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Spinal disorder?

TransversTransversalalmyelopathy:: myelopathy Common Spinal Alteration caudal to the lesion: Disorders ►► Postural deficits ►► Ataxia PPéteréter Csébi DVM ►► Paresis Veterinary University ►► Abnormal spinal reflexes (Hypo(Hypo--,, hyperreflexia))hyperreflexia Surgical Department ►► Hungary Micturation abnormalities (UMN and LMN bladder) ►► (Pain)

Severity ––GradingGrading 11--55 scale ►►Grade 11:: only hyperaesthesia ►►Grade 22:: mild paraparesis and ataxia ►►Grade 3:3: severe paraparesis and ataxia ►►Grade 4:4: nonnon--ambulatoryambulatory paraparesis with intact deep pain perception ►►Grade 5:5: paraplegiparaplegiaa without deep pain perception

This scoring is used in most of the neurological textboooks. (See the detailed explanation in pathophysiology lecture!)

Severity ––GradingGrading Diagnostic work up in suspected Modified Frankel Score (MFS) spinal diseases ►►0: non--ambulatorynon ambulatorypara//tetraplegia para tetraplegia,, lack of ►► Signalment superficial and deep nociception ►► History ►►1: non--ambulatorynon ambulatorypara//tetraplegia para tetraplegia,, lack of ►► Neurologic examination superficial but retained deep nociception

Localization

Assesment of severity --gradinggrading ►►2: non--ambulatorynon ambulatorypara//tetraplegia para tetraplegia,, ►► Ancillary tests retained superficial and deep nociception

Blood workwork,, urineanalysis ►►3: non--ambulatorynon ambulatorypara//tetraparesis para tetraparesis

Radiography

Advanced imaging: MRI, CT ►►4: ambulatorypara//tetraparesis para tetraparesis ((ataxiaataxia))

CSF analysis ►►5: segmental hyperaesthesia ►► Differential diagnosis, diagnosis ►► Prognosis This is the preferred scoring in some surgery literature. ►► Therapeutic plan

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Gait Localisation Postural reactions Differential diagnosis – VITAMIN D Reflexes „Anatomical diagnosis”

►► V = vascular ►► I = immunmediatedimmun mediated,, inflammatoryinfl ammatory//infinfectiousectious ►► T = trauma,traum a, toxicctoxi ►► A = anomalyalyanom (malformation) ►► M = metaboliccmetaboli C1-C5 C6-T2 T3-L3 L4-S ►► II = idiopathic craniocervical caudocervical thoracolumbal lumbosacral ►► N = neoplasm,neoplasm , nutritional Fore limb: UMN Fore limb: LMN Fore limb: normal Fore limb: LMN ►► D = degenerativ,degenerat iv, developmental Rear limb: UMN Rear limb: UMN Rear limb: UMN Rear limb: LMN

Vascular FCEFCEMM, EEpiduralpiduralbleeding Inflammatory/infectious Discospondylitis , Meningitis , Ancillary Meningomyelitis , Empyema, OsteomyelitisOsteomyelitis,, GME diagnosdiagnosticstics Trauma FFracturracturee,, LLuxatiouxationn,, TTraumraumaticatic disc herniaherniationtion,, TTraumraumaticatic AA--LL lux. Toxic NNoo AnomAnomalyaly AA--LL luxationnluxatio , ChiariChiari--likelikemalformationnand malformatio and SSyringomyeliayringomyelia , HemivertebraHemivertebraee, Arachnoid cyst , Spina bifida, Dysraphismus, Multiple CSF analysis cartilaginous exostoses (total protein, cell count, MetaboliMetabolicc NNoo cytology, PCR etc.) Idiopathic Disseminated Dissemin ated idiopathic skeletal hyperostosis NeoplasNeoplasiaia PrimPrimaryary or sesecocondndaryarytumorss tumor Meningitis, DegeneratDegenerativeive Intervertebral disc disease , DegeneratDegeneratiivvee meningomyelitis! myelopathmyelopathyy, DegeneratDegeneratiivveelumbosacrallumbosacral stenosis , Osteoarthritis, EExtraduralxtradural synovial cyst,cyst , Spondylosis deformans, Spinal stenosis, etc. Developmental or Cervical spondylomyelopathspondylomyelopathyy Degenerative Occipital puncture can be seen.

Imaging The position of the lesion relative to the spinal cord

►► TraumTrauma?a? ––CT,CT, (RTG) ►► Extradural : Disc herniation Trauma ►► Compression? ––MRI,MRI, (myelographyy,(myelograph , CT, CT--CT Neoplasia myelo) Discospondylitis ►► Developmental abnormality? ––RTG,RTG, CT, CT--CT myelo, MRI ►► Intradural, ►► Vascular? ––MRIMRI extramedullary ::Neoplasia, Cyst

►► Intramedullary: Neoplasia Inflammatory Ischaemic Haematoma

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Intervertebral disc disease , The Intervertebral Disc DDegenerategenerativeive DegeneratDegeneratiivveemyelopathmyelopathyy, Annulus fibrosus diseases DegeneratDegeneratiivveelumbosacrallumbosacral stenosis , Osteoarthritis,

Concentric rings of EExtraduralxtradural synovial cystcyst,, fibrocartilagenous lamellae Spondylosis deformans, Spinal Nucleus pulposus stenosis

80 ––88%88% water bound by proteoglycans Intervertebral Disc Disease

Type II collagen

Chondrocytes, fibrocytes and notochordal cells Cartilagenous endplates of the vertebrae

Thin layer of hyaline cartilage

Disc Degeneration Hansen TypeType--I.I. disc herniation (extrusion)

►►Chondrodystrophoid breeds ►► Described in

Chondroid metaplasia of the nucleus chondrodystrophoid –– Hansen type--IItype dogs ►►Nonchondrodystrophoid breeds ►► Peak incidence: 3 ––6 y6 y

Fibroid metaplasia –– Hansen type--IIIItype ►► 75% TL herniations between T11T11/12/12 and L1/2

TypeType--II.II. disk herniations „„OtherOther Acute Disc HerniationsHerniations”” ►► Often multiple ►►Low volume, high velocity; missile; „„typetype 3””3 ►► Occur at points of greatest

Can be traumatic mobility ►►Large breed acute annular disc herniations ►► Dehydration and fibrosis of the nucleus results in ►►Acute herniation of dehydrated, fibrotic transference of load to the nucleus: old dachshund, large breeds annulus

Undergone chondroid metaplasia but not ►► Annulus bulges and degeneration and calcification fragments ►►Acute herniation of hydrated nucleus ►► Generally large breeds

Most common in the cervical spine ►► >8 y

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Breed predisposition The Dachshund

►► Occurrence of 19% across dachshunds, some families as high as 75% (Ball et al., 1982) ►► Complex trait, environmental factors important

MyelographyMyelography:: Imaging Disk extrusion Survey radiography: ►► Disk disease

(Occipital puncture)

Myelography: DisDiskk protusion

(Lumbal puncture)

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CT: discus hernia Myelo-CT: discus hernia

Simon Platt: Small Animal Spinal MRI Hansen I discus hernia MR image of dehydrated & protruded disk in multiple region

Therapy Decision making in therapy

►►ConservativeConservative:: ►►Acute or chronic? --CageCagerest forfor atat least 2 weeks after clinical ►►Severity? signs have resolved!! resolved --MedicationMedication ::NSAIDsNSAIDs oror steroidssteroids,, tramadol,tramadol , ►►Grading! gabapentingabapentin,, gastric protection

Grade 55:: surgical ►►SurgicalSurgical::

Grade 44:: surgical, may be conservative decompression , fenestration

Grade 2, 33:: surgical or conservative --SevereSevere neurologic signs

Grade 55:: conservative --FailureFailure of nonsurgicaltherapy ►►+ Physiotherapy

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Succes of cconservativeonservative vs. ssurgicalurgical Chance of relapse in case of treatment conservative management

►►ThoracolumbalThoracolumbal: 3: 300.9%.9% Grade 1, 2, 3, 82%--88% 82% 88% 1100%00% ►►CervicalCervical:: 33%

Grade 44 43%43%--51%51% 8800--100%100% Levin et al. Evaluation of the Success of Medical Management for Presumptive Thoracolumbar Intervertebral Disk Herniation in Dogs. Veterinary Surgery. 2007

Levin et al. Evaluation of the Success of Medical Management for Grade 55 00--7%7% 00--75%*75%* Presumptive Cervical Intervertebral Disk Herniation in Dogs. Veterinary Surgery. 2007

*It mainly depends on the time of the surgical decompression!

►► Loughin (VCOT 2005) When should be performed the

In 12 hh→ 6600%% recovered surgical decompression?

More then 48 hh → 6.7% ►► Laitinien (Acta Vet Scan, 2005) ►► As soon as possible!

In 24 h 41.3% recovered in avarage 12.5 month ►►Prevent secondary damage caused by the

More then 24 h no recovery!

In cases when deep pain sensation recovered in 2 weeks the prolonged compression and loss of recovery rate was 66.7%, when only later the rate was 110%0%

circulation ►► Olby (JAVMA 2003) ►►What if there is no more deep pain

58% recovered if treated in 48 h

78% regained deep pain sensation in the first 2 weeksweeks sensation?

19% in the second two weeks

Does it make sense to do surgery in 1212--2424--4848

3%3%later

41% was incontinent later hours or even later?

Progressive hemorrhagic myelomalacia occurs in up to 11% of dogs that have lost nociception!

What is the prognosis in general? Current surgical treatment of IVDD ►►Intact deep pain s.s.:: favourable Aim is to decompress the spinal cord ►► HemilamiHemilaminnectomectomyy ►►No deep pain s.s.:: grave ––poorpoor ►► Pediculectomy ►► Foramenotomy ►► Lateral corpectomy ►►If deep pain s. regains in 2 weeksweeks:: ►► Fenestration favourable ►► LaminectomLaminectomyy ►► Ventral slot (cervical) ►► Dorsal laminectomy (cervical)

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Which surgical approach? Which surgical approach? Hemilaminectomy ►► Hemilaminectomy + Great access laterally and ventrally + Minimal laminectomy membrane problems -- Access to contralateral side limited -- Access ventrally is limited if disc is firm, adherent -- Can cause instability if performed bilaterally

►► Ventral slot

Cervical disc disease ►► MiniMini--HemilaminectomyHemilaminectomy (Pediculectomy,

Wobbler syndrome Foramenotomy)

Preserves articular facets

Dorsal limit ––dorsaldorsal aspect of accessory process

Can be performed bilaterally

Less access to the vertebral canal and therefore the disc material

Can cause instability ►► Possible complications:

Severe bleeding

Respiratory failure

Ventral slot Other surgical approaches

►► LS spine ––dorsaldorsal or sometimes a dorso--dorso lateral approach

►► Cervical spine ––dorsal or hemi

►► TL spine: lateral corpectomy in case of chronic disc protrusion

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Other surgical approaches What can go wrong?

►► Fenestration ►► Cut the wrong site Fenestrate calcified disks, ►► Recurrence fenestrate higher risk disks ►► Iatrogenic damage of the spinal cord T11T11/12/12 --L2/3L2/3 ►► Failure to remove disk material + Decreased recurrence of the ►► Hemorrhage disease ►► Arrhytmias --LongerLonger surgical procedure ►► Damage to local soft tissue --CanCan cause instability ►► Instability --ExtensiveExtensive muscle dissection ►► Laminectomy membrane ►► Seroma ►► Infection

Treatment doesn`t end with Treatment doesn`t end with surgery! surgery! ►► Management of pain ►► Management of incision ►► Prevention of decubital ulcers ►► Rehabilitation exercises, hydrotherapy ►► Bladder care (evacuation 3 times daily!) ►► Mental stimulation

►► The most common mistake made in managing animals Take home messages with disk extrusions is administration of corticosteroids and analgesics without appropriate concurrent ►► Most commonly the Th11Th11--L2L2 sites are involved in T--LT L disk confinement. Strict cage rest is mandatory in these extrusion patientspatients..

►► It is generally accepted that patients with paresis should ►► It is extremely important that deep pain be properly be treated by early decompressiondecompression.. assessed. The withdrawal reflex does not verify the presence of deep pain. The animal should vocalize or ►► Patients without deep pain s. should be operated on otherwise indicate that pain was feltfelt.. within 24 ((––48)48) hours of disk extrusion..extrusion

►► It is not sufficient to remove lamina, facets and ►► Control of adequate bladder function is very important pedicules alone without the compressive disk material..material

►► The role of prophylactic fenestration remains unclear.

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Intervertebral disc disease , DDegenerategenerativeive DegeneratDegeneratiivveemyelopathmyelopathyy, The most common diseases DegeneratDegeneratiivveelumbosacrallumbosacralstenosis , causes of LS stenosis Osteoarthritis, EExtraduralxtradural synovial cystcyst,, Spondylosis deformans, Spinal stenosis ►► Hansen TypeType--II.II. disc Degenerative lumbosacral stenosis protrusion (Cauda Equina Compression) ►► Lumbosacral instability ►► Neoplasia Cauda Equina CompressioCompressionn = compression of the ►► Fracture terminal nerve filaments ►► Discospondylitis ►► Spondylosis deformans compressing L7 nerve root ►► OCD of the sacrum

Clinical signs Ancillary tests (LMN signs + pain)

►► LLumboumbo--sacralsacral painpain!! ►► Radiography ►► Difficult to stand up or jump ►► Myelography ►► Dragging the toes on the ground ►► Hind limb paresis ►► Epidurography ►► Muscle atrophy except m. quadriceps ►► Discography ►► Low carriage of the tail ►► CTCT ►► Fecal and urinary incontinence ►► MRI ►► Decreased anal reflex ►► Electrophysiology ►► Hyperaesthesia, prurituspruritus,, automutilation is possible LS stenosis can be seen

Myelography C.E.C. epidurogrepidurographyaphy Disk protusion --CECCEC

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CTCT

Sacrum OCD és CEC

MRI Therapy

►► Conservative ►► Surgical

In mild cases

In case of gait ((onlyonlypain)) pain abnormalities

Exercise restriction

In case of failure of (4(4--66 w) the cons. treatment

NSAIDs, corticosteroids

Dorsal laminectomy

Physiotherapy ►►(+(+foramenotomyforamenotomy)) ►►(+(+stabilisationstabilisation))

L7L7--S1S1 dorsal laminectomyylaminectom L7L7--S1S1 dorsal laminectomyylaminectom

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DDeevelopmentalvelopmental or Caudocervical The most common causes of WobblerWobbler-- degenerative disease spondylomyelopathy syndrome

Cervical spondylomyelopathy ►► Narrowing of the vertebral canal because of (Wobbler-syndrome) osseus malformation (Great Danes) ►► Cervical vertebral malformation or malarticulation results in ►► compression of the cervical spinal cord segments Hypertrophy of the lig. ►► Most common in middle aged Dobermans (3(3--99 y) and flavum and joint capsules young Great Danes (2) ►► Annulus hypertrophy and ►► C5C5--66 and C6--7C6 7 is the most common dorsal longitudinal ►► Chronic, slowly progradiating disease ligament pathology

Clinical signs chronic compression of the cervical spinal cord

►► Stiff neck ►► AtaxiAtaxiaa ►► Paresis ►► „Two engine dog” ►► LMN signs on the front limbs ►► UMN signs on the hind limbs ►► First signs on the hind limbs

Wobbler therapy Continuous dorsal llaminectomaminectomyy

►► Conservative ►► Surgical

In mild cases

High potential for morbidity

Exercise restriction and postop. complications!

NSAIDs,

In case of gait abnormalities corticosteroids

In case of failure of the cons.

Physiotherapy treatment ►►Dorsal laminectomy ►►Ventral slot ►►Ventral slot + stabilisation

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Intervertebral disc disease , Trauma FFracturracturee,, LLuxatiouxationn,, TTraumraumaticatic disc DDegenerategenerativeive DegeneratDegeneratiivveemyelopathmyelopathyy, herniaherniationtion,, TTraumraumaticatic AA--LL lux. diseases DegeneratDegeneratiivveelumbosacrallumbosacralstenosis , Osteoarthritis, EExtraduralxtradural synovial cystcyst,, Spondylosis deformans, Spinal stenosis Fracture, luxation Degenerative myelopathy ►► Direct trauma to the spinal cord results primary ►► Slowly progressive axonal degeneration and and secondary injuries (See in closed demyelindemyelinisisationation mechanical injuries lecture!) ►► Older German shepherd (>8 y)and mixes, boxer ►► Emergency initial examination and stabilization etc., rarely in cats

Immobilize the spine to prevent further ►► Hind limb ataxia and paresis, nonpainful!!nonpainful damage! ►► Imaging: spinal cord atrophy ►► Detailed nneuroleurologicalogicalexamination ►► Genetic test is available ►► Radiography, CT ►► No curative treatment, poor prognosis ►► Physiotherapy ►► Surgical or conservative treatment

►► Decompression

Laminectomy

Durotomy (in case of severe swelling)

►► Stabilization:

Pins, screws and polymethylmethacrylate

Vertebral body plates

C5 fracture

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NeoplasNeoplasiaia PrimPrimaryary or sesecocondndaryarytumorss tumor

►► Tumors can affect the vertebrae, meninges and spinal cord ►► Neoplasia can be classified as extradural,extradural , intraduralintradural--extramedullaryextramedullary,, or intramedullary

Extradural tutummorsors can be primary or secondary. ►►Primary vertebral tumors: fibrosarcoma,fibrosarcoma , osteosarcoma,osteosarcoma , chondrosarcomachondrosarcoma,, hemangiosarcoma,hemangiosarcoma , myeloma ►►Secondary vertebral tumors: mammary, prostatic, thyroid carcinomas, malignant melanoma, metastatic osteosarcoma osteosarcoma Post op. ►►Epidural tumors: lymphoma, metastatic tumors

IntraduralIntradural--extramedullaryextramedullary:: meningiiomamening oma,, peripheral nerve sheat tumor, lymphoma, nephroblastoma

IntramedullaryIntramedullary:: astrocytoma,astrocytoma , oligodendrogliomaoligodendroglioma,, ependymomaependymoma,, metastaticticmetasta

Clinical signs Vertebral tumors: Osteolyis ––osteoproliferatioosteoproliferationn on radiographs ►► Ventral part of the vertebral body or proc. spinosus ►►Pain! ►►TransversTransversalal myelopathy ►►Any breed, most common in older large breed dogs ►►Cats: lymphoma, meningioma,meningioma , osteosarcomaosteosarcoma!!

Osteosarcoma of the sacrum

Imaging Intramedullar tumor ExtraduralExtradural?? IntraduralIntradural--exramedullaryexramedullary?? IntramedullaryIntramedullary??

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Lymphoma Fibrosarcoma Located intraduralintradural--extramedullaryextramedullary

Treatment Multiplex myeloma ►►LongLong--termterm prognosis is poor ►►Medical therapy consists:

Prednisone palliatively

Chemotherapy (lymphoma, solitary plasmacytoma)

Radiation therapy ►►Surgical therapy

Decompression + surgical resection or debulking

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Inflammatory/ Discospondylitis , Meningitis , XX--rayray:: osteolysis surrounded by sclerosis on the vertebral infectious Meningomyelitis , Empyema, endplates OsteomyelitisOsteomyelitis,, GME Cave: radiographic signs only after the first 2 weeks Discospondylitis

►► Septic infection of the disc and adjacent vertebrae ►► Common: Staph. intermedius, Streptococcus, E. coli, Actinomyces, Aspergilllus, Brucella canis!, Pasteurella ►► Mainly in middlemiddle--agedaged large breed dogs ►► Single or multiple sites ►► Clinical signs reflect the location, pain is the most common! ►► Other infection or systemic disease can be in the background! ►► Therapy: long term antibiotic treatment (6(6--88 weeks), NSAIDNSAID’s’s

Osteomyelitis Meningitis ►►Most common form is the immuneimmune--mediatedmediated ((„„beaglebeagle--painpain””,, „„steroidsteroid responsive meningitis””))meningitis

Typically in young (7(7--1818 month) dogs

Most common in beagle, bernese, boxer, vizsla

Severe neck pain and fever

CSF cytology is the definitive diagnostic test

Treatment is longlong--termterm (min. 6 month) immunosuppression with tapering dosage of prednisolon

Prednisolon can be combined with other immunsuppresants (azathioprin, cyclosporin)

Infectious meningomyelitis Vascular FCE , EEpiduralpiduralbleeding

►►Viral, bacterial, protozoal or fungal ►► Vascular compromise of the spinal cord that often progresses to local infarction

Cats: FIP, FeLV , toxoplasmosis etc. ►► Fibrocartilaginous embolic myelopathy (FCEM) or

Dogs: distemper, toxoplasmosis, neosporosis, spinal cord infarct or ischemic myelopathy cryptococcosis etc. ►► Peracute onset, nonprogressive, nonpainful, often asymmetrical ►► Multifocal neurological signs, can iclude ►► Transverse myelopathy (ataxia, paresis) paresis and ataxia ►► Most common in large breed dogs, miniature ►►Often systemic signs too schnauzers and cats ►► Imaging: MRI is definitive ►►CSF test is the basis of the diagnostics ►► Treatment: physiotherapy

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AA--LL luxationnluxatio , ChiariChiari--likelikemalformationn malformatio and SSyringomyeliayringomyelia , Hemivertebra , AnomAnomalyaly Arachnoid cyst , Spina bifida, Dysraphismus, Multiple cartilaginous exostoses AtlantoAtlanto--axialaxial luxation ►► Instability or malformation of the atlantoaxial joint allows excessive flexion of the cervical 11--22 joint ►► Subsequent ventral cord compression occurs from the cranial aspect of the body of the axis ►► Most common in young toy breeds FCEM on MRI ►► Neck pain, ataxia, tetraparesis ►► XX--ray,ray, CT, MRI is definitive ►► Treatment

Conservative: neck splinting for 88--1010 weeks (long term efficacy:?)

Surgical: Fusion of the C1C1--C2C2

ChiariChiari--likelike malformation and syringomyelia and hydromyelia

►► Hydromyelia is a fluid dilatation of the central canal ►► Syringomyelia is a fluid dilatation in the spinal cord that may communicate with the central canal ►► Any condition that causes obstruction of normal CSF flow along the spinal cord can cause it ►► Most common in cervical region ►► Cervical syringohydromyeliaoccurs as a component of congenital anomalies associated with caudal occipital malformation syndrome ((ChiariChiari),), which is most common in Cavalier King Charles spaniel ►► Neck pain, persistant scratching, ataxia, paresis

MRI is definitive ►►Treatment ((inincase of clinical signs)) signs

Prednisolon 0,5 mg/kg/SID

Gabapentin 55--1010 mg/kg/TID

Pregabalin 33--44 mg/kg/TID

Omeprazol 0,5 mg/kg/SID

NSAID ((MeloxicamMeloxicam,, Carprofen,Carprofen , Coxib))Coxib

Other painkillers (pl. Fentanylpatch)

Furosemid

Surgical decompression++titanium decompression titaniummash?? mash

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Hemivertebrae ►► Wedge shaped malformation, with the apex dorsally, ventrally, or medially across the midline which often results in angulation of the v. column ►► Spinal cord compression can occur ►► Most common: bulldog, pug, yorkie, boston terrier, german shorthair pointer ►► Clinical signs: slowly progressive ataxia, paresis, (pain) ►► Imaging: XX--ray,ray, Myelography, CT, MRI ►► Treatment

Conservative: physiotherapy, NSAIDs, steroids?

Surgical for progressive clinical signs: stabilisation + (Massimo Baroni felvételei) decompression

Arachnoid cyst

►► CSF filled diverticuli of the arachnoid membrane ►► Most common in young adult rottweilers, cervically ►► Chronic progressive ►► Clinical signs: ataxia, paresis, (pain), incontinence ►► Imaging: Myelography, MRI ►► Treatment:

Conservative in mild cases: NSAIDs, steroids

In severe cases surgical decompression, partial excision Subarachnoideal cyst and marsupalisation of the dura is recommended

Thank you for your attention!

Literature

•BSAVA Manual of Canine and Feline Neurology •Handbook of Veterinary Neurology •Small Animal Spinal Disorders •Veterinary Neuroanatomy and Clinical Neurology •Small Animal Surgery

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