular population, post-operative follow up was avail- whether the type of corticosteroid used (methylpredniso- able and clinical progression could be documented to as- lone sodium succinate versus other (dexamethasone, sess whether or not the dog developed PMM. The goal prednisolone sodium succinate and prednisone)) was im- of this exploratory, retrospective study was to identify portant. When looking specifically at dogs that received Castel et al. BMC Veterinary Research (2019) 15:433
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