2013.03.28. Spinal disorder? TransversTransversalal myelopathymyelopathy:: 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,, urine analysis ►►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 1 2013.03.28. 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 luxatioluxationn, 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 cystcyst,, 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 2 2013.03.28. 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 typetype--II dogs ►►Nonchondrodystrophoid breeds ►► Peak incidence: 3 ––6 y6 y Fibroid metaplasia –– Hansen typetype--IIII ►► 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 3 2013.03.28. 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) 4 2013.03.28. 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? --CageCage rest forfor atat least 2 weeks after clinical ►►Severity? signs have resolvedresolved!! --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 5 2013.03.28. 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) 6 2013.03.28. 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 dorsodorso-- lateral approach ►► Cervical spine ––dorsal or hemi ►► TL spine: lateral corpectomy in case of chronic disc protrusion