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Corpectomy (Imhc) for Treatment of Thoracolumbar Intervertebral Disc Herniation in Large Breed Dogs

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Corpectomy (Imhc) for Treatment of Thoracolumbar Intervertebral Disc Herniation in Large Breed Dogs Received: 27 February 2015 | Accepted: 12 September 2016 DOI 10.1111/vsu.12616 ORIGINAL ARTICLE Individualized mini-hemilaminectomy-corpectomy (iMHC) for treatment of thoracolumbar intervertebral disc herniation in large breed dogs Susanne C. Medl1 | Sven Reese2 | Nikola S. Medl1 1 Small Animal Clinic Dr. Medl, Abstract Babenhausen, Bavaria, Germany 2 Institute of Anatomy, Histology, and Objective: To assess the short-term, mid-term, and long-term results after an individ- Embryology, Department of ualized mini-hemilaminectomy-corpectomy (iMHC) procedure for treatment of acute Veterinary Sciences, Faculty of and chronic thoracolumbar intervertebral disc disease in non-chondrodystrophic Veterinary Medicine, Ludwig- dogs. Maximilians-University, Munich, Study Design: Prospective study. Germany Animals: Client-owned non-chondrodystrophic large breed dogs (n 5 57). Correspondence Susanne C. Medl, Tierärztliche Methods: The iMHC procedure, combining mini-hemilaminectomy (MH) and par- Klinik, Alpenstr. 27, 87727 tial lateral corpectomy, was performed on non-chondrodystrophic dogs with Babenhausen, Bavaria, Germany. thoracolumbar disc disease. Neurological status was evaluated before surgery, for Email: [email protected] short-term outcome on days 1 and 7 after surgery, for mid-term outcome at 6 months after surgery, and for long-term outcome at the conclusion of the study. Prognostic factors were statistically evaluated. P < .05 was considered significant. Results: iMHC was performed on 57 dogs, with minimal intraoperative and postop- erative complications. Short-term neurological improvement was observed in 85.7% of dogs. Median hospitalization time after surgery was 2 days (range 0-14) and was significantly shorter for dogs with a chronic history of clinical signs (1 day, range 0- 5) compared to acute onset (3 days, range 0-14) and for those that were ambulatory at initial presentation (1 day, range 0-5) compared to those that were not (3 days, range 0-14). Long-term evaluation included 53 surgeries with a mean follow-up time of 29.4 months. Outcome was excellent in 19 dogs and good in 29 dogs (90.6% suc- cess rate). Excellent mid-term and long-term results were significantly more common in the dogs with only 1 affected disc space. Conclusion: The iMHC procedure resulted in a short hospitalization time, minimal postoperative deterioration, and a high success rate. 1 | INTRODUCTION have been proposed to address decompression of the spinal cord. Currently, hemilaminectomy (HL) is the standard pro- Disc herniation is considered the most common cause of spi- cedure used, as there are over 2000 published cases in at nal cord trauma in dogs.1 A variety of surgical approaches least 37 publications. However, a certain degree of spinal cord manipulation is frequently inevitable by HL exposure, *Presented at the European College of Veterinary Neurology with potential untoward neurological sequelae due to verte- 2,3 Annual Symposium, Ghent, Belgium, September 2012, Veterinary bral canal entry from a dorsolateral direction. Deterioration Neurosurgical Society Symposium, Portland, OR, August 2013, of neurological status after surgery has been observed fol- and FECAVA Eurocongress, Munich, Germany, November 2014. lowing HL.3-7 422 | VC 2017 The American College of Veterinary Surgeons wileyonlinelibrary.com/journal/vsu Veterinary Surgery 2017; 46: 422-432 MEDL ET AL. | 423 Surgical treatment by HL typically yields considerably less favorable results in large breed dogs than in small breed dogs.8-10 In a study performed in 1997 on non- chondrodystrophic dogs with thoracolumbar intervertebral disc disease (IVDD), the reported time to recovery after dor- sal laminectomy (DL) or HL was 5.6 weeks in dogs that were ambulatory before surgery and 7 weeks in dogs that were non-ambulatory before surgery.10 Another study on small and large breed dogs showed postoperative deteriora- tion in 60% of cases when HL was combined with vertebral stabilization.11 Mini-hemilaminectomy was first described in 1978 by Braund.2 In this procedure, access to the spinal canal by removing the accessory process and enlarging the interverte- bral foramen cranially and caudally is gained with minimal removal of bone. The articular facets remain preserved and vertebral column stability, particularly when combined with fenestration, is better maintained than in HL.2,12,13 The FIGURE 1 Computed tomography image of a dog with removal of ventrally located disc material is facilitated and chronic disc extrusion showing the spinal cord wrapped around the risks of iatrogenic spinal cord trauma and laminar mem- the herniated disc material (arrow). The disc material cannot be brane formation are minimized.14 Mini-hemilaminectomy removed by a dorsolateral approach to the spinal canal without has yielded considerably more promising results than HL in considerable manipulation of the spinal cord terms of both postoperative status and recovery time in small and large breed dogs.2,15-17 (iMHC) procedure for the treatment of acute and chronic Due to the pathogenesis of the primarily fibrous disc thoracolumbar IVDD in non-chondrodystrophic dogs. degeneration in non-chondrodystrophic dogs, disc hernia- tions typically begin with annular protrusions. These are pre- 2 | MATERIALS AND METHODS dominantly centrally located18 and over time can progress to extrusions, become hard or calcified, and adhere to the floor In this prospective study, iMHC was performed on all dogs of the spinal canal and/or dura mater. In these cases (Figure selected by the below-mentioned inclusion criteria. The 1), removal of disc material using the dorsolateral approach observational period was a minimum of 6 months. Written to the spinal canal by HL requires considerable manipulation informed consent was obtained from all owners before study of the spinal cord.2,3,9,19 In human neurosurgery, the use of entry. Consecutive clinical cases presented from January evoked motor potentials has revealed that an already com- 2006 to April 2013 were included. Inclusion criteria were promised spinal cord is highly sensitive to surgical manipula- non-chondrodystrophic breed, body weight of 18 kg, com- tion.20,21 Although surgical intervention often is required in pressive thoracolumbar IVDD confirmed by diagnostic imag- cases of compressive IVDD, the surgery by itself should not ing, neurological deficits, and pain consistent with a result in deterioration of clinical signs. Recently, promising neuroanatomical localization from T3 to L4 or recurrent results have been achieved in dogs with chronic disc hernia- back pain that did not respond to pain medication. Exclusion tion with the introduction of partial lateral corpectomy criterion was a postoperative lack of owner compliance. (PLC).19 Portions of the intervertebral disc and adjacent ver- Clinical presentation, breed, body weight, age, and sex of tebral body are removed and the herniated and compressing each dog were recorded. disc material is addressed from a ventral direction, thereby On clinical presentation, general and neurological exami- avoiding surgical manipulation of the spinal cord. nations were performed and the rate of onset, duration of In comparisons of outcomes and recovery times in dogs, clinical signs, and neurological status were noted. The rate of mini-hemilaminectomy (MH) and PLC each have yielded onset of neurological signs was defined as the time from the best results to date.15-17,19,22 The objectives of this study being clinically normal to attaining the worst neurological were to combine both methods to add the advantages of the status and was classified as peracute (<1 hour), acute (1-24 lateral and ventral approach and to minimize the dimensions hours), chronic (>24 hours), or chronic with acute deteriora- of the PLC to the individual needs of each dog, as well as to tion.8,10,23 Duration of clinical signs was defined as the time assess the short-term, mid-term, and long-term outcomes from when the owner first observed neurological dysfunction after this individualized mini-hemilaminectomy-corpectomy until the time of presentation. Based on the severity of 424 | MEDL ET AL. TABLE 1 Grading system used to assign dogs to 1 of 5 neurologic categories based on the severity of the neurological dysfunction Grade Ambulatory Definition # Dogs 1 Yes Back pain without any neurological deficits 1 2 2a Yes Very mild ambulatory paraparesis, mild ataxia, or conscious proprioceptive deficit 0 2b Yes Moderate ambulatory paraparesis 9 2c Yes Severe ambulatory paraparesis 23 3 No Non-ambulatory paraparesis 14 4 No Paraplegia with or without bladder function 13 5 No Paraplegia without deep pain perception 3 neurological dysfunction, dogs were assigned to 1 of 5 neu- diseased side up on a tilting surgery table. A dorsolateral rologic categories.13,23-26 Because grade 2 comprised a wide- approach to the spine was performed at the affected site.28 spread group of dogs with considerable difference in the The area around the intervertebral foramen and adjacent ped- severity of neurological signs, it was further subdivided to icles were freed bluntly from the surrounding musculature allow for a more precise evaluation of the effects of the sur- using a periosteal elevator and the tendinous attachment of gery into grades 2a, 2b, and 2c (Table 1).8,11,27 the longissimus muscle to the accessory process at the The diagnosis of disc herniation and information about its affected site was severed using Metzenbaum scissors (Figure localization and possible lateralization, the number of affected
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