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Preface
generally divided into intraoperative, early postoperative and late postoperative. These are listed in tabular
format and are also discussed and illustrated where
possible in the main text. Furthermore, prognostic
information continues to be derived mainly from the
literature rather than from anecdote, at least where
information is available. Physiotherapy now receives
four pages of special emphasis in the postoperative care
chapter. An additional change is the separation of the
procedures section from the main chapter, so that photographs of surgical techniques no longer interrupt the
text. Finally, at the end of most chapters, key issues for
future investigation have been identified, to highlight
areas where we need to focus our creative energy and
future research efforts.
Additional information relating to this text and to
neurosurgery in general has been made available on the
Internet at www.vetneurosurgery.com. This includes
direct links that provide abstract information to many
of the citations used in the second edition, along with
further information on CT and MRI anatomy. It also
provides many links to other websites that contain
information aimed at owners, referring veterinarians
and specialists.
There will come a time when veterinary neurosurgery becomes a specialty recognized in its own right,
just as it is in human healthcare. Until that time it will
fall upon individuals, mainly from the European and
North American specialties of neurology and surgery,
to advance our knowledge one step at a time. This book
aims to bring all of the various quite disparate sources
of information together, in order to provide a comprehensive summary of the current state of knowledge of
veterinary neurosurgery.
Nick Sharp
Simon Wheeler
List of Abbreviations
ACE
b.i.d.
CDV
CK
CMC
CNS
COX
CSM
CSF
CT
DISH
DVT
ECG
EMG
FCE
FeLV
FIP
FIV
GI
GME
IM
angiotensin-converting enzyme
bis in die (twice daily)
canine distemper virus
creatine kinase
cerebello medullary cistern
central nervous system
cyclooxygenase
cervical spondylomyelopathy
cerebrospinal fluid
computed tomography
disseminated idiopathic skeletal hyperostosis
deep vein thrombosis
electrocardiogram
electromyography
fibrocartilaginous embolism
feline leukemia virus
feline infectious peritonitis
feline immunodeficiency virus
gastrointestinal
granulomatous meningoencephalomyelitis
intramuscular
IV
LMN
MPSS
MR
MRI
NSAID
OCD
PCV
PgE
PO
PTE
RBC
SQ
STIR
TMJ
TSH
UMN
UTI
VW
WBC
intravenous
lower motor neuron
methylprednisolone sodium succinate
magnetic resonance
magnetic resonance imaging
non-steroidal anti-inflammatory drug
osteochondritis dissecans
packed cell volume
prostaglandin E
per os
pulmonary thromboembolism
red blood cells
subcutaneous
short tau inversion recovery
temporomandibular joint
thyroid-stimulating hormone
upper motor neuron
urinary tract infection
von Willebrand
white blood cell
Functional anatomy
Skeleton 6
Vertebrae 6
Articulations 9
Blood supply 14
Vertebral column 14
17
Further reading
17
c
a
b
e
NERVOUS TISSUE
Spinal cord
Nervous tissue 1
Spinal cord 1
Relationship of spinal cord segments to
vertebrae 2
Cauda equina 3
Meninges 3
Cerebrospinal fluid 4
Spinal cord white matter tracts 5
Spinal cord nerve fibers and the effect of
compression 6
References
Chapter
4
5
6
1.3 Normal cervical MRI. A: Sagittal, T2-weighted MRI of the cervical spine in a 7-year-old Doberman. It had undergone a ventral
slot at C6/7 2 years ago and is now clinically normal. The other discs show the expected high signal intensity of the nucleus
pulposus (arrow). B: Transverse, T2-weighted MRI of the cervical spine through mid-C5 vertebra; the gray matter is visible clearly
within the spinal cord, which is surrounded by a hyperintense rim of cerebrospinal fluid (arrow). The black crescent on one side
between CSF and epidural fat is a chemical shift artifact.
C5
T2
C6
T1
C8
C7
a
d
1.4 Brachial plexus: lateral thoracic (a); ulnar (b); median (c);
radial (d); axillary (e); and musculocutaneous nerves (f). The
subscapular and suprascapular nerves arise just cranial to
the musculocutaneous nerve.
Functional anatomy
1.5 Position of spinal cord segments within the lumbar vertebrae. Segments L1 and L2 lie in their respective vertebrae. The lumbar
intumescence lies within vertebrae L3L5; lesions as far cranial as L3/4 intervertebral disc may cause LMN signs in the pelvic limbs.
The sacral segments S1S3 are within L5 vertebra in most dogs (the 5 in L5 resembles the S for sacral). The spinal cord ends in
L6 in most dogs; L7 in cats. The cauda equina runs from L5 vertebra into the sacrum (1.7, 1.8B).
1.6 Normal thoracolumbar MRI. A: Sagittal, T2-weighted MRI of the thoracolumbar spine of a normal 6-year-old Golden retriever.
Nucleus pulposus in this pulse sequence shows intermediate signal intensity; the thin layer of cerebrospinal fluid (CSF) is of
intermediate signal intensity (arrow); epidural fat is high signal intensity (arrowhead). Note the nutrient vessels arising from the aorta
(arrowheads) (Parker, 1973). B: Transverse, T1-weighted MRI of the thoracic spine at the level of T13. The spinal cord is surrounded
by high signal epidural fat (arrow); CSF is of low signal intensity and does not show clearly. Note the aorta (arrowhead) (1.23).
a
1.7 Nerve roots of the cauda equina. Conus medullaris (a). Nerve roots and rootlets (b). Intervertebral foramen (c). Spinal ganglion
(d). Spinal nerve (e). L6 vertebra (f). L7 vertebra (g). Sacrum (h).
Cauda equina
Meninges
L5
L6
L5
L7
L6
a
L7
d
c
B
1.9 Normal lumbosacral MRI. A: Sagittal,
T2-weighted MRI of the lumbosacral
spine in extension (same dog as 1.8).
There is loss of signal of the L7/S1
nucleus pulposus (arrowhead) but there is
no dorsal displacement of the disc.
B: Transverse, T1-weighted MRI through
the L7/S1 disc space and foramen of the
same dog; the nerve roots (arrowheads)
are surrounded by high-signal epidural fat.
See also 1.19B.
Cerebrospinal fluid
Cerebrospinal fluid is formed in the brain, mainly by
the choroid plexuses, with contributions from the
Functional anatomy
Sensory to brain
Spinal ganglion
Sensory
fiber
UMN
LMN
LMN
rubrospinal tract of the lateral funiculus. The vestibulospinal tracts and reticulospinal tracts also influence
motor function. The function of extensor muscles is
facilitated by these tracts, which lie in the ventral funiculi. The vestibulospinal fibers arise in the ipsilateral
vestibular nuclei. They facilitate extensors and inhibit
flexors on the ipsilateral side, and have the opposite
effect on the muscles of the contralateral limbs.
Voluntary bladder emptying is mediated through
fibers in the tectospinal and reticulospinal tracts of the
ventral funiculi.
SKELETON
The vertebral column is composed of a series of vertebrae, most of which are joined by the intervertebral
discs and by synovial joints between the articular
processes.
Vertebrae
The numbers of different types of vertebrae are as
follows: cervical 7; thoracic 13; lumbar 7; sacral 3; and
caudal 20 (approximately). Variations are possible,
particularly in the transition zones between thoracic
to lumbar, and lumbar to sacral vertebrae. The most
common variations are in the number of ribs (8.19,
8.21), and abnormal articulations with the ilium (see
Chapter 10). The importance of this lies in recognizing
Functional anatomy
e
d
c
h
CERVICAL VERTEBRAE
There are seven cervical vertebrae. The first two are distinct: the atlas (C1) and axis (C2) (1.14, 1.15). The vertebral body of C1 is very small, the bulk of the vertebra
a
d
c
b
1.16 Cervical vertebrae. The spinous processes are small (a),
and the transverse processes (b) project laterally (with the
exception of C6, where they are directed ventrally (4.6, 7.37B).
There are transverse foramina (c), through which pass the
vertebral arteries (1.17, 1.36), except in C7. The articular
processes (d) lie in an oblique dorsal plane.
1.17 CT scans through the mid-bodies of A: C5; B: C6; and C: C7 vertebrae. Note the transverse foramen in C5 and C6. The
transverse processes of C7 have no foramina and have a characteristic horizontal orientation.
Functional anatomy
b
c
A
b
a
B
1.20 A: Thoracic vertebrae. The vertebral bodies are small with
large spinous processes (a). The articular processes vary with the
location along the thoracic spine (b). The transverse processes are
short and have a fovea (c) that articulates with a rib. Caudal to the
mid-thoracic area, caudally projecting accessory processes are
present on the pedicle (13.55A). B: Radiograph of the anticlinal
region. Spinous processes of cranial thoracic vertebrae (a); caudal
thoracic and lumbar vertebrae (b); and T11, the anticlinal vertebra
(c). This can be a useful surgical landmark, but the position must
be ascertained in each animal from the radiographs.
vertebra overlying the cranial process of the caudalmost vertebra (1.20A). In the caudal thoracic vertebra,
the articular processes adopt a more vertical orientation, as between the lumbar vertebrae (13.55). The
change in orientation occurs near the anticlinal vertebra.
The location of the vertebral canal relative to external vertebra landmarks at the thoracolumbar junction is
variable, due largely to the orientation of the ribs (1.21,
1.22). It appears fairly constant within each breed of
dog and also in the cat.
The aorta and vena cava are in close proximity to
many of the thoracic and lumbar vertebrae. Damage
could be caused to these vascular structures when drilling or placing implants into vertebral bodies (Garcia
et al., 1994). The relationship of the aorta to T13 vertebra is shown in 1.6B and 1.23A; to L1 in 1.23B and
4.44B; and to L2 in 4.43.
There are seven lumbar vertebrae (1.241.28A). The
L1 transverse processes are usually small, an important
feature in identifying the thoracolumbar junction at
surgery (8.19, 8.20). They are also difficult to palpate
as they are obscured by the last rib. More caudally, the
transverse processes are narrower and longer.
The three sacral vertebrae are fused into one body,
which articulates with the pelvis via the sacroiliac joint
(1.28B). There is a marked notch in the cranial lamina of
the sacrum, such that the lamina is not complete over
the cauda equina at the lumbosacral junction (10.48).
There are two pairs of dorsal and ventral sacral foramina, through which pass spinal nerves and blood vessels.
The sacrum articulates caudally with the first caudal
vertebra (1.26).
Articulations
SYNOVIAL ARTICULATIONS
The articular processes of the vertebral bodies have dorsal articulations (except for C1/2 where the articulations
10
1.21 CT scans through the mid-bodies of A: T11, T12, T13 and L1 vertebrae in a Dachshund (same dog as 8.60, 8.61B); and
B: T12, T13, L1 and L2 vertebrae in a Springer spaniel after myelography. There is accumulation of contrast within the center of the
spinal cord at T12, as well as leakage through a presumed dural tear (arrow) after trauma (13.10). The rib articulates progressively
higher up the pedicle from T11 vertebra to T13.
1.22 CT scans through the
mid-bodies of A: T12 in a cat; and
B: L2 in a cat. T12 vertebra of a
cat is shown in 1.23A. Compare
these images with the dogs shown
in 1.21.
B
1.23 The proximity of the aorta
(arrowheads) is shown relative to
A: T12T13 intervertebral space in
a cat (shown on a CT scan); and
B: L1 vertebra in a dog (shown on a
T1-weighted MRI). The vena cava is also
evident (arrow). The cava lies to the right
and somewhat ventral to the aorta.
Functional anatomy
d
a
c
d
Sacrum
L7
INTERVERTEBRAL DISCS
B
1.25 CT scans through the mid-bodies of A: L6; and B: L7
vertebrae. Note that the transverse process is located a little more
dorsally on L7 relative to the vertebral canal than on L6 (13.56B).
11
12
b
1.29 The divisions of the intervertebral disc are the outer anulus
fibrosus (a) and the inner nucleus pulposus (b). The anulus
fibrosus is made up of concentric fibrous laminae. The laminae
may not form complete rings, but they are interconnected with
the adjacent laminae, thus forming a strong complete structure.
The anulus fibrosus is thicker ventrally and laterally than it is
dorsally and the nucleus pulposus is therefore eccentrically
positioned (1.9A). The anulus fibrosus is attached firmly to the
vertebral end plates by deeply penetrating (Sharpeys) fibers.
The nucleus pulposus is a gelatinous structure in young dogs,
but its characteristics change with age (see below).
Functional anatomy
LIGAMENTS
13
14
a
b
e
a
1.34 The dorsal longitudinal ligament (a) lies on the floor of the
vertebral canal. The ligament is compact and narrow over the
vertebral bodies (b). It diverges and is thus thinner over the
intervertebral disc (c). Between the heads of the ribs (except T1,
T12 and T13) there is a reinforcing intercapital ligament (d),
which lies under the dorsal longitudinal ligament.
1.33 Dorsal view of the floor of the vertebral canal with the
spinal cord removed to show a type I disc extrusion. The
calcified nuclear material lies at the level of the intervertebral
foramen, to one side of the dorsal longitudinal ligament. Note
how this ligament fans out over, and then merges with, the
dorsal surface of the anulus fibrosus.
BLOOD SUPPLY
Vertebral column
The arterial supply to the vertebral column is segmental, with a spinal branch entering the vertebral canal via
the intervertebral foramen, closely associated with the
spinal nerve. The origin of the branches varies between
the regions of the spine (1.361.39) (Forsythe and
Ghoshal, 1984).
Venous drainage is via the internal vertebral venous
plexus, which comprises two valveless veins on the floor
of the vertebral canal (often termed the venous
sinuses). The veins converge at mid-vertebral body (and
Functional anatomy
e
k
l
m
j
d
c
f
b
a
1.36 Blood supply to the cervical spine. The arterial supply to the cervical vertebrae is from the paired vertebral arteries (a), which
run cranially from their origin on the subclavian arteries in the thorax. The arteries run through the transverse foramina (b) in the
transverse processes of the vertebrae (except C7). At each segment, there are dorsal (c) and ventral (d) muscular branches.
A significant vessel runs near the caudal edge of the articular processes (e). A spinal branch (f) enters the vertebral canal at each
intervertebral foramen; these supply the spinal cord. The vertebral artery branches at the atlas. The dorsal branch (g) runs over the
transverse process of C1, anastomoses with a branch of the occipital artery (h), and enters the vertebral canal through the lateral
vertebral foramen of C1 (i). The ventral branch runs under the transverse process and also anastomoses with a branch of the
occipital artery ( j). The internal vertebral venous plexus (venous sinus) (k) lies on the floor of the vertebral canal. The veins converge
at midvertebral body (and sometimes join) (l), and then diverge again over the intervertebral disc (m). In the atlas and axis, the veins
of the internal vertebral venous plexus are much more laterally positioned. Thus, in attempting to collect CSF from the
cerebellomedullary cistern, the veins may be perforated if the needle strays from the midline.
1.37 The thoracic spine is supplied by
spinal branches (a) from the intercostal
arteries (b), which enter the vertebral
canal via the intervertebral foramina.
The internal vertebral venous plexus
drains into the major veins of the dorsal
thorax (c), mainly the azygous vein.
a
15
16
d
a
g
e
1.39 The blood supply to the spinal cord arises from the spinal arteries (a), which enter the vertebral canal through the intervertebral
foramina. These branch into dorsal (b) and ventral (c) radicular arteries. These arteries supply an anastomotic network on the surface
of the spinal cord, deep to the dura mater. There are paired dorsolateral spinal arteries (d), which run on the dorsal spinal cord.
These vessels may be tortuous and not recognizable as a distinct entity. There is a ventral spinal artery (e), which runs in the ventral
fissure. There are multiple anastomotic arteries connecting the main vessels. The segmental arteries are inconsistently present, such
that several segments may be supplied by one spinal artery. The distribution is also not symmetrical. The spinal cord substance is
supplied by various arteries that penetrate the surface. The vertical arteries (f) arise from the ventral spinal artery and pass dorsally
through the ventral fissure. They supply most of the gray matter and some white matter. Radial arteries (g) pass centrally from the
arteries on the cord surface, and enter the spinal cord substance. They supply the white matter and the peripheral gray matter.
The areas of spinal cord supplied by each branch have been described (de Lahunta and Alexander, 1976). The venous drainage of
the cord is also in a radial pattern, to a network of surface veins (h). These drain into the internal vertebral venous plexus on the floor
of the vertebral canal (i). These are large, valve-free vessels that have occasional anastomoses in the midline. The plexus drains at
the intervertebral foramina through the intervertebral veins. There are also veins draining the vertebral bodies into the plexus, and
drainage through the vertebral bodies (1.19).
Functional anatomy
REFERENCES
Brant-Zawadzki, M.N., Jensen, M.C., Obuchowski, N., Ross, J.S., Modic,
M.T. (1995) Interobserver and intraobserver variability in interpretation
of lumbar disc abnormalities. A comparison of two nomenclatures. Spine
20, 12571263; discussion 1264.
Bray, J.P., Burbidge, H.M. (1998) The canine intervertebral disk. Part Two:
degenerative changesnon-chondrodystrophoid versus chondrodystrophoid disks. Journal of the American Animal Hospital Association 34,
135144.
Cole, T.C., Ghosh, P., Taylor, T.K.F. (1986) Variations of the proteoglycans
of the canine intervertebral disc with ageing. Biochimica et Biophysica
Acta 880, 209219.
Cook, J.R., Oliver, J.E. (1981) Atlantoaxial luxation in the dog. Compendium
on Continuing Education for the Practicing Veterinarian 3, 242250.
Cudia, S.P., Duval, J.M. (1997) Thoracolumbar intervertebral disk disease
in large, nonchondrodystrophic dogs: a retrospective study. Journal of the
American Animal Hospital Association 33, 456460.
de Lahunta, A., Alexander, J.W. (1976) Ischemic myelopathy secondary
to presumed fibrocartilaginous embolism in nine dogs. Journal of the
Americal Animal Hospital Association 12, 3748.
Evans, H.E. (1993) Millers Anatomy of the Dog, 3rd edn. Philadelphia:
WB Saunders.
Fletcher, T.F. (1970) Lumbosacral plexus and pelvic limb myotomes of the
dog. American Journal of Veterinary Research 31, 3541.
Forsythe, W.B., Ghoshal, N.G. (1984) Innervation of the canine thoracolumbar vertebral column. The Anatomical Record 208, 5763.
Garcia, J.N.P., Milthorpe, B.K., Russell, D., Johnson, K.A. (1994)
Biomechanical study of canine spinal fracture fixation using pins or bone
screws with polymethylmethacrylate. Veterinary Surgery 23, 322329.
Gorman, W.F., Hodak, J.A. (1997) Herniated intervertebral disc without
pain. Journal of the Oklahoma State Medical Association 90, 185190.
Gysling, C. (1985) Ageing process of intervertebral disks in the German
Shepherd dog [Abstract of Dissertation, Zurich Univ.]. Schweizer Archiv
fur Tierheilkunde 127, 5354.
Hansen, H.J. (1952) A pathologicanatomical study on disc degeneration
in dogs. Acta Orthopaedica Scandinavia Suppl. 11, 1117.
FURTHER READING
Boyd, J.S., Patterson, C. (1991) A Colour Atlas of Clinical Anatomy of the
Dog and Cat. London: Wolfe Publishing.
Caulkins, S.E., Purinton, P.T., Oliver, J.E. (1989) Arterial supply to the
spinal cord of dogs and cats. American Journal of Veterinary Research 50,
425430.
de Lahunta, A. (1983) Veterinary Neuroanatomy and Clinical Neurology.
Philadelphia: WB Saunders.
Jenkins, T.W. (1978) Functional Mammalian Neuroanatomy. Philadelphia:
Lea & Febiger.
King, A.S. (1987) Physiological and Clinical Anatomy of the Domestic
Mammals, Vol. 1, Central nervous system. Oxford: Oxford University
Press.
Worthman, R.P. (1956) The longitudinal vertebral venous sinuses of the
dog. American Journal of Veterinary Research 17, 341363.
17
Patient examination
Chapter
19
19
HISTORY
Physical examination
19
Neurological examination 20
Stage 1: Patient in upright position 20
Stage 2: Patient in lateral recumbency 25
Localization of lesions 28
Assessment of the brachial and lumbosacral
plexus 30
Assessing the severity of the lesion
Determining the etiology
References
31
32
Taking a history and performing a full clinical examination are prerequisites to the neurological examination.
The history often leads to a provisional diagnosis. Of
particular note is evidence of trauma; whether the condition is progressive, static, or episodic; previous episodes
of disease; signs of pain; vaccination status; travel history;
and urinary function. In particular, does the animal let
the owner know that it needs to urinate, can it void a
stream of urine or does it just dribble urine without
being aware of it? Owners sometimes say that their dog
is incontinent because every time they pick it up it urinates, when in fact this just occurs because of pressure
being placed on its abdomen.
32
Further reading
33
The clinical syndromes seen in animals with spinal disease are recognized generally from either the history or
the physical findings. Spinal disease should also be considered in animals with non-specific pain, exercise intolerance or lameness not caused by orthopedic disease
(McDonnell et al., 2001). This chapter discusses the
approach to a patient in which spinal disease is suspected.
PHYSICAL EXAMINATION
A general physical examination must be made in all
patients. If there has been trauma or if anesthesia is contemplated, involvement of other body systems must be
determined (Neer, 1992) (2.1). Also, some patients in
which spinal disease is suspected have disorders of other
20
NEUROLOGICAL EXAMINATION
The neurological examination is carried out with the aims
of determining the precise location of the spinal lesion
and its severity. The neurological examination described
here is performed readily with the animal upright in the
first instance, and later placed in lateral recumbency.
It is useful to have a form on which to write the findings of the neurological examination (2.2). This insures
that no aspect of the examination is missed, provides a
permanent record, prevents errors and permits more
accurate comparisons of any serial examinations. A video
can also be made of the patient for this purpose.
Uni- or Bilateral
orthopedic disorders
Generalized orthopedic
disorders
Neuromuscular
disorders
Endocarditis
Cardiac insufficiency
Hypertension
Upper airway disease
Hyperkalemia
Hypokalemia
Hypocalcemia
Hypoglycemia
Hyperthyroidism
Addisons disease
Pheochromocytoma
Osteochondritis dissecans
Cranial cruciate ligament injury
Tibial crest avulsion
Fractures
Coxofemoral osteoarthritis
Patellar luxation
Septic arthritis
Biceps tendonitis
Infraspinatus contracture
Gracilis contracture
Achilles tendon rupture
Psoas muscle injury
Hypertrophic osteodystrophy
Polyarthritis
Panosteitis
Generalized myopathies
Ischemic neuromyopathy
Neuropathies
Radiculopathies
Junctionopathies
Observation
Mental status
Posture
Gait
Postural
reactions
Cranial
nerves
Spinal
reflexes
Spinal
hyperesthesia
Bladder
function
Paw position
Hopping
Menace
Pupillary light reflex
Oculovestibular
response
Jaw tone; temporal
muscle mass
Facial sensation
Palpebral reflex
Patellar
Withdrawal
Perineal
Cutaneous trunci
reflexes
Cervical
Thoracolumbar
Lumbosacral
Historical
Leakage?
Voiding?
Patient examination
SPINAL REFLEXES
HISTORY
PHYSICAL EXAMINATION
OBSERVATION
Reflex
(Nerve)
(Spinal cord segments)
LEFT
RIGHT
Triceps
(Radial)
(C7-T1)
Biceps
(Musculocutaneous)
(C6-C8)
Withdrawal (thoracic limb)
(Multiple)
(C6-T2)
Patellar
(Femoral)
(L4-L6)
Gastrocnemius
(Tibial, sciatic)
(L6-S1)
Withdrawal (pelvic limb)
(Sciatic)
(L6-S1)
POSTURAL REACTIONS
LEFT
RIGHT
Hopping
Front
Rear
Paw position
Front
Rear
Reflex step
Front
Rear
Tactile placing
Front
Rear
Visual placing
Front
Rear
Perineal
(S1-S2)
URINARY FUNCTION
Hemistanding
Voluntary urination?
Hemiwalking
Wheelbarrowing
Bladder distention?
CRANIAL NERVES
SPINAL HYPERAESTHESIA
Test
(Innervation)
LEFT
RIGHT
Menace response
(II & VII)
Vision
(II)
SML
Pupil size
Pupillary light reflex
(II & III)
Stimulate left eye
Stimulate right eye
Strabismus
(III, IV & VI)
Spontaneous nystagmus
(III, IV, VI & VIII)
Positional nystagmus
(III, IV, VI & VIII)
Oculovestibular response
(III, IV, VI & VIII)
Facial sensation
(V)
Jaw tone
(V)
Temporal muscle mass
(V)
Corneal reflex
(V, VI & VII)
Facial symmetry
(VIII)
Palpebral reflex
(V & VII)
Hearing (hand clap)
(VIII)
Swallowing or gag reflex
(IX & X)
Tongue
(XII)
EYES
PANNICULUS REFLEX
Level of cut-off (dermatome)
LEFT
SML
RIGHT
LESION LOCALIZATION
BRAIN
Side
Forebrain
Brainstem
Cerebellum
Vestibular - peripheral
Vestibular - central
Multifocal
SPINAL CORD
C1 - C5
C6 - T2
T3 - L3
L4 - S3
MULTIFOCAL CNS
PERIPHERAL NERVE
Local
Generalised
Horners Syndrome
(Sympathetic)
NEUROMUSCULAR
Fundic examination
MUSCULAR
MUSCLE PALPATION
NORMAL
Tone
Atrophy
2.2 Form for neurological examination. The DAMNIT scheme can be listed on the reverse side with room to add differential
diagnoses and the diagnostic plan(s).
21
22
A
2.4 Proprioception: paw position response where an animals
body-weight is supported fully and then each paw is turned
over individually to bring the dorsal surface into contact with the
ground. Normal animals return the paw to an upright position
almost immediately; those with neurological disease cranial to
the limb may leave the paw flexed. If proprioception is normal,
spinal cord disease is unlikely to be present.
B
2.3 A: Hopping in the thoracic limb. The patients body is
supported with only one limb bearing weight on the ground,
and then it is moved laterally. The animal will not be able to hop
normally if it has a proprioceptive deficit or impaired motor
function. In a large dog this can be done by just lifting one
thoracic limb and then moving the dog sideways. B: Hopping
in the pelvic limb. Large dogs can be hopped as described for
the thoracic limb.
ASSESS PROPRIOCEPTION
This is evaluated in the standing animal by the paw
position test and the reflex step (2.4, 2.6). Animals
with deficits of proprioception that can still walk often
wear the dorsum of their digit(s) or claw(s).
2.5 Boxer dog with proprioceptive loss in the left pelvic limb.
Severe deficits such as this are evident even if the animals
weight is not supported properly.
Patient examination
2.7 Wheelbarrowing test. The pelvic limbs are lifted off the
ground as shown and the animal made to walk forward.
This test can reveal thoracic limb paresis and exacerbates
asymmetrical lesions. Elevating the head on this test will
sometimes unmask hypermetria.
23
24
T13
L1
T13
T12
T11
Patient examination
25
26
Motor function
Paresis or paralysis
Paresis or paralysis
Reflexes
Absent or reduced
Normal or increased
Muscle tone
Reduced
Normal or increased
Muscle atrophy
Severe, earlyneurogenic
Late, milddisuse
MUSCLE MASS
signs that allow differentiation between UMN and
LMN abnormalities are summarized in Table 2.3.
LMN deficits are characterized by paresis or paralysis; severe (neurogenic) muscle atrophy (2.16);
reduced tone in the affected muscles; and depressed or
absent reflexes. UMN deficits show paresis or paralysis; mild (disuse) muscle atrophy; normal or increased
muscle tone; and normal or hyperactive reflexes. There
is some variation in mild cases, but from the neurological examination, it should be possible to categorize each
limb as being normal, UMN-type abnormality, or
LMN-type abnormality.
MUSCLE TONE
Test muscle tone by gently flexing and extending
the joints. Normally there is some resistance to such
manipulation. An incorrect impression of increased
tone may be gained in excitable or fractious animals,
or if the animal has a painful orthopedic condition.
Increased tone in the thoracic limbs is seen in the
SchiffSherrington sign (2.17). This sign (see Ascending
motor tract, page 6) does not necessarily denote a
hopeless prognosis (13.7).
MOTOR FUNCTION
REFLEX TESTING
There are a number of local reflexes available for examination, but it is usual to concentrate on the patellar,
Patient examination
27
28
a
b
SITE OF INJURY
LOCALIZATION OF LESIONS
On the basis of the neurological examination, it is usually possible to identify the location of the spinal cord
lesion (2.22). Functionally, the spinal cord may be
divided into four regions:
A: C1C5.
B: C6T2 (cervical intumescence).
C: T3L3.
D: L4S3 (lumbar intumescence).
Areas A and C, the cervical and thoracolumbar spinal
cord, convey primarily the UMNs. Areas B and D, the
cervicothoracic and lumbosacral spinal cord, provide
THORACIC LIMB
DEFICIT
PELVIC LIMB
DEFICIT
UMN
UMN
LMN
UMN
NORMAL
UMN
NORMAL
LMN
C1C5
C6T2
T3L3
L4S3
innervation to the thoracic and pelvic limbs respectively. Area B also conveys UMNs to the pelvic limbs.
It can be seen in 1.12 that part of the LMN lies
within the spinal cord; lesions in areas B and D of the
spinal cord will therefore produce LMN signs in the
limbs. Variations are possible, for example in some animals with myelopathy affecting the caudal cervical
segments, the thoracic limbs often show a mixture
of UMN and LMN signs. They may show increased
thoracic limb muscle tone, which is an UMN effect on
the elbow and carpal extensor muscles (Seim and
Withrow, 1982). In addition, there is often an associated LMN weakness of the elbow flexors resulting in a
weak withdrawal reflex. Dogs with severe C6T2 signs
also have a short-strided, choppy or disconnected
thoracic limb gait and a long-strided, ataxic pelvic limb
gait (see Chapter 11). In contrast, dogs with C1C5
signs often show a long-strided or floating thoracic
limb gait together with a long-strided, ataxic pelvic limb
gait (Baum et al., 1992).
Patient examination
2.24 Aged Dalmatian with mild, progressive paraparesis, dilated anus and urinary incontinence. Neurological deficits localized to
the L7S2 spinal cord segments. A CT scan of the lumbosacral space was unremarkable (10.2B, 10.10A). A: Myelography
revealed masses (arrowheads) in the subarachnoid space at C1/2 on the right; caudal C2 on the left. B: Cranial C6 on the right;
mid-C7 on the right; and a number of small filling defects over the lumbar cord (not shown). The mass at C2 was a nerve sheath
tumor with subarachnoid metastasis (4.27, 4.28).
29
30
2.25 Seven-year-old Shih Tzu that presented initially with loss of tail tone and then mild paraparesis, anal arreflexia and incontinence
over the next 8 months. Localization was to the cauda equina or L4S3 spinal cord segments. T1-weighted MRIs post contrast
medium. A: sagittal and B: transverse images show that the dog has an enhancing mass (arrows), most likely a nerve sheath tumor,
involving the right L5 nerve root and invading the sacral spinal cord segments. The lumbosacral disc space appears normal.
Patient examination
2.27 When assessing the withdrawal reflex in the pelvic limb, all
three joints should be assessed. An animal can flex both its hip
and stifle joints by using the femoral and sciatic nerves whereas
it can only flex its hock joint by using the peroneal division of the
sciatic nerve. Weak or absent hock flexion can be appreciated
best by pulling the hock joint gently into extension and then
applying a stimulus to the digits.
31
32
REFERENCES
Bailey, C.S., Kitchell, R.L. (1987) Cutaneous sensory testing in the dog.
Journal of Veterinary Internal Medicine 1, 128135.
Baum, F., Trotter, E.J., de Lahunta, A.D. (1992) Cervical fibrotic stenosis
in a young Rottweiler. Journal of the American Veterinary Medical
Association 201, 12221224.
Biemond, A., De Jong, J.M. (1969) On cervical nystagmus and related disorders. Brain 92, 437458.
Boswood, A., Lamb, C.R., White, R.N. (2000) Aortic and iliac thrombosis
in six dogs. Journal of Small Animal Practice 41, 109114.
Braund, K.G., Sharp, N.J.H. (2003) Neurological examination and localization. In: D. Slatter (ed.), Textbook of Small Animal Surgery, 3rd edn,
10921107. Philadelphia: Elsevier Science.
de Lahunta, A. (2001) Neurological examination. In: K.G. Braund (ed.),
Clinical Neurology in Small AnimalLocalization, Diagnosis and Treatment.
Ithaca: International Veterinary Information Service. http://www.ivis.org/
special_books/Braund/deLahunta/chapter_frm.asp?LA1
Dhupa, S., Glickman, N.W., Waters, D.J., Dhupa, S. (1999) Functional
outcome in dogs after surgical treatment of caudal lumbar intervertebral
disk herniation. Journal of the American Animal Hospital Association 35,
323331.
Gilson, S.D. (2003) Neuro-oncologic surgery. In: D. Slatter (ed.), Textbook of
Small Animal Surgery, 3rd edn, 12771286. Philadelphia: Elsevier Science.
Patient examination
Gopal, M.S., Jeffery, N.D. (2001) Magnetic resonance imaging in the diagnosis and treatment of a canine spinal cord injury. Journal of Small
Animal Practice 42, 2931.
Griffiths, I. (1970) A syndrome produced by dorso-lateral explosions of
the cervical intervertebral discs. Veterinary Record 87, 737741.
Holliday, T.A. (1980) Clinical signs of acute and chronic experimental lesions
of the cerebellum. Veterinary Science Communications 3, 259278.
Hunt, G.B., Chapman, B.L. (1991) Trophic ulceration of two digital pads.
Australian Veterinary Practitioner 21, 196, 205.
Mayhew, I.G. (1999) The healthy spinal cord. American Association of
Equine Practitioners 45, 5666.
McDonnell, J.J., Platt, S.R., Clayton, L.A. (2001) Neurologic conditions
causing lameness in companion animals. Veterinary Clinics of North
America, Small Animal Practice 31, 1738.
Morgan, P.W., Parent, J., Holmberg, D.L. (1993) Cervical pain secondary
to intervertebral disc disease in dogs; radiographic findings and surgical
implications. Progress in Veterinary Neurology 4, 7680.
Neer, T.M. (1992) A review of disorders of the gallbladder and extrahepatic biliary tract in the dog and cat. Journal of Veterinary Internal
Medicine 6, 186192.
Olby, N.J., Harris, T., Munana, K.R., Skeen, T.M., Sharp, N.J.H. (2003)
Long-term functional outcome of dogs with severe spinal cord injuries.
Journal of Neurotrauma (in press).
Pang, W.W., Mok, M.S., Lin, M.L., Chang, D.P., Hwang, M.H. (1998)
Application of spinal pain mapping in the diagnosis of low back pain
analysis of 104 cases. Acta Anaesthesiology Singapore 36, 7174.
FURTHER READING
de Lahunta, A. (2001) Neurological examination. In: K.G. Braund (ed.),
Clinical Neurology in Small AnimalsLocalization, Diagnosis and
Treatment. Ithaca: International Veterinary Information Service
(www.ivis.org), B0201.1001. http://www.ivis.org/special_books/Braund/
deLahunta/chapter_frm.asp?LA1
33
Differential diagnosis
A: C1C5 35
B: C6T2 35
C: T3L3 36
D: L4S3 37
Further reading
35
39
Chapter
DIFFERENTIAL DIAGNOSIS
A: C1C5
In adult dogs, intervertebral disc disease (Table 3.2) is
the most common condition affecting this region. In
dogs less than 2 years of age the differential diagnoses are
different. Here, atlantoaxial subluxation, inflammatory
CNS disease, discospondylitis and trauma are the most
likely causes. Spinal tumors can occur in dogs of any
age. The most common tumors in the cervical spine are
meningiomas and nerve sheath tumors; both are more
common in older dogs.
Some dogs with cervical spondylomyelopathy (CSM)
have neurological signs with a C1C5 pattern of dysfunction (see page 28), although the lesion is often
more caudal in the cervical spine. Acute, non-painful,
non-progressive deficits usually result from ischemic
myelopathy due to fibrocartilaginous embolism (FCE).
Signs are often asymmetrical and severe.
In cats, clinical disc disease is rare in the neck.
The likely diagnoses are trauma, neoplasia (usually
lymphoma) and inflammatory diseases, particularly
feline infectious peritonitis (FIP). Atlantoaxial subluxation is rare in cats.
B: C6T2
Similar considerations apply here to those causing C1C5
signs, although atlantoaxial subluxation does not occur.
36
Table 3.1 Differential diagnoses for spinal disease using the DAMNIT scheme *
Category
Degenerative
Degenerative myelopathy
Synovial cysts
Leukodystrophies
Lumbosacral disease
Facet joint pain
Cervical spondylomyelopathy
Disc disease
Lysosomal storage disease
Cervical fibrotic stenosis
Sacroiliac joint pain
Anomalous
Syringo(hydro)myelia
Pilonidal (dermoid) sinus
Spinal arachnoid cyst
Epidermoid cyst
Atlantoaxial subluxation
Spina bifida
Tethered cord syndrome
Sacral osteochondritis dissecans
Vertebral malformations
Cartilaginous exostoses
Meningo(myelo)celes
Spinal dysraphism
Hereditary myelopathy
Sacrocaudal dysgenesis
Schmorls node
Atlantooccipital dysplasia
Metabolic
Neoplastic
Epidural lipomatosis
Nutritional
Hypervitaminosis A
Thiamine deficiency
Idiopathic
Tumoral calcinosis
Iatrogenic injury
Peridural scar
Inflammatory and
Infectious
Discospondylitis
Spinal epidural empyema
Gelfoam reaction
Meningo(encephalo)myelitis
Cauda equina neuritis
Foreign body migration
Traumatic
Sacrocaudal injury
Brachial plexus avulsion myelopathy
Gunshot injury
Dural tear
Traumatic disc injury
Fracture/luxation
Toxic
Vascular
Fibrocartilaginous embolism
Spinal cord hematoma
Vascular malformation
Fat graft necrosis
Ischemic neuromyopathy
C: T3L3
This region of the spine accounts for most cases of spinal
disease. Disc herniation is the most likely diagnosis in
dogs older than 1 year. In younger dogs, inflammatory
CNS disease, discospondylitis and trauma are common. In cats, disc disease is uncommon but does occur,
Painful
Non-painful
Acute
Chronic
Atlantoaxial
subluxation
CSM
Disc disease
Neoplasia
Discospondylitis
Meningomyelitis
Fracture/luxation
Spinal cord
hematoma
Atlantoaxial
subluxation
Atlantooccipital
dysplasia
CSM
Cervical fibrotic stenosis
Synovial cysts
Syringohydromyelia
Hypervitaminosis A
FCE
Painful
Non-painful
Chronic
Painful
Disc disease
Neoplasia
Discospondylitis
Meningomyelitis
Fracture/luxation
Ascending
myelomalacia
Disc disease
Synovial cysts
Tumoral calcinosis
Non-painful
Traumatic feline
ischemic
myelopathy
FCE
Degenerative
myelopathy
Spinal arachnoid cyst
Neoplasia
Acute
Chronic
Painful
Neoplasia
Discospondylitis
Meningomyelitis
Fracture/luxation
Disc disease
Ascending
myelomalacia
Psoas muscle injury
Lumbosacral
disease
Tethered cord
syndrome
Sacral OCD
Non-painful
Cauda equina
neuritis
Ischemic
neuromyopathy
FCE
Degenerative
myelopathy
Spina bifida
Sacrocaudal
dysgenesis
Dermoid sinus
Neoplasia
Chronic
CSM
CSM
Disc disease
Synovial cysts
Neoplasia
Discospondylitis
Meningomyelitis
Fracture/luxation
Spinal cord hematoma
Brachial plexus
avulsion
FCE
Acute
Spinal arachnoid
cyst
Dermoid sinus
Neoplasia
D: L4S3
Subacute or chronic presentations with signs localizing
to this region are usually referable to the lumbosacral
junction (Table 10.2). Neoplasia or discospondylitis
37
38
Table 3.6 Differential diagnoses for diffuse pain, non-spinal neurological disease and exercise intolerance
Diffuse pain
Exercise intolerance
Polyarthritis
Polymyositis
Pancreatitis
Renal or ureteral calculi
Gallstones
Gastrointestinal parasites
Kidney worm
Osteoporotic vertebral fracture
Mid-thoracic vertebral lesion
Other abdominal pain
Meningoencephalitis
Thalamic pain syndrome
Prostatic disease
Urethral tumor
Myositis or myopathy
Peripheral neuropathies
Radiculopathies
Myasthenia gravis
Tick paralysis
Subacute organophosphate toxicity
Myasthenia gravis
Mild cervical myelopathy
Addisons disease
Hypoglycemia
Polymyositis
Toxic myopathy
Hypokalemic polymyopathy
Hyperthyroidism
Congenital myopathy
Tick paralysis
Coonhound paralysis
Lumbosacral pain
Idiopathic polyradiculoneuritis
Protozoal myositis and
polyradiculoneuritis
Subacute organophosphate
toxicity
Botulism
Peripheral neuropathy
Ischemic neuromyopathy
Intermittent claudication
Cardiac disease
Upper airway disease
Botulism
Localized tetanus
Brain tumor
Intermittent claudication
Ischemic neuromyopathy
Psoas muscle hemorrhage
FURTHER READING
Braund, K.G. (2003) Clinical Neurology in Small Animals: Localization,
Diagnosis and Treatment. http://www.ivis.org/special_books/Braund/
toc.asp
39
Diagnostic aids
41
4
Biopsy
61
Cerebrospinal fluid 42
Indications and contraindications for CSF
collection 43
Collection of CSF 43 (64)
Sample handling and laboratory analysis 43
Normal CSF findings 45
Abnormal CSF findings 45
Normal findings in the face of disease 45
Radiography 45
Survey radiographs 45
Radiographic positioning and normal spinal
radiographs 46
Special radiographic procedures
Myelography 48 (70)
Epidurography 50
Discography 50
48
Chapter
62
Procedures 64
Collection of CSF 64
Myelography 70
Hematology
In the majority of animals with spinal disease, the
hemogram is unremarkable, although a stress leukogram (lymphopenia, eosinopenia and leukocytosis) is a
common finding.
Patients with inflammatory diseases of the spinal
cord and meninges usually have normal hemograms.
Dogs with discospondylitis or rickettsial disease and
cats with feline infectious peritonitis (FIP) may have
inflammatory hemograms, but this is not consistent.
51
62
Biochemistry
61
42
Urinalysis
Urinalysis may provide specific diagnostic information
regarding renal and hepatic function or urinary tract
infection.
If bladder function is in doubt in patients with spinal
disease, urinalysis should be performed on a sample
collected by cystocentesis when the patient is first
evaluated. Ultrasound may aid collection of urine if the
bladder is not palpable. Subsequent urinalysis should
be performed periodically until normal urinary function returns (see Chapter 15).
Urinary tract infection (UTI) associated with urine
retention is present frequently in animals with spinal
disease. Urinalysis reveals high white blood cell counts
and elevated total protein, and bacteria may be present
in the sediment. If so, urine culture should be performed
and antibiotic sensitivity determined. Fungal hyphae
may be detected in dogs with systemic aspergillosis,
especially if the urine has been at room temperature
for more than 12 h.
For routine urinalysis, aseptic catheterization or
cystocentesis is suitable. For culture, cystocentesis is
preferred.
BenceJones proteinuria may be a feature of
myeloma.
Serology
Serology is useful in many diseases, and should be considered in any spinal patient where the origin of the disorder is obscure. Specific examples include Neospora
caninum, Cryptococcus neoformans, Coccidioides immitis,
Bartonella sp., Ehrlichia sp., and also Brucella canis in
dogs with discospondylitis. Acute and convalescent
Microbiology
Urine culture is indicated in patients with cystitis related
to neurological disease. Sensitivity testing should also be
performed to determine the most appropriate antibiotic
with which to treat infections. However, bladder infections usually only resolve when urinary function returns
to normal.
In patients with discospondylitis, urine and blood
culture may be attempted to isolate the causative
organism along with direct aspiration from the affected
disc space(s).
If wound infections occur following surgery, culture
from the depths of the wound should be performed
after aseptic preparation of the skin surface (see
Wound infection, page 357).
Other
Endocrine testing, analysis of Von Willebrand (VW) factor, and bleeding times may all be deemed necessary
during preoperative evaluation (see Chapters 6 and 11).
Coagulation profiles and testing for warfarin are indicated in animals with coagulopathies. Blood gas analysis should be performed in tetraplegic animals where
hypoventilation is suspected (7.11).
CEREBROSPINAL FLUID
Cerebrospinal fluid (CSF) analysis is an important tool
in the investigation of neurological patients, but there
are many limitations to CSF analysis. Abnormal CSF is
strongly indicative of neurological disease, but it is a
relatively non-specific finding.
Cerebrospinal fluid should be collected routinely
from either the cerebello-medullary cistern (CMC
cisterna magna) or the lumbar region. It is important
to do this prior to performing myelography as injection
of contrast medium induces a sterile meningitis that
Diagnostic aids
Collection of CSF
CONTRAINDICATIONS
4.1 A: Left to rightnormal CSF; xanthochromia (which is caused by hemoglobin breakdown products and indicates previous
intrathecal hemorrhage); and hemorrhage at collection. B: Degenerate neutrophils containing bacteria from the CSF of a dog with
severe, diffuse pain and fever secondary to myelography performed 24 h earlier using iohexol from a contaminated, multi-use bottle.
A filter should be used with multi-use containers.
43
44
B
4.2 Hans Wolfgang Kolmel Sedimentation Chamber (Free
University of Berlin, with permission). A: Glass microscope
slide is placed on the apparatus, B: filterpaper is placed on the
glass slide, and C: the chamber is fitted. CSF is placed in the
chamber and the filter paper absorbs fluid, while cells remain
on the slide. The slide is then stained for cytology and
differential count.
GROSS EXAMINATION
CELL COUNTS
These are performed using a hemocytometer; the
cell numbers are too low to be counted accurately by
Diagnostic aids
PROTEIN CONTENT
Protein content of CSF is estimated by a number of
methods; use of a professional laboratory is best. Normal
CSF collected from the CMC has a protein concentration of less than 30 mg/dl; it may be up to 45 mg/dl at
the lumbar site. Total protein may be increased in many
diseases but is non-specific. Electrophoresis provides
information regarding the composition of the CSF
protein.
MICROBIOLOGY
Examination for the presence of bacteria may be performed by microscopy of stained samples (4.1B) and by
culture. If CSF culture is attempted, enhancement
using blood culture bottles is recommended. Bacterial
diseases of the CNS are uncommon in dogs and cats and
even when present, culture of CSF tends to be unrewarding (Remedios et al., 1996; Lavely et al., 2002;
Radaelli and Platt, 2002) (see below). Care should be
exercised in interpreting positive results in the absence
of pleocytosis, as bacteria may be contaminants.
Clear, colorless
1.0041.006
5/l
Lymphocytes and monocytes
Total protein
Cerebello-medullary cistern
Lumbar
RADIOGRAPHY
Survey radiographs
Radiography is a valuable diagnostic aid for spinal
patients. Good quality survey radiographs will provide
the diagnosis in some cases. To obtain diagnostic
radiographs of the spine, general anesthesia is usually
45
46
necessary to position the patient correctly and to minimize radiation exposure of personnel. In many animals
with spinal disease, the radiological features are subtle
so that accurate positioning is essential. An exception is
in acute spinal injuries, where general anesthesia or
manipulations could exacerbate the neural damage.
The area of interest must be centered properly and the
beam collimated closely. Survey radiographs of large
areas of the spine are rarely useful. Stress radiography
may be helpful but is not without risk (Farrow, 1982)
(9.5, 10.12, 11.10, 13.17).
a
b
Diagnostic aids
47
48
SPECIAL RADIOGRAPHIC
PROCEDURES
Myelography
Diagnostic aids
49
50
Normal
Extradural
Intradural
extramedullary
Epidurography
In epidurography, contrast medium is introduced into
the epidural space. For some radiologists this was the
preferred method for evaluating the lumbosacral region
(Barthez et al., 1994; Ramirez and Thrall, 1998) (10.8B).
CT or MRI are superior in most cases.
Discography
In discography, contrast medium is injected into the
nucleus pulposus of the intervertebral disc (Sisson et al.,
1992; Barthez et al., 1994). Normally, only a very small
amount can be introduced (0.10.2 ml in the lumbosacral disc). If there is damage to the anulus fibrosus,
more contrast can be injected and the leakage will be evident on subsequent radiographs (10.8A). The technique
may be particularly useful if combined with CT
(Ohnmeiss et al., 1997; Milette et al., 1999).
PRINCIPLES OF SPINAL
RADIOLOGY
It is important to take a systematic approach to evaluating spinal radiographs. The clinician has the advantage
of having similar adjacent structures with which to compare the suspected lesion. Accuracy of interpretation is
limited by the radiographs, and it is well worth paying
attention to obtaining good images as discussed above.
Also, knowledge of the normal radiographic anatomy is
required, as discussed in this chapter and in Chapter 1.
One system used to evaluate lateral radiographs is
to assess each structure in turn from cranial to caudal:
start ventrally with the hypaxial muscles and end with
the spinous processes dorsally. For ventrodorsal radiographs, start on the left side and work cranial to caudal.
This technique should be employed even if there is an
obvious lesion, to avoid overlooking other important
features or additional lesions.
General radiological principles dictate that images
are evaluated for the following features: position, size,
number, contour, architecture and opacity.
Many of these alterations are seen in spinal disease
and most are shown in this book.
Myelographic interpretation
From the myelogram, it is usually possible to gain an
impression of the location of the lesion relative to the
spinal cord (4.244.31, 14.4). Note that lesions in all
locations may give the appearance of an expanded or
swollen cord in an image taken face on to the lesion.
For this reason, it is essential that perpendicular
projections (lateral and ventrodorsal) are made (4.30,
4.31, 7.2).
Interpretation is relatively straightforward if there
are changes in the skeleton at the site of the myelographic abnormality, for example in disc herniation or
vertebral neoplasia (4.47). Generally, it is possible to
make some estimate of the location of the lesion as
shown in 4.21. Causes of these compression patterns
are given in Table 4.2. Extradural lesions are shown in
Diagnostic aids
Extradural
Intradural
extramedullary
Intramedullary
Degenerative
Disc herniation
Synovial cyst
Congenital
Atlantoaxial subluxation
Arachnoid cyst
Syringohydromyelia
Neoplasia
Primary or metastatic
Vertebral or soft tissue
Meningioma
Nerve sheath tumor
Nephroblastoma
Glioma
Ependymoma
Metastatic
Inflammatory
Discospondylitis
Epidural abscess
Myelitis
Trauma
Disc
Bone fragments
Vascular
Hematoma
EXTRADURAL LESIONS
INTRADURALEXTRAMEDULLARY LESIONS
INTRAMEDULLARY LESIONS
Spinal cord swelling may be evident although myelography rarely delineates parenchymal lesions. One
COMPLICATIONS OF
MYELOGRAPHY
The most common complications after cervical injection
are either that the contrast has entered the subdural
space (1.11); that the needle has been displaced from
the vertebral canal; that excessive contrast has entered
the cranial vault (4.65); or either that the contrast has
not reached the lesion or that it has flowed past the
lesion (Lamb, 1994; Penderis et al., 1999)(4.32). The
most common problem after lumbar myelography is
51
52
B
4.25 Same dog as in 4.23. A: Column splitting was due to a
probable left-sided synovial cyst (its location shifted slightly into
C7 with the dog on its back for the CT). A ventral slot was done
at C6/7 but little disc material was removed and the dog was
much worse the next day. B: A postoperative CT myelogram
showed more marked compression, due in part to collapse of
the interspace. Compression in this dog was probably
exacerbated by the synovial cyst (11.8). In retrospect this dog
should have undergone a distraction-stabilization procedure.
Diagnostic aids
53
54
days. Clearly, if the spinal puncture or injection technique itself is at fault, significant neurological damage
may result (4.34). Injection of contrast into the central
canal can occur in cisternal myelography; the effect on
the patient varies but is generally serious. Cardiovascular
effects are usually seen and neurological deterioration is
likely. Central canal injection in the lumbar spine can
cause temporary deterioration of deficits and the severity is related to the volume injected. The likelihood of
this complication increases with injections at sites cranial
to L5/6 (Kirberger and Wrigley, 1993). This is particularly true in small dogs where the spinal cord terminates
more caudally than in large dogs (Morgan et al., 1987).
Injection of contrast medium can be made between T13
and L2 vertebrae but the incidence of epidural leakage
(4.67), and of central canal injection is then higher compared to more caudal injections (McCartney, 1997).
Nevertheless, provided that a test injection is employed,
this technique can be useful when injection is not successful at more caudal sites. It is also useful in dogs with
lesions that localize to the L4S3 spinal cord segments as
there is then much less risk of injecting into the lesion
itself; use of this site is much less desirable in dogs when
the lesion is located in the thoracolumbar region.
Manipulations involved in obtaining flexion, extension or traction radiographs during myelography can lead
to neurological deterioration and it is wise not to
maintain these positions for excessive periods of time,
particularly when extending the cervical spine (11.9,
11.10).
Seizures occur infrequently on recovery from anesthesia following myelography (Wheeler and Davies, 1985;
Allen and Wood, 1988). The site of injection appears not
to influence the frequency of seizures; dogs with CSM
may be prone to this complication (Lewis and Hosgood,
1992). Seizures are best managed by intravenous
diazepam or barbiturates and so it is prudent to leave an
intravenous catheter in place in any patient recovering
after a myelogram to facilitate medication.
Diagnostic aids
resection or prevent the surgeon leaving behind significant amounts of disc material (Nakayama, 1993;
Finn Bodner et al., 1995; Hudson et al., 1995; Ham
et al., 1995) (7.8, 8.6). Sonography has also proven
useful in determining the extent of arachnoid cysts
(Galloway et al., 1999). In addition, it can show
irregular new bone on vertebrae affected by tumors or
discospondylitis.
Computed tomography
Computed tomography (CT) of the vertebral column
is very useful in certain circumstances, particularly
in patients with mineralized disc extrusions, vertebral
tumors or cervical spondylomyelopathy. Contrast
enhancement by myelography (7.3A), rather than
intravenous contrast administration as performed in
intracranial imaging, outlines the subarachnoid space if
needed. A much lower dose of contrast medium is
required for CT myelography than for conventional
myelograms. If only a CT study is planned, the dose of
contrast medium is reduced to about one quarter of the
55
56
B
4.40 A: CT scan through the T12/13
intervertebral disc space from the same
dog as shown in 4.37B. There is loss of
the normal epidural fat pattern at the
level of the right foramen (arrow). Disc
extrusion was confirmed at surgery.
B: Hemorrhage in the epidural or
subdural space (arrow) following a disc
extrusion in the thoracolumbar area.
Often the rim of hyperattenuation is less
distinct than this (Olby et al., 2000).
Contrast has not been administered.
Diagnostic aids
4.41 The A: lateral and B: ventrodorsal myelogram in this dog revealed slight expansion of the spinal cord over the cranial C5/6
disc space. The myelogram was followed by a CT scan, which was inconclusive (not shown). C: 3D reconstruction of the CT
myelogram identified an expansile lesion within the spinal cord. The dog was euthanized; necropsy was not performed. Had MRI
been available it would have been a more efficient way to demonstrate this lesion.
57
58
B
4.43 A: Transverse, T1-weighted MRI of
the L2/3 disc in an 11-year-old paraparetic
Labrador (same dog as in 8.2B). The
spinal cord is deformed by a large,
somewhat right-sided, low signal mass.
B: Corresponding image after gadoteridol
(Prohance, Bracco Diagnostics,
Mississauga, Ontario) administration.
There is a rim of enhancement to the mass
(arrow) (Vroomen et al., 1998; Saifuddin
et al., 1999). Mini-hemilaminectomy with
corpectomy was used to remove the
chronic disc material.
Diagnostic aids
The terms bulge and protrusion are also nonspecific and a morphological description of the
disc displacement is preferred.
Criteria for differentiating clinically insignificant
lesions from incidental, age-related changes (7.15A)
are discussed below and in Chapter 10.
It must be remembered that some disc herniations are
incidental, age-related findings (4.42A) that are not
responsible for the clinical signs (Jensen et al., 1994;
Milette et al., 1999; Jones and Inzana, 2000b) (see
Chapters 1, 10, page 188 and 11, page 213). MRI of people without back pain has shown that 50% have one disc
herniation and 25% have two (Jensen et al., 1994).
Interpretation must therefore be made using clinical
signs, electromyographic (EMG) changes in local muscles, and imaging characteristics (Ramirez and Thrall,
1998). Indicators of clinical relevance in dogs include
changes in posture or evidence of pain such as spontaneous vocalization or discomfort on palpation of local
paralumbar muscles (Chrisman, 1975; Nardin et al.,
1999). Overall, MRI shows excellent anatomical detail
with reasonably high sensitivity but only low specificity,
resulting in a high rate of false positives. In contrast to
MRI, electromyography has high specificity and is therefore useful to confirm which lesions are physiologically
significant, thereby avoiding unnecessary interventions
(Nardin et al., 1999; Robinson, 1999). Imaging features
of disc lesions that suggest physiological relevance include
edema in bone marrow adjacent to the disc (Sether et al.,
1990a; Morrison et al., 2000); edema within the spinal
cord over the affected disc space (4.42, 13.7); contrast
enhancement, which shows a high correlation with rupture of the anulus (Vroomen et al., 1998; Saifuddin
et al., 1999) (4.43); and changes within the disc itself
(Jenkins et al., 1985; Milette et al., 1999) (8.2B).
MRI signal characteristics within the disc itself are
useful in characterizing internal derangement, which
in humans with low back pain can indicate that the
lesion is symptomatic even in the absence of a change
in disc contour. Decreased central disc signal intensity
Scintigraphy
Bone scintigraphy evaluates certain functional aspects of
bone, particularly related to blood supply and metabolic
59
60
4.45 Nuclear bone scan from a 10year-old German shepherd dog with
paraparesis and back pain of 1 week
duration. A: An osteoproductive lesion is
visible at T5 (arrow); note also the soft
tissue mass ventral to the affected
vertebral body. B: Increased uptake of
technetium is evident on the bone scan.
Final diagnosis was osteosarcoma.
CLINICAL ELECTROPHYSIOLOGY
Electromyography
Electromyography (EMG) is the method by which the
electrical activity of muscle is studied and analyzed.
This technique can assist the neurosurgeon by helping
to localize some of the more subtle lesions as being
either UMN or LMN in nature. If LMN deficits are
present they will generally be associated with spontaneous electrical activity in those muscles supplied by the
injured spinal cord segment or nerve root (4.46). It is
important to remember that this spontaneous activity
takes between 4 and 7 days to appear, which is the time
taken for the axons to degenerate from the site of injury
to the neuromuscular junctions (Cuddon et al., 2003).
Two broad categories of LMN lesions can be seen.
The first relates to lesions that are restricted to either the
brachial or lumbosacral regions, such as brachial plexus
avulsion injury or damage to the cauda equina. In this
case, the spontaneous activity will be restricted to a
discrete muscle group(s). Use of EMG in radiculopathy
has high specificity and as such is a very useful complement to MRI. In particular, the combination of these
two tests is one way to overcome the high rate of falsepositive diagnosis that can occur using MRI alone (Nardin
et al., 1999; Robinson, 1999). The second category of
LMN disease is when the animal is suffering from a
generalized peripheral neuropathy, or possibly a myopathy, in which case spontaneous activity will be widespread throughout the body and will not be restricted
to any particular muscle group.
If an UMN lesion is present, electromyography of
the paraspinal muscles can sometimes be useful to help
localize the lesion. Although UMN deficits are evident
mainly through their effects on white matter tracts,
they will also impair neurons in the local gray matter
at the same level. Damage to these neurons often
produces spontaneous activity in epaxial and hypaxial
spinal muscles adjacent to the injured spinal cord segment. This activity seems to occur as a result of both
degenerative and irritative effects, so the latter may be
evident on an acute basis (Chrisman, 1975).
Diagnostic aids
B
4.47 A: Radiograph of the lumbar spine of a 4-year-old Golden
retriever with a 2-week history of lumbar pain and asymmetrical
paraparesis. Loss of bone within the L4 vertebral body is seen.
B: Myelogram of the same dog showing ventral extradural
compression. A spinal radiographic survey, bone scan and
thoracic radiographs revealed no other lesions.
BIOPSY
(4.474.49)
61
62
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PROCEDURES
Collection of CSF
General anesthesia is required for CSF collection in dogs and cats; the depth must be suitable so that the
animal will not move during the procedure. Patients should be intubated and ventilator support must be
available. The collection site must be clipped and prepared aseptically. Sterile surgical gloves should be worn. An
assistant is required to hold the patient in the correct position when collecting from the cerebello-medullary
cistern (CMC).
Which collection site to use warrants some consideration? The two sites available are the CMC and the lumbar
region. Collection from the CMC is easier and is less likely to produce a sample contaminated with blood.
However, as CSF flows in a cranial to caudal direction, abnormal CSF is more likely to be present caudal to a
lesion. Thus, lumbar CSF is more likely to be useful diagnostically. However, lumbar collection is more difficult and
blood contamination occurs more often.
If raised intracranial pressure is present, lumbar collection is somewhat safer. This is not because brain
herniation is any less likely, but because the risk of direct damage to already-herniated tissue is not a factor with
lumbar collection. If CSF collection is necessary when intracranial pressure could be elevated (see page 43), then
Diagnostic aids
the animal should be ventilated prophylactically and a capnometer used to maintain end-tidal pCO2 at
3035 mmHg. Mannitol, lasix and dexamethasone should also be on hand for emergency use (see below).
Spinal needles are preferred for CSF collection (4.50). The CSF is collected into sterile vials; plain vials without
anticoagulant are generally used.
Remove the stilette once the tip of the needle enters muscle and then advance the needle until CSF
appears in the hub of the needle.
2.
Advance the needle with the stilette still in place in small increments, removing the stilette between each
movement to check whether CSF is present in the needle. A slight pop can sometimes be felt when the
needle enters the subarachnoid space but this sensation can also be produced by movements of the
needle if the tip has been blunted on bone.
If the tip of the needle hits bone, it is most common for it to be too far rostral. The point of the needle is
redirected caudally by withdrawing it to a subcutaneous position and moving the hub rostrally.
If CSF flows, but is tinged with a trickle of bright red blood in the base of the hub, a dural vessel has been
penetrated. This may clear after a few seconds, and then the CSF may be collected. Rotating the needle helps
to clear this type of hemorrhage. The initial blood contamination can be evacuated from the hub of the needle
using a separate, small needle and syringe although it is often better to just remove the needle and start again.
Dark venous blood flows from the needle. This indicates that a venous structure has been penetrated,
usually because the needle has strayed from the midline. This causes no harm but it is best to start again
with a fresh needle.
No CSF flows, even though all the features of a successful tap appear to be present and the needle
appears to have penetrated to an adequate depth. The stilette should be replaced in case the needle has
plugged with tissue or blood clot. If CSF still does not flow, this may be because either the needle is far
off the midline; the brain has herniated; a mass occupies part of the cisterna magna; or the spinal cord
has been penetrated. The latter is a significant risk if the needle is advanced with the stilette in place.
The needle should be removed, the patient placed in a normal position and the respiratory pattern
observed. If respiration is normal after several minutes, the procedure may be repeated or a lumbar
puncture performed. In some patients with soft tissue lesions in the cranial cervical vertebral canal, CSF
cannot be collected from the CMC.
The patient moves suddenly; this is usually because the spinal cord has been damaged. The needle must
be removed and the patient ventilated. This is a potentially serious situation leading to marked neurological
deterioration or death. It may be useful to give the patient methylprednisolone sodium succinate (MPSS)
(30 mg/kg IV) in an attempt to limit the spinal cord damage.
The CSF flows forcefully from the needle. It is not always clear why this happens, but it clearly indicates
high CSF pressure at the CMC. Some dogs do not suffer any apparent deleterious effects from this, but
others do deteriorate. The needle should be removed and the precautions mentioned above taken. It may
65
66
also be useful to hyperventilate the patient as discussed below if increased intracranial pressure is
suspected as the cause.
CSF enters the hub but then flow stops abruptly and the animals heart rate drops below 40/min. This
indicates that brain herniation has occurred; the needle must be removed and the animal ventilated to
maintain end-tidal pCO2 at 3035 mmHg. Mannitol (1.0 g/kg) and furosemide should be administered
intravenously. This strategy is often successful in reversing the herniation if instituted immediately; a
capnometer and emergency drugs should therefore always be available and ready for immediate use for
any patient considered to be at increased risk of herniating.
4.50
4.52
b
a
4.53
Diagnostic aids
4.55
4.56
4.57
67
68
4.58
The needle strikes bone. The space available for penetration of the vertebral canal is relatively small,
particularly in large dogs with significant vertebral new bone formation. Also, the ligamentous tissue may be
mineralized and have the feel of bone. Repeated attempts may be required to position the needle and, in
some patients, the technique may fail. Flexing the spine by drawing the pelvic limbs forward may open up
the interarcuate spaces.
The considerations for hemorrhage are similar to those mentioned above. If the needle appears to be
positioned correctly and yet CSF does not appear, the needle can be rotated slowly or withdrawn slightly.
Provided that intracranial pressure is normal, one or both jugular veins may be occluded to cause CSF to
flow. If these approaches are not successful then a second attempt at collection can be made. Aspiration
of CSF with a syringe is possible, but blood contamination is more likely.
4.59
Diagnostic aids
4.60
4.61
4.62
4.63
69
70
Myelography
As a guide, a dose of iohexol contrast medium from 0.25 to 0.5 ml/kg body weight is used, although this can vary
with the site of the injection and the expected location of the lesion. Better contrast may be obtained when using
a concentration of 300 mg iodine/ml compared to 240 mg iodine/ml.
4.64
Diagnostic aids
4.65
71
72
4.67
4.68 T2-weighted MRI of the lumbar region of a largebreed dog to show the high-signal epidural
(arrowheads) and subarachnoid spaces (arrow).
Note that the epidural space is usually much
wider relative to the subarachnoid space at L6/7
than at L5/6. The L4/5, L5/6 and L6/7 discs
show normal signal intensities but there is loss of
signal of the L7/S1 disc along with extension of
the disc dorsally compressing the nerve roots of
the cauda equina.
4.68
Cervical spine
The traction view, where tension is applied to the cervical spine. It can indicate whether the lesion is
dynamic or static, which can then have a bearing on surgical planning (11.4, 11.5).
The extension view, where the neck is extended dorsally, can reveal other lesions that may become significant
in the future; that is, the domino effect (11.23). This view is not without hazard and must be done with care
(11.9, 11.10).
Flexed and extended views may reveal lesions that cause minor trauma as the animal moves its neck
around (11.6).
Lumbosacral spine
Instrumentation
Draping
Chapter
78
References
79
74
Instrumentation
B
5.13 Periosteal elevator and freer, for removal of muscle from
the vertebrae (7.38) and for vertebral distraction (11.33).
75
76
5.21 These delicate rongeurs are used for fine bone removal.
Larger, double action rongeurs are available for heavier bone
removal (10.28).
5.22 Mini chuck for insertion of small pins, such as those used
for atlantoaxial subluxation (Chapter 9) and to stabilize articular
facets after spinal trauma (13.48A).
Instrumentation
5.24 Angled bur guard is useful for the cement plug technique
used in Wobbler surgery (11.38).
5.26 Adson suction tip and bulb syringe for bur irrigation
(8.29, 8.30, 8.398.41).
77
78
B
5.33 Methylmethacrylate bone cement is used in several of the
procedures described in this book. It is worth emphasizing the
requirement for sterility when using these products (13.60).
DRAPING
The patient should be completely covered by sterile,
waterproof surgical drapes. Their additional expense
must be weighed against the morbidity and the cost of
Instrumentation
REFERENCES
79
Preoperative assessment
Pharmacological considerations 83
Antibiotics 83
Non-steroidal anti-inflammatories 83
Corticosteroids 83
Preoperative analgesia 84
Adverse drug reactions and interactions
85
85
References
Cushings disease
Orthopedic disease
Hypothyroidism
Cardiac disease
Diabetes mellitus
Hepatic disease
Disorders of hemostasis
Renal disease
Neoplasia
Metastatic disease
87
Prostatic disease
Pyometra
Concurrent disease
88
Undetected primary
Surgical considerations 86
Laminectomy healing 86
Durotomy 87
Myelotomy 87
Mechanisms of recovery after spinal cord injury
Client communication
Clinical assessment 81
Concurrent disease 81
Hemostasis 82
Hypoventilation 82
Anesthetic considerations
Premedication 85
Induction 85
Maintenance 85
Recovery 85
Complications 86
Chapter
88
88
CLINICAL ASSESSMENT
It is easy to overlook concurrent clinical or subclinical
disorders that may have an important bearing on the case
The physical examination must be thorough. Skin disorders may necessitate delaying elective surgery because
pyoderma, clipper rash, or povidoneiodine reactions
may predispose to wound infection. Fleas should be
eliminated to prevent them from entering the surgical
field. Osteoarthritic joints may cause major interference
with rehabilitation from neurological deficits, especially
for large or obese dogs.
Laboratory evaluation should include a hematological
and biochemical profile, along with a urinalysis (see
Chapter 4). In cats, the feline leukemia virus (FeLV)
and feline immunodeficiency virus (FIV) status should
be determined. When positive, the likelihood of lymphoma as a cause for neurological deficits increases
markedly. If there is suspicion of cardiac dysfunction in
large- or giant-breed dogs, suitable investigations should
82
Hemostasis
Hemostasis is divided into primary and secondary events
(Kerwin and Maudlin, 2003). Primary hemostasis
depends on platelet aggregation and adhesion, and usually causes most concern to the neurosurgeon. It may be
disturbed in the following conditions:
von Willebrand disease (see Chapter 11, page 217).
Severe thrombocytopenia
(platelet count 20 000/l).
Azotemia (serum creatinine 5.6 mg/dl).
Non-steroidal anti-inflammatory drug (NSAID)induced platelet dysfunction, including aspirin at
all therapeutic doses and especially above 25 mg/kg.
Anticoagulant intoxication.
Disorders of primary hemostasis should be identified
by a platelet count and bleeding time evaluation (11.11).
Perturbed hemostasis can cause decreased visualization
during surgery, postoperative bruising (15.2), hematoma
formation and other more serious complications (15.40).
The dog shown in 6.1, represented 4 months after surgery with a packed cell volume (PCV) of 12% from a
bleeding gastric ulcer but survived after a transfusion.
The owner had treated the dog with aspirin at 40 mg/kg
for 2 weeks.
Hypoventilation
This is a serious potential complication that can occur in
any animal with a serious cervical spinal cord injury.
Patients that are severely tetraparetic on initial presentation should be evaluated for hypoventilation using blood
gas analysis or a capnometer. Tetraplegic animals are
at even higher risk. Occasionally an animal may need
Preoperative assessment
PHARMACOLOGICAL
CONSIDERATIONS
Antibiotics
Corticosteroids
Dermatitis
Periodontal disease
Obesity
Shock or sepsis
Cushings disease
Diabetes mellitus
Non-steroidal anti-inflammatories
These drugs are valuable analgesics although they are
often less effective than corticosteroids as specific
anti-inflammatory agents for neurological disease. They
can have a number of important adverse effects. Such
effects are most marked in drugs that inhibit mainly
cyclooxygenase-1 (COX-1) as opposed to COX-2
(Kay-Mugford et al., 2000) (see Chapter 15, page 341).
NSAIDs must not be used at more than the recommended dose, used in combination with other NSAIDs
METHYLPREDNISOLONE SODIUM
SUCCINATE (MPSS)
MPSS has received wide interest in human, and, to a
lesser extent, veterinary medicine in the past 10 years
because of proposed benefits in spinal cord injury. After
acute injury, the blood supply to the spinal cord is progressively reduced. When the injured tissue is reperfused,
massive amounts of highly reactive chemicals called free
radicals are liberated. These free radicals are especially
damaging to the plasma membrane of cells via a process
called lipid peroxidation. Free radical-induced lipid peroxidation is now recognized as a key pathophysiological
mechanism for irreversible tissue loss following spinal
cord trauma and ischemia (Brown and Hall, 1992).
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84
Preoperative analgesia
Fentanyl patches provide a useful way to deliver preoperative analgesia and they can also be combined with
one of the analgesics discussed under postoperative care
(see Chapter 15), however the rate of absorption of fentanyl can vary considerably in an individual animal over
time and can also vary at different times in the same animal
(Kyles et al., 1996; Egger et al., 1998). The dose range is
25 g/kg/h. Increasing the patch size did not increase
the plasma fentanyl concentration in one study but did
in a second (Egger et al., 1998; Welch et al., 2002a). The
analgesic effect provided by fentanyl in dogs is equivalent
to that provided by intramuscular oxymorphone and is
often superior to epidural morphine; in cats it is superior
to butorphanol (Kyles et al., 1998; Robinson et al., 1999;
Franks et al., 2000). The onset of action is faster in cats
(26 h) than in dogs (2436 h) (Scherk Nixon, 1996;
Robinson et al., 1999). The patch should therefore be
placed 24 h prior to surgery in dogs and supplemental
analgesia is often required during this period (Egger
et al., 1998). Concentrations fall rapidly after patch
removal and are often below therapeutic concentrations
within 1 h (Egger et al., 1998).
Respiratory depression can be a serious side-effect in
humans but was not seen in dogs at high doses
(5 g/kg/h) following thoracotomy (Welch et al., 2002a).
Caution should be used in dogs that are hypoventilating
due to head or spinal cord injury (see Chapter 15).
Other potential side-effects in dogs include bradycardia,
Preoperative assessment
dysphoria and vomiting; acepromazine and glycopyrrolate may alleviate these effects. Skin reactions may also
occur (15.1). The patch must not be placed on a heating
pad as this will increase the rate of absorption from the
patch (Egger et al., 1998). Fentanyl is a useful way to
provide non-invasive, inexpensive, long-lasting analgesia
that is tolerated well (Scherk Nixon, 1996; Kyles, 1998).
However, careful monitoring is needed to insure adequate analgesia and minimize adverse effects (Scherk
Nixon, 1996; Kyles, 1998) (see also Postoperative analgesia, page 339).
ANESTHETIC CONSIDERATIONS
Many neurosurgical patients will be dehydrated at presentation, usually when pain or weakness reduce fluid
intake. They must be rehydrated adequately prior to
anesthetic induction, because of the detrimental effect
of hypotension on spinal cord perfusion (Tator and
Fehlings, 1991; Nuwer, 1999). Another way to reduce
dehydration is to increase preoperative fluid intake; fasting recommendations for humans now permit water up
Premedication
Premedication should have a calming effect and relieve
pain. Hypotension and loss of protective muscle tone
should be avoided in an animal with severe neurological
deficits or an unstable vertebral column. Glycopyrrolate
is the preferred anticholinergic as it is less likely to
induce tachycardia; atropine may still be required to treat
severe bradyarrhythmias (Stauffer et al., 1988).
Induction
A laryngoscope should be used for intubation with as little movement of the spine as possible, especially in dogs
with unstable lesions or lesions in the cervical area. An
armoured endotracheal tube is recommended if cerebrospinal fluid (CSF) is to be taken from the cerebellomedullary cistern (CMC), if stress radiographs are to be
taken, or if a ventral approach to the neck is to be used.
Maintenance
Isofluorane is the usual inhalation agent of choice,
because it is both less depressant to the cardiovascular
system and less arrhythmogenic than halothane. Methoxyfluorane provides good muscle relaxation and better
postoperative analgesia than isofluorane, but is contraindicated in animals receiving opioids or NSAIDs, or in
those with renal disease. Sevofluorane is a good inhalational agent in dogs and may be superior to isofluorane
(Branson et al., 2001). Autoregulation in the brain is
preserved better with sevofluorane than with isofluorane
(Summors et al., 1999; Endoh et al., 2001); both agents
maintain good spinal cord blood flow (Hoffman et al.,
1991; Crawford et al., 1992).
Maintenance of anesthesia should be at a depth sufficient to prevent movement of the patient, which could
be dangerous during surgery. Mechanical ventilation is
recommended in large or debilitated animals, those that
are positioned in dorsal recumbency and those with
neurological deficits cranial to the thoracolumbar junction. Barotrauma must be avoided, especially in small
animals (Manning and Brunson, 1994; Parent et al.,
1996). Nitrous oxide is not recommended as it may
result in a rapid onset of hypoxia if the patient hypoventilates during CSF collection or if it will be disconnected
temporarily from the gas supply during radiography.
Recovery
The recovery from anesthesia should be smooth, and
this may be helped by the use of narcotics, diazepam, or
both. If the animal has undergone myelography, its head
85
86
Complications
Anesthesia must optimize both cardiovascular and
respiratory function in order to minimize ischemia of the
spinal cord. Spinal cord blood flow is autoregulated in a
manner analogous to cerebral blood flow; volatile anesthetic agents may depress this autoregulation and trauma
to the spinal cord can abolish it altogether (Tator, 1991;
Nuwer, 1999; Olby and Jeffery, 2003). Any cardiac
arrhythmia or systemic hypotension will compound this by
reducing spinal cord blood flow further and so should be
avoided if at all possible.
Iohexol is a safe agent for myelography (Wheeler and
Davies, 1985), although the incidence of seizures can be
around 7% in large-breed dogs with Wobbler syndome
(Lewis and Hosgood, 1992; Widmer et al., 1992b).
Seizures can cause the animal to extend its neck, which
might have an adverse effect on a dynamic cervical lesion
(11.10). It is recommended that the patient be at an adequate depth of anesthesia before the injection is made,
that the contrast be used at body temperature, and that
it is injected at a steady rate (Lamb, 1994). In one study,
six out of 66 dogs developed bradycardia during iohexol
injection and one died; two also developed bradycardia
during recovery (Lewis and Hosgood, 1992). The ECG
must be monitored closely during the study and any problems treated promptly. Hypothermia is another potential
problem, particularly in small animals or if the anesthetic
period is prolonged.
Surgical techniques can also affect the patient during
anesthesia. Cervical spinal surgery is associated with a
much higher risk of arrhythmias and ventricular premature contractions than thoracolumbar surgery (Stauffer
et al., 1988). This may result from manipulation of either
the spinal cord itself, or of nerves in the ventral neck. Both
positioning the spine in extension and manipulation of the
vagosympathetic trunk should be minimized. A paramedian approach to the neck provides better protection for
vital structures and may therefore reduce the incidence of
intraoperative arrhythmias (11.2511.27). Magnification
is recommended when performing surgery on the cervical
spinal cord in order to reduce unnecessary manipulation
(see Chapters 7 and 11). Severe cervical myelopathies can
result in sympathetic blockade (11.10), which can be fatal
SURGICAL CONSIDERATIONS
Laminectomy healing
A laminectomy heals as the hematoma forms a fibrous
callus, which then undergoes metaplasia to cartilage and
bone (Trotter et al., 1988). Adhesions can involve the
dura and nerve root(s) if no attempt is made to protect
them after laminectomy (Cook et al., 1994). Adhesions
around local nerve roots can cause considerable postoperative morbidity in humans, probably by causing a
tethering effect (Songer et al., 1990; Geisler, 1999).
This has not been identified specifically in animals
although those with postoperative back pain and evidence of probable peridural fibrosis on CT scan have
been reported (Olby et al., 2000). The preferred way to
assess epidural scarring is by using MRI (Ross et al.,
1999). The more scar tissue that is evident on MRI, the
more pain is reported in humans after lumbar discectomy
(Ross et al., 1996; Maroon et al., 1999). It is advisable to
keep the exposed dura mater separate from the damaged
epaxial muscles during healing in order to minimize the
development of adhesions, which can even cause subsequent spinal cord compression (Trotter et al., 1988; Cook
et al., 1994).
Several implants have been used to minimize adhesions but none is ideal (Cook et al., 1994). One study
using Gelfoam (Pharmacia, Kalamazoo, MI) showed no
reduction of peridural scarring in dogs; two more studies
showed that scarring was actually increased (Gill et al.,
1979; Songer et al., 1990; Robertson et al., 1993) and a
fourth study showed reduction in scar using Gelfoam
(LaRocca and Macnab, 1974).
Better overall results seem to be obtained in dogs using
autogenous fat (Gill et al., 1979; Cook et al., 1994).
Histopathological evaluation of free fat grafts after
laminectomy for disc disease in 21 dogs showed that
5090% of the graft was made up of fat with no scar. In
a further eight dogs, myelography was used to verify the
lack of scar formation in the subarachnoid space over
the surgical site. Overall follow-up times ranged from
1 month to 5 years (Biggart, 1988). CT scans can also
be used to verify the presence and viability of fat graft at
a previous laminectomy site (Biggart, 1988; Olby
et al., 2000). However, two other studies found either
no benefit from free fat grafts (Songer et al., 1995), or
that grafts do not prevent dural adhesions (Trevor et al.,
1991). Free fat grafts must revascularize and so should be
Preoperative assessment
Durotomy
Durotomy, or incision of the dura mater, results in mild,
temporary deficits in normal dogs (Parker and Smith,
1972). As the dural incision heals, the edges rejoin but
they often adhere to the spinal cord as well (Trevor et al.,
1991). Durotomy is necessary to evaluate intradural
and intramedullary lesions (Jeffery and Phillips, 1995)
(12.40). It is sometimes performed at laminectomy in
an attempt to decompress the spinal cord further (8.49,
8.50). Although this may improve decompression, the
relative risks and benefits are unclear (Perkins and Deane,
1988). In experimental situations, durotomy may have
value when performed immediately after trauma, but
was found to have no benefit 2 h after the injury (Parker
and Smith, 1974, 1975). However, studies of intracranial pressure show that craniotomy and durotomy
lower pressure by 15 and 65%, respectively (Bagley
et al., 1996). This suggests that durotomy might also produce a significant decompressive benefit for spinal cord.
Durotomy is not recommended in order to provide prognostic information after spinal cord injury and euthanasia
should not be based solely on the gross appearance of the
spinal cord (Salisbury and Cook, 1988) (8.50).
Myelotomy
Myelotomy involves incising the spinal cord on the dorsal
midline to the level of the central canal. It has been performed in normal dogs at the T3L3 region with minimal
6.2 Thoracic spinal cord from a dog that did not regain deep
pain sensation after a spinal fracture 6 weeks previously. There
is a large area of central necrosis with small groups of surviving
axons in the periphery (arrows). These axons may mediate late
recovery of motor function in dogs that never regain deep pain
sensation and that remain incontinent (Olby et al., 2002).
87
88
CLIENT COMMUNICATION
The client should always be offered the textbook
approach for managing a patient in terms of the diagnostic
evaluation and treatment. This should be offered regardless of the clinicians perception of whether the client will
pursue treatment, and even when it involves referral.
In this manner, the client is made aware that the very best
is available for their animal, and any compromises arrived
at will be seen in the proper perspective.
Whenever possible, the clinical problems and the diagnostic and therapeutic options should be explained to the
client in non-scientific terms. Anatomical specimens, websites, drawings and the animals own laboratory data and
images should be used to illustrate the situation. On the
other hand, care must be taken not to overload the client
with excessive information, and they should be given time
and the opportunity to think privately about their decision. It is also important that the client be given as accurate
a prognosis as possible, both for the degree of recovery and
the time required. Giving the client prior knowledge of
the probable prognosis and of the most likely complications is invaluable should the patient suffer either a protracted recovery or setbacks in its postoperative course.
The client should never be pressured into consenting
to a course with which they are not comfortable, even if
the clinician feels that it is in the animals best interests.
If complications do arise the client may then hold the
clinician responsible, not only for the decision but also
for the complications.
Finally, the client should be given, and asked to sign, a
consent form and a written estimate of the likely cost
for the entire procedure. It is vital that the client be
made aware that there is some risk even in a routine general anesthetic and scan. This estimate should include a
price range to take into account any foreseeable variations in the postoperative course. Should the bill begin to
approach the upper end of the estimate, or if unforeseen
complications develop, the client must be notified
immediately (Thacher, 1989).
Key issues for future investigation
1. Does MPSS provide significant neuroprotection in dogs
after spinal cord trauma?
2. Does MPSS provide benefit when given prophylactically
prior to surgery?
3. What are the relative merits of MPSS and Vitamin E?
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91
Clinical signs
94
Treatment options 96
Non-surgical treatment 96
Surgical treatment 96
Fenestration 96
Ventral decompression 96
Ventral decompression and fixation
Dorsal decompression 98
CLINICAL SIGNS
97
Complications 98
Intraoperative 98
Early postoperative 99
Postoperative care
Prognosis
102
102
103
93
Diagnosis 94
Survey radiography
CSF analysis 94
Myelography 95
CT and MRI 95
Chapter
103
104
Procedures 106
Approach to the ventral neck 106
Fenestration 109
Ventral decompression 111
Ventral decompression with
distraction-stabilization 117
Dorsal hemilaminectomy 119
Dorsal laminectomy 120
Cervical disc disease is a frequent disorder of dogs.
Small dogs are affected commonly, particularly those
with chondrodystrophoid characteristics although the
condition can occur in any breed (Gage, 1975; Dallman
94
Neck pain
Spontaneous screaming
Hemiparesis
Tetraparesis
DIAGNOSIS
Survey radiography
Schmorls node
Synovial cyst
Bicipital bursitis
Otitis media
Cervical spondylomyelopathy
Atlantoaxial subluxation
Syringohydromyelia
Intracranial lesion
CSF analysis
Meningomyelitis
Polyarthritis
Polymyositis
Myelography
CT and MRI
C3
C4
C5
C6
B
7.4 A: Transverse CT and B: 3D
reconstruction of CT scan from a
5-year-old Lhasa Apso that had neck
pain and was unable to walk. The scan
revealed a large mineralized extrusion at
the C4/5 disc space. The postoperative
scan is shown in 7.5.
95
96
TREATMENT OPTIONS
Treatment may be non-surgical or surgical.
Non-surgical treatment
This entails cage rest and use of anti-inflammatory medications. It can be tried in any patient unless marked
neurological deficits are present. Either non-steroidal
anti-inflammatory drugs (NSAIDs), low-dose prednisolone, or narcotics may be used, sometimes combined with diazepam or methocarbamol (Tables 15.1,
15.2). Acupuncture may also be of benefit (Janssens,
1985). The catastrophic worsening of neurological status that can occur with medical treatment of thoracolumbar discs is rare with cervical disc disease. However,
the neck pain in cervical disc disease seems to be less
responsive to non-surgical treatment than does the pain
from thoracolumbar disc disease. Progression of signs or
lack of response in 12 weeks indicates treatment failure. A dog that is responding well to non-surgical treatment should be kept rested for at least 6 weeks
after clinical signs have resolved. Recurrence of clinical
signs after non-surgical treatment has been reported
in over 30% of patients (Russell and Griffiths, 1968;
Janssens, 1985). The role of chemonucleolysis is unclear
and cervical discs must first be exposed surgically if this
procedure is planned (Atilola et al., 1993).
Surgical treatment
Indications for surgical treatment include:
Failure of non-surgical treatment.
Unremitting pain.
Severe or progressive neurological deficits.
Ventral decompression is the preferred procedure. It
may need to be combined with stabilization for caudal
disc extrusions. Dorsal or dorsolateral decompression
may be required in extrusions that cannot be reached
via ventral slot or if there is doubt about the diagnosis.
Fenestration (7.307.36)
Although the value and desirability of fenestration has
been questioned (Fingeroth, 1989), it should prevent
further extrusion of disc material into the vertebral canal
and so reduce the recurrence rate (Russell and Griffiths,
1968). It also appears effective for dogs with discogenic
pain (Morgan et al., 1993 (Algorithm 7.1)). It is usual to
fenestrate the discs from C2/3 to C5/6 inclusive; C6/7
is fenestrated if there is evidence of disease. Advantages
and disadvantages of fenestration compared to ventral
slot decompression are shown in Table 7.1. Fenestration
is only recommended as a primary procedure for dogs
with discogenic pain and as a prophylactic procedure in
combination with ventral decompression. In small breed
dogs that develop signs suggestive of Wobbler syndrome, fenestration is probably contraindicated as it
may exacerbate bulging of the dorsal anulus (7.15A).
Ventral decompression (7.377.52)
General indications for decompression include:
Presence of neurological deficits.
Spinal cord compression on neuroimaging.
Failure of fenestration.
Removal of disc material by ventral slot decompression provides the most rapid resolution of clinical signs
and it is therefore the treatment of choice. Accurate
Neuroimaging
No spinal cord
compression
Traction
non-responsive
Reassess
diagnosis
Traction
responsive
(small dogs*)
Single
lesions
Fenestrate
for
discogenic
pain
Cranial discs
C2/3 to C3/4
Multiple
lesions
Caudal discs
C4/5 to C6/7
Dorsal
laminectomy
C7/T1 or very
lateral extrusion
Ventral
slot
Dorsolateral
hemilaminectomy
or dorsal
laminectomy
Distraction
(7.55)
Slot
Technically
Easy
Difficult
Accurate identification
of disc involved
Not required
Required
Special equipment
required
No
Yes
Unlikely
Possible
No
Yes
Slow in
many dogs
Usually within
a few days
identification of the disc involved is an obvious prerequisite. The width of the slot should be about one third the
width of the vertebral body and certainly no more than
50% (7.10, 7.16). These parameters are especially
important for the C4/5 to C6/7 discs inclusive (Fitch
et al., 2000; Lemarie et al., 2000). The inverted cone
technique can be used to improve access while minimizing any potential instability (Goring et al., 1991) (7.50).
97
98
from the ilium are effective but necessitate two surgical approaches (Prata and Stoll, 1973). A more recent
study preferred a bone allograft block placed in the
interspace without use of additional implants (Lemarie
et al., 2000). Autografts give better radiographic fusion
than allografts but other factors such as graft site
morbidity also affect final outcome in humans (Floyd
and Ohnmeiss, 2000). Whatever method is used, bony
fusion should be encouraged so that long-term fixation
does not depend solely on the implant(s). The prognosis is good for dogs that subluxate after a ventral
slot provided that the site can be stabilized (Lemarie
et al., 2000).
In general, adherence to the recommendation to
limit the width of the slot to near 33% is preferable to
managing potential or subsequent complications.
C4
C5
C4
C5
COMPLICATIONS
Intraoperative
The ventral surgical approach itself has few complications unless the surgeon does not identify the midline
correctly and damages the vertebral artery. It is also possible to damage vital structures such as the recurrent
laryngeal nerve (7.25, 7.54); the esophagus can be perforated if mistaken for the longus colli muscle and
pleura or other vital structures may be damaged at the
level of the thoracic inlet (Funkquist and Svalastoga,
1979). Spinal cord damage during fenestration can
7.8 Two weeks after surgery the dog was tetraparetic and
unable to stand. The ventral slot had been performed at the
correct interspace; the cranial margin is just visible in the
caudal portion of C4 (arrowhead). However, the degree of
spinal cord compression is now worse than before. The slot
was re-explored; it was noted to have been directed to one
side. The slot was redirected to the midline and a large
amount of disc material was removed; hemorrhage was
minimal. The dog made a good recovery and was able to walk
2 weeks later.
Early postoperative
These relate mainly to continued pain; neurological
deterioration (7.8); or respiratory complications (Box
7.4). After fenestration neck pain can persist in a significant number of dogs and may take 12 months to
resolve completely (Denny, 1978) (see Prognosis,
page 102). Neurological deterioration after fenestration can also occur, probably when incorrect fenestration technique leads to disc material being forced into
the vertebral canal (Tomlinson, 1985).
After ventral slot decompression neck pain should
improve within a few days. Moderate or severe pain
has been reported 3 days after surgery in up to 65% of
dogs although this could have been due to excessive
slot width in some of these dogs (Fitch et al., 2000).
Persistence of severe pain beyond 72 h, or progressive
neurological deficits, warrant repeat imaging (Seim and
Box 7.4 Early postoperative complications
Extradural hematoma
Hyperflexion injury
Dyspnea (7.12)
Infection or sepsis
Vascular decompensation of spinal cord
Iatrogenic injury
Cardiopulmonary arrest
Implant complications
Edema (7.12)
Hemorrhage (7.7)
Horners syndrome
Megaesophagus
Laryngeal paralysis
Aspiration
Pneumonia
Intraoperative
Postoperative
99
100
A
R
C7
A
C7
they are unable to breathe spontaneously. In these animals the only option is to put them on a mechanical
ventilator. Ventilation should be considered once the
paCO2 exceeds 50 mmHg and the dog should either be
ventilated or euthanized on humane grounds if the
paCO2 is greater than 70 mmHg (7.11).
Swelling or edema in the ventral neck can also cause
problems after surgery (Fry et al., 1991; Smith et al.,
1997) (7.12). Care with hemostasis and wound closure
helps to avoid this. Seroma is a particular risk after dorsal decompression (15.34).
Technical problems may occur when trying to place
implants in small dogs (7.13, 7.54). Other potential
101
102
T1
T1
POSTOPERATIVE CARE
PROGNOSIS
Resolution of clinical signs may be slow after fenestration. Of 12 dogs with neck pain, six recovered rapidly
but five continued to have intermittent pain for 14
weeks. Of a further 16 dogs with thoracic limb paresis,
12 (75%) recovered in an average of 38 weeks. Of
nine with severe deficits (tetraparesis or tetraplegia),
five (56%) recovered in 16 weeks (Denny, 1978).
Fenestration has been compared to ventral slot decompression in 111 dogs that were able to walk prior to
surgery. Intraoperative and postoperative complications,
other than simple incisional swelling, were more common after ventral decompression (30% vs 12%), resulting
in longer hospital stays (7.12). However, neurological
recovery was slower following fenestration. Fenestrated
dogs were three times more likely to have static signs
at discharge and twice as likely to be unchanged at their
last hospital visit (Fry et al., 1991). Ventral slot decompression gives much better results overall (Table 7.3).
This is probably because even dogs with no neurological deficits usually have substantial amounts of
disc material in the vertebral canal.
The prognosis for dogs with pain or moderate
neurological deficits is usually good after a ventral slot
(Table 7.3). The prognosis for dogs that cannot walk is
more guarded. Complete recoveries are reported in
5560% of such dogs, a further 1520% recover with
residual deficits and 2025% die or are euthanized.
Dogs that do not walk within 2 weeks are likely to
continue to have residual deficits (Waters, 1989; Smith
et al., 1997). Others have reported better recovery
rates for severely affected dogs (Seim and Prata, 1982).
The outcome after ventral slot decompression in
small-breed dogs appears to be better for dogs with
cranial cervical lesions (C2/3 or C3/4) than for those
No. of
dogs
No. recovered*
by 2 days (%)
No. recovered*
by 7 days (%)
No. recovered*
by 28 days (%)
No. recovered*
by 365 days (%)
No recovery
Pain / RS1
33
16 (48)
24 (73)
30 (91)
33 (100)
Can walk1
14
6 (43)
10 (71)
12 (86)
14 (100)
18
5 (28)
10 (56)
14 (78)
15 (83)
3 (17)
1
Seim and Prata (1982); 2 Waters (1989).
* Recovered defined as no neck pain; ability to walk for dogs unable to walk before surgery.
RS, Root signature.
103
104
7.15 A: Multiple herniations in a Pomeranian with neck pain, mild tetraparesis and a disconnected gait (see page 28). Extradural
compression is evident from C2/3 to C7/T1 inclusive; several lesions were of mineralized material. Fenestration of these disc spaces
led to recurrence of signs within a year. B: Miniature pinscher with neck pain and thoracic limb root signature. Traction-responsive,
ventral extradural compression is present from C2/3 to C6/7 inclusive.
7.16 A: Ventrodorsal survey radiograph from a 6-year-old Yorkshire terrier that suffered a vertebral subluxation at the site of a
previous ventral slot at C4/5 (arrow). The width of the slot is 55% (same dog as in 7.52). B: Seven-year-old Dachshund with
neck pain and root signature that was unable to walk after ventral slot at C3/4; slot width is 66%. An external splint was applied;
the dog could walk within 2 weeks.
5. Are cranial lesions more resistant to subluxation (Lemarie et al., 2000) (7.16B)?
6. What is the best way to fuse interspaces in small-breed dogs? Options include metal and bone cement (page 118) or bone
allografts combined with ventral slot (Fitch et al., 2000). Non-biological materials that permit bone in-growth may become
available in the future (Cook et al., 1994; Emery et al., 1996).
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105
106
PROCEDURES
Approach to the ventral neck (7.177.29)
The cervical spine is extended over a sandbag; the thoracic limbs are pulled in a caudal direction, and tape is used to
immobilize the head and thorax (7.17). It is important to have the dog straight to insure that the neck is aligned correctly.
Note that extension of the caudal portion of the neck as shown here will tend to close the dorsal intervertebral space of
C5/6 and C6/7 spaces. Ventral slot decompression at these sites is easier to perform if the neck is put in a more neutral
position. If access needs to be improved to C6/7, it is preferable to put the neck in gentle traction using a weight on the
maxilla (11.24), or consider a dorsal (11.4411.55, 7.59) or dorsolateral laminectomy (7.567.58, 12.1512.29).
Deep anatomy includes the carotid sheaths, recurrent laryngeal nerves and esophagus (7.257.27). Careful dissection
of the loose fascial layers in a longitudinal direction will expose these structures. Finger dissection here is safe and
effective. Further dissection of the deep fascia reveals the longus colli muscles, which lie ventral to the cervical vertebrae
(7.28). If preferred, the paramedian approach to the ventral neck can be used instead of the approach described here
in order to provide greater protection for blood vessels, nerves, trachea and esophagus (11.2511.27).
Blunt-jawed self-retaining retractors (5.8) are used initially to maintain exposure (7.29). The retractors must not interfere
with gas flow in the airway. Palpate the end of the endotracheal tube and insure that it is positioned distal to the retractors.
Moist towels or sponges are used to protect the tissues. The longus colli muscles join in the midline and insert on the ventral
process of the vertebra, thus overlying the intervertebral discs (7.29). Accurate identification of the intervertebral discs at this
stage is crucial. The ventral process of C5 vertebral body lies in the midline between the cranial borders of the large C6 transverse processes (4.6, 7.37B); the C5/6 intervertebral disc lies immediately behind this ventral process. The ventral process
of C1 is particularly prominent and sharp (7.19); this also can or may be palpated. There is no intervertebral disc at C1/2.
7.17
c
a
7.18
7.19
b
a
7.20
7.21
7.22
107
108
7.24
a
c
7.25
b
7.26
b
7.27
7.28
7.29
Fenestration (7.307.36)
During fenestration it is important not to confuse the ventral process of C2C5 vertebrae with the transverse processes
(see under Approach, page 106). The longus colli muscles run cranially to insert on the ventral process in the midline.
The transverse processes can be palpated on each side of the ventral process. The three rows of structures (ventral
processes in the midline, transverse processes laterally on each side) should be identified before proceeding.
7.30
109
110
7.31
7.32
7.33
7.34
7.36
111
112
7.37
A
7.38
7.39
7.40
7.41
b
a
7.42
113
114
7.45
7.46
7.47
7.48
115
116
7.49
7.50
C6
C6
7.52
A
T1
T1
7.53
A
117
118
7.55
7.55 Miniature pinscher with severe neck pain and left thoracic limb root
signature. A: Preoperative myelogram shows collapse and
mineralized material at C6/7. B: CT myelogram shows mineralized
extrusion or osteophytes within the left foramen also (arrowhead)
(Prata and Stoll, 1973). C: Postoperative radiograph of stabilization
using 2.7-mm screws and bone cement following traction on the
maxilla as the cement hardened (compare disc space to A). The
caudal screw is positioned poorly but the dog has shown no
clinical signs for 6 years.
A
L
Distraction can be maintained with a small amount of bone cement wedged into a partial ventral slot. The edges of
the slot are undercut to prevent slippage of the cement. This method can also be used to rescue a wide or
subluxated ventral slot, as the main goal here is to prevent excessive collapse or subluxation as seen in 7.10.
Gelfoam (Pharmacia, Kalamazoo, MI) should be used to insulate the spinal cord (page 235 and 239). The cement
wedge should be kept to the ventral half of the interspace.
7.56
7.57 A: Preoperative
myelogram and B: 3D
reconstruction of the
postoperative CT
scan to show the
hemilaminectomy
(arrowheads) used to
access the mass. The gap
between C6 and C7
(arrow) is an artefact of
reconstruction. Head is to
the right in these images.
7.57
7.58
7.58 Postoperative A:
Transverse and B: 3D
reconstruction of a CT
scan from the same dog as
shown in 7.567.57. The
mass was confirmed to be
a large, fibrous disc
herniation; about 75% of it
was removed using a
B
A
combination of scalpel and
rongeurs. A pocket of gas is visible at the surgical site in A. The extent of the hemilaminectomy is shown
clearly in B. The dog made a rapid recovery.
119
120
R
7.59
Clinical signs
122
CLINICAL SIGNS
Treatment 123
Non-surgical 123
Decompression (hemilaminectomy,
mini-hemilaminectomy or pediculectomy)
Fenestration without decompression 127
126
Complications 127
Intraoperative complications 127
Early postoperative complications 127
Late postoperative complications 130
Postoperative care
Prognosis
132
132
121
Diagnosis 122
Radiography 122
Cerebrospinal fluid analysis
Myelography 122
CT and MR imaging 123
Chapter
133
133
134
Procedures 136
Dorsolateral hemilaminectomy 136
Pediculectomy and mini-hemilaminectomy
Lateral fenestration 154
151
122
Neoplasia
Tumoral calcinosis
Discospondylitis
Epidural abscess
Polyarthritis
Polymyositis
Trauma
Dural tear
Ischemic myelopathy
Ischemic neuromyopathy
Pancreatitis
Renal pain
Ureteral calculi
Gallstones
Gastrointestinal parasites
Kidney worm
Prostatic disease
Urethral tumor
DIAGNOSIS
Radiography
Survey radiographs may indicate if disc disease is present but are only 6070% accurate in identifying the
exact location (Kirberger et al., 1992; Olby et al.,
1994). Survey radiographs must not be used as the sole
means of confirming the diagnosis if decompressive
surgery is planned. The main roles of radiography are to
help rule out differential diagnoses (Box 8.1) and to
confirm anatomical landmarks (8.198.21).
B
8.1 A: Lateral myelogram from a dog with a disc extrusion at
T12/13. There is poor filling of the subarachnoid space over T12
vertebral body because of a ventral, extradural mass. Filling can
often be improved by injecting contrast as the radiograph is
being taken. B: The ventrodorsal view of the same dog reveals
poor contrast filling of the subarachnoid space over T12 and
T13 vertebral bodies. The mass is mainly left-sided over the
T12/13 space (arrow) (from Olby et al., 2000).
Myelography
Either myelography or advanced imaging should be
performed for definitive diagnosis. A lumbar injection
is preferred for myelography because there is often
considerable spinal cord swelling, which tends to cause
cervical myelograms to stop cranial to the lesion (see
Chapter 4, page 71). Lateral and ventrodorsal images
should be taken (8.1A, B). If it is not clear on which
B
8.3 A: Transverse CT image and B: 3D
reconstruction from different dogs, each
demonstrating disc material occupying
both sides of the vertebral canal
(arrows). These images show why it can
sometimes be hard to judge on which
side to perform surgery (Schulz et al.,
1998; Grevel and Schwartau, 1997).
CT and MR imaging
CT is more accurate and usually much faster than myelography, especially in chondrodystrophoid breeds (Olby
et al., 1999). CT is non-invasive as mineralized disc
material shows clearly without the need for contrast, even
when it is not visible on survey radiographs. It is usually
much easier to decide what side(s) the disc material is
on from a CT than from a myelogram (see Chapter 4,
page 55; 8.2A, 8.3). A heterogenous, hyperattenuating,
extradural mass with loss of epidural fat are characteristic features of mineralized disc extrusions (Olby et al.,
2000) (4.37B, 4.40A, 8.3A). Contrast medium may be
necessary if the extruded material is not mineralized
(4.40A, 11.52). CT has become increasingly popular
with neurologists for diagnosing disc disease in chondrodystrophoid breeds and is the modality of choice for
many. It does not show the extent of spinal cord swelling
as well as myelography but, conversely, swelling does not
degrade the CT image. If a CT is not diagnostic it can
always be followed by a myelogram. Scanners can also
be used to show the exact location and extent of disc
material on a scout image (4.39, 4.44A).
MRI also provides transverse imaging and is superior to
CT when the disc material is not mineralized (4.42, 4.43,
8.2B). The increased sensitivity of CT and MRI reveal
TREATMENT
Many dogs will recover from moderate neurological
deficits following either non-surgical or surgical treatment. Certain generalizations can be made regarding
the advantages of each type of therapy. An algorithm
for surgical decision-making is shown in Algorithm 8.1.
Patients with marked deficits (see Assessing the
severity of spinal cord injury, page 31) seen within 8 h
of spinal cord injury may benefit from concomitant
methylprednisolone sodium succinate (MPSS) therapy
(see page 83).
Non-surgical
Strict cage rest is the overriding principle here although
judicious use of analgesics or anti-inflammatory drugs
may also be needed. These drugs should be withheld
when feasible in order to encourage the animal to rest.
The animal must rest quietly in a confined space (traveling cage size) for at least 4 weeks, during which time
it should only be removed to urinate and defecate.
A satisfactory response should be followed by a further
2 weeks rest and a gradual increase in activity between
123
124
Neurological examination
Grades 1 or 2
First episode
Grades 3 or 4
Grade 5 or
rapid
progression
Persistent or
recurrent
Neuroimaging
Rest and monitor
Elective
neuroimaging
URGENT
ELECTIVE
Fenestration alone
Decompression
Large dog
Acute
Pediculectomy
mini-hemilaminectomy, or
hemilaminectomy and stabilize
DO NOT FENESTRATE
AFFECTED DISC
Small dog
Chronic
Pediculectomy
mini-hemilaminectomy, or
hemilaminectomy and stabilize
DO NOT FENESTRATE
AFFECTED DISC?
Acute
Decompress in
the least
invasive way
FENESTRATE
Table 8.1 Results of treatment for thoracolumbar disc disease (See also Table 8.1a)
Treatment as % success (no. of dogs)
Neurological grade
Conservative4
Decompression1,2,5,6,7,8
Fenestration3
1no deficits
100 (8/8)
97 (29/30)
92 (1/12)
2paresis walking
84 (32/38)
95 (36/38)
93 (40/43)
84 (32/38)
93 (43/46)
85 (22/26)
4paraplegia
81 (13/16)
95 (37/39)
88 (1/8)
64 (86/135)*
33 (2/6)
7 (1/14)
Anderson et al., 1991; 2 Black, 1988; 3 Butterworth and Denny, 1991; 4 Davies and Sharp, 1983; 5 Olby et al., 2003;
Scott and McKee, 1999; 7 Sukhiani et al., 1996; 8 Yovich et al.,1994.
*See Table 8.1a.
the 6th and 8th weeks. This is the minimum time needed
for an avascular structure like the anulus fibrosus to
repair. Activities like jumping should be avoided for
46 months.
Animals that will not rest or are confined inadequately
may fail to respond or get worse. The patient must be
evaluated regularly for any deterioration, which indicates
treatment failure, as does a lack of improvement within
2 weeks.
Advantages of non-surgical treatment are minimal
expense and equipment-needs. Treatment can be continued at home, ideally after an initial few days of direct
observation. Overall recovery rates are good for dogs
with grade 1 to 3 deficits (Table 8.1). About 50% of
paraplegic animals that are also incontinent will recover,
57 (38/67)2,3
71 (48/68)1,4,5
64 (86/135)1,2,3,4,5
Anderson et al., 1991; 2 Olby et al., 2003; 3 Scott, 1997; 4 Scott and
McKee, 1999; 5 Yovich et al., 1994.
*An additional 8/67 dogs (12%) regained voluntary motor function
without regaining deep pain (Olby et al., 2003).
Table 8.2 Recovery times and recurrence rates after treatment for thoracolumbar disc disease
Mean recovery time in weeks
Neurological grade
Conservative4
Decompression7,8,9,10
Fenestration2
1no deficits
2paresis walking
2 (25, 673)
68
4paraplegia
912
14
68
N/A
10
344, 406
Brisson et al., 2002; 2 Butterworth and Denny, 1991; 3 Cudia and Duval, 1997; 4 Davies and Sharp, 1983; 5 Davis and Brown, 2001; 6 Levine and
Caywood, 1984; 7 Olby et al., 2003; 8 Scott, 1997; 9 Scott and McKee, 1999; 10 Yovich et al., 1994.
*After hemilaminectomy with fenestration of a variable number of disc spaces.
N/A, not available.
125
126
Decompression (hemilaminectomy,
mini-hemilaminectomy or pediculectomy)
Although decompression is the treatment of choice for
disc disease it does require good-quality imaging. Imaging
usually identifies the affected interspace but determining which side to decompress can be more problematic.
Myelography is more reliable than neurological signs,
but CT or MR imaging are superior (Smith et al., 1997;
Schulz et al., 1998; Olby et al., 1999). This is because
spinal cord swelling can confound myelographic interpretation regarding the side of the lesion and because
the disc material may actually be on both sides (Schulz
et al., 1998) (8.3). Good surgical technique is needed
to retrieve as much disc material as possible once the
spinal cord has been exposed. Any material on the contralateral side must be removed by probing over or under
the spinal cord; alternatively bilateral decompression
may be needed (8.3). Bilateral hemilaminectomy does
not appear to prejudice the outcome in small dogs
despite causing an increase in range of motion or even
overt instability (Anderson et al., 1991; Shires et al.,
1991; Grevel and Schwartau, 1997; Corse et al., 2002;
Viguier et al., 2002). Instability will be worsened by
concomitant fenestration (Shires et al., 1991). Preservation of facet joints is therefore recommended on at
least one side (Yovich et al., 1994).
Decompression is the treatment of choice for dogs with
spinal cord compression causing persistent or recurrent
grade 1 signs and for most dogs with neurological
deficits. The rate of recovery is faster after decompression
COMPLICATIONS
Complications common to both surgical and non-surgical
management include gastrointestinal (GI) ulceration,
iatrogenic hyperadrenocorticism, pancreatitis, pulmonary thromboembolism (PTE), deep vein thrombosis
(DVT), decubitus, urine scald, urine retention and
urinary tract infection (UTI) (see Chapters 6 and 15).
Intraoperative complications
These are listed in Box 8.2. The main problems are
finding the correct disc space and removing all of the
disc material. The problems are discussed below.
Box 8.2 Intraoperative complications
Myelomalacia (8.5)
Self-mutilation
Scoliosis
Pneumothorax
Instability
Wound infection
Cutaneous fistula
127
128
8.8 This dog had good deep pain 24 h after hemilaminectomy at L1/2 but had lost it after 48 h. Myelogram at 48 h reveals
extradural compression over the hemilaminectomy defect. A: Marked ventral deviation of the dorsal contrast column (arrowheads).
B: Thinning of right contrast column between arrowheads. The fat graft was swollen and edematous (12.10). It was replaced by
Gelfoam (Pharmacia, Kalamazoo, MI) and the dog made a good recovery.
129
130
Table 8.3 Outcome for dogs according to size following decompression for thoracolumbar disc disease
Neurological
grade
As % success (total
number)ALL dogs*
As % success (total
number)LARGE dogs
2paresis, walking
95 (38) 2,5,7
92 (13) 3
94 (85) 2,5,7
90 (31) 3
64 (135) 1,4,5,6,7
25 (4) 3
Anderson et al., 1991; 2 Black, 1988; 3 Cudia and Duval, 1997; 4 Olby et al., 2003; 5 Scott, 1997; 6 Scott and McKee,
1999; 7 Yovich et al., 1994.
*Mostly small-breed dogs.
Peridural fibrosis
Infection
Fecal incontinence
Recurrent UTI
131
132
POSTOPERATIVE CARE
PROGNOSIS
The prognosis is excellent for dogs with grade 1, 2 and
3 deficits, especially following decompression. Dogs
with grade 3 and 4 deficits have a better outcome after
surgery and the response is better after decompression
than after fenestration alone. Decompression is clearly
the treatment of choice for dogs with grade 5 lesions,
with between 60 and 70% making a functional recovery
in most studies (Tables 8.1, 8.1a). When deep pain was
assessed using bone clamps or pliers the rate was 62%
(23/37) (Scott and McKee, 1999). Specific evaluation
of all dogs for recovery of deep pain, rather than the
ability to walk, also brings the recovery rate close to
60% (Olby et al., 2003) (Table 8.1a). Most dogs that
make a functional recovery have regained deep pain
within 2 weeks. However, 19% (8/42) recovered deep
pain in the 3rd or 4th weeks and so a final assessment
should not be made prior to 1 month post-surgery
(Scott and McKee, 1999; Olby et al., 2003). Recovery
of deep pain may take even longer for large-breed dogs
(Olby et al., 2003).
Studies show conflicting results for both the prognostic
value of the speed of onset of clinical signs and of spinal
cord swelling at myelography (Duval et al., 1996; Scott
and McKee, 1999; Olby et al., 2003). The prognosis
for dogs with LMN signs was no worse than those with
UMN signs (Dhupa et al., 1999b; Olby et al., 2003).
Furthermore, prognosis did not correlate with the duration of signs prior to surgery. Good results were still
obtained if surgery was performed within 48 h, or even
more than 72 h after onset of signs (Anderson et al.,
1991; Scott and McKee, 1999; Olby et al., 2003), which
is in contrast to the recommendations in many standard
textbooks. Taken together, these data suggest that a delay
in decompression of a few hours seems to make little difference to outcome, with the possible exception of dogs
THORACOLUMBAR DISC
DISEASE IN CATS
Neurological deficits caused by disc disease in cats are
more common than was thought previously. Affected
cats tend to be older but often have acute, type I
extrusions (8.10). Cats with neurological deficits
may not show back pain. Lesions are visible on CT
scan although subarachnoid contrast may be helpful.
Differential diagnoses to be considered include trauma,
neoplasia (lymphoma), inflammatory CNS disease
(feline infectious peritonitisFIP) and ischemic neuromyopathy (see Chapter 14). A diagnosis of feline disc
disease should only be made after thorough patient evaluation and neuroimaging (Knipe et al., 2001; Munana
et al., 2001). The response to surgery appears to be
equivalent to that reported in dogs.
133
134
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135
136
PROCEDURES
Dorsolateral hemilaminectomy (8.118.56)
Knowledge of how disc material is distributed threedimensionally across the vertebral canal at the
affected interspace(s).
Removal of a minimum of bone in order to access disc material and decompress the spinal cord. In
retrospect, the surgeon could have removed this disc material by mini-hemilaminectomy.
8.11
8.13
8.13
8.14
8.15
8.17
137
138
8.19
8.20
8.21
8.23
139
140
8.27
8.26
8.28
8.29
8.30
8.31
141
142
8.32
8.33
In order to remove the inner cortical bone, the surgeon makes fine movements of the bur as shown in 8.34.
Holding the drill close to the remaining plate of bone the surgeon makes fine movements, approximately 1 mm in
excursion, until the bur is felt to bite and cut away fragments of bone. The softness of the inner plate should be
tested often using the bur as a probe but with the power off. This method of drilling is continued until the inner
plate yields to gentle pressure, at which point it can be broken down with fine instruments. The surgeon should
again note that there is a seam of cortical bone at the level of the articular facet joint that unites the outer and
inner plates with no intervening cancellous bone.
8.34
8.35 Once through the inner cortical plate, the surgeon may want to
palpate the floor of the canal with instruments to clarify exactly how
the defect needs to be enlarged.
8.35
8.36
143
144
8.40
8.42
145
146
8.43
8.44
There has been a small volume, high-energy disc herniation causing an impact injury.
If landmarks confirm that the site is correct (8.20), the defect must be extended in whichever direction the spinal
cord appears most compressed or swollen (8.56, 8.61A). If the spinal cord still appears compressed after removal
of all visible disc material then it is possible that more material exists on the far side of the spinal cord (8.3, 8.6). The
defect may then have to be extended either to one side (8.45), dorsally (8.46) or bilaterally (Schulz et al., 1998).
8.45
8.47
A
B
8.48
147
148
8.49
Although durotomy may provide additional spinal cord decompression, the relative risks and benefits are not
clear (see page 87):
Local necrosis of gray matter over one or two spinal cord segments is common after severe injury and it is
not unusual for this material to ooze out after durotomy (8.50).
This does not necessarily indicate a poor prognosis, such as with complete spinal cord transection, or that
there is progressive myelomalacia (Salisbury and Cook, 1988).
It is only necessary for 510% of the white matter to survive in order for an animal to recover; this would
be very hard to quantify after durotomy (Blight and Decrescito, 1986; Basso et al., 1996; Jeffery and
Blakemore, 1999; Olby et al., 2003) (see Prognosis, page 132).
Durotomy should therefore not be used to infer prognosis (Muir et al., 1995); its use purely as an additional
decompressive procedure may warrant further study (Anderson et al., 1991; Bagley et al., 1996).
Routine use of durotomy is not yet recommended in dogs with grade 5 deficits, particularly as more than
half of these dogs recover without one (Muir et al., 1995) (see Prognosis, page 132).
There is a small risk of spinal cord herniation through the durotomy defect, which can cause severe
distortion and compression (Osterholm, 1974; Henry et al., 1997).
8.51
Rhizotomy improved the degree of decompression although it is not known if cutting the associated segmental
blood supply has any adverse effect on perfusion at that level.
149
150
8.55
Extensive hemilaminectomy does not appear to affect recovery rates but movement at the surgical site is
increased (Corse et al., 2002); this may cause delayed morbidity in some dogs (Anderson et al., 1991; Grevel and
Schwartau, 1997; Applewhite et al., 1999; Scott and McKee, 1999).
8.56
151
152
8.58
8.59
A
8.60
A
8.61
A
153
154
8.62
A
155
156
8.69
8.70
To fenestrate a disc:
The window is made by four separate stab incisions, which are joined at the corners.
The hole in the anulus must be made larger than any instrument used for removal of nucleus pulposus.
Disc removal is by small curette, a Rosen mobilizer or, failing that, by twisting the #11 blade.
It is important to remove as much nuclear material as possible, as any left will remain in the intervertebral
space and could cause a clinical problem later.
Power fenestration with a small drill bit may allow more complete evacuation (Holmberg et al., 1990). Care
must be taken to prevent the drill bit from slipping toward the foramen.
8.71
8.72
8.73
157
158
8.75
8.76
8.78
159
Atlantoaxial subluxation
Clinical signs
161
Diagnosis 163
Examination 163
Differential diagnosis
Radiography 163
163
Treatment 164
Non-surgical treatment
Surgery 165
Complications 167
Non-surgical treatment
Ventral fusion 167
Dorsal fixation 168
Postoperative care
Prognosis
164
167
169
169
169
170
170
Procedures 171
Ventral transarticular fixation 171
Multiple ventral implants and bone cement
Dorsal wire fixation 178
Dorsal cross-pin fixation 180
177
Chapter
CLINICAL SIGNS
Neck pain is seen in most dogs following traumatic
lesions and in 3060% of dogs with congenital lesions
(Thomas et al., 1991; Beaver et al., 2000). Neurological
signs reflect cervical spinal cord compression. In mild
cases only proprioceptive deficits are seen. Tetraparesis
indicates more significant spinal cord compression.
Asymmetry of signs, or preferential involvement of
162
9.1 3D reconstruction of CT scans; the dens is indicated by arrows. A: A normal toy-breed dog. B: A dog with atlantoaxial subluxation
and a malformed dens, which occupies much of the vertebral canal. The spinous process of C2 is also angled away from the arch of
the axis (arrowhead). Two-dimensional images of these dogs are shown in 9.6; sagittal 3D reconstructions in 9.19; postoperative
radiographs for dog B in 9.32.
9.2 A: Diagram to show the normal relationship between C1 and C2 (1.14, 1.35, 9.19). B: Congenital absence or hypoplasia of
the dens is the most common abnormality. C: There is an ossification center between the dens and the body of C2, which
predisposes to fracture or separation. D: Rupture or malformation of the ligaments.
Atlantoaxial subluxation
DIAGNOSIS
Examination
Atlantoaxial subluxation should be considered in any
young, small-breed dog with the clinical signs described.
Neurological examination indicates a lesion between
C1 and C5 and palpation of the neck often localizes
the origin of the pain to the C1C2 region. It is unwise
to flex the neck forcibly in a patient where atlantoaxial
Syringohydromyelia
Neoplasia
Intracranial disease
Discospondylitis
Polyarthritis
Polymyositis
Trauma
Differential diagnosis
The differential diagnosis for a small-breed dog with
cranial cervical signs is given in Box 9.1. Inflammatory
CNS disease is the most likely consideration in immature
dogs. Cervical disc disease is more likely in older dogs but
is rare in dogs less than 2 years of age. Discospondylitis or
fractures could be present at any age. Atlantoaxial subluxation is encountered in cats rarely (see page 169).
Radiography
SURVEY RADIOGRAPHY
Survey radiographs provide the diagnosis in most cases
(9.3). General anesthesia is usually required, although
great care must be taken when intubating the patient. If
non-surgical management is to be used following trauma
then it may be worth trying to obtain diagnostic images
without anesthesia (see page 283). However, accurate
positioning is essential to evaluate the cranial cervical
region and this may be impossible in the conscious patient,
particularly if severe neck pain is present (see page 46).
It is a common error to diagnose congenital atlantoaxial
subluxation on radiographs of conscious dogs where the
positioning is inadequate and the region of interest is
far from the center of the film. Fluoroscopic observation
while flexing the neck gently in a conscious animal can
provide rapid and accurate diagnosis by revealing the
dynamic nature of the lesion while allowing the animal to
maintain some protective muscle tone.
The lateral projection is the most useful. Mild flexion
of the cranial cervical region may be required to demonstrate misalignment but this must not be excessive. A
ventrodorsal view will highlight the dens; it is safe to
position the dog in dorsal recumbency with the neck
extended for the ventrodorsal projection, which is
preferable to the open-mouth view. Oblique radiographs
can also provide an excellent image of the dens (9.3B,
9.4B) (Cook and Oliver, 1981).
163
164
9.4 Eight year-old Bull mastiff with acute pelvic limb ataxia. Survey radiographs revealed severe hypoplasia of the dens; a lumbar
myelogram revealed no other abnormality. A: Flexed view and B: extended view of C1 and C2. Note the narrowing of the dorsal
subarachnoid space and the hypoplastic dens (arrowhead). Neurological deficits worsened after the myelogram but the dog made
a good recovery and had no neurological deficits 4 months later. Subclinical atlantoaxial malformation has been reported in humans
(McKeever, 1968).
B
9.6 A: CT scan through the atlas of a
normal toy-breed dog. The dens is of
normal size and occupies the floor of the
vertebral canal. B: Dog with a malformed
dens. The same dogs are also shown
in 9.1 and 9.19.
MYELOGRAPHY
Myelography should not be necessary for diagnosis and
any post-myelographic seizures could be disastrous.
Cerebello-medullary cistern puncture either for myelography or CSF sampling should not be performed in
dogs that could have atlantoaxial subluxation (9.5);
lumbar puncture is preferable.
CT AND MRI
Although much simpler techniques are available to
assess atlantoaxial stability, advanced imaging can add
important preoperative information (Johnson and
Hulse, 1989) (9.6, 9.12). CT provides excellent bone
TREATMENT
Non-surgical treatment
Non-surgical treatment entails cage rest, application of
a neck brace (13.18) and use of analgesics (Tables 15.1,
Atlantoaxial subluxation
9.7 Sagittal MRIs of a dog with atlantoaxial subluxation. A: T2-weighted and B: short tau inversion recovery (STIR) images.
Note the high signal intensity (edema) and severe spinal cord compression at C1C2 (arrowheads).
Survey radiographs
Malformed dens
Normal or
hypoplastic dens
Consider odontoidectomy
Failure
Success
CT scan
Dorsal cross
pinning
External
splint
Replace implant
Surgery
Surgical treatment is indicated in most patients with
congenital lesions. Even dogs with profound neurological
deficits are likely to benefit from stabilization (Thomas
et al., 1991; Beaver et al., 2000). The two main options
are either ventral fusion or dorsal stabilization. Ventral
fusion is the treatment of choice. An algorithm for surgical decision-making is shown in Algorithm 9.1.
165
166
(1)
(2)
(6)
Total
transarticular
(5)
(4)
(3)
Total
multiple
31/40 (78)
9/10 (90)
8/18 (44)
48/68 (71)
5/6 (83)
5/6 (83)
12/13 (92)
22/25 (88)
Median follow-up
months
12 (mean)
N/A
21
N/A
36
6/31 (19)
N/A
N/A
6/31 (19)
0/5
N/A
4/13 (31)
4/18 (22)
3/31 (10)
N/A
N/A
3/31 (10)
0/5
N/A
0/13
0/18
4/35 (11)
0/9
3/18 (17)*
7/62 (11)
0/5
1/23 (4)
Mortality (%)
5/40 (13)
1/10 (10)
7/18 (39)
13/68 (19)
1/6 (17)
0/6
2/25 (8)
1/13 (8)
(1) Beaver et al., 2000; (2) Denny et al., 1988; (3) Knipe et al., 2002; (4) Sanders et al., 2000; (5) Schulz et al., 1997; (6) Thomas et al., 1991.
* Two of these recovered.
** Signs recurred but did not actually undergo second surgery.
N/A, not available.
VENTRAL FUSION
Fusion of the atlantoaxial joints can be performed using
either transarticular fixation (9.8) or using multiple
implants and bone cement (9.329.34). Good results
can be obtained using transarticular fixation; threaded
pins or screws give superior results to smooth pins.
However, there is little margin for error with only
two implants and overall failure rates approach 30%
with transarticular fixation (Table 9.1). Furthermore,
radiographic evidence suggests that fusion is often
delayed or incomplete (Thomson and Read, 1996;
Beaver et al., 2000). Multiple implant techniques
should reduce the failure rate; they add little technical
difficulty and almost certainly provide more rigid
fixation (Schulz et al., 1997; Sanders et al., 2000;
Knipe et al., 2002) (9.329.34). Use of multiple
DORSAL STABILIZATION
Dorsal wiring has a high failure rate (Table 9.2), such
that many animals need repeat surgery (9.11). Reinforcement with bone cement may be useful but any thermal
necrosis could weaken the bone further (Renegar and
Stoll, 1979; Cook and Oliver, 1981; Martinez et al.,
1997). It does provide an option should ventral fusion
fail (Beaver et al., 2000), but a second attempt at fusion
using multiple implants or by dorsal cross-pinning are
more logical approaches (Thomas et al., 1991; Jeffery,
1996; Schulz et al., 1997; Sanders et al., 2000).
Atlantoaxial subluxation
(2)
(3)
(4)
Total dorsal
9/12 (75)
6/6 (100)
7/13 (54)
2/7 (29)
24/38 (63)
23
N/A
N/A
4/9 (44)
5/6 (83)
N/A
N/A
9/15 (60)
1/9 (11)
0/6
N/A
N/A
1/15 (6)
2/11 (18)
2/6 (33)
N/A
3/7 (43)*
7/24 (29)
Mortality (%)
1/12 (8)
0/6
5/13 (38)
0/7
6/38 (16)
(1) Beaver et al., 2000; (2) Chambers et al., 1977; (3) Denny et al., 1988; (4) Thomas et al., 1991.
* One dog recovered.
COMPLICATIONS
The most common non-surgical and surgical complications are listed in Table 9.3.
Non-surgical treatment
The splinted animal must initially be assessed daily for
problems (Table 9.3), including the tendency for moisture to seep into the splint around the mouth. Dyspnea
can occur if the splint is too restrictive in the pharyngeal
or thoracic regions but it must also be tight enough to stay
in place (Schulz et al., 1997). Aspiration is a particular
problem if the neck is extended excessively as it is almost
impossible for the dog to swallow in this position.
Nasogastric or gastrostomy feeding may reduce the risk
of aspiration and also helps to keep the splint clean
(Shelton et al., 1991).
Ventral fusion
The ventral approach to the neck is straightforward but
care must be taken to avoid damage to vital structures,
particularly the recurrent laryngeal nerve and the vascular supply to the thyroid gland. Particular care must be
taken to prevent excessive traction or compression on
the trachea and esophagus (Thomas et al., 1991).
The main complications are death, or implant failure
that necessitates a second surgery (Table 9.3). The
primary causes of death are cardiac or respiratory arrest
and pulmonary edema (Thomas et al., 1991; Schulz
et al., 1997; Beaver et al., 2000). One potential cause of
pulmonary edema is barotrauma; care must be taken
when ventilating toy-breed dogs (see page 85).
Implant failure is more likely after ventral transarticular fixation than after use of multiple implants. The main
Surgical
complications
Dyspnea
Aspiration
Abrasions
Decubitus
Otitis externa
Dermatitis
Recurrence
Cardiac arrest
Respiratory arrest
Pulmonary edema
Implant failure (9.11, 9.31)
Soft tissue injury
Tracheal collapse
167
168
9.9 A: Postoperative radiographs from a 1-year-old Toy poodle show K-wires with bone cement over the exposed ends. Angles are
mediolateral: left 53 and right 55; ventrodorsal angle is 2530. B: Failure occurred as one implant is anchored only poorly in C1.
An external splint was applied but both pins had failed by 5 weeks. The splint was maintained for 12 weeks in all; the dog was
pain-free with no deficits 4 years later apart from a lump on its neck from a migrated pin. A metallic skin staple is visible.
Dorsal fixation
The main complications are death or failure of fixation.
Death is due to cardiac or respiratory arrest, which
may occur during placement or tightening of the wires
(Denny et al., 1988). The wire suture can also break or
cheese-wire though C2 spinous process (Beaver et al.,
2000; Thomas et al., 1991)(9.11). Almost 30% of dogs
Atlantoaxial subluxation
require a second surgery after standard dorsal fixation (Table 9.2). Other failures reported after dorsal
wiring include wire suture breakage and fracture of the
spinous process of C2 (Chambers et al., 1977; Thomas
et al., 1991; Beaver et al., 2000).
POSTOPERATIVE CARE
PROGNOSIS
The prognosis for dogs with congenital lesions is good
if the animal survives the perioperative period (Beaver
et al., 2000). The best predictor of a successful outcome is when the onset of signs is prior to 2 years of
age (Beaver et al., 2000). The final outcome also tends
to be better if signs have been present for less than
ATLANTOAXIAL SUBLUXATION
IN CATS
Clinical signs of congenital luxation are similar to those
seen in dogs. All three cats described had good outcomes after transarticular pin fixation (Jaggy et al.,
1991; Shelton et al., 1991; Thomson and Read, 1996).
Differential diagnoses for cats include disc disease (see
Chapter 8), mucopolysaccharidosis, hypervitaminosis
A (see Chapter 14), lymphoma or other spinal cord
tumors (see Chapter 12), trauma (see Chapter 13),
meningoencephalitis, discospondylitis and possibly
fibrocartilaginous embolism (FCE) (see Chapter 14).
169
170
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Barchard, C. (2000) Risk factors affecting the outcome of surgery for
atlantoaxial subluxation in dogs: 46 cases (19781998). Journal of the
American Veterinary Medical Association 216, 11041109.
Chambers, J.N., Betts, C.W., Oliver, J.E. (1977) The use of nonmetallic
suture material for stabilization of atlantoaxial subluxation. Journal of the
American Animal Hospital Association 13, 602604.
Cook, J.R., Oliver, J.E. (1981) Atlantoaxial luxation in the dog. Compendium
on Continuing Education for the Practicing Veterinarian 3, 242250.
Denny, H.R., Gibbs, C., Waterman, A. (1988) Atlantoaxial subluxation in
the dog: a review of thirty cases and an evaluation of treatment by lag
screw fixation. Journal of Small Animal Practice 26, 3747.
Gibson, K.L., Ihle, S.L., Hogan, P.M. (1995) Severe spinal cord compression
caused by a dorsally angulated dens. Progress in Veterinary Neurology 6,
5557.
Hawthorne, J.C., Cornell, K.K., Blevins, W.E., Waters, D.J. (1998) Nonsurgical treatment of atlantoaxial instability: A retrospective study.
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Huibregtse, B.A., Smith, C.W., Fagin, B.D. (1992) Atlantoaxial luxation in
a Doberman Pinscher. Canine Practice 17, 710.
Hurov, L. (1979) Congenital atlantoaxial malformation and acute subluxation in a mature Basset Houndsurgical treatment by wire stabilization.
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Jaggy, A., Hutto, V.L., Roberts, R.E., Oliver, J.E. (1991) Occipitoatlantoaxial malformation with atlantoaxial subluxation in a cat. Journal of Small
Animal Practice 32, 366372.
Jeffery, N.D. (1996) Dorsal cross pinning of the atlantoaxial joint: new
surgical technique for atlantoaxial subluxation. Journal of Small Animal
Practice 37, 2629.
Johnson, S.G., Hulse, D.A. (1989) Odontoid dysplasia with atlantoaxial
instability in a dog. Journal of the American Animal Hospital Association
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Knipe, M.F., Sturges, B.K., Vernau, K.M., Berry, W.L., Dickinson, P.J.,
Anor, S., LeCouteur, R.A. (2002) Atlantoaxial instability in 17 dogs.
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LeCouteur, R.A., Child, G. (1995) Diseases of the spinal cord. In:
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Lorinson, D., Bright, R.M., Thomas, W.B., Selcer, R.R., Wilkens, B.A. (1998)
Atlantoaxial subluxation in dogs: the results of conservative and surgical
therapy. Canine Practice 23, 1618.
Martinez, S.A., Arnoczky, S.P., Flo, G.L., Brinker, W.O. (1997) Dissipation
of heat during polymerization of acrylics used for external skeletal fixator connecting bars. Veterinary Surgery 26, 290294.
Mayhew, I.G. (1999) The healthy spinal cord. American Association of
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McCarthy, R.J., Lewis, D.D., Hosgood, G. (1995) Atlantoaxial subluxation in
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McKeever, F.M. (1968) Atlantoaxial instability. Surgical Clinics of North
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Renegar, W.R., Stoll, S.G. (1979) The use of methylmethacrylate bone
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Atlantoaxial subluxation
PROCEDURES
The patient is placed with the neck in extension; this helps to reduce the subluxation. Although positioning the
neck like this helps, reduction of C1 and C2 is usually incomplete. The mid-body of C2 must be grasped with
bone holding forceps and pulled in a caudoventral direction (9.19). Breaking down the joint capsule may also be
necessary to complete reduction. Occasionally malformation or secondary changes make complete reduction
impossible (9.32). The approach can either be the standard ventral approach (see page 106) or the paramedian
approach to the neck (see page 232). Preserving the thyroid artery (9.18) is much easier when using the paramedian approach as the carotid artery and its thyroid branch are reflected along with the trachea and larynx. The
dogs head is to the left in all illustrations.
9.13
9.14
a
b
9.15
171
172
9.16
9.17
9.19
Atlantoaxial subluxation
9.20
9.21
9.22
9.23
173
174
9.24
9.25
9.26
Atlantoaxial subluxation
The following order for drilling, tapping and screw placement is preferred:
1. Drill both 1.1-mm holes in C2.
2. Drill 1.1-mm hole through one of these holes into C1 on one side only. Insure that far cortex is penetrated.
3. Drill 1.5-mm glide hole on the same side in C2.
4. Measure depth of the hole through C2 into C1.
5. Tap this hole with 1.5-mm tap.
6. Place screw through C2 into C1. Do not tighten fully.
7. Repeat steps 2 to 6 on the other side.
Performing the operations in the order shown above avoids the problem of drilling holes and not being able to
locate one after the other screw has been tightened. A similar sequence can be used with threaded pins. These
still require a pilot hole and should be inserted using a low power setting or ideally with a small hand-held chuck
(5.22). Pins must also be encased completely within bone cement (Johnson and Hulse, 1989). Cannulated
screws provide another alternative as they permit repositioning of the guide wires if necessary before placing
screws. These screws are self-tapping and come in 4.0- and 3.0-mm diameters (Rochat and Shores, 1999).
The average mediolateral pin angle in dogs undergoing a successful stabilization was between 22 and 27,
with a theoretical ideal of 29 and a practical range of 10 and 45. If implants are directed too laterally across the
atlantoaxial joints, they may damage the vertebral artery; if directed too medially they may damage spinal cord
(Rochat and Shores, 1999). The average ventrodorsal angle in the same dogs was between 28.5 and 34.5 with
a theoretical ideal of 22 and a practical range of 15 and 45 (9.8, 9.29, 9.31). The theoretical ideal ventrodorsal
angle is hard to approach and in practice the angle should be as near horizontal as possible. Starting the implants
as far caudally as possible in C2 may facilitate this (Sorjonen and Shires, 1981; Jaggy et al., 1991). Malformation
of C1 or C2 can make assessment of the correct angles very difficult (Thomas et al., 1991). Use of a goniometer
during surgery may help improve accuracy (Thomson and Read, 1996). Vertebral positioning must also be perfectly symmetrical.
Odontoidectomy is usually described prior to reduction but may be easier and safer once the joint is reduced
and stabilized (Johnson and Hulse, 1989; Jaggy et al., 1991; Gibson et al., 1995) (9.27). Access to the dens is
through a short slot in C1. Odontoidectomy is recommended if the dens has a marked dorsal angulation (Swaim
and Greene, 1975; Johnson and Hulse, 1989; Jaggy et al., 1991; Gibson et al., 1995) but is not necessary in
most dogs (Schulz et al., 1997).
9.27
175
176
9.28
9.29
A
9.31 The screw on the left is not angled adequately away from the midline
and was probably not crossing the joint. It snapped soon after
surgery and the dog had a partial recurrence of signs. The dog was
managed by addition of an external support and made a good
recovery. Angles are mediolateral: left 14 and right 41.
9.31
Atlantoaxial subluxation
177
178
9.35
9.36
Atlantoaxial subluxation
9.37
9.38
9.39
9.40 The loop of wire is retrieved from the atlantooccipital space. This space may need to be
enlarged in order to grasp the wire. This is best
achieved by removing bone from the occiput,
thus preserving the dorsal arch of C1 required
for the fixation.
9.40
179
180
9.41
9.42
9.43
A
Lumbosacral disease
Clinical signs
Chapter
10
183
Diagnosis 183
Examination 183
Differential diagnosis 184
Electrophysiology 184
Radiography 185
Treatment 188
Non-surgical treatment 188
Surgical treatment 188
Surgery 189
Dorsal laminectomy 189
Foraminal decompression or facetectomy
Dorsal fusionfixation 190
190
Complications 191
Intraoperative 191
Early postoperative 191
Late postoperative 191
Postoperative care
Prognosis
192
192
193
193
Procedures 195
Dorsal laminectomy 195
Foraminal decompression and facetectomy
Dorsal fixationfusion 204
202
182
10.2 A: Sagittal section to show the normal relationship between L7 and the sacrum. B: 3D reconstruction from a dog with a
normal lumbosacral spine (same dog as in 2.24). The dog was free of signs for lumbosacral disease and a transverse CT study
through this region was normal (10.10A).
10.4 A: Ventral subluxation of the sacrum relative to L7. This may occur in normal dogs, although a step of more than 4 mm
suggests an abnormal lumbosacral junction (Wright, 1980; Denny et al., 1982; Schmid and Lang, 1993). B: Six-year-old working
German shepherd dog presenting with mild paraparesis, weak hock flexion and lumbosacral pain. The dog was seropositive for
Ehrlichia canis and returned to work after antibiotics; the subluxation did not seem to cause any clinical signs (3.2, 4.35).
Lumbosacral disease
CLINICAL SIGNS
Lumbosacral lesions can cause pelvic limb gait abnormalities, lameness, or lower motor neuron (LMN) neurological deficits. Pain is common but additional signs vary
depending on the nature and severity of the neurological
impairment (McKee, 1993) (Table 10.1). There may be
pain with no deficits; mild paresis with proprioceptive
deficits; or paraparesis, tail paralysis and incontinence
(Oliver et al., 1978; de Risio et al., 2001). Limb signs
include lameness or sciatic deficits affecting the caudal
thigh muscles and those distal to the stifle (Tarvin and
Prata, 1980; Meij et al., 1993). Lameness in performance
animals is often exacerbated by work (Jones et al., 2000).
Severe
DIAGNOSIS
Examination
Clinical signs may be vague in some dogs, which makes
accurate diagnosis difficult. A thorough physical,
orthopedic and neurological examination is essential,
along with a rectal examination. In view of the difficulty in interpreting some of the ancillary diagnostic
tests the clinical signs may provide the main basis for
reaching a diagnosis (Table 10.1).
The anal reflex, sphincter tone and tail tone should
be evaluated. Reduced or absent hock flexion during
the withdrawal reflex (2.27) is a sensitive indicator of
motor dysfunction in the sciatic nerve (but mild lesions
will only cause loss of proprioception). The patellar
reflex may also appear exaggerated if sciatic nerve
function is depressed. This phenomenon of pseudohyperreflexia must be differentiated from the increased
reflex that occurs with upper motor neuron (UMN)
deficits seen with lesions cranial to the L4 segment.
Pseudohyperreflexia results from decreased tone in the
muscles innervated by the sciatic nerve, which normally
183
184
Differential diagnosis
Differentials vary depending on whether the dog has
non-specific signs or obvious neurological deficits (Table
3.5 and 10.2). Dogs with the orthopedic diseases listed
in Table 10.2 have a normal neurological examination.
Dogs with pain and no neurological deficits could have
synovial cysts (Webb et al., 2001); tethering of the dural
sac (Huttmann et al., 2001; Shamir et al., 2001); inflammation of disc, meninges or nerve root; or possibly either
facet or sacroiliac joint pain (Pang et al., 1998) (see
Chapter 14). Dogs with degenerative myelopathy are
pain free and the withdrawal reflex is normal, but the
patellar reflex may be depressed because of dorsal nerve
root involvement (see Chapter 14). It may not be possible to differentiate degenerative lumbosacral disease,
discospondylitis and neoplasia on physical examination.
In some dogs, disorders such as degenerative myelopathy
(10.53) or a thoracolumbar disc(s) may coexist with
lumbosacral disease and this can confound the neurological localization (2.24). The deficits of lumbosacral disease are referable to the L4S3 nerve roots and so may
be difficult to differentiate from L4S3 lesions that
are situated within the dural sac (2.25). In such dogs,
Electrophysiology
Clinical electrophysiological studies are useful to confirm
LMN disease and nerve root dysfunction (Sisson et al.,
1992; Meij, 1993; de Risio et al., 2001; Cuddon, 2002;
Cuddon et al., 2003) (see page 60). Electromyography
of the limbs, tail and perineum may reveal spontaneous
activity, which is consistent with LMN involvement.
However, a normal electromyogram does not eliminate
the possibility of lumbosacral disease (de Risio et al.,
2001). Electromyography is particularly useful to reduce
the number of false-positive diagnoses associated with
MRI evidence of nerve root disorders (Nardin et al.,
1999) (see page 60). Nerve conduction studies and Fwave latencies may also be useful (Cuddon, 2002;
Cuddon et al., 2003) (see page 61). Abnormal findings
confirm LMN disease but do not specify the etiology.
Severe neurological
deficits
Degenerative myelopathy
Ischemic myelopathy
Ischemic neuromyopathy
Neoplasia
Discospondylitis or epidural
abscess
Polyradiculoneuritis
Myelitis
Trauma
Lumbosacral disease
Radiography
SURVEY RADIOGRAPHY
It is advisable that the patient be anesthetized or
sedated heavily when radiographing the lumbosacral
joint. Rotation of the spine and pelvis must be avoided
(4.14, 4.15). The value of flexed and extended positional survey radiographs appears limited (Mattoon and
Koblik, 1993; Schmid and Lang, 1993). The main role
of survey radiographs is to rule out neoplasia (12.11A),
trauma (13.21) and discospondylitis (14.12).
Many clinically normal dogs have radiographic abnormalities of the lumbosacral junction (10.5). Conversely,
occasional dogs with lumbosacral disease will have
MYELOGRAPHY
10.6 A, B: Five-year-old German shepherd dog with lumbosacral pain. Sacral OCD is present; the fragment moves with flexion and
extension (Lang et al., 1992). Subluxation of the articular facets (arrowhead) with foraminal narrowing is also evident (10.11, 10.46).
C: Four-year-old dog with transitional vertebra and left nerve root signature. 3D reconstruction of the CT scan shows foraminal
narrowing on the left due to a large articular facet (10.9). There is only one transverse process (arrow); the other is fused to the ilium.
185
186
COMPUTED TOMOGRAPHY
CT is particularly useful as it shows clearly the vertebral
canal (10.10), lateral recesses (1.28), intervertebral
foramina (1.26, 1.27) and articular processes (10.9) in
cross-sectional images (Jones et al., 1995a, 1996b).
Reformatting can be used to create dorsal and sagittal
images (10.11) and facet joint subluxation may be visible using bone window images or 3D reconstructions
(Jones et al., 1994; Meij et al., 1996) (10.6, 10.48). CT
can also be used for dynamic studies (10.11) and is helpful when performed after surgery (Meij et al., 1996;
Jones et al., 2000) (10.54). The primary abnormalities
visible on CT are a replacement of epidural fat with soft
tissue density (10.10), which often represents epidural
fibrosis, and multilevel compression (Jones et al., 1996b)
(10.17). Use of intravenous contrast may improve surgical decision-making by identifying compressed tissues,
which tend to enhance (Jones et al., 1999) (10.40).
Some CT findings, such as loss of epidural fat, may not
be of clinical significance in older animals (Jones and
Inzana, 2000). In contrast to MRI, CT offers lower cost
B
10.7 Seven-year-old German shepherd dog with mild paraparesis
and lumbosacral pain. There is a change in the degree of
compression at the lumbosacral space between flexion and
extension. A: Good filling of the dural sac when the spine is
flexed; mild disc herniation is present at L6/7. B: There is dorsal
displacement of the dural sac in extension and marked
attenuation of contrast filling from L6/7 caudally. Fixation fusion
was done using two screws and a bone graft but fixation was
suboptimal (10.16).
10.8 A: Discogram demonstrating a large disc herniation. B: The needle was then withdrawn slightly to perform the
epidurogram, which also outlines the bulging disc. Attenuation of more than 50% of the canal is considered abnormal (Ramirez
and Thrall, 1998).
Lumbosacral disease
and thinner slice thickness along with better discrimination of bone spurs, articular process disease, soft tissue
calcification, and soft tissue gas opacities (Jones et al.,
2000). Scans should include at least the L6 vertebral
body and, ideally, additional images should also be made
through the L4/5 and L5/6 disc spaces (10.17).
MRI
This provides better soft tissue resolution than CT as
well as an ability to acquire images in multiple planes
without image degradation; earlier detection of disc
degeneration (1.9, 4.68) and evaluation of the entire
lumbar spine in a single sagittal examination (Ramirez
and Thrall, 1998; Jones et al., 2000) (1.9, 2.25, 10.12).
Slice thickness is often greater than for CT, however,
which increases volume averaging artefacts (Jones et al.,
2000). Transverse images provide the best visualization
of disc or foraminal anatomy (Adams et al., 1995) (1.9).
They also reveal lesions in a foramen that cannot be
detected by myelography or epidurography (Chambers
et al., 1997). Sagittal views made with the spine in
flexion and then extension help to identify a dynamic
B
10.10 A: Transverse CT scan at the level of the L7/S1 disc in a
dog with a normal lumbosacral spine. The nerve roots and
dural sac are surrounded by epidural fat. Same dog as in 10.2.
B: In this dog (also shown in 10.3) there is almost complete loss
of epidural fat and a general increase in soft tissue opacity.
B
10.9 Marked foraminal compression is evident on A: transverse
CT scan, and B: 3D reconstruction. Same dog as in 10.6C.
187
188
clinical signs and this must be considered prior to instituting treatment (Deyo, 1994; Jensen et al., 1994; Jones
and Inzana, 2000). A herniated disc is detected in a high
proportion of people who have never had spinal pain and
so imaging alone, both in dogs and in humans, should not
serve as confirmation of a clinical diagnosis (Gorman and
Hodak, 1997). Electrophysiological testing provides an
additional means of independent confirmation of lesions
(Nardin et al., 1999).
TREATMENT
Non-surgical treatment
Most dogs are treated initially with rest and antiinflammatory medication (Table 15.2). This may be successful if pain is the main clinical sign; 34 months of
exercise restriction produced improvement in 8/16 dogs
(50%) (Ness, 1994). Such a course is seldom effective in
working dogs and signs often recur when normal activities are resumed (Danielsson and Sjostrom, 1999;
Janssens et al., 2000; Sjostrum, 2003).
Surgical treatment
Surgical treatment is indicated when non-surgical treatment has failed; in working dogs; and in those with pain
or neurological deficits (Sjostrum, 2003). Further indications for surgery include CT or MR findings of increased
soft tissue suggestive of epidural fibrosis, especially if it
enhances with contrast. The choice of surgical procedure
is then between dorsal laminectomy, distraction and
fusion, or a combination of the two. Definitive criteria for
these procedures are lacking. Laminectomy alone is not
effective for dogs with chronic incontinence (de Risio
et al., 2001). Fusion alone may be insufficient for dogs with
neurological deficits or severe pain (Slocum and Devine,
10.12 T2-weighted MRIs of a 7-year-old Labrador with lumbosacral pain. A: Image made with the spine in flexion. There is loss of
signal in the L7/S1 disc but little compression of the cauda equina (arrowhead). B: Image from the same dog with the spine in
extension. There is severe compression at L7/S1 caused by both disc and ligamentum flavum (arrowhead). A large disc herniation
was confirmed at surgery.
Lumbosacral disease
SURGERY
Dorsal laminectomy (10.1810.39)
Decompression of the cauda equina and spinal nerves can
be achieved by dorsal laminectomy (10.13), which can
be combined with foraminal decompression or even facetectomy (10.4010.45). The anulus fibrosus should be
Pain, mild
Neurological
deficits or
severe pain
without
incontinence
Dorsal
laminectomy
+/ foraminal
decompression
Fixation
fusion
Incontinence
Severe
radiculopathy
Severe
instability
on imaging
Dorsal
laminectomy, +/
foraminal
decompression
AND fixation
fusion
Dorsal laminectomy,
foraminal
decompression
or facetectomy
+/ fusion
10.13 Postoperative appearance 1 year after dorsal laminectomy; this dog remained painful until it underwent a fixation fusion
(10.53). An asterisk indicates the L7/S1 disc space. A: Mid-sagittal 3D reconstruction after CT scan. B: Dorsal view of the 3D
reconstruction shown in A. Same dog as shown in 10.6A,B, 10.11 and 10.46.
189
190
Foraminal decompression or
facetectomy (10.4010.45)
An increase in soft tissue within the foramen, loss of
epidural fat or facet osteophytosis are indicators of probable radiculopathy (Adams et al., 1995; Jones et al.,
1996b). Contrast enhancement after CT or MRI further
increases preoperative suspicion of foraminal disease
(Jones et al., 1999, 2000) (10.40). Together with radicular pain and delayed late waves (see Chapter 4), these
features are indicators for some form of foraminal
decompression (Oliver et al., 1978; Chambers et al.,
1988). The laminectomy can be simply undercut or
widened over the foramen and any osteophytes can also
be removed by undercutting (10.4110.43). However,
the foramen can be difficult to examine fully until the
facet is removed (Watt, 1991). The risks and benefits of
facetectomy are unclear as is the need for subsequent
stabilization (Slocum and Devine, 1998) (10.45).
Lumbosacral stiffness is decreased markedly after bilateral facetectomy (Smith and Bebchuk, 2002).
Chambers et al.,
1988
Danielsson and
Sjostrom, 1999
Risio et al.,
2001
Dogs (n)
10
26
131
69
9 (90)
19 (73)
122 (93)
54 (78)
13 (148)
21 (255)
26 /17 (573)
38 /22 (696)
18
N/A
36
Incontinence resolved
3/4
1/8
N/A
5/11
Lumbosacral disease
COMPLICATIONS
Early postoperative
Seroma formation is particularly likely in the lumbosacral region if there is any dead space (Oliver et al.,
1978; Slocum and Devine, 1986; Chambers et al.,
1988; Watt, 1991; Ness, 1994). Infection can occur,
especially as some dogs have established urinary tract
infection (UTI) (Oliver et al., 1978). Occasionally, a dog
may be unable to void after surgery because of increased
sympathetic tone (10.3), analogous to that seen after
sacrocaudal injury (see page 351).
If pain persists after surgery this suggests implant failure, residual compression or possibly instability (10.53).
Intraoperative
The surgeon must be vigilant while using a scalpel in the
vertebral canal to fenestrate the L7/S1 disc, and also
while using a bur to undercut a facet, to avoid inadvertent
damage to the cauda equina. In some cases an AO drill
guard can be used to protect neural tissues from the bur.
The base of the L7 articular process must not be thinned
excessively (10.41, 10.42), especially when foraminal
decompression is performed. In addition, over-tightening
must be avoided when placing a screw across the L7/S1
facet or the facet could fracture. When placing screws,
the drill bit, tap and screw must not extend beyond the
Intraoperative
Iatrogenic nerve
root injury
Fracture of L7
articular facet
Poor implant
position (10.16)
Spinal nerve injury
Inadequate
decompression
Early
postoperative
Late
postoperative
Implant failure
Instability (10.16)
Dorsal seroma
Infection
Increased sphincter
tone
Implant failure
Recurrence of
signs (10.53)
Dural herniation
Scar formation
Infection (10.45)
Late postoperative
Implant loosening or failure is always a risk after instrumented fusion (Fox et al., 1996; Gibson et al., 2002).
It is usually due to poor implant selection or suboptimal technique (10.16). Sometimes implant failure does
not cause clinical problems, especially if physiological
fusion progresses fast enough (Slocum and Devine,
1986; Bagley, 2003) (10.14, 10.53).
Postoperative imaging for recurrent lumbosacral pain
may reveal residual disc material or fibrous scar, especially when intravenous contrast is used (Jones et al.,
1999, 2000). Postoperative scarring has been reported
in several studies (Adams et al., 1995; Danielsson and
Sjostrom, 1999; Risio et al., 2001). Herniation of the
dural sac through the laminectomy defect has also been
reported; this may be secondary to tearing of the dura
(Lang, 1988; Markwalder, 1993; Fox et al., 1996). Patient
age and operative time are predictors of complications
in humans undergoing lumbar disc surgery (Stolke
et al., 1989). Additional reasons for failure to improve
include surgery done at the wrong site, insufficient
191
192
10.16 A: Eight week follow-up radiograph reveals implant failure due to poor
technique. The screws were put in at too
steep an angle in the sagittal plane.
Immediate postoperative radiographs
and fluoroscopy showed the screws to
be in bone and not the disc space; the
dog was confined in the hope that fusion
would occur before implant failure. One
screw has now backed out (10.14,
10.15, 10.53). B: 3D reconstruction
shows the screws also do not diverge
sufficiently from each other in a transverse plane (10.50).
A
POSTOPERATIVE CARE
PROGNOSIS
Laminectomy provides rapid relief of pain in most dogs.
Similarly, lameness and mild neurological deficits usually
improve rapidly. More severe deficits probably carry a
less favorable prognosis (Denny et al., 1982; Chambers
et al., 1988; Chambers, 1989). Few studies document
long-term follow-up after lumbosacral surgery. Studies
with mean follow-up periods beyond 1 year show overall
success rates from 73 to 93% (Table 10.3). The presence
Lumbosacral disease
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PROCEDURES
Dorsal laminectomy (10.1810.39)
Discectomy may or may not provide additional benefit to laminectomy although it is logical for dogs in which the
disc is causing significant compression (Danielsson and Sjostrom, 1999; Janssens et al., 2000; de Risio et al.,
2001). A cancellous bone graft can be placed into the disc space following curettage and this may enhance
fusion (Auger et al., 2000) (10.52, 14.12).
10.19
195
196
10.20 Here the upper instrument is over the lumbosacral space, and the lower instrument on the
wing of the left ilium.
10.20
10.21
b
a
10.22
10.23
Lumbosacral disease
10.24 The muscles are elevated from the spinous processes and retracted. The L6
(a), L7 (b), and sacral (c) spinous
processes are visible. Note that the spinous process of L6 is taller than L7.
c
b
10.24
10.25
c
b
10.26
a
10.27
197
198
10.28
b
a
10.29
10.30
Lumbosacral disease
10.31
10.32
10.33
199
200
10.34
10.35
10.36
10.37
c d
Lumbosacral disease
10.38
A
201
202
10.41
Lumbosacral disease
10.42
10.43
203
204
10.46
A
Lumbosacral disease
10.47
A
205
206
10.48
A
Lumbosacral disease
10.49
A
10.50
207
208
10.52
A
Lumbosacral disease
10.54 3D reconstruction of a CT
scan made after fusion using
bone screws and graft
(same dog as 10.53). Areas
of new bone production are
shown (white arrows). The
black arrowhead indicates
the position of the sacral
spinous process; above it is
the bent spinous process of
L7 (white arrowhead).
10.54
209
Cervical spondylomyelopathy
Clinical signs
Chapter
11
Ligamentous hypertrophy.
Joint capsule proliferation or cyst formation.
Osteophyte production.
Disc herniation.
Vertebral malformation and canal stenosis may be present at birth in the Doberman, suggesting either a congenital or inherited disorder (Burbidge, 2001; Drost
et al., 2002) (11.1).
An early onset of clinical signs is most common in
giant-breed dogs. Most other breeds show clinical signs
from middle age onwards. These usually develop due to
212
Diagnosis 212
Radiography 213
Presurgical evaluation 216
Hypothyroidism 217
Bleeding disorders 217
Treatment 217
Non-surgical treatment 218
Surgical treatment 218
Complications 224
Intraoperative complications 224
Early postoperative complications 226
Late postoperative complications 228
Postoperative care 228
Prognosis
229
229
229
Procedures 232
Paramedian approach to the ventral neck 232
Ventral decompression 233
Vertebral distraction 235
Cement plug 237
Metal implant and bone cement method 239
Dorsal decompression 241
Laminoplasty 245
212
acquired soft tissue or osseous lesions, which are probably a consequence of low-grade instability. Compression
is seen mainly at C5/6 and C6/7 in the Doberman but
lesions in other breeds often affect more cranial disc
spaces.
Both C5/6 and C6/7 sites are at high risk of causing
spinal cord compression; twenty per cent of dogs present with both C5/6 and C6/7 lesions at the time of
initial diagnosis. In addition, if either one of these
intervertebral spaces fuses then the other one seems
even more likely to cause compression (Bruecker et al.,
1989a). Any surgical procedure should therefore
address all high-risk spaces in an individual animal
(Dixon et al., 1996; Hilibrand et al., 1999).
CLINICAL SIGNS
The most common presentation is a gait disturbance,
which is most severe in the pelvic limbs and ranges from
DIAGNOSIS
Anomalous/developmental
disorders
Neoplastic
disorders
Inflammatory/infectious
disorders
Ischemic
disorders
Degenerative
myelopathy
Leukodystrophies
Synovial cyst(s)
Orthopedic
disease
Disc extrusion
Cervical
fibrotic stenosis
Congenital vertebral
malformations
Atlantoaxial subluxation
Multiple cartilaginous exostoses
Tumoral calcinosis (calcinosis
circumscripta)
Meningocele/
meningomyelocele
Spinal dysraphism
Hydromyelia, syringomyelia,
or both
Pilonidal sinus (dermoid sinus)
Epidermoid cyst
Spinal arachnoid cyst
Meningioma,
Nerve sheath
tumor
Other tumors
Discospondylitis
Epidural abscess
Meningomyelitis
Fibrocartilaginous
embolic
myelopathy (FCE)
Spinal cord
hematoma
Ischemic
neuromyopathy
Cervical spondylomyelopathy
Radiography
SURVEY RADIOGRAPHY
Survey radiographs are useful to rule out potential
differential diagnoses but are not definitive for CSM.
Severe articular facet changes or vertebral body malformation do raise the index of suspicion for CSM,
especially in giant-breed dogs (11.3).
Traction-responsive lesions
MYELOGRAPHY
This is the standard means of confirming a diagnosis
of CSM and has the advantage that the lesion can
be observed readily in different positions of the spine.
Contrast should be first concentrated at the lesion by
positioning the site of interest at the low point of the
spine for several minutes (McKee et al., 2000) (4.32).
Lateral, ventrodorsal (for cranial cervical vertebrae),
dorsoventral (for caudal cervical vertebrae), flexion
and traction views should then be taken (Rendano and
Smith, 1981; Lamb, 1995).
The lesion may alter appearance as the relative positions of adjacent vertebrae are changed. Formerly,
lesions were categorized based on whether or not compression changed in the stressed positions of traction,
213
214
11.5 Traction non-responsive type of static lesion in a middle-aged Doberman (same dog as 11.30B). A: Ventral spinal cord
compression at C6/7 due to disc herniation. B: Same dog but with traction applied to the vertebral column. C: CT myelogram of the
same dog to show extruded, mineralized disc material at C6/7 (arrow).
CT-MYELOGRAPHY
Ideally all conventional myelograms for CSM should be
followed by a CT scan (Sharp et al., 1992). The CT provides excellent bone imaging (11.7) and when used with
contrast it also gives a good transverse image of the spinal
cord (11.8, 11.10). This information can improve surgical planning and may provide prognostic information by
detecting spinal cord atrophy (Chambers and Betts,
1977; Sharp et al., 1995). Sagittal or three-dimensional
reconstructions may also prove useful (11.8B). Finally,
Cervical spondylomyelopathy
215
216
postoperative imaging can be used to gauge the effectiveness of a surgical procedure (4.25, 7.5, 7.8, 7.9,
11.10, 11.12, 11.56, 11.57).
CT can also be used to study positional lesions.
However, keeping the neck in an extended position for
the duration of the scan can cause severe injury (11.10).
The dog shown in 11.9 and 11.10 suffered seizures
during recovery, which were very difficult to control.
He was put on a ventilator but became profoundly
hypotensive and died 12 h after the study. The cause
of death was not determined but was probably complicated by sympathetic blockade secondary to
severe cervical spinal cord compression (see page 82)
(Rosenbluth and Meirowsky, 1953; Seim and Withrow,
1982; Clark, 1986). It is likely that maintaining the
neck in an extended position for the time that it took
to complete the second CT scan caused severe spinal
cord injury; this was probably exacerbated by the
seizures.
MR IMAGING
PRESURGICAL EVALUATION
Cervical spondylomyelopathy
other breeds (Lewis and Hosgood, 1992). This highlights the need for constant monitoring during recovery,
with diazepam on hand to control any seizures as they
could also exacerbate the spinal cord injury (Lipsitz
et al., 2001) (11.10).
Care should be taken to maintain adequate systemic
blood pressure and spinal cord perfusion throughout the
procedure (see page 86). Dogs with chronic spinal cord
lesions are particularly susceptible to postoperative
deterioration, especially following dorsal laminectomy
or ventral slot (Kohno et al., 1997; Rusbridge et al.,
1998; de Risio et al., 2002). Preoperative methylprednisolone sodium succinate (MPSS) may be useful but the
risks and benefits of this strategy remain unproven
(Olby, 1999; Pietila et al., 2000). Preoperative vitamin E
may be a useful alternative for elective surgeries (see
page 85).
Hypothyroidism
Doberman pinschers and Great Danes are predisposed
to hypothyroidism although this disorder is probably
over-diagnosed. Lethargy, muscle weakness and peripheral neuropathy may occur, all of which are undesirable
in a surgical candidate. The best diagnostic test is
thyroid-stimulating hormone (TSH) stimulation but
this is not widely available. In its absence a high endogenous TSH level with a low total T4 is highly suggestive
of hypothyroidism if the history and clinical signs are
compatible. Glucocorticoids, phenobarbitone and some
non-steroidal anti-inflammatory drugs (NSAIDs) may
interfere with thyroid function testing (Gieger et al.,
2000). Hypothyroid dogs should probably receive supplementation for at least 48 h prior to surgery although
hypothyroidism does not induce VW disease as was
once thought, nor does it cause defects in primary
hemostasis (Panciera and Johnson, 1996).
Bleeding disorders
It has been estimated that 16% of Doberman pinschers
in the USA have a bleeding tendency related to VW
disease (Dodds, 1989). Bleeding from the internal vertebral venous plexus is a potential problem during ventral decompression and can be almost impossible to
arrest unless the dog has normal hemostatic abilities.
After a ventral approach to the neck, the inability to
close dead space under the strap muscles can lead to
hematoma formation several days after surgery
(15.40). The easiest way to test an animals VW status is to perform a standardized bleeding time test
(11.11). A stopwatch is started just as the incisions
are made. Blood is blotted at 5-s intervals using filter
paper, taking care not to touch the incision itself. The
mean buccal mucosal bleeding time for normal dogs is
TREATMENT
The decision on the best way to treat each patient is
based on the presenting history, neurological status,
results of imaging, and on the owners expectations and
their ability to undertake any necessary aftercare. Most
dogs that show neurological deficits are surgical candidates, but consideration will also be given here to nonsurgical treatment.
217
218
Table 11.2 Reported results for surgical treatment of cervical spondylomyelopathy (CSM)
Ventral slot
Total
Metal and
cement
Cement
plug
Dorsal laminectomy
Total
Dogs (n)
182
273
147
59
411
225
188
146
214
53
Successes
(as %)
14
(78)
18
(67)
13
(91)
45
(76)
37
(90)
18
(82)
14
(78)
11
(79)
20
(93)
45
(85)
Follow-up (months)
(Mean)
1060
(29)
648
N/A
640
N/A
350
(20)
360
(21)
1.553
(17)
N/A
N/A
7108
(38)
4/14
(28)
N/A
N/A
5/13
(38)
8/37
(22)
2/18
(11)
0/14
(0)
N/A
N/A
4/21
(19)
1260
(32)
N/A
N/A
1633
(23)
542
N/A
833
N/A
N/A
N/A
N/A
N/A
448
(23)
9/27
(33)
4/35
(11)
Bruecker et al., 1989a; 2 Bruecker et al., 1989b; 3 Chambers et al., 1986; 4 de Risio et al., 2002; 5 Dixon et al., 1996; 6 Lipsitz et al., 2001;
Rusbridge et al., 1998; 8 Trotter et al., 1976.
N/A, not available.
7
Non-surgical treatment
Non-surgical treatment is warranted in two situations.
The first situation is when a normal dog develops neurological deficits following minor trauma; these may resolve
completely within a few weeks unless severe injury is sustained. The second is when a dog develops CSM before it
is skeletally mature and so may benefit from correction of
nutritional imbalances together with severe caloric reduction. This is analogous to the strategy used for management of young horses with Wobbler syndrome but it is
unproven in dogs (Donawick et al., 1993). For most other
dogs, however, surgery is the treatment of choice as the
majority probably show progressive deterioration without
treatment (Jeffery and McKee, 2001).
For most dogs with CSM the surgery is elective. A
24 week trial period of severe exercise reduction and
use of a chest harness is often justified (15.11); if this
fails it often emphasizes the need for surgery to the
owner. Anti-inflammatory doses of prednisolone may
also be used, but for short periods only and preferably
on an alternate day basis (VanGundy, 1988). One additional role for corticosteroids is to use the resultant
response, or lack of response, as a crude indicator of
the reversibility of any neurological deficit prior to performing surgery.
Surgical treatment
A large number of different surgical techniques have
been proposed for CSM, with many of the authors
claiming between 70 and 90% success rates (Table 11.2).
Cervical spondylomyelopathy
Table 11.3 General indications for surgical procedures in cervical spondylomyelopathy (CSM)
Procedure
Lesion(s) addressed
Ventral decompression
Ventral slot
Disc extrusion
Can be used for anulus
Distraction-stabilization
Cement plug
Dorsal decompression
Dorsal laminectomy
Laminoplasty
(needs further evaluation)
}
}
*In addition to the operated site, any additional subclinical lesion, in particular at C5/6 and C6/7 interspaces, should be addressed routinely in an
attempt to reduce the incidence of domino lesions (see 11.30 and page 221).
219
220
11.13 A: A ventral slot has been performed at C5/6 intervertebral space. Bone screws have been placed in C5 and C6 ready for
bone cement to be applied once the space has been distracted. Distraction using a Gelpi retractor in adjacent disc spaces is no
longer recommended (Wilson et al., 1994) (see Vertebral distraction, page 235). B, C: Seven-month postoperative radiographs
of a Doberman treated using Syncage-C intervertebral implant and Cervical Spine Locking Plate (AO) at C6/7. Outcome at 1 year
was excellent (Matis, 2001).
Cervical spondylomyelopathy
VERTEBRAL DISTRACTION-STABILIZATION
(11.3111.43)
The primary indications for distraction and stabilization are the presence of a traction-responsive lesion and
to relieve nerve root compression. Lesions may be
either single or multiple and cause either dorsal or ventral spinal cord compression (Algorithms 11.1A,B).
Distraction-stabilization has been attempted in the
past using a number of different techniques, but the
ones now recommended are the cement plug, Synthes
221
222
Cement plugs should be placed routinely at the highest risk disc spaces (usually C5/6 and C6/7), and
ideally to any other space that shows subclinical
lesions. An alternate approach is to implant cement plugs
at sites of spinal cord compression and fuse other sites
that are considered to be at risk by forage and grafting
(11.30). Obviously not every cervical intervertebral
space can be fused and the maximum is probably three
interspaces (Bolesta et al., 2000). It may also be difficult to decide exactly which sites to fuse in any given
dog. For the Great Dane and other giant breeds, C4/5
or even C3/4 may be involved along with C5/6 and
C6/7 (Olsson et al., 1982; Lewis, 1989; Lipsitz et al.,
2001). For the Doberman usually only C6/7 and C5/6
discs are at high risk although in some dogs C4/5
should probably also be addressed (11.14).
The aim of fusing multiple spaces routinely is to
reduce the incidence of domino lesions (Dixon et al.,
1996; Jeffery and McKee, 2001) (Table 11.2). Support
for this more aggressive approach also comes from
work in humans with cervical spondylosis. In humans,
the risk of new disease at an adjacent level was found to
be significantly lower following a multilevel arthrodesis
than it was following a single-level arthrodesis.
Therefore, it has been proposed in humans that all
Cervical spondylomyelopathy
Locking plate
DORSAL DECOMPRESSION
This technique is an alternative for dogs with single dorsal lesions
that do not respond to traction as well as those with
multiple dorsal lesions (Dickinson et al., 2001; Lipsitz
et al., 2001) (11.8, 11.56, 11.57). This technique also
provides an option for dogs with ventral lesions at multiple intervertebral spaces (Lyman, 1991) (7.15).
Traction non-responsive
Ventral
lesion
Ventral slot*
Dorsal
lesion
Positional
Ventral
lesion
Cement plug(s)*,
locking plate,
laminoplasty or
dorsal
laminectomy
Traction responsive
Ventral
lesion
Cement
plug(s)* or
locking
plate
Dorsal
lesion
Cement
plug(s)* or
locking
plate
Cement plug(s)*
or locking plate
Algorithm 11.1A
a single lesion.
223
224
Traction non-responsive
Ventral
lesions
Dorsal
lesions
Positional
Ventral
lesions
Dorsal
lesions
Ventral
slot*
Traction responsive
Ventral
lesions
Dorsal
lesions
Cement
plugs
Cement
plugs
Cement plugs
or dorsal laminectomy
Laminoplasty (11.58)
COMPLICATIONS
Some risks are either inherent to surgery on the cervical
spine or to a particular breed and as such should be
explained clearly to the owner. Many of the respiratory
and cardiovascular problems discussed in Chapter 7 also
occur in CSM (Boxes 7.3, 7.4; Table 11.4). These problems emphasize further the need for a thorough presurgical evaluation (Calvert et al., 1996). Complications
can be divided into three main categories (Table 11.4).
Intraoperative complications
These are mainly due to either iatrogenic injury or
technical errors (Table 11.5). Overzealous retraction of
Intraoperative
Iatrogenic injury
Technical errors
Early
postoperative
Late
postoperative
Implant failure
Postoperative
morbidity
Infection
Adjacent segment
disease
Adjacent segment
disease
Recurrence of signs
Cervical spondylomyelopathy
Intraoperative
Early postoperative
Late postoperative
11.16 A, B: A single midline screw has been used to keep each cement plug in place (11.3511.38). Unfortunately each screw
passed through a vascular foramen (1.18) to enter the vertebral canal and cause dramatic compression of the spinal cord, especially
over C5. C: The screws were removed and replaced by shorter ones. The dog walked without assistance the next day and had an
excellent outcome; the screw probably caused only mild, transient spinal cord compression.
11.17 A, B: These screws are all inserted too caudally in their respective vertebral bodies. Two have penetrated an end plate and
all four have the potential to damage the nerve roots or spinal nerves (Swaim, 1975). C: An excess of bone cement can compress
structures within the thoracic inlet to cause dysphagia or even esophageal perforation (Halligan and Hubschmann, 1993; Dixon
et al., 1996). Note that in this dog, the implants span two intervertebral spaces. If this is done, more implants and cement
reinforcement are needed (page 221) (13.25).
225
226
11.20 A: Loss of distraction after a cement plug was used at C5/6 (11.38B). The dog showed sudden deterioration 4 weeks after
surgery. A small fracture is visible at the ventral portion of the plug (arrow) and there is failure of the cranial end plate of C6 (arrowhead)
with recurrent spinal cord compression. B: This dog did well until it fell down the stairs 6 weeks after distraction at C6/7. Failure of a
screw in C7 did not cause clinical signs (McKee et al., 1990). The dog had also shown a change in bark since surgery.
Cervical spondylomyelopathy
227
228
Postoperative care
B
11.23 A: This dog underwent a ventral slot decompression at
C6/7 1 year previously. It had recurrent tetraparesis due to a new
lesion at C5/6. This is the domino effect. B: CT myelogram
made at C5/6 in a Great Dane that underwent a dorsal
laminectomy 1 year previously. The dog improved but then
deteriorated 10 months later. Proliferation of new bone has almost
reformed the lamina of the vertebral canal resulting in severe spinal
cord compression with atrophy (A and B from Sharp et al., 1992).
Cervical spondylomyelopathy
PROGNOSIS
The seriousness of this condition is best illustrated by
the fact that a quarter of dogs with CSM in one series
were euthanized within 6 weeks of surgery as a result
of neurological problems (Seim, 1986). Overall longterm mortality rates for CSM vary from 19 to 43%
(Seim et al., 1986; Dixon et al., 1996; Rusbridge et al.,
1998; McKee et al., 1999; de Risio et al., 2002). Dogs
with more than one lesion generally have a worse prognosis than dogs with single lesions, and dogs with
chronic tetraparesis have a guarded prognosis (Seim,
1986). Most severely tetraparetic dogs that are going to
recover will do so within 6 weeks. In some dogs surgery
will only halt the progression of disease (VanGundy,
1988). This is presumably because there is often significant loss of neural tissue at the site of the lesion (Read
et al., 1983; Sharp et al., 1995). It is therefore likely
that the outcome will be better if surgery is done earlier
in the disease process (Chambers et al., 1986; VanGundy,
1988; McKee et al., 1990).
The general estimate provided by Seim is still useful
to predict the likely outcome after surgery for
CSM. For dogs with single lesions, about 80% of those
that are walking prior to surgery will have a favorable
outcome (Seim, 1986). Success rates quoted in the
literature vary from 70 to 90% but these figures do
not include dogs that undergo euthanasia later for
reasons related to CSM, usually due to recurrence of
signs (Chambers et al., 1986; de Risio et al., 2002)
(Table 11.2). Any apparent differences in success rates
between the various techniques are not statistically significant (Jeffery and McKee, 2001). There are conflicting results from the limited studies conducted to date
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232
PROCEDURES
Paramedian approach to the ventral neck
Excessive extension should be avoided during positioning as it tends to close the dorsal part of the disc space and
also increases spinal cord compression. Rather than position the neck in extension to improve access to the caudal vertebrae, the dog is positioned with the neck in a relatively neutral position and with a weight tied to the rostral
maxilla. The mild traction also tends to open the disc space, keep the anulus under tension and reduce spinal cord
compression (Goring et al., 1991) (11.24). Exposure to the caudal vertebrae may also be improved using the lateral
muscle separating approach and the strap muscles then serve to protect the trachea, recurrent laryngeal nerve,
carotid sheath and jugular vein (11.2511.27). Regardless of the approach used it is important to take great care
during dissection near the thoracic inlet and to protect all exposed tissues with damp sponges (Cechner, 1980).
11.24
Cervical spondylomyelopathy
11.26
Ventral decompression
The ventral slot technique can be challenging in CSM because of ventral osteophytosis, malformed vertebral
bodies, intraoperative hemorrhage, friable anulus fibrosus, or a combination of these (11.28, 11.29). Surgery at
C6/7 may be especially difficult but access can be improved by taking particular care with patient positioning, by
use of traction (11.24) and possibly by using a paramedian approach (11.2511.27). Decompression should be
performed as described under 7.377.51. If the slot is too narrow the decompression will be inadequate and the
outcome will be more like a fenestration (Chambers et al., 1986; Ellison et al., 1988). However, a slot that
approaches 50% of the vertebral body carries a high risk of subluxation (Fitch et al., 2000; Lemarie et al., 2000).
In general the slot should be about one third of the vertebral width unless it is shaped like an inverted cone
(Goring et al., 1991; Lemarie et al., 2000) (7.50).
233
234
Osseous fusion is common following a ventral slot (Swaim, 1975; Gilpin, 1976; Sharp et al., 1995) (11.12). This
may be beneficial in preventing motion at the operated site but probably causes increased stress at adjacent spaces
(Fox et al., 1996; Hilibrand et al., 1999). Normal disc spaces can tolerate this stress but subclinically affected spaces
suffer a high incidence of domino lesions (Bruecker et al., 1989a; Hilibrand et al., 1999) (Table 11.2). A technique is
therefore needed to prevent domino lesions after single site ventral slot surgery. One technique that might accomplish this is to try to promote fusion at subclinically affected spaces by forage and grafting (11.30).
11.28
11.29
A
Cervical spondylomyelopathy
11.31
Ventral
Dorsal
A
Ventral
Dorsal
B
235
236
11.32
11.33
A
Cervical spondylomyelopathy
11.34
A
11.35
The handle of a small instrument is used to compress the cement on either side of the Gelpi tip; this tip must be
kept clear of cement to facilitate its removal after cement hardens.
Ideally the two or three high-risk spaces are distracted using this procedure as shown in 11.16 and 11.37.
Alternatively, any subclinically affected spaces can be foraged and then grafted as shown in 11.30.
If no hole has been drilled into the end plate to anchor the cement plug, then a single 4.5-mm screw can be
used to prevent the plug from falling out. A single screw is inserted by drilling and tapping the first cortex only; the
screw then taps its own thread (11.36) as tapping may weaken fixation in cancellous bone (Krag, 1991; Bagley et
al., 2000). The second (inner) cortex should prevent the screw from entering the vertebral canal (see 11.16 for
potential complication). The advantages of using this technique to anchor the plug is that the vertebral end plates
should be less likely to collapse as they are not weakened (11.20A, 11.38) and there is also no need for the dog
to wear a splint after surgery. Some collapse of the space does still occur, presumably from thermal damage to the
end plates (Anderson, 1988; Boker et al., 1989), and to pressure-induced resorption. This technique has worked
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238
well in the small number of dogs studied provided that the screw is positioned so the head sits over the cement
plug (11.36, 11.37). A similar approach uses threaded pins to anchor the plug instead (McKee and Sharp, 2003).
The original method for anchoring a cement plug is to drill holes in each end plate and to fill these with cement
(Dixon et al., 1996) (11.38). Having an angled bur guard for the drill (5.24) makes it easier to drill the anchor hole
into the cranial end plate.
It is not clear if an external splint provides additional benefit following the standard cement-plug technique.
Although dogs that were not splinted had outcomes as good as those that were, most surgeons who use this
technique recommend use of a splint (Dixon et al., 1996). The dog should be assessed closely for the appearance of rub sores, discomfort, odor or any type of malaise that might signify infection under the splint. If there is
any doubt it should be replaced. A Halti and chest harness are an easier way to restrict movement (13.18B).
Cervical spondylomyelopathy
11.39
239
240
11.41
B
11.42
11.43
A
Cervical spondylomyelopathy
11.44
11.45
241
242
11.47
11.49
Cervical spondylomyelopathy
11.50
11.51 The spinal cord is now visible (a). Large veins may
be present in the epidural space (11.52). Bleeding
may respond to bipolar cautery but a Hemoclip
(Pilling Weck Inc., Research Triangle Park, NC) or
fine suture is needed if a vein is torn.
a
11.51
11.53
243
244
11.55
A
Cervical spondylomyelopathy
Laminoplasty
Laminoplasty can be performed using a variety of techniques (McKee, 1988; Kohno et al., 1997; Shaffrey et al.,
1999). In the method illustrated in 11.58, a fine-tipped bur is used to make a cut three quarters of the way along
the midline of the C6 dorsal lamina. Great care is needed to avoid the spinal cord, especially cranially. The cut is
extended into a T-shape caudally. Grooves are cut down to the inner cortical bone at the junction of the lamina
with each pedicle. The laminar flap is elevated sufficiently to make a small bur hole in its medial edge for 0
polypropylene suture. The inner cortical bone is weakened further by drilling until each flap can be elevated
almost vertically. The interarcuate ligament and any dural adhesions must be separated with care. 3.5-mm
screws are placed in lag fashion across the C5/6 articular facets in order to attach and tighten the sutures. A cancellous bone graft is packed around the joints and a fat graft then placed over the spinal cord (McKee, 1988).
245
246
11.58
Neoplasia
Clinical signs
Chapter
12
247
References
Procedures 266
Hemilaminectomy 266
Dorsal laminectomy 270
Vertebrectomy 273
Nerve sheath tumor resection
249
Diagnosis 250
Radiography 250
Ultrasound 250
Electrophysiology 250
Myelography 251
Computed tomography 251
Magnetic resonance imaging 251
Biopsy 251
Staging
263
275
Although tumors are uncommon causes of spinal disease, they are significant once the more common problems such as disc disease (in dogs) and trauma are
eliminated. Older animals are usually affected, although
certain tumor types do occur in young individuals.
252
CLINICAL SIGNS
Treatment 254
Medical treatment 254
Radiation treatment 254
Surgical treatment 255
Complications
258
Postoperative care
259
Prognosis 259
Extradural tumors 260
Intradural/extramedullary tumors
Intramedullary tumors 261
Feline spinal tumors
Diagnosis 262
Treatment 263
Prognosis 263
260
261
263
248
TUMOR BIOLOGY
There are a large number of tumor types that affect
the spine. Many tumors are only reported in small
numbers and these have been reviewed elsewhere
(LeCouteur and Child, 1995; LeCouteur, 2001; Oakley
and Paterson, 2003). Common tumor types are listed
in Table 12.1.
Spinal tumors may be classified by histopathology
(Table 12.1) or according to their anatomic location in
the spine (4.21):
Extradural.
Intradural/extramedullary.
Intramedullary.
Extradural tumors are the most prevalent type in
dogs, accounting for approximately half of all cases.
Intradural/extramedullary tumors make up another
third and intramedullary tumors the remainder
(LeCouteur, 2001). Tumors of bone and nerve roots are
most common in dogs; extradural lymphoma is most
common in cats (Oakley and Patterson, 2003). The
biology and expected behavior of a tumor must be
understood if it is to be diagnosed, staged, and treated
properly.
Extradural tumors
As the name implies these tumors lie outside the dura
mater. They typically cause pain with rapid neurological deterioration and include vertebral body tumors
and those that occupy the epidural space. Most vertebral body tumors are osteosarcomas; fibrosarcomas are
the next most common type (Dernell et al., 2000).
Chondrosarcoma, hemangiosarcoma and myeloma
are less frequent (Dernell et al., 2000; LeCouteur,
2001; Withrow and MacEwan, 2001). Meningiomas
and nerve sheath tumors can be extradural in location
Table 12.1 Classification of major spinal tumor types according to location within the spine
Extradural
Intradural/extramedullary
Intramedullary
Primary
Osteosarcoma
Fibrosarcoma
Chondrosarcoma
Lymphoma
Hemangiosarcoma
Meningioma
Nerve sheath tumours
(schwannoma, neurofibroma,
neurofibrosarcoma, lymphoma)
Nephroblastoma
Sarcoma
Lymphoma
Ependymoma
Glioma
Lymphoma
Hemangiosarcoma
Reticulosis (focal
granulomatous
meningoencephalomyelitis (GME))
Metastatic
Metastatic
Metastatic
Carcinoma
Sarcoma
Melanoma
Lymphoma
Myeloma
Neoplasia
but are discussed under intradural tumors. Extradural tumors may also be metastatic in origin (osteosarcomas or carcinomas). Discovery of an extradural
tumor indicates the possibility of a primary mass elsewhere, particularly the mammary or thyroid glands,
kidney or urinary bladder.
Osteosarcoma and fibrosarcoma of the spine show
similar biological behavior. The usual cause of treatment failure is local recurrence (Dernell et al., 2000).
Spinal osteosarcomas are moderately aggressive with a
metastatic rate reported as 17% (Heyman et al., 1992).
A new grading system has been developed for osteosarcoma; most tumors are high grade (Kirpensteijn et al.,
2002). Grading for fibrosarcoma is less clear cut
(Ciekot et al., 1994; Hung et al., 2000).
Vertebral plasma cell tumors may exist as a solitary plasmacytoma or as multiple myeloma. Solitary
plasmacytoma is not associated with paraneoplastic
syndromes and usually does not cause monoclonal gammopathy. It has a better prognosis than multiple
myeloma but in humans about 50% go on to develop
disseminated disease (Rusbridge et al., 1999) (12.12).
This may be because a third of humans thought to have
solitary disease actually have occult multiple myeloma
on MRI (Moulopoulos et al., 1993). Multiple myeloma
does cause monoclonal gammopathy and additional
clinical signs can occur from hyperviscosity or paraneoplastic syndromes (Rusbridge et al., 1999).
Lymphoma has the propensity to involve the dura
mater and the spinal cord substance itself but is included
here as the usual site is extradural (Britt et al., 1984).
Canine lymphoma is usually a manifestation of multicentric disease. Lymphoma can affect nerve roots. Spinal
cord compression is often extradural and the mass can
sometimes be mistaken for epidural fat (Summers et al.,
1994). Some dogs show meningeal infiltration and most
have neoplastic lymphocytes in the CSF (Rosin, 1982;
Britt et al., 1984; Couto et al., 1984). Grading techniques for multicentric lymphoma can predict outcome
and these may be applicable to spinal lymphoma (Kiupel
et al., 1999; Dobson et al., 2001). Malignant histiocytosis and mastocytosis also affect the spinal cord occasionally (Moore and Rosin, 1986; Tyrrell and Davis, 2001;
Uchida et al., 2001; Moore et al., 2002). Feline lymphoma is discussed on page 261.
Intradural/extramedullary
These tumors lie within the dura mater but outside
the spinal cord parenchyma. The most common tumors
in this category are meningiomas and nerve sheath
tumors (neurofibroma, neurofibrosarcoma, schwannoma, lymphoma). Both types can also be in an extradural location.
Meningiomas usually cause pain or chronic discomfort with slowly progressive neurological deficits. Some
meningiomas show an intramedullary pattern on myelography due to associated edema, even though they are
located outside the spinal cord (Fingeroth et al., 1987).
They tend to be discrete, firm to rubbery extramedullary masses. Meningiomas usually compress rather
than infiltrate spinal cord but some show invasion along
the perivascular space (Summers et al., 1994). Four of
13 spinal cord meningiomas in one report were invasive
(Fingeroth et al., 1987). Distant metastasis has been
reported for intracranial but not for spinal meningioma.
Meningiomas show a remarkable histopathological diversity, probably because the meninges arise from both
neural crest and mesodermal cells. They originate from
arachnoid granulations and cap cells, and often have receptors for progesterone (Summers et al., 1994; Theon
et al., 2000). Histopathological grading is not standardized although characteristics of benign versus malignant
meningiomas have been reviewed (Ribas et al., 1991;
Summers et al., 1994; Theon et al., 2000).
Nerve sheath tumors usually cause a chronic, progressive lameness. The two most common sites of origin are
from the plexus or from a nerve root within the
vertebral canal (Brehm et al., 1995). Brachial plexus
tumors are fusiform thickenings of one or more nerve
trunks, which sometimes coalesce into a common mass.
Spinal cord compression is usually a late event for
brachial plexus tumors but is often a presenting sign for
tumors that arise from within a nerve root (Brehm
et al., 1995). Malignant peripheral nerve sheath tumor is
the term preferred to malignant schwannoma or neurofibrosarcoma as it is usually not possible to discriminate
the cell of origin. These tumors are usually malignant
both cytologically and biologically (Summers et al.,
1994). Nerve sheath tumors often invade extensively
along the nerve (Oliver et al., 1965; Bradley et al., 1982;
McCarthy et al., 1993; Brehm et al., 1995; Jones et al.,
1995). Invasion into the spinal cord can occur but local
or distant metastasis is unusual (Brehm et al., 1995;
Sharp, 1988; Summers et al., 1994). They also metastasize occasionally along the subarachnoid space (2.24,
4.27, 4.28, 4.44B). Histopathologically, nerve sheath
tumors are often anaplastic with abundant mitosis and
necrosis. Specific grading systems are not yet standardized (Summers et al., 1994; Kuntz et al., 1997).
Nephroblastoma is another type of intradural/
extramedullary tumor that occurs between T10 and L2
vertebrae in young dogs (Pearson et al., 1997; Summers
et al., 1988; Terrell et al., 2000) (12.40). It was
referred to formerly as neuroepithelioma but this
tumor is really an extrarenal nephroblastoma equivalent to Wilms tumor in humans (Pearson et al., 1997).
249
250
Intramedullary
Intramedullary tumors occur within the spinal cord
substance and are the least common type. They typically cause neurological deficits that progress rapidly.
Tumors are either gliomas (12.4) or, very occasionally, metastatic tumors (Waters and Hayden, 1990;
LeCouteur, 2001). Staging relies mainly on neuroimaging
and MRI gives the best definition for intramedullary
lesions. However, MRI may not always differentiate
intramedullary tumors from those in the intradural/
extramedullary compartment. This is due partly to
the limitations of slice thickness and partly because
some tumors are only classified accurately using histopathology (Kippenes et al., 1999). A rare, non-neoplastic
differential diagnosis for an intramedullary spaceoccupying lesion is epidermoid cyst (Tomlinson et al.,
1988).
Radiography
Spinal tumors are usually relatively easy to diagnose
using standard methods. Following a physical and neurological examination, routine blood work and urinalysis
are performed. Radiography is often the technique with
the highest diagnostic yield. Survey radiographs of the
spine may not be diagnostic of soft tissue tumors, part
of the value of negative findings lies in the elimination
of obvious, destructive lesions and of differential diagnoses such as discospondylitis (14.11). The axial and
appendicular skeleton should be surveyed in suspected
plasma cell tumors in order to stage the tumor as solitary or disseminated (Rusbridge et al., 1999). Bony
changes will be seen mainly in vertebral tumors (12.1)
but other tumors, such as meningiomas and nerve sheath
tumors can cause mineralization or bone remodeling.
Spinal tumors do not metastasize frequently to the thorax but chest radiographs (three projectionsboth right
and left laterals with ventrodorsal or dorsoventral
views) should always be taken. Chest radiography is followed by abdominal ultrasound; in some animals the
spinal tumor itself may be a metastatic lesion (Bentley
et al., 1990; Jeffery, 1991).
Ultrasound
DIAGNOSIS
Diagnosis of a tumor is usually straightforward but
degenerative conditions like disc disease (see Chapters
7 and 8) and degenerative myelopathy, congenital
anomaly with late onset such as an arachnoid cyst, infectious inflammatory disease including discospondylitis and
focal granulomatous meningoencephalomyelitis (GME),
or vascular diseases such as ischemic neuromyopathy in
both dogs and cats, warrant consideration (see Chapter
14). Bone tumors may cross a disc space but this is rare;
this helps to differentiate them from discospondylitis
(Moore et al., 2000).
Electrophysiology
Evidence of denervation on electromyography (EMG)
is highly suggestive of nerve sheath tumor in a dog
with suspicious clinical signs (Wheeler et al., 1986;
Steinberg, 1988; Brehm et al., 1995). Nerve conduction
Neoplasia
studies, late wave assessment and cord dorsum potentials may also provide supportive evidence (Cuddon
et al., 2003).
Myelography
This provides useful information about the location of
the tumor and its position within the vertebral canal
relative to the dura mater and spinal cord (4.274.31).
It is important to take two views (lateral and ventrodorsal) for correct localization (4.30, 4.31). Although
it will remain an important imaging modality, myelography is invasive and image quality can vary due to
technical problems such as contrast leakage or poor
filling of the subarachnoid space (see Chapter 4).
False-negative results can also occur, especially with
nerve sheath tumors (Carmichael and Griffiths, 1981;
Bradley et al., 1982; McCarthy et al., 1993) and myelography may miss as many as 42% of intramedullary
tumors (4.41) (Grem et al., 1985; Waters and Hayden,
1990). Transverse imaging by CT or MRI in general
allows earlier detection and better surgical planning
than myelography (Waters and Hayden, 1990; Brehm
et al., 1995).
Computed tomography
Computed tomography excels in imaging tumors that
destroy cortical bone (Dernell et al., 2000; Moore et al.,
2000) (12.6A, 12.7). Administration of intravenous
contrast may improve detection further, especially for
some nerve sheath tumors (McCarthy et al., 1993;
Niles et al., 2001). Beam-hardening artefact from the
humerus can interfere with resolution of brachial plexus
lesions (Platt et al., 1999). False-positive results can
occur in some animals that show thickening of nerve
roots on CT myelography suggestive of tumor (12.2).
Thickening can also be due to edema and not to neoplastic invasion (Simpson et al., 1999). MRI is probably
better than CT myelography at differentiating tumor
from edema (Simpson et al., 1999).
Biopsy
This may be done as a needle aspirate or as an incisional
or excisional procedure. The choice is important and
biopsy tracts must be within the final field of surgical or
radiation treatment. Percutaneous fine needle aspiration
12.2 CT myelogram from a dog with chronic lameness, LMN deficits, Horners syndrome, and a painful mass in the right axilla.
Myelography was unremarkable. A: A CT scan showed subtle, right-sided, extradural compression at the cranial edge of T1
vertebra (arrow). B: Filling defects caused by C8 nerve roots as they cross the subarachnoid space (arrows). The right ventral
nerve root is much thicker than the left side. In this dog the ventral C8 and T1 nerve roots were invaded by tumor (12.49).
251
252
12.3 MRI of a dog with a 5-month history of unilateral pelvic limb lameness. It was unable to extend its stifle due to severe atrophy
and paralysis of the quadriceps muscle, the patellar reflex was absent but the withdrawal reflex was intact. A: Post-contrast,
T1-weighted image shows a high signal area in the dorsal portion of one psoas muscle (arrowhead). B: T2-weighted image with fat
suppression reveals a high signal mass at the same location as shown in A (arrowhead). Diagnosis was a nerve sheath tumor.
12.4 Five-year-old dog with a 1-week history of mild paraparesis and dribbling urine. Myelography revealed lack of subarachnoid
contrast from T10 to T13. A: CT-guided needle biopsy (arrowhead) at T11/12 was non-diagnostic. B: Hemilaminectomy revealed
discolored spinal cord and a needle aspirate was done over T11. C: Cytological diagnosis was ependymoma or oligodendroglioma.
Euthanasia was performed and histopathological diagnosis was poorly differentiated glioma (Fernandez et al., 1997). In humans the
histological grade of ependymoma does not necessarily correlate with prognosis (Mork and Loken, 1977; Ritter et al., 1998).
STAGING
General staging includes neurolocalization, screening for
any concurrent or paraneoplastic disorders, radiographic
survey of the entire vertebral column, abdominal ultrasound, and screening for pulmonary metastases using
thoracic radiographs or spiral CT. Aspiration of lymph
nodes and bone marrow may also be indicated (Withrow
and MacEwan, 2001). Screening for bone metastases in
humans is done best with a bone scan as this is more
accurate than survey radiography although false-positive
results have been reported in dogs (Bentley et al., 1990;
Berg and Lamb, 1990; Rusbridge et al., 1999; Dernell
Neoplasia
12.6 A: CT scan of the dog shown in 12.1A reveals an osteolytic, expansile mass within the spinous process of T3 (zone I,
arrowhead). B: Transverse, T1-weighted MRI of the dog shown in 12.1B reveals a large mass ventral to the vertebra (zone III, white
arrowheads); it has also extended dorsally around the rib (*) into zone II and into the vertebral canal (white arrows). The spinal cord
(black arrow) is displaced by tumor within the vertebral canal (zone IV) (12.41).
et al., 2000) (see page 59). Bone scan may also fail to
identify plasma cell tumors (Rusbridge et al., 1999).
A CSF sample should be collected as neoplastic cells will
be identified occasionally. Neoplastic cells were found in
CSF from 10 of 12 dogs with lymphoma, which is more
often than for feline lymphoma (one third of cats, see
Feline spinal tumors, page 262) (Rosin, 1982; Couto
et al., 1984). Local and regional tumor imaging is done by
myelography, CT or MRI. CT is very useful for looking
at cortical bone but MRI is now the gold standard modality for both neural and vertebral tumors (Gilson, 2003)
(12.3, 12.6B).
253
254
Medical treatment
Resections in zone II at certain sites may be challenging because of the vertebral artery, ribs or wings of
the ilium. Depending on their size, many tumors in
zones II, III and IV will either require piecemeal intracapsular resection, vertebrectomy or both (Chauvet
et al., 1999; Dernell et al., 2000) (12.612.8). Tumors
in zone III must be assessed critically for adherence to
cervical soft tissues or to the thoracoabdominal great
vessels or organs (12.41) (Gilson, 2003).
TREATMENT
Treatment is not possible in every animal with a spinal
tumor, but an aggressive approach will prove rewarding
in some patients. With the exception of myeloma, vertebral body tumors are difficult to treat, but the fundamental techniques are well established. Based on
Medical treatment of spinal tumors is unlikely to provide curative therapy in most patients. The exception
is for animals with multiple myeloma where good
responses are obtained with chemotherapy alone or in
combination with radiotherapy; melphalan and prednisone are the standard chemotherapeutic agents
(Rusbridge et al., 1999). In lymphoma, chemotherapeutic regimens are employed ideally without surgical
intervention. Agents such as cytosine arabinoside may
be added due to the difficulty of getting drugs across
the blood brain barrier (Couto et al., 1984; Withrow
and McEwan, 2001). Lomustine is of value for CNS
tumors (Jeffery and Brearley, 1993; Moore et al., 1999;
Fan and Kitchell, 2000) and oral hydroxyurea may
prove useful for meningioma (Mason et al., 2002).
Doxorubicin or cisplatin (in either systemic or slowrelease formulations) have been used to treat various
other tumor types (Jeffery, 1991; Dernell et al., 2000).
Palliative therapy (analgesics, anti-inflammatory agents)
may also be used to alleviate pain and peritumoral
edema, although when used alone they only relieve
clinical signs for relatively short periods.
Radiation treatment
Ideally, radiation treatment is used as an adjunct to surgery, unless the tumor is small, well localized and particularly sensitive to radiation (e.g. lymphoma or plasma
cell tumor) in which case radiation may be used as the
only therapy (LeCouteur, 2001; Rusbridge et al., 1999;
Withrow and MacEwan, 2001). An important consideration is that previous surgery decreases the radiation
tolerance of brain (and probably spinal cord) by causing
injury to local blood vessels. If surgery reduces tumor
Neoplasia
Surgical treatment
Owing to the inherent anatomical limitations of dealing
with the CNS, aggressive surgical margins are rarely possible for vertebral or spinal cord tumors. Nevertheless,
removal of vertebral tumors using wide margins for
most of a mass, with a more limited margin for the portion nearest the spinal cord, may not affect adversely
the success of local tumor control (Gilson, 2003).
Effective biological barriers to neoplastic tissue should be
used to advantage; these include collagen rich/vascular
poor structures such as intervertebral disc, cortical bone,
dorsal longitudinal ligament, dura mater, interspinous
and intertransverse ligaments, and fascial sheaths of
paraspinal muscles (1.29, 1.321.35, 8.65). General
principles of surgical oncology must be adhered to in
order to insure a successful outcome (Gilson, 2003).
Normal tissues must be protected by impenetrable barriers and copious lavage with suction used to clear the
surgery field of tumor cells. Contaminated instruments
should be discarded after tumor excision and new materials and instruments are used for closure. The most
proximal portion of the specimen is identified and the
tumor margins are assessed histologically (Gilson,
2003). The goal of surgery is to achieve complete resection or, at minimum, reduce tumor burden to residual
microscopic disease (Algorithm 12.1).
The best results are obtained in humans when the
surgical approach and type of resection is targeted to
255
256
Neurological
localization
Vertebral
tumour
Survey radiographs of
spine and thorax, plus
abdominal ultrasound
Spinal cord
tumour
Biopsy
Neuroimaging - CT or
MRI or (myelography)
Laminectomy
Lymphoma, myeloma,
nerve sheath tumor,
see text
Resection under
magnification
Anatomical
classification
Surgical
approach
and margins
Dorsal or dorsolateral
approach en bloc
resection
Zone III
Ventral or
lateral approach
intracapsular
or vertebrectomy
Zone IV or
crossing
Zones II or III
Combined approach
vertebrectomy
12.9 Intraoperative photographs from the dog in 12.7 and 12.8. A: Exposure of the vertebral column revealed a mass of abnormal
tissue on one vertebra (arrow). B: Hemilaminectomy was performed; much of the vertebral arch was absent. Debulking of the soft
tissues revealed a large defect in the vertebral body (a). The spinal cord (b), spinal nerve (c) and spinal ganglion (d) are seen. The
dog recovered well and was able to walk within 2 days. Histopathological diagnosis was anaplastic carcinoma. Attempts to find the
primary tumor failed, and the dog was paraparetic again within 4 weeks, when it was euthanized (12.8).
Neoplasia
necessitates that the limb be amputated as the resultant deficit to the radial, median and ulnar nerves will
be too disabling. Good preoperative imaging is especially helpful in surgical planning, such as in determining the exact nerve roots involved and where to
perform the laminectomy (Sakai et al., 1996; Platt
et al., 1999).
TUMOR DISSECTION
Gentle tissue handling is vital for tumors in or near the
spinal cord. Manipulation must be kept to a minimum to
avoid iatrogenic damage; it is preferable to avoid touching
the spinal cord at all. If manipulation is necessary then
dural sutures are used (Yturraspe and Lumb, 1973)
(12.40). The spinal nerve and vessels can be sacrificed in
257
258
COMPLICATIONS
The main sources of complications are listed in Table
12.2. Intraoperative complications include iatrogenic
spinal cord injury, which can occur from manipulation,
instability or vascular compromise (Brasmer and Lumb,
1972; Fingeroth et al., 1987) (Table 12.3). The surgeon may also be unable to find the tumor, especially if
it is intramedullary. Intraoperative ultrasound is particularly useful in this situation (Nakayama, 1993). The
tumor may be invasive and therefore difficult to resect,
or access to the tumor can be difficult if it extends ventral to the spinal cord. Access may be improved by
performing a partial corpectomy of the vertebral
body (Moissonnier et al., 2002b) (8.47B). If nerve roots
are involved at an intumescence it may be impossible to
Intraoperative
Technical problems
Technical errors
Early
postoperative
Late
postoperative
Infection
Lack of stability
Non-neurological
problems
Infection
Implant failure
Intraoperative
Iatrogenic spinal
cord injury
Difficulty locating
tumor
Invasive tumor
Poor access to
tumor
Incomplete
resection
Early
postoperative
Late
postoperative
Instability
Pathological
fracture (12.12,
12.12)
Implant failure
Wound infection
Sepsis
Fat graft necrosis
(12.10)
Diagnostic error
Implant failure
Tumor recurrence
(12.11, 12.50)
Peridural scar
Neoplasia
B
12.11 A: Lateral radiograph of the lumbar spine of a
paraparetic 3-year-old mixed-breed dog with a destructive
lesion in the L5 vertebral body (arrow). It underwent a dorsal
laminectomy and biopsy. B: The dog became paraplegic with
reduced deep pain sensation 2 days later. There is marked
collapse of the L5 vertebral body compared to the preoperative
radiographs. Histological diagnosis was fibrosarcoma (12.42)
(from Chauvet et al., 1999).
POSTOPERATIVE CARE
Routine nursing considerations are discussed in
Chapter 15. Any postoperative deterioration in neurological status will necessitate a high standard of nursing
care (Chauvet et al., 1999). If radiation treatment is
planned, it is usual to delay this for 10 days or until the
wound has healed (Siegel et al., 1996).
PROGNOSIS
In some circumstances where a tumor is not amenable
to treatment because of its location or because a pathological fracture has occurred, euthanasia is indicated.
Alternatively, palliative radiation therapy may be considered along with analgesia as discussed in Chapter 15.
259
260
Osteosarcoma3
Osteosarcoma2
Fibrosarcoma2
Fibrosarcoma1
Adjuvant
treatment
None
None
Variable
Variable
Vaccine
Chemotherapy
radiation
Survival
(months)
11; 19; 35
1; 10
4.4
3.7
24
Final
outcome
N/A
N/A
Variable
Variable
N/A
Recurrence
Tumor
type
Plasma cell
tumors4
1
Chauvet et al., 1999; 2 Dernell et al., 2000; 3 Levy et al., 1997a; 4 Rusbridge et al., 1999.
* One dog euthanized at 4 months due to radiation myelopathy.
N/A, not available.
Extradural tumors
Extradural tumors, with the exception of plasma cell
tumors and lymphomas, carry a guarded prognosis
(Dernell et al., 2000; Gilson, 2003) (Table 12.4).
Preoperative neurological status is one important
determinant of final outcome in both humans and
dogs (Dernell et al., 2000; Gilson, 2003). In
humans, between 60 and 95% of patients who could
walk well before surgery still did so after surgery but
only 3565% of paretic patients and less than 25%
of paraplegic patients walked again (Gilson, 2003).
Another factor is anatomic location; four dogs with
tumors in the dorsal spinal compartment were alive
from 7 to 30 months after excisional surgery; a
fifth died from complications after 2 months
(Klopp and Quinn, 2001).
Local disease control is also an important prognostic
factor for overall survival (Kuntz et al., 1997;
Dernell et al., 2000). Dogs with soft tissue
sarcomas that are resected with incomplete margins
are 10 times more likely to have local recurrence
than dogs with complete margins (Kuntz et al.,
1997). One dog with a fibrosarcoma treated by
vertebrectomy survived for over 2 years (Chauvet
et al., 1999) (12.42). Another dog that underwent a
tail amputation for a caudal osteosarcoma survived
2.5 years (Heyman et al., 1992).
Intradural/extramedullary tumors
Intradural/extramedullary tumors have a variable prognosis depending largely on tumor type:
Meningiomas treated by surgical excision alone in
nine dogs gave good long-term outcomes in six
(Fingeroth et al., 1987). Survival is probably
improved further by use of adjunctive therapies
(Bell et al., 1992; Siegel et al., 1996). Even
incomplete resection of meningioma can give a
good outcome when followed by radiation therapy;
three such dogs had 8-, 15- and 25-month survival
times (Siegel et al., 1996) (12.28). A mean survival
of 19.5 months was reported for another 10 dogs
with meningioma (Moissonnier et al., 2002a).
Survival data for dogs with meningioma are shown
in Table 12.5.
Nerve sheath tumors on the other hand have
given very disappointing results overall. This is
particularly true for dogs with tumors that arise
within the vertebral canal and for those undergoing
incomplete resections (Bradley et al., 1982; Brehm
et al., 1995; Jones et al., 1995; Kuntz et al., 1997;
McCarthy et al., 1993; Schueler et al., 1993;
Targett et al., 1993). Only 6 of 51 dogs (12%)
where margins were not assessed remained disease
free after 1 year (Brehm et al., 1995). Ideally all
Neoplasia
Table 12.5 Outcome of dogs with intradural/extramedullary lesions (excluding nerve sheath tumors (12.6))
Tumor
type
Hemangio-4
sarcoma
Nephroblastoma5
Nephroblastoma2
Nephroblastoma8
Meningioma8
Meningioma7
Meningioma1
Meningioma3
Meningioma6
No. of dogs
10
Adjuvant
treatment
Doxorubicin
Radiation
None
Radiation
Radiation
N/A
Radiation
None
None
Survival
(months)
11
36
6.5
825
median
13.5
46 & 47
19
5 live
6 months;
1 alive at
36 months
Mean
19.5
Final
outcome
Metastasis
N/A
N/A
Recurrence
See
citation
N/A
Recurrence
See
citation
N/A
Bell et al., 1992; 2 Ferretti et al., 1993; 3 Fingeroth et al., 1987; 4 Jeffery, 1991; 5 Jeffery and Phillips, 1995; 6 Moissonier et al., 2002a; 7 Levy et al., 1997a;
Siegel et al., 1996.
N/A, not available.
8
Table 12.6 Outcome for nerve sheath tumors following complete excision
Targett et al.,
1993
Bailey, 1990
Platt et al.,
1999
Niles et al.,
2001
Siegel et al.,
1996
Unpublished
(NCSU)
Number of dogs
Survival (months)
9*, 18*
42*
9*
16*
25*
Adjuvant
None
None
None
None
Radiation
None
* Without recurrence.
** Probable recurrence, no necropsy; histological margins had not been evaluated.
NCSU, North Carolina State University.
Intramedullary tumors
Intramedullary tumor resection has only been reported
in three dogs. Two had ependymomas and both underwent surgery and radiation therapy (Jeffery and
Phillips, 1995; Siegel et al., 1996). One dog made a full
recovery and survived for 70 months (Siegel et al.,
1996). The second had a poorly differentiated tumor;
it could walk well 3 months after surgery but was euthanized because it remained incontinent (Jeffery and
Phillips, 1995) (see also 12.4). A third dog had a paraganglioma that was removed and the dog was still alive
10 months later (Poncelet et al., 1994).
261
262
Neurological signs are seen in 512% of cats with systemic lymphoma (Spodnick et al., 1992; Lane et al.,
1994). Most lymphomas are solitary and extradural but
in some cats the tumor may extend over multiple
vertebrae or there may be distant meningeal infiltration
(12.13). Nerve root infiltration is also reported
(Spodnick et al., 1992; Lane et al., 1994). About two
thirds of cats with lymphoma are feline leukemia virus
(FeLV) positive (35/54) and have involvement of other
organs (32/50), mostly in the kidney (Spodnick et al.,
1992; Lane et al., 1994; Noonan et al., 1997).
A less common cause of spinal lymphoma is feline
immunodeficiency virus (FIV). In contrast to FeLVassociated lymphoma, which is a disease of T cells,
most FIV-associated lymphomas are B cell in origin (Callanan, 1996) (12.14). Other tumor types
Diagnosis
Some extradural tumors may affect the vertebral
bodies, causing bony changes on survey radiographs,
but this is not typical. Myelography or transverse imaging is required to confirm the diagnosis in most cats
(Asperio et al., 1999). Compression is usually extradural
in lymphoma (12.13, 12.14) although occasionally other
patterns are seen, particularly if nerve roots are affected.
Other findings that may indicate possible neoplasia
include soft tissue opacities in the cranial thorax with
mediastinal lymphosarcoma, organomegaly or pulmonary metastases.
Other diagnostic tests are indicated to confirm the
presence of a tumor and to define its nature. The bone
marrow is involved in approximately 75% of cats
(14/19) with extradural lymphoma and bone marrow
aspiration is indicated for cytological analysis (Spodnick
et al., 1992; Noonan et al., 1997). CSF contains malignant lymphocytes in only 11 of 31 of cats with CNS
lymphoma (Spodnick et al., 1992; Lane et al., 1994;
Noonan et al., 1997). In some instances, fine-needle
aspiration (page 252) or biopsy at exploratory surgery
may be the only means of making a definitive diagnosis
12.14 Myelogram from a cat with acute ataxia, paraparesis, generalized lymphadenopathy and herpes keratitis; it was FeLV negative
but FIV positive. Neurological deficits localized to T3L3 spinal cord; the thoracic limbs were normal. Neoplastic lymphocytes were
detected in the CSF; flow cytology identified these as B-cells. A: Myelogram reveals extradural compression at T12, which was
unexpected given the normal thoracic limbs. B: CT myelography confirms the mass as extradural (arrow). Response to chemotherapy
was excellent and remission lasted 1 year. Radiation produced a second remission; lomustine produced a third, brief remission but the
cat was euthanized 18 months after presentation.
Neoplasia
Treatment
Chemotherapy often leads to a rapid improvement in
neurological function but remission times may be brief.
Chemotherapeutic protocols are described elsewhere
(Withrow and MacEwan, 2001). Clearly, surgical treatment alone in lymphoma has only a limited role because
of the multifocal nature of the disease (Spodnick et al.,
1992). Radiotherapy may be of benefit in lymphoma,
but should probably be combined with chemotherapy
for the same reason (Lane et al., 1994). If lymphoma is
not suspected strongly, biopsy is required to diagnose
tumor type and can be combined with surgical excision
of the mass (Levy et al., 1997b).
Prognosis
Although initial improvement may be seen after therapy
for lymphoma, long-term prognosis is unfavorable
because of the propensity for multifocal involvement,
local recurrence or the development of systemic FeLVrelated disease. Three of six cats treated with chemotherapy went into complete remission but this usually lasted
less than 6 months (mean 3.5 months). Remission for
more than 1 year was seen in only 2 of 14 cats, one of
which underwent surgery and chemotherapy (Spodnick
et al., 1992; Lane et al., 1994). Cats usually succumb to
systemic effects of the disease (Spodnick et al., 1992;
Lane et al., 1994).
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PROCEDURES
Hemilaminectomy (12.1512.29)
Cervical hemilaminectomy is described below. The ventral slot approach is rarely useful for spinal tumor exploration as
access to the spinal cord and nerve roots is severely limited. Thoracolumbar hemilaminectomy is described in 8.118.37.
12.15
Neoplasia
12.17
12.18
12.19
12.20
267
268
b
c
a
12.21
12.22
12.23
Neoplasia
12.24
a
c
b
12.25
12.26
269
270
12.29
12.30
Neoplasia
12.31
12.32
a
b
c
12.33
12.34
271
272
12.35
12.36
12.37
12.38
Neoplasia
273
Trauma
Chapter
13
Neurological examination
Dural tear
Fibrocartilaginous embolus
282
Radiography 283
Survey radiography 283
Additional imaging 283
Pathophysiology 286
Spinal fracture biomechanics 286
Biomechanics of fixation devices 289
Treatment 293
Choice of therapy 293
Anatomical location of the injury
Postoperative care
295
297
Complications 297
Intraoperative complications 297
Early postoperative complications 299
Late postoperative complications 299
Feline spinal injuries
Prognosis
301
301
303
Procedures 305
Non-surgical 305
Metal and bone cement 309
Modified segmental fixation 315
External fixation 316
302
Cervical spondylomyelopathy
INITIAL ASSESSMENT
Other injuries
The first priority is to treat shock and other lifethreatening disorders (13.1). A thorough and meticulous
282
Urinary tract
Bladder rupture usually causes discomfort on abdominal
palpation, vomiting, depression and hematuria within
2448 h. Damage to the more proximal urinary tract
may take longer to manifest itself (Weisse et al., 2002).
Pubic or perineal swelling indicates potential urethral
trauma.
13.1 This dog sustained spinal trauma 2 h previously. It has been
strapped to a rigid board for evaluation and transport. The head
can also be taped down for cervical injuries. Early immobilization
is very important as up to 50% of animals continue to deteriorate
after injury, particularly when referral is delayed (McKee, 1990;
Hawthorne et al., 1999). A muzzle would be a useful precaution.
Aggressive intravenous fluid therapy is in progress.
Shock
Diaphragmatic hernia
Traumatic cardiomyopathy
Head injuries
Other
Bile duct rupture, although rare, can result in patient
deterioration up to 15 days after injury (Neer, 1992)
(2.1). As some injuries are not apparent immediately,
the owner should be forewarned of the potential need
for further diagnostic evaluation and treatment (Lanz
et al., 2000).
After initial assessment (including nociceptive evaluationsee below) the patient is given analgesics.
Narcotic agonists are preferred unless there is concomitant hypoventilation; they should also be used with care
after head injury (Table 15.1). Analgesia must be combined with some form of stabilization, so that the animal does not injure itself further. If presented within
8 h of injury high-dose MPSS should be considered
although the available evidence for its use is not compelling (Hurlbert, 2000) (see page 83). Sedatives should
not be used routinely because they may decrease
protective muscle tone; adverse effects on the cardiovascular system may also exacerbate shock and compromise spinal cord blood flow (see page 86).
NEUROLOGICAL EXAMINATION
physical examination is essential at this stage as many
animals have non-neural injuries, which could be overlooked (Box 13.2). In one study, 20% of dogs with
injuries to lumbar vertebrae had concomitant pelvic
fractures; 33% had cardiopulmonary lesions (Turner,
1987). Brachial plexus injury must also be ruled out
(page 30, 2.15, 2.26, 13.1).
Cardiothoracic
Post-traumatic cardiac arrhythmias are common and
are easily overlooked as they can be delayed in onset by
up to 24 h. Continuous electrocardiogram (ECG) monitoring is recommended for 24 h or until any arrhythmia
resolves. Arrhythmias can decrease cardiac output,
Trauma
RADIOGRAPHY
Survey radiography
Once the patient has been stabilized and a neuroanatomical diagnosis has been reached, survey radiographs are
taken. The clinician must remember that radiographs
are no substitute for the neurological examination; it is
not possible to estimate the neurological status from
the radiographs alone unless there is 100% vertebral displacement (McKee, 1990; Bagley, 2000) (13.6, 13.35).
Lateral views are taken first. Oblique views to assess the
articular facets may be taken with the animal in lateral
recumbency and the beam angled (13.2, 13.3),
although CT is more accurate (13.12, 13.16).
Ventrodorsal radiographs are best taken using a horizontal beam. Failing that, extreme care must be taken
when positioning the animal for ventrodorsal or
dorsoventral radiographs (4.38). Temporary stability
should be provided by a wood or Perspex splint.
Anesthesia or heavy sedation is undesirable prior to this
as it will reduce the stabilizing effect of paravertebral
muscle spasm (Blass et al., 1988).
Multiple fractures are not common except when
adjacent vertebrae are involved or with injuries caudal
to the lumbosacral junction (Feeney and Oliver, 1980;
Turner, 1987; McKee, 1990; Selcer et al., 1991;
Hawthorne et al., 1999). The neurological localization
and assessment for focal hyperesthesia should help to
rule out multiple injuries. As lower motor neuron (LMN)
lesions can mask upper motor neuron (UMN) deficits,
the T3L3 region should be surveyed when L4S3
deficits are present, likewise the C15 region with
C6T2 deficits (see page 29).
Additional imaging
Specific indications for spinal cord imaging by myelography, CT or MRI include:
Identification of additional lesions, such as when
survey radiographs do not correlate with the
neurological localization.
Identification of lesions that require removal such
as extradural bone fragments, blood clots or disc
material.
MYELOGRAPHY
Advantages of myelography are that:
The entire spine can be evaluated easily.
It may rule out differential diagnoses (Box 13.1).
Dural tears (Hay and Muir, 2000) (13.10)
and spinal cord transection (13.4) can be
283
284
COMPUTED TOMOGRAPHY
Computed tomography should detect bone fragments
within the vertebral canal (13.5, 13.12, 13.16). It is
better than survey radiography at detecting articular
facet fractures and it also allows fracture stability to be
assessed using a three-compartment or column model
(Denis, 1984; Shires et al., 1991). In addition, images
can be used to make 2D and 3D reconstructions of the
lesion (13.5, 13.6).
After localizing the lesion, scans should be made
through the region of interest (see page 55). A CT can
aid the choice of entry points and trajectories if an
implant is to be placed in the vertebral bodies (13.49
13.57). The scan should identify bone fragments, mineralized disc and acute hemorrhage (Tidwell et al., 1994;
Lanz et al., 2000). Use of Hounsfield units (i.e. CT numbers, a measure of tissue attenuation properties) might
also distinguish spinal cord edema, which is potentially
13.5 A CT scan was used in this dog to look for bone fragments in the vertebral canal. A: Survey radiograph. Note the instability
evident between this and image B. B: Sagittal view of 3D reconstruction. A small fragment is visible on the floor of the canal but it is
not causing compression (arrowhead). C: Transverse view of 3D reconstruction. Fracture of the transverse process is visible. The
postoperative radiograph for this dog is shown in 13.24. A myelogram was not performed.
Trauma
reversible, from intramedullary hemorrhage, which carries a poor prognosis (Ramon et al., 1997). CT may
miss traumatic disc herniations although these are usually impact injuries with little residual mass effect. A
disadvantage of CT is that it may underestimate significantly the extent of spinal cord compression and so
should ideally be combined with an MRI (Tator et al.,
1999). Both CT and MRI still carry the risk of fracture
displacement during positioning. Animals with failure
of the disc or end plate (13.5) may be prone to hyperextension injury (4.38). A temporary (non-magnetic
for MRI, below) splint could be used to reduce the risk.
MR IMAGING
A mid-sagittal, T2-weighted MRI allows a large area of
the spinal cord to be surveyed for injury and can also
provide a quantitative assessment of compression. MR
HL
13.7 This dog was paraplegic and incontinent with SchiffSherrington syndrome and UMN deficits 2 days after vehicular trauma.
A: 3-mm, sagittal, T2-weighted image. T13L1, L1L2 and L2L3 discs show subtle loss of signal and extend dorsally; there is
high signal within the spinal cord adjacent to these discs consistent with edema. B: 3-mm, axial, T2-weighted image at L1L2,
same dog. Spinal cord is displaced to the left but not compressed. A low signal, extra-dural mass thought to be a hematoma is
ventrolateral to the spinal cord (arrow). Diagnosis was traumatic disc herniation with focal spinal cord edema, malacia, or both (see
also Gopal and Jeffery, 2001). Treatment was non-surgical; 8 days after trauma the dog could stand and it was normal after 1 month.
285
286
PATHOPHYSIOLOGY
Huge forces are necessary to disrupt the vertebral column and so the spinal cord often sustains a much more
severe injury than it does after a simple disc extrusion
(Tator et al., 1999). Although secondary injury mechanisms are the same, the prognosis is much worse after
trauma than it is after a disc extrusion for animals that
have severe injuries (see page 302). In some animals the
bony elements are spared but catastrophic failure of
the disc can still cause serious spinal cord injury (traumatic disc herniation). The sudden trauma may tear the
anulus causing a previously healthy nucleus pulposus to
rupture explosively into the vertebral canal. This type
of extrusion does not produce the usual mass effect
associated with the mineralized material of degenerative
disc disease. In the cervical region the explosion of
nucleus pulposus is directed dorsolaterally by the dorsal longitudinal ligament and can cause devastating,
asymmetrical neurological deficits. Hemiplegia results
together with loss of sympathetic function and poor
nociception on the affected side (Griffiths, 1970).
Catastrophic disc failure in the thoracolumbar region
can also cause severe spinal cord injury and the sudden
change in subdural pressure may tear the dura mater
(1.21, 13.10). Severe spinal cord injuries with dural
tears can even occur after vigorous running or struggling without any vertebral injury (Hay and Muir,
2000; Yarrow and Jeffery, 2000).
Dorsal
Ventral
Intact component(s)
I Intervertebral disc
II Articular facet
III Vertebral buttress
IV Articular facets and
intervertebral disc
IV Vertebral buttress and
intervertebral disc
IV Vertebral buttress and
articular facets
IV Vertebral buttress,
articular facets and
intervertebral disc
Articular facets
Intervertebral disc
None
Trauma
13.9 I: Vertebral buttress and articular facets are intact but the
anulus has failed (arrow) (13.10).
B
13.10 This dog presented with paraplegia and a lack of deep
pain sensation in one limb. A: Myelography revealed extensive
spinal cord malacia with leakage of contrast over T12 (Lu et al.,
2002) (13.52A, 14.18). There is an isolated ventral compartment
injury; the ventral buttress is intact but the disc has failed. B: 3D
reconstruction of a CT scan from the same dog. There is
leakage of contrast (arrowhead) secondary to a presumed dural
tear (1.21, 13.52). See 13.20 and 13.30 for follow-up.
13.11 II: The vertebral buttress and disc are intact; an articular
facet is fractured (13.12).
287
288
13.14 This dog jumped out of a truck at 20 mph. It could walk and was continent but had decreased anal tone. There is a fracture
of the L7 buttress; the facets are intact. A: Survey radiograph. B: Mid-sagittal 3D reconstruction of the same dog. C: Dorsal view of
the 3D reconstruction. The facets are intact but overridden (10.48). Postoperative radiographs are shown in 13.21.
Trauma
13.15 IV: Vertebral buttress and articular facet fracture; the disc
may also fail.
13.16 Images of a 1.6 kg dog with articular facet fractures; the vertebral buttress has also failed through the disc. The dog had
decreased anal tone but could walk and was continent despite the marked displacement. A: Survey radiograph. B: Mid-sagittal
3D reconstruction of a CT scan through the fracture site. C: Transverse CT scan to show articular facet fractures. Spinal stapling
was successful although not at all ideal for this fracture (13.63).
289
290
13.17 A, B: Severe instability of a spinal fracture as demonstrated by a change in position between two radiographs (McKee, 1990).
Although there is only a small fracture, loss of the disc removes 3040% of the spines overall stability (Shires et al., 1991).
It is inexpensive, there are no complications related to implants and the spinal cord is not
subject to myelography, anesthetic hypotension or
manipulation. Hospitalization times may be less than
for internal fixation (Selcer et al., 1991).
Advantages
Disadvantages
injuries that preserve the ventral buttress; it can sometimes work with severe compromise of the ventral buttress although it is not the ideal technique for such
injuries (Patterson and Smith, 1992).
The advantages are similar to conservative management but this technique provides much
greater stability (13.46). It can be used as the sole means
of fixation or as a supplement to internal fixation. It is
most applicable to mid-thoracic or lumbar fractures but
can also be used for cervical or lumbosacral injuries.
Advantages
Trauma
The advantages are that it is economical, most clinics have the necessary orthopedic implants
and it can work well when the vertebral buttress is
intact.
Advantages
The disadvantages are that it immobilizes a long segment of the vertebral column with the
weak link being the orthopedic wire, not the Steinmann
pin. In addition, the wire can cause fracture of the articular facets. It is not recommended for stabilizing a compromised vertebral buttress (13.13, 13.15).
Disadvantages
Advantages
Disadvantages include the potential to introduce infection and place excessive tension
on the skin or fascia (Shores et al., 1989; Lanz et al.,
2000); the pin tracts need regular cleaning; additional
postoperative management can be labor intensive
(Lanz et al., 2000); limited pin lengths for large dogs
using some systems (14.13); and the risk of traumatic
removal (13.65). Removal of the device prior to optimal fracture healing could result in catastrophic failure.
Disadvantages
INTERNAL FIXATION
The procedures described are usually performed via a
standard dorsal approach to the thoracolumbar spine
(12.3012.33). The dorsal spinal plate, vertebral body
plate, transilial pin techniques (Lewis et al., 1989), and
spinal stapling are no longer recommended. Bilateral
plating has similar biomechanical properties to pins and
bone cement but is harder to perform over the thoracic
and caudal lumbar regions (Viguier et al., 2002). AO
locking plates may be useful in some situations
(11.13B); these can now be made from bioabsorbable
materials that avoid stress protection by transferring
load gradually to the spine (Yerby et al., 1998; Vaccaro
and Madigan, 2002; Vaccaro et al., 2002) (13.33).
Disadvantages
291
292
BONE GRAFTS
These have a wide range of potential uses, which include
to enhance the healing of fractures and luxations. Grafts
are either cortical or cancellous in origin; they can be
derived from the host (autograft) or from a donor (allograft) (Millis and Martinez, 2003). Autogenous cancellous graft is the most effective material to improve bone
healing. It does not provide useful mechanical strength
but up to 10% of transplanted cells survive to produce
bone (osteogenesis). It also induces adjacent cells to
make new bone (osteoinduction) and it forms a
weak scaffold for bone ingrowth (osteoconduction).
Harvesting autogenous cancellous bone requires a separate surgical approach; the proximal humerus is the
most accessible site during ventral surgical approaches
(11.24) and the iliac crest during dorsal approaches.
Cortical autografts can be harvested from the
ilium, rib, fibula or ulna.
Caudal vertebra can be used as a free vascularized
graft (Yeh and Hou, 1994).
Corticocancellous autograft can be obtained from
the ilium, sternum, wing of C6 vertebra, or from
adjacent spinous processes (Chauvet et al., 1999).
Cancellous allograft (Veterinary Transplant Services,
Seattle, WA) can be used like fresh cancellous graft;
it can also be combined with a small amount of
autogenous graft. Cancellous allografts contain no
live cells; they are not osteogenic but are both
osteoconductive and osteoinductive. Small blocks of
allograft can also be used to temporarily distract a
ventral slot during fixation.
Cortical allografts (Veterinary Transplant Services,
Seattle, WA) are used to provide some mechanical
support and a strong scaffold for new host bone
ingrowth. They may be packed with cancellous
bone to enhance healing further.
Demineralized bone matrix can also be used to
enhance bone healing. It is available as a powder
(Veterinary Transplant Services, Seattle, WA) made
from cortical bone after acid-extraction of the
mineral to expose osteoinductive proteins. These
proteins then cause adjacent mesenchymal cells to
differentiate into osteogenic cells.
Potential indications for bone grafts in neurosurgery
are to improve healing potential such as in a diabetic or
geriatric animal; for arthrodesis (9.28, 10.52D, 11.30A),
to replace bone loss such as after vertebrectomy
(12.42) and to manage infection (13.28, 14.12).
Trauma
TREATMENT
Choice of therapy
Presentation
Euthanasia
Deep pain
present
No deep
pain
Examine for
spinal cord
transection by
durotomy
Euthanasia
Imaging
Cord intact
Cord
transected
Euthanasia
No compression
Severe
compression
Stabilize
Decompress
External
fixation
Internal
fixation
Cord
transected
Euthanasia
293
294
Consider
anatomical
location
Surgical
Non-surgical
Advanced
imaging
External
fixation
(Splint)
Compression
No
compression
Decompress by
realignment
Improves
Deteriorates
Continue
Surgical
Bone, disc
hematoma
Decompress by
(mini) hemilaminectomy
Fixation
Internal fixation
External fixator
Trauma
B
13.18 A: Dog with a fracture/luxation of C2 treated with an
external splint. The splint should ideally extend from near the
lateral canthus of the eyes to the mid-thoracic region. B: An
alternative means of stabilizing the upper cervical area using
a chest harness and Halti collar; the Halti with harness can also
be used in cervical spondylomyelopathy (CSM).
295
296
Trauma
13.22 A: Cat with a sacrocaudal injury and transverse sacral fracture (arrow). Six weeks post trauma the cat still had a paralysed
tail, no anal reflex and was incontinent. Dorsal laminectomy revealed fibrosis; neurolysis produced no improvement and the cat was
euthanized at 18 weeks. Histopathology revealed lesions in the S2, S1 and L7 nerve roots caused by traction injury to the cauda
equina (Smeak and Olmstead, 1985; Kuntz and Bonagura, 2000). B: Necropsy specimen from a dog with a transverse sacral
fracture that has severed all nerve roots at this level (arrowheads).
POSTOPERATIVE CARE
(see also
Chapter 15)
The surgical wound must be examined at least daily for
any sign of infection. A urinary tract infection (UTI)
should be anticipated in any animal whose deficits are
severe enough that it cannot walk. Urine obtained by
cystocentesis should be analysed every 2 days or if the
urine appears cloudy; culture should be done if there is
any sign of infection. Bacteremia from the urinary and
gastrointestinal tracts or from skin lesions increases the
risk of infection at the surgical site (see page 355). Any
sudden increase in pain (13.27) or deterioration in neurological status (13.30) suggests infection or implant
failure and requires repeat radiographs. A deterioration
in patient status can also occur from non-neurological
complications of the original trauma (Box 13.2).
COMPLICATIONS
These are discussed for three major time points
intraoperative, early and late postoperative (Table 13.2).
Intraoperative
Poor reduction
(13.2413.26)
Poor implant
selection (13.27)
Poor implant
placement
(13.23)
Inadequate
cement
(13.27, 13.28A)
Pneumothorax
Fat embolism
Cardiac
arrythmias
Early
postoperative
Late
postoperative
Complications
of trauma
Implant failure
(13.28, 13.29)
Wound infection
(13.28)
Gastrointestinal
ulceration
Urinary tract
infection
Decubitus
Urine scald
Pneumonia
Vascular
complications
Sepsis
Implant failure
Infection (13.34)
Callus
encroachment
Syringomyelia
Arachnoid cyst
(13.32)
Late deformity
Adjacent segment
disease (13.28)
Intraoperative complications
These fall into two main groups: cardiopulmonary complications and technical errors (Table 13.2). Cardiovascular complications are most likely in animals with
cervical and thoracic injuries (Hawthorne et al., 1999)
(see page 86). Pneumothorax is common and may be
iatrogenic (Swaim, 1971; Blass and Seim, 1984; Selcer
et al., 1991). Fat embolism may occur during fracture
repair (Schwarz et al., 2001). Technical errors in fixation
include improper placement of implants (Blass and Seim,
1984) (13.19, 13.23), poor postoperative alignment
(13.2413.26) that can even lead to a delayed onset
297
298
13.23 One Steinmann pin has been inserted too far and could
damage vital structures in the retroperitoneal space or abdomen
(see 1.23 for relationship of vertebrae to the aorta and vena
cava). This dog was normal at 5-year follow-up.
B
13.24 This dog was progressively paraparetic 7 days after a lowimpact injury. An external splint was applied but the neurological
status deteriorated. A: Preoperative radiograph shows an injury at
L4/5 (same dog as 13.5). B: Although facet joint alignment was
good, the surgeon exerted excessive ventral pressure causing a
misalignment in extension (Matthieson, 1983). Use of a towel or
sandbag under the abdomen helps to prevent this as does gentle
traction on the spinous processes as the cement hardens (Blass
and Seim, 1984; Lewis et al., 1989; Berry et al., 1999). Fortunately
the dog recovered quickly and was normal within 2 months.
Trauma
13.28 Implant failure 5 days after surgery. A: The cement has broken; either the bar was not thick enough (13.59) or a bubble
(13.33), fold or thin area was present at this site (McAfee et al., 1986) (13.27). Wound culture yielded Streptococcus fecalis.
B: Wound discharge resolved 2 weeks after the implant was replaced with screws and cement plus modified segmental fixation
(13.6113.63). The dog did well for 2 years when pain and discharge returned. The implant was removed and discharge
resolved again. The dog did well for 3 more years but then developed a marked kyphotic deformity.
299
300
13.30 This dog lost deep pain sensation 8 days after surgery at
T12/13 (13.20). This unusual failure may be a type of adjacent
segment disease (MacMillan and Stauffer, 1991; Fox et al.,
1996; Lanz et al., 2000; Wheeler et al., 2002) (11.23, 13.31).
A: Radiography revealed luxation at the adjacent T13/L1
interspace. The implant was intact. B: Marked rotational
deformity was also present. The preoperative myelogram and
CT scan were re-examined but no injury was found at T13/L1.
3D CT scan reconstructions were also examined to view the
articular facets but no abnormality was detected (13.10B). The
dog recovered motor function at 3 months; it could walk by
6 months but did not recover continence or deep pain
(Olby et al., 2003) (see pages 32, 131, 302).
B
13.32 A: Preoperative myelogram of the dog shown in 13.31
and 13.33. The T12 vertebral buttress has failed and the facet
joints have luxated. Despite the severity of the injury the dog
made an excellent recovery and did very well for 3 years when
it developed progressive paraparesis. B: A myelogram then
revealed an arachnoid cyst (arrowhead) at T12/13 (see
pages 321, 323). The dog remained stable for a further 21
months without intervention (Skeen et al., 2003).
Trauma
PROGNOSIS
This varies somewhat with the location of injury. Prognosis is very good after cervical injury if the animal does not
die acutely from respiratory arrest (see pages 28, 82). In
the largest series to date, 32 of 39 dogs (82%) with neck
injuries made a functional recovery; results were much
better after non-surgical treatment because the mortality
rate was only one third of that in the surgically treated
dogs. Twenty-five of 28 dogs recovered after non-surgical
management compared with seven of 11 after surgery
(89% vs 64%). Results were good after non-surgical management even for dogs that were unable to walk. Delay in
instituting definitive treatment was a predictor of poor
outcome (Hawthorne et al., 1999). Immediate decompression by vertebral realignment is likely to benefit animals with tetraplegia or hypoventilation secondary to
cervical injury (Papadopoulos et al., 2002).
The prognosis following thoracic and lumbar injury is
similar to that for disc disease provided that the animal
has good deep pain at presentation. However, studies
with good follow-up are limited. Surgical management
of 24 such animals gave good results in 21 (88%),
although 10 had residual deficits and one was euthanized due to implant migration after 22 months (Blass
and Seim, 1984; McKee, 1990). In another study, 19
of 23 dogs (83%) presenting with intact deep pain
made good recoveries (Sharp et al., 1998). Non-surgical
management in a further 25 animals, comprising either
cage confinement or splinting, gave good results in 24
(96%). Three had residual deficits (Carberry et al.,
301
302
13.36 A: This dog showed progressive paraparesis after trauma. It had subluxation at T2/3, which was managed with an
external splint. This is a difficult area to stabilize so the sides of the splint were extended down each flank to just above the elbow
but this made it impossible to check beneath the splint without removing it. The dog would not eat 5 days after splinting and was
found in extremis on day 6. A huge, phlegmon-like, subcutaneous abscess was present associated with a small decubital lesion.
Bone cement and threaded implants would have been preferable in this dog. B: The prognosis for dogs with traumatic injuries
and without nociception on presentation is very poor (Olby et al., 2003). It would be helpful to be able to differentiate animals
without deep pain that are capable of functional recovery from those with irreversible injuries. Here an electrical stimulator from
an electromyography (EMG) machine is being used but there was no response in this dog. Alternative methods include strong
pliers or a cattle prod (see page 132).
Trauma
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Trauma
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PROCEDURES
Non-surgical (13.3713.47)
Cage confinement can give excellent results and is the only non-surgical option for most cats (Carberry et al., 1989;
Selcer et al., 1991). A splint is preferred for dogs if certain criteria are satisfied including intact deep pain sensation,
an intact ventral buttress and no pelvic, thoracic or soft tissue injuries (Patterson and Smith, 1992) (see page 290).
It is essential that as much of the area under the splint as possible along with the skin of the groin and axilla be
examined daily. Urine soiled straps must be replaced. Areas at risk from urine scalding or fecal soiling benefit from
application of Desitin ointment (Pfizer Inc., New York). If there is any doubt, the straps or splint must be loosened
sufficiently to allow proper inspection and then reattached. If doubt remains the splint must be removed.
Useful indicators of potential problems are the animals mental attitude, its appetite, and the presence of pain
or fever (13.36A). Most animals are surprisingly comfortable in a splint unless problems such as decubital ulcers
develop. The splint should be maintained for a minimum of 4 weeks (3 weeks for immature animals), and is
preferably then followed by a further 24 weeks of strict cage confinement.
305
306
13.37
13.38
13.40
Trauma
13.42
307
308
13.45 In the pectoral region, the straps are applied as a figure of eight,
extending in front of the shoulder and under the neck like a
harness. The straps around the chest must be snug but must
not impede ventilation. Radiographs can be taken through the
splint to check fracture alignment.
13.45
13.47
Trauma
Intravenous antibiotic effective against staphylococci (such as a cephalosporin) is given and repeated every
12 h during surgery (Marcellin Little et al., 1996; Novelli, 1999; Kriaras et al., 2000).
Fracture reduction can be very difficult in some injuries without some type of mechanical assistance (Boudrieau,
1997; Schulz et al., 1997; Bagley et al., 2000) (13.64). A laminectomy spreader, Senn retractor, or a curved
hemostat can be used for reduction of L7 fractures or manual traction can be put on the tail (Blass and Seim,
1984; Beaver et al., 1996; Harrington and Bagley, 1998; Bagley et al., 2000). Cervical injuries can be reduced
using traction on the maxilla or a Gelpi retractor can be placed in holes drilled in the middle of a vertebra (Blass
and Seim, 1984; Blass et al., 1988) (11.38). A ScovilleHaverfield or similar retractor can also be placed in adjacent
disc spaces or between a disc space and the base of the skull for C2 fractures (Boudrieau, 1997).
Initial stabilization is provided by bone-holding forceps (13.48, 13.60) while K-wires are placed across the articular facets to provide additional stability and maintain alignment (Blass and Seim, 1984; Beaver et al., 1996; Berry
et al., 1999) (13.28A, 13.48). When a hemilaminectomy must be performed, when a facet is fractured, and when
a ventral approach is used for cervical fractures, the K-wire can instead be placed across a disc space to maintain reduction (Blass et al., 1988). Additional methods for reducing a fracture are discussed in 13.64.
A small K wire is used initially to make a point of purchase for the drill bit. It can also be used to make a test hole
to evaluate bone quality over the chosen path of the implant. If bone quality is poor this small test hole can easily
be redirected without prejudicing the final pilot hole. Pins should be placed using a low power setting to reduce
bone necrosis; a pilot hole is recommended for threaded pins (Egger et al., 1986; Walker et al., 2002). Muscle
should be protected during drilling with a drill guard. If brisk hemorrhage arises from the pilot hole then a finger
or bone wax should be placed over the hole, which should be tapped and screwed as soon as possible (1.19).
A flatter implant trajectory increases implant holding strength due to the greater bone contact (Garcia et al.,
1994). Such an angle is also necessary if a hemilaminectomy has been performed so that the cement can be positioned well away from the spinal cord. Landmarks for lumbar vertebrae are the ventral portion of the base of the
accessory process and the junction of the transverse process with the vertebral body (Rouse and Miller, 1975; Blass
and Seim, 1984; Wong and Emms, 1992; Bagley et al., 2000; LeCouteur and Sturgess, 2003). Entry points should
be between these landmarks and are discussed in 13.55. A skeleton should always be available for reference.
The implant entry point should be no higher than the base of the accessory process. If a flat trajectory is to be used
then the entry point should ideally be no higher than the floor of the vertebral canal otherwise the vertebral canal may
be entered inadvertently (Walker et al., 2002). There is some variation based on the exact vertebra (1.211.23, 1.25,
13.56). Also, due to the concave ventral surface in the middle of each vertebral body, implant placement must be
more precise centrally. A CT scan is invaluable for planning the entry point as well as the trajectory.
The bone cement is applied in a cylindrical pattern on each side of the spine. Wound closure is then much easier than when cement is applied in a doughnut pattern. Implants must be encased fully by the cement (13.57).
The wound is irrigated with saline to dissipate heat generated by the curing of the cement. The spinal cord and
nerves must not contact the cement, especially following hemilaminectomy. Gelfoam (Pharmacia, Kalamazoo,
MI) has good insulating properties and should be used to protect exposed spinal cord (Roosen et al., 1978;
Boker et al., 1989). Excision of epaxial muscle facilitates wound closure (Blass and Seim, 1984). Potential causes
of cement failure include a fold or thin region of the cement bar. Cement can be reinforced with a pin provided
that this is encased fully by the cement (Bagley et al., 2000) (13.25, 13.28, 13.48). Antibiotic should not be added
to the methylmethacrylate unless done in a very carefully controlled fashion as it tends to reduce strength (Ethell
et al., 2000; Weisman et al., 2000). It is preferable to give a second dose of intravenous antibiotic just prior to
bone cement application.
309
310
13.49 Diagrams to
illustrate one
possible implant
pattern. The
preferred pattern is
13.49
to drive implants
perpendicular to
A
the vertebral body
(13.54A), which allows placement of three implants in each vertebra
instead of the two shown here (Garcia et al., 1994). A: Dorsoventral
view. B: Transverse view.
Trauma
13.51
A
311
312
13.53
A
13.54
Trauma
13.55
A
313
314
13.58
13.59
A
Trauma
13.60
A
13.61
315
316
13.62
13.63
A
Trauma
13.64
A
317
318
Miscellaneous conditions
Degenerative 319
Degenerative myelopathy (chronic degenerative
radiculomyelopathy, CDRM) 319
Synovial cyst 320
Facet joint pain 320
Sacroiliac joint pain 320
Leukodystrophies 320
Arachnoid cyst 321
Spondylosis deformans 321
Anomalous 321
Congenital vertebral anomalies
Sacrocaudal dysgenesis 322
Spina bifida 322
Tethered spinal cord 322
Spinal dysraphism 322
Syringomyelia and hydromyelia
Cartilaginous exostoses 323
Dermoid sinus 323
Epidermoid cyst 323
Arachnoid cyst 323
Metabolic 326
Lysosomal storage diseases
Osteoporosis 326
Nutritional 326
Hypervitaminosis A
321
331
Vascular 332
Fibrocartilaginous embolism (ischemic
myelopathy) 332
Ascending myelomalacia 332
Ischemic neuromyopathy (aortic embolism, iliac
thrombosis) 332
Spinal cord hemorrhage, hematoma 333
Intermittent claudication 334
Key issues for future investigation
334
334
Further reading
337
322
326
326
Infectious/inflammatory 326
Discospondylitis 326
Epidural empyema 328
Inflammatory CNS diseases 329
Epidural steatitis 331
331
14
References
Idiopathic 326
Tumoral calcinosis 326
Disseminated idiopathic skeletal hyperostosis
(DISH) 326
Trauma
Chapter
DEGENERATIVE
Degenerative myelopathy (chronic
degenerative radiculomyelopathy, CDRM)
This is a degenerative condition of the spinal cord of older
dogs; it is mostly seen in large breeds and particularly
German shepherd dogs. A similar disorder has been
described in a cat (Mesfin et al., 1980). There are probably several different types of canine degenerative
myelopathy that are grouped together and cannot be differentiated at present. Phenotypes in the various breeds
of dog may vary somewhat from that of the classic condition found in the German shepherd dog (Matthews et al.,
320
Synovial cyst
Leukodystrophies
Several breed-specific disorders are described in Afghan
hounds, Dalmatians, Miniature poodles and Dutch
kooiker dogs. The most common examples are seen in
Rottweilers.
ROTTWEILER LEUKOENCEPHALOMALACIA
Miscellaneous conditions
Arachnoid cyst
In an arachnoid cyst there is a focal accumulation of
CSF in the subarachnoid space, which compresses the
spinal cord (Dyce et al., 1991; Skeen et al., 2003). These
can be acquired secondary to some type of injury (13.32)
although they are usually congenital lesions (see below).
Spondylosis deformans
Spondylosis deformans is a common radiographic finding
in older dogs, but it is rarely associated with clinical signs
(Morgan et al., 1989). Generally the osteophytes develop
ventrally and laterally on the vertebral body, and they
may grow to the point that they bridge the intervertebral
space (Larsen and Selby, 1981) (14.1). Osteophytes
around the articular facet joints may be of more significance (see Facet joint pain, above). The thoracolumbar
junction and lumbosacral joint are particularly affected.
Where these changes are seen at the lumbosacral joint
they may be related to clinical signs of lumbosacral disease. However, this diagnosis should not be reached on
the basis of survey radiographs alone, as such changes
are seen in many normal dogs (see page 188). It is
important to differentiate spondylosis deformans from
the changes seen in discospondylitis (14.1114.13).
ANOMALOUS
Congenital vertebral anomalies
Vertebral malformations are common findings in dogs
and are also seen occasionally in cats. Some do cause
compressive myelopathy or are associated with anomalies of the spinal cord (Bailey, 1975; Bailey and Morgan,
1992). Many cases of atlantoaxial subluxation also have
an underlying congenital vertebral malformation (see
Chapter 9). Anomalies such as hemivertebrae, butterfly
vertebrae and block vertebrae are relatively common
but they rarely cause clinical signs. Hemivertebrae are
seen usually in the small, brachycephalic breeds. They
14.2 Dog with severe ataxia and paraparesis due to a hemivertebra at T7. Threaded pins and bone cement were used to stabilize
the site prior to performing a dorsal laminectomy. Neurological function was unchanged postoperatively and the dog was walking
well within a few days.
321
322
Sacrocaudal dysgenesis
Cats and dogs with congenital tail defects often have vertebral abnormalities of the sacrum and caudal vertebrae.
Manx cats, Pugs and Bulldogs are affected most often
and the condition is inherited in the Manx. The vertebral
abnormalities may themselves cause neurological
deficits that affect the pelvic limbs, lower urinary tract
and anus or there may be malformations of the spinal
cord such as spina bifida. Diagnosis is suspected from the
clinical signs. Radiography will demonstrate vertebral
abnormalities and myelography or MRI may reveal spinal
cord malformations. Treatment is not possible and the
prognosis is poor.
Spina bifida
This is a developmental defect resulting from failure of
the embryonic vertebral arch to fuse normally. There
may be protrusion of the meninges or spinal cord into
a meningocele, a myelocele or a meningomyelocele; this
is termed spina bifida aperta. Alternatively, there may
be no protrusion of nervous tissue, which is termed
spina bifida occulta (Wilson et al., 1979; Wilson, 1982).
There is a high incidence of these conditions in English
bulldogs and Manx cats.
Spina bifida usually involves the caudal lumbar spine.
Clinical signs indicative of L4S3 spinal cord dysfunction
occur. Radiography may reveal defects in the dorsal
vertebral arch, such as paired spinous processes, and
myelography or MRI may demonstrate a meningocele.
Treatment is not possible but untethering may help (see
below). When there is an opening in the skin, closure
should be considered to prevent meningomyelitis.
Spinal dysraphism
Malformations of the spinal cord have been described in
several breeds of dogs, particularly Weimaraners (Broek
et al., 1991). Various lesions of the central canal, gray
matter, dorsal sulcus and ventral fissure have been
described and a syringohydromyelia may also be present.
A bunny-hopping pelvic limb gait, abnormalities of the
hair coat, a depression of the sternum, and head tilt may
be seen. Neurological deficits localize to the T3L3 spinal
cord and signs are often evident in affected puppies. The
signs are usually non-progressive. Abnormalities may be
detected using MRI (Dewey et al., 2003).
Miscellaneous conditions
ribs and limb bones. It is caused by abnormal differentiation of cartilage cells in bones that develop by endochondral ossification, leading to the production of large
masses composed of a thin cortex lined by cartilage and
with a core of cancellous bone. The etiology is unclear
(Gambardella et al., 1975; Meomartino et al., 1997).
The masses continue to grow until skeletal maturity is
reached and may also continue thereafter in some dogs.
Diagnosis is by radiography (14.3B). Surgical decompression of compressive lesions may be necessary but the
prognosis is guarded in dogs and is considered to be poor
in cats. Neoplastic transformation can result in clinical
signs in adult animals and this may actually be more
common than was thought previously (Jacobson and
Kirberger, 1996; Dewey et al., 2003).
Dermoid sinus
B
14.3 A: Syringohydromyelia (arrow), mild hydrocephalus and
caudal occipital malformation in a Cavalier King Charles
spaniel with persistent scratching at the shoulder. B: Multiple
cartilaginous exostoses affecting the last rib and L4 vertebra.
Cartilaginous exostoses
Cartilaginous exospores (osteochondromatosis) may
cause spinal cord compression at any site of the vertebral
column of dogs and cats. Lesions may also occur on the
In dermoid sinus (pilonidal sinus) the skin over the dorsal midline is inverted and, in some dogs, the invagination communicates with the dura mater. Rhodesian
ridgebacks and Shih tzus have a high incidence
(Tshamala and Moens, 2000). Infection from the cyst
may extend to the spinal cord, causing meningitis and
myelitis with associated clinical signs.
Diagnosis is based on physical examination and clinical signs. If a cyst is suspected to be in communication
with the vertebral canal, myelography or MRI is
preferable to fistulography. Infected lesions are treated
by antibiotics and surgical excision; it may be necessary
to perform a laminectomy to retrieve all the tissue.
Careless exploration of this type of lesion, without a
full appreciation of its extent, can lead to the development of marked neurological deficits.
Epidermoid cyst
This is a rare cystic lesion that arises from entrapment of
epithelial cells within the neural tube. This lesion can be
congenital or it can be acquired secondary to mechanical
implantation of epithelial cells, such as by puncture of
the spinal cord by a needle (Tomlinson et al., 1988).
Myelography or MRI will show an intramedullary
lesion, which is likely to be mistaken for a spinal cord
tumor such as nephroblastoma of young dogs (see
page 249).
Arachnoid cyst
These are not true cysts as they do not have an epithelial
lining (Dyce et al., 1991). Rather there is a focal accumulation of CSF, probably due to adhesions within the
subarachnoid space (Dyce et al., 1991; Moissonier et al.,
2002) (14.6). The natural pulsation of CSF is sufficient
to produce a bulbous or tear-drop enlargement of the
subarachnoid space and this can then cause marked spinal
323
324
14.4 Ten-month-old Retriever with progressive paraparesis for 2 months. A: Well-defined, bulbous dilation of the dorsal subarachnoid
space at C2/3. This communicates with the rest of the subarachnoid space as contrast flowed caudally within a few minutes
(14.8B). B: Dorsoventral view confirms the discrete border of this lesion. Surgical appearance of the lesion is shown in 14.8A.
14.5 Seven-month-old Labrador with tetraparesis for 1 month. Myelography revealed a subarachnoid cyst at C2/3. A: The dura
has been opened over the cyst; the wall is still intact and compressing the spinal cord (arrow). B: The cyst wall (arrow) has been
incised to reveal the spinal cord beneath a pool of CSF. The dog was normal 2 years after surgery (Skeen et al., 2003).
Miscellaneous conditions
14.7 A: Marsupialization at T12/13 in a 9-year-old Westie with progressive paraparesis and fecal incontinence for 2 months.
A release incision may be needed if marsupialization puts tension on the dura (arrow). The dog was doing well 22 months after
surgery (Skeen et al., 2003). B: The laminectomy in this dog is not as wide but still gave enough access to suture the dura accurately.
14.8 A: A wide dural fenestration has been made after hemilaminectomy at C2/3. The dog was much improved 24 months after
surgery (Skeen et al., 2003). B: Radiograph taken 10 min after the images shown in 14.4. Contrast has flowed from the previous
point of obstruction (arrow) into the remainder of the subarachnoid space. CSF flow dynamics have been studied in one dog
with an arachnoid cyst and showed normal communication with the subarachnoid space (Moissonier et al., 2002).
325
326
METABOLIC
Lysosomal storage diseases
Lysosomal storage diseases occur where there is a defect
of metabolism caused by dysfunction in a specific
enzyme pathway. They are relatively common disorders
in dogs and cats and frequently cause neurological signs,
which are usually seen from early in life and are progressive. Most cause signs of intracranial disease but cats
with mucopolysaccharidosis type VI can present with
paraparesis. Neurological deficits are caused by vertebral exostoses that can resemble cartilaginous exostosis
and hypervitaminosis A (Haskins et al., 1980, 1983).
Mucopolysaccharidosis type IIIA in dogs can present as
an adult onset pelvic limb ataxia or hypermetric gait
(Fischer et al., 1998; Jolly et al., 2000). Cytoplasmic
inclusions may be detected in hepatocytes but definitive diagnosis requires specialized techniques. There is
no treatment and the prognosis is poor.
Osteoporosis
This is a common problem in humans, the incidence of
which increases with age as well as in women after menopause or ovariectomy (Riggs, 2002). Other risk factors
include chronic renal disease, type I diabetes, corticosteroid use and Cushings disease (Khanine et al., 2000;
Vestergaard et al., 2002). Vertebral fractures are a common sequel to osteoporosis in humans (Khanine et al.,
2000); diagnosis is made by radiography, scintigraphy,
CT or MRI (Cook et al., 2002; Tan et al., 2002). Even
though vertebral fracture due to osteoporosis is a common problem in humans it is nevertheless underdiagnosed (Gehlbach et al., 2000). Osteoporosis has been
produced experimentally in canine lumbar vertebrae as a
result of ovariectomy or steroid administration (Norrdin
et al., 1990; Yamaura et al., 1993); it has also been recognized as a clinical problem in dogs with Cushings disease
as well as in routine post-mortem studies (Pellegrini et al.,
1979; Huntley et al., 1982; Schleithoff, 1984). Vertebral
fracture secondary to osteoporosis is therefore likely to be
an under-recognized cause of spinal pain in dogs, especially in older, neutered animals with Cushings disease.
IDIOPATHIC
Tumoral calcinosis
Also known as calcinosis circumscripta, this condition
has been described as a cause of compressive spinal cord
dysfunction in young dogs. The most common site is
between C1 and C2 but it has also been reported in the
thoracolumbar region (McEwan et al., 1992; de Risio
and Olby, 2000). Diagnosis is by radiography; a mineralized mass is visible at the site of cord compression
(14.10). The cause is not known. Surgical decompression may be successful.
NUTRITIONAL
Hypervitaminosis A
INFECTIOUS/INFLAMMATORY
Discospondylitis
Miscellaneous conditions
327
328
14.13 A: The dog shown in 14.12 at 6-week follow-up. B: Dorsal view of the external fixator (SK External Fixation System, Imex
Veterinary Inc., Longview, TX). A potential limiting factor in large dogs is the length of pin; these were only just long enough to attach
the clamps.
Epidural empyema
This is an emergency situation that requires rapid diagnosis and treatment (14.14). Clinical signs include fever,
Miscellaneous conditions
14.14 A: Doberman that underwent a ventral slot and distraction stabilization using screws and bone cement for a dynamic lesion
at C5/6. The dog did well for 4 days but then became febrile and suffered progressive neurological deterioration. B: A repeat
myelogram 2 weeks after surgery revealed small erosions of the C6/7 end plates and a diffuse epidural mass extending from the
mid-body of C5 vertebra to mid-C7 (arrowheads). The dog died; epidural abscess was found at necropsy.
even thousands per microliter), mainly comprising neutrophils along with an increase in protein concentration.
Infectious agents are not seen in the CSF and culture is
negative; an immune-mediated mechanism is suspected.
The CSF may be relatively normal between bouts of the
disease.
Treatment with long-term corticosteroids is recommended (prednisolone 24 mg/kg/day initially, reducing
to anti-inflammatory doses) until the clinical signs and
CSF pleocytosis resolve. The prognosis is fair, although
some dogs experience relapses. Older dogs with high
IgA levels in their CSF require a longer duration of corticosteroid therapy and have a less favorable prognosis
(Tipold and Jaggy, 1994; Cizinauskas et al., 2000).
329
330
GRANULOMATOUS
MENINGOENCEPHALOMYELITIS (GME)
This is an inflammatory disease of unknown etiology; any
part of the CNS may be involved and the lesions can
either be focal or diffuse in nature. The retina and optic
nerves may also be affected. Perivascular accumulations
of mononuclear cells are present throughout the CNS,
Bacteria
Rickettsia
Fungi
Protozoa
Helminth
Canine distemper
Feline infectious
peritonitis
Rabies
Staphylococcus sp.
Brucella canis
Rickettsia sp.
Ehrlichia sp.
Bartonella sp.
Cryptococcus neoformans
Coccidioides imitis
Blastomycoides dermatidis
Histoplasma capsulatum
Miscellaneous conditions
Epidural steatitis
This is a common complication to epidural empyema but
could also occur secondary to infection with Brucella,
Bartonella or Mycobacterium sp. (Postacchini and
Montanaro, 1980; Nas et al., 2001). Epidural fibrosis and
fat necrosis are also seen secondary to vascular compromise in lumbosacral disease (see page 190).
TRAUMA
The most common disorders are discussed on pages
30 and 283. Brachial plexus injuries are a common
331
332
VASCULAR
Fibrinocartilaginous embolism
(ischemic myelopathy)
Fibrocartilaginous embolism (FCE) is a syndrome of
acute, severe neurological dysfunction of dogs. It is an
important differential diagnosis in cases of disc disease,
trauma, and other acute spinal conditions (Cauzinille
and Kornegay, 1996). The emboli are composed of fibrocartilage, identical to the material within the nucleus
pulposus. In pathological studies of FCE, emboli are
found in the vasculature of the spinal cord substance or
nerve roots. The exact mechanism by which they gain
access to these areas is not clear.
Adult dogs of large and giant breeds are affected most
often along with Miniature schnauzers, but this condition can affect any dog. FCE can occur in dogs as early
as 8 weeks of age, although it is seen most often in
adults between 3 and 7 years (Cauzinille and Kornegay,
1996; Junker et al., 2000; Hawthorne et al., 2001). The
condition appears to be very rare in cats (Scott and
OLeary, 1996; Abramson et al., 2002).
Peracute, severe neurological presentations occur,
often following vigorous exercise or mild trauma.
Owners may note a progression of the signs over a
period of several hours, often from an initial lameness to
eventual paralysis. However, progression beyond the
first 24 h is very unusual and this helps to differentiate
the condition from other myelopathies. Spinal hyperesthesia is not usually present on clinical examination,
but sometimes severe discomfort is apparent during
the development of the condition and this can persist
for several hours after onset (Cauzinille and Kornegay,
1996). Any part of the spinal cord may be affected, and
often the signs are markedly asymmetrical.
Ascending myelomalacia
This is probably an ischemic lesion induced by the
diffuse spread of extruded disc material; it is illustrated in 8.5 and 14.18 and discussed on page 128.
Extensive malacia may also be evident following
trauma (13.10).
14.17 10-year-old cat that was normal prior to an acute onset of symmetrical tetraparesis localizing to the C6T2 spinal cord. T2weighted MRIs show high signal within the spinal cord (arrows) that extends A from the level of C2 to C7 vertebral bodies and that
B occupies much of the cross-sectional area of the spinal cord. Histological diagnosis was FCE.
Miscellaneous conditions
14.19 T2-weighted MRI of a 9-month-old dog with neck pain and tetraplegia for one day caused by a hematoma (arrowheads).
Platelet numbers, coagulation profile and a buccal mucosal bleeding time were normal. The dog failed to improve and was
euthanized after 3 weeks; necropsy showed that the hematoma was subarachnoid; no cause was identified. A: Sagittal image.
The dotted line shows the level of the transverse image. B: Transverse image. For MRI of blood, see page 58. C: Necropsy.
333
334
Intermittent claudication
This is recognized in both humans and dogs with
lesions in the lumbar and lumbosacral regions (Tarvin
and Prata, 1980; Markwalder, 1993; Porter, 1996). It is
characterized by circulatory impairment of neural
structures that occurs secondary to exercise. Intermittent claudication has also been recognized in humans
with cervical or thoracic spinal cord compression where
it can complicate cervical spondylotic myelopathy
(Kikuchi et al., 1996).
Key issues for future investigation
1. Is decompression indicated for severe vertebral
deformities and if so, should it be performed at the same
time as stabilization or at a second surgery?
2. What is the long-term recurrence rate following medical
treatment for discospondylitis? Is this influenced by the
duration of antibiotic therapy?
3. Is MPSS of any value in FCE?
4. Is any treatment regime useful in degenerative myelopathy?
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Miscellaneous conditions
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FURTHER READING
Braund, K.G. (2003) Clinical Neurology in Small Animals: Localization,
Diagnosis and Treatment. http://www.ivis.org/special_books/Braund/
toc.asp
337
Postoperative care
Chapter
15
Analgesia 339
Opioid analgesics 340
Non-steroidal anti-inflammatory drug (NSAID)
analgesia 341
Analgesia in cats 343
Other agents 343
344
345
346
351
360
The surgeon should accept that some form of postoperative complication will develop in many neurosurgical patients. This may range from a simple urinary tract
infection (UTI) to less common but life-threatening
Post-myelographic seizures
Inappetance
Depression
Persistent fever
Wound discharge
Diarrhea or vomiting
Abdominal pain
Odiferous urine
Urine scald
Decubital ulcers
conditions such as pneumonia or pancreatitis. If complications are viewed as something to be expected the
surgeon is more likely to have the patient monitored
appropriately (Box 15.1).
Care of neurosurgical patients can be labor intensive
(Table 15.4). It is important that hospital nursing staff
have a high standard of training and are properly
informed about what parameters to monitor, how often
to monitor them, and what the most likely complications are going to be in each individual patient. Clear
written instructions should also be given to the client at
the time of discharge.
ANALGESIA
Neurosurgical procedures often cause a great deal of
pain for human patients. It is likely that in the past veterinarians have tended to overlook the degree of pain
suffered by our patients (Hansen and Hardie, 1993;
Dohoo and Dohoo, 1996; Lascelles et al., 1999). Doubt
as to whether an animal really is in pain often caused a
340
Opioid analgesics
Opioids are the most effective analgesic for severe pain.
The approximate duration of action of these drugs,
together with their advantages and disadvantages, are
outlined in Table 15.1. Preoperative or intraoperative
opioid administration is recommended to reduce the
requirement for postoperative analgesia. Fentanyl patches
are a convenient way to provide long-lasting analgesia
(15.1). As these patches have a delayed onset of action
(see Chapter 6, page 84), they should be applied the
night before elective surgeries and are supplemented
with additional intravenous opioid agonists as needed.
The pure opioid agonists are the most potent analgesics but they also have more potential side-effects.
They should be given on a fixed schedule every 24 h;
the interval can be decreased if greater analgesia is
needed. The response varies markedly between patients.
Therefore small, intravenous doses should be given
every 5 min (for dogs and cats 0.1 mg/kg morphine;
0.05 mg/kg oxymorphone; 0.05 mg/kg hydromorphone)
until a satisfactory level of analgesia is achieved (stop
administration if mydriasis occurs in cats). The total dose
required for that patient is then repeated on the fixed
schedule thereafter. A continuous intravenous infusion
can also be used by delivering the cumulative dose for
each time interval as a constant rate infusion over
that same period, but the animal must be re-evaluated
frequently in case adjustments are needed to the
rate. Common side-effects include ileus and nausea.
Dose
Interval
Advantages
Disadvantages
4h
46 h
4h
Inexpensive, sedative
Respiratory depression
Bradycardia**
Caution IV**
Emesis
Oxymorphone (pure
agonist)
24 h
As for morphine
Expense, availability
Hydromorphone
(pure agonist)
24 h
Similar to oxymorphone
As for morphine
Expense
Butorphanol
(agonist/antagonist)
12 h
Reduced respiratory or
cardiovascular effects
Reduced respiratory
or cardiovascular
effects
If respiratory depression
does occur it can be
difficult to reverse
26 h
68 h
Buprenorphine
(partial agonist)
Fentanyl transdermal
patch (pure agonist)
Dog: 10 kg: 25 g
1029 kg: 50 g
30 kg: 75150 g
Cat: 25 g patch
Lasts up to
Convenient, well
3 days; longer tolerated, apply before
in cats
surgery (see page 84)
Codeine 60 mg with
300 mg acetaminophen
8h
Inexpensive
Useful orally
1
B. Hansen, personal communication.
* Consult appropriate source for contraindications and adverse reactions and to verify doses. Many opioids are controlled substances.
** Concomitant administration of atropine may be required to overcome bradycardia; this is only a problem if hypovolemic or under anesthesia.
GI, gastrointestinal.
Postoperative care
Non-steroidal anti-inflammatory
drug (NSAID) analgesia
The NSAIDs are indicated either as a supplement to
opioid analgesia or when opioids are unsuitable (Table
15.2). Carprofen is particularly useful as it can also be
given intravenously; it is most effective when given preoperatively (Lascelles et al., 1998). All NSAIDs provide
analgesia by blocking the cyclooxygenase enzymes that
produce prostaglandins. Cyclooxygenase (COX) activity
is either primarily constitutive (the COX-1 enzyme constantly produces prostaglandins necessary for normal
metabolic functions in many tissues) or primarily
inducible (the COX-2 enzyme is induced by inflammation to produce prostaglandins locally). Prostaglandins are
integral to the inflammatory process and they enhance
nociception both peripherally and centrally. Some
prostaglandins, particularly prostaglandin E (PgE) are
important for homeostasis in tissues like kidney and
intestine.
Newer NSAIDs have now been developed that only
inhibit COX-1 weakly. Carprofen, ketoprofen, etodolac
and meloxicam are COX-1 sparing; carprofen and ketoprofen being somewhat less so than meloxicam (KayMugford et al., 2000; Brideau et al., 2001). The analgesic
effects of these newer NSAIDs are good and they are
roughly equivalent to each other. Carprofen provides
superior analgesia to the opioid pethidine in dogs and
cats (Lascelles et al., 1994; Balmer et al., 1998); higher
doses of most NSAIDs provide analgesia comparable to
low doses of opioids in most studies.
The COX-1 sparing NSAIDs in general cause less
gastrointestinal ulceration than more potent COX-1
inhibitors. The gastrointestinal side-effects of etodoloc
and carprofen are significantly less than aspirin (Reimer
et al., 1999). Carprofen is known to preserve protective
levels of PgE in the gut and no significant gastrointestinal problems were observed in more than 200 dogs with
degenerative joint disease (Holtsinger et al., 1992).
However, meloxicam in higher doses can cause severe
341
342
Dosedog
Dosecat
Comment**
Aspirin
10 mg/kg PO q3648 h
Coagulopathy
Ketoprofen
Meloxicam
Acute pain:
0.2 mg/kg PO, IV, SC once, then
0.1 mg/kg q24 h
Acute pain:
0.2 mg/kg PO, IV, SC once,
then 0.1 mg/kg PO q24 h for
34 days
Long-term therapy: up to
0.1 mg per cat q4872 h
Long-term therapy:
0.1 mg/kg q24 h
Etodolac
N/A
Meclofenamic acid
N/A
Deracoxib
34 mg/kg q24 h
N/A
Carprofen
1
B. Hansen, personal communication.
* Consult appropriate source for full list of contraindications and adverse reactions and to verify doses.
** All NSAIDs have the potential to cause GI side-effects.
N/A, not available.
Postoperative care
Analgesia in cats
Selected opioids can be used in cats (Table 15.1).
Meloxicam and carprofen are also tolerated well by cats
using oral (both drugs) and IV (carprofen) routes (Parton
et al., 2000; Slingsby et al., 2000; Lascelles et al., 2001)
(Table 15.2). Acetaminophen should not be used in cats.
Other agents
These include:
Gabapentin is an anticonvulsant that has also
been used to alleviate trigeminal pain in humans.
It can be an effective analgesic for animals with
pain caused by neoplasia or inflammation of a
nerve root. The dose range starts at 5 mg/kg q8h
and extends in dogs up to 50 mg/kg q8h given to
effect; potential side-effects include sedation and
ataxia.
Medetomidine can provide useful supplemental
analgesic at low doses (13 g/kg/h). The drugs
cardiovascular effects are much shorter in duration
when used at such low doses but are quite
dramatic with an IV bolus. The dose should
therefore be given over 10 min to avoid
hypotension; it can also be delivered by syringe
pump or in IV fluids.
The skeletal muscle relaxants methocarbamol
(55132 mg/kg PO in divided doses) or diazepam
( Table 15.7) are useful to relieve muscle spasm
after spinal surgery.
Acupuncture may also be a helpful adjunctive
means of providing analgesia (Haskins, 1987;
Still, 1989; Janssens, 1992).
Physiotherapy such as heat, ultrasound (15.13B)
and laser (15.14A) can provide additional pain
relief. Pain relief after laser therapy is probably
mediated mainly through serotonin release
(Walker, 1983; Clokie et al., 1991).
NURSING CARE
Moving patients
Proper support must be provided for the spine when
moving an animal with a spinal lesion, especially an
anesthetized patient. Use of a board or stretcher is
indicated (13.1).
Myelography
It is important that the animals head is kept elevated
at all times following the injection of contrast into the
subarachnoid space, both during the myelogram and
during recovery from anesthesia. This simple precaution is easily overlooked as a means of preventing postmyelographic seizures.
Treatment plans
The best way to nurse a neurological patient, especially
one with multiple problems, is to make a plan for each
day as illustrated in Tables 15.3 and 15.4. In this manner, voiding requirements, physiotherapy needs, medications, laboratory work and routine tasks are planned
out and not forgotten. A specific plan for physiotherapy is also useful (Table 15.5).
Cleanliness
Animals that soil themselves repeatedly may be easier
to manage if their entire hindquarters are shaved.
Soiled areas should be bathed as necessary; bathing of
the perineal area may be needed several times a day in
some animals. It is often suggested that patients with
surgical wounds should not be bathed until a minimum
of 5 days after surgery. However, in one study bathing
Table 15.3 Nursing plan for a neurological patient*
Task
0800
TPR
(X)
Express bladder
(X)
(X)
(X)
Phenoxybenzamine
5 mg PO
(X)
( )
Diazepam 2.5 mg PO
(X)
( )
Trimethoprim-sulfa
120 mg PO
(X)
Urinalysis
1200
1600
2000(etc)
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
343
344
Urinalysis
If urinary incontinence is present, a urinalysis should be
done every 23 days, regardless of whether the patient
is on antibiotics. Most animals with neurological deficits
that are severe enough to interfere with motor function
will also have inefficient bladder emptying that predisposes them to retention cystitis.
Recumbency
Recumbent, tetraparetic animals need to be turned every
2 h because sustained hypostatic congestion predisposes
the patient to pneumonia; alternating between lateral
and sternal recumbency will also help to improve
8 am 10 am 12 noon 2 pm 4 pm 6 pm
8 pm 10 pm 12 midnight 2 am 4 am 6 am
TPR b.i.d.
(X)
( )
Express bladder
q 6 h; take outside
(X)
Nil per os
except water
Offer water q4 h
and place sternal
(X)
Sucralfate 500 mg
per os q12 h
(X)
( )
375 mg Amoxycillin
clavulanic acid q12 h
(X)
( )
Rebandage feet
(X)
Turn q4 h
(X)
( )
Chest radiograph
( )
( )
( )
( )
( )
( )
( )
( )
( )
(X)
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
* Taken from the hospital record of a 6-year-old male Doberman (same dog as shown in 15.7) with cervical spondylomyelopathy that had
undergone a ventral decompression 1 week previously. The dog was recumbent, tetraparetic, and although continent, he needed manual
expression of his bladder to initiate voiding. Food was being withheld as he had suffered severe bloody diarrhea the previous day, for which he was
being treated with sucralfate. The dog also tended to chew his feet if they were left unbandaged. The chest radiograph was scheduled because
the dog appeared depressed and auscultation of the lungs suggested early pneumonia. Coupage and turning the animal effectively every hour is
preferable for pneumonia; propping the animal into sternal recumbency is also helpful. The nursing care for this patient is particularly complex, and
illustrates the support needed for certain types of neurosurgical patients.
TPR b.i.d., temperature, pulse and respiration rate, twice a day; (X), task completed; ( ), task still to be completed.
Postoperative care
345
346
PHYSIOTHERAPY
However good the flooring material, the aim is to minimize the recumbency period, because this is when
the animal is most susceptible to complications. This
period can be shortened by physiotherapy and early
mobilization. Towel walking of paraplegic dogs or
supporting a tetraparetic patient in a sling are often
possible within 2448 h of surgery (15.9, 15.10).
B
15.9 A: Walking a paraplegic dog by supporting its
hindquarters with a towel placed under the abdomen just in
front of the pelvic limbs. The tail can also be used to provide
support provided that it is held at the base to avoid injury.
B: A Walkabout sling (Walkabout Harnesses, Santa Cruz, CA)
can also be useful for early mobilization.
B
15.10 These two slings with frames provide an excellent way
to rehabilitate tetraparetic dogs. A: A canvas sling and metal
frame; this sling tends to rub more than the one shown in B.
B: This sling is made from Neoprene (Dupont-Dow, Wilmington,
DE); it is shown in 15.16 supporting a dog in a whirlpool bath.
Postoperative care
passive range of motion can usually begin almost immediately after recovery from surgery. Massage of the
limbs for 15 min once or twice a day is usually well
tolerated especially for recumbent animals. Massage
should be performed in a distal to proximal direction
in order to promote venous return (Berry and Reyers,
1990). Hot packing is useful to reduce swelling, pain
and muscle spasm (7.12). Hot packs should be insulated from the animals skin; treatments should last
1020 min repeated every 812 h (Jerram et al., 1997).
Ultrasound is another way of applying warmth to
deeper tissues and is useful to prevent and treat muscle
spasm (Taylor, 1992) (15.13B). Ultrasound is converted
to heat, mainly at the bonetissue interface; it causes
little temperature rise in superficial tissue. Intensities
from 0.5 to 4 W/s are used; pain indicates excessive heat
generation. Creative thinking can adapt other human
techniques to veterinary patients (Taylor, 1992) (15.14,
15.15). Neuromuscular stimulator packs (Respond Dual
Channel Neuromuscular Stimulator, Medtronic) can
build specific muscle groups and can be useful (Taylor,
1992), for example after brachial plexus injury has
caused shoulder muscle atrophy (see Chapter 2). As for
nursing care, it is recommended to develop a specific
plan for each animal (Table 15.5). An external splint (see
B
15.13 A: Passive range of motion; this
is done for 510 times in two or three
sessions a day (Jerram et al., 1997).
B: Ultrasound should not be used over
nerves or directly over a laminectomy
defect as it generates heat (Taylor, 1992).
Here the energy is being directed away
from the bony defect.
347
348
8 am
Range of motion
10 am
12 noon
2 pm
4 pm
6 pm
8 pm
10 pm
12 midnight
Massage (effleurage)
X
X
* Taken from the hospital record of an 11-year-old dog (similar to the dog shown in 15.10A) with cervical spondylomyelopathy that had undergone
a ventral decompression 1 week previously. Active postoperative physical therapy begins postoperative Day 1. Active mobilization and sensory
stimulation continues every 4 h until the dog is discharged.
X, task completed.
Postoperative care
349
350
Cortical
neurons
UMN-sphincter
L
1 2 34
Motordetrusor
Sensorydetrusor
Sympathetic
S
1 23
Sensorysphincter
Motorsphincter
Postoperative care
out when the bladder fills to the point where intravesicular pressure exceeds sphincter pressure causing urinary
retention and overflow. After approximately 1 month, a
reflexive emptying of the bladder develops.
In LMN lesions, the sphincter tone is decreased and
so urine will tend to leak continuously (Table 15.6).
Occasionally some animals, such as cats with sacrocaudal
injuries, have an LMN bladder that is difficult to express
because of increased sympathetic tone (OBrien, 1988).
Disorders of micturition
Pharmacological manipulation
of micturition
The most common problem is excessive urethral sphincter tone in UMN bladder dysfunction. The patients voluntary efforts to void, or attempts at manual expression
of the bladder, may be unable to overcome this excessive
urethral tone. The result is an increase in the residual
volume of urine in the bladder. As it is not usually possible to distinguish smooth from striated muscle effects
in any individual patient, the simplest approach is to block
the activity of both sphincters (15.23, Table 15.7). Dogs
Table 15.6 Differences in urinary function associated with UMN or LMN lesions
UMN (cranial to
sacral segments)
paraplegicacute
UMN (cranial to
sacral segments)
paraplegicchronic
LMN lesions
(sacral segments)
Detrusor function
or
or
or
or
Somatic sympathetic
Contracts and closes
Parasympatheticcontracts
Sympathetic relaxes
351
352
Drug*
Species
Dose
Alpha antagonist
Phenoxybenzamine
Dog
Cat
Hypotension
Start at lowest dose
Carcinogen?
Availability?
Alpha antagonist
Prazosin
Dog
Cat
1 mg /15 kg PO q1224 h
Per cat0.250.5 mg PO q1224 h
Hypotension
Start at lowest dose
Care in CRF
Seizures
Alpha antagonist
Terazosin
Dog
Cat
Hypotension
Start at lowest dose
Priapism, rare, needs
immediate treatment
Skeletal muscle
relaxant
Diazepam
Dog
Cat
Per dog210 mg PO q8 h
Not recommended
Skeletal muscle
relaxant
Dantrolene
Dog
Cat
15 mg/kg PO q812 h
0.52.0 mg/kg PO q8 h
Alternative to diazepam
Potential for hepatic toxicity
Urinary antiseptic
Methenamine
mandelate
Dog
Cat
Postoperative care
INTERMITTENT ASEPTIC
CATHETERIZATION (15.2615.28)
This may prove necessary in some difficult or fractious
patients, or in dogs whose sphincter tone has not been
modified successfully. Strict attention must be paid to
aseptic technique. Even with these precautions, bacteria
may still be introduced into the bladder because the
353
354
distal urethra has a normal flora that includes Staphylococcus intermedius and Escherichia coli in particular
(Stone and Barsanti, 1992). Nosocomial organisms
may also be introduced by poor technique. Urinary
catheters are the second most common source of nosocomial bloodstream infection in people (Maki and
Tambyah, 2001); the risk of infection also increases
with the number of catheterizations (Lees, 1986;
Lulich and Osborne, 1995). Irrigation of the prepuce
or vestibule with 0.02% chlorhexidine prior to each
catheterization may help to reduce the infection rate
(see Closed collection system, below).
Postoperative care
TUBE CYSTOSTOMY
In certain circumstances a prepubic tube cystostomy
provides an alternative to repeated catheterization
(15.32). An interlocking box suture pattern is recommended to anchor the tube (Daye et al., 1999). Tubes
are left in place for a minimum of 7 days; animals are
able to void normally after tube removal once the initiating problem has resolved (Williams and White, 1991).
Tube cystostomy can also be used occasionally as a longterm option for animals that are permanently incontinent and difficult to express (Smith et al., 1994).
Gastrointestinal disturbances
POSTOPERATIVE COMPLICATIONS
The most important potential complications are UTI,
gastrointestinal disturbances, pancreatitis, surgical
wound complications, urine scald and decubital ulcers.
Up to 15% of dogs with disc disease will develop gastrointestinal problems and the mortality rate has been
reported to be as high as 2%. The major risk factor in one
study was use of dexamethasone; dose and duration of
therapy were not important (Moore and Withrow, 1982).
Vomiting can have a variety of causes including corticosteroids, antibiotics, NSAIDs or pancreatitis. If vomiting
occurs, food, water and non-critical medications should
be withheld for 24 h and intravenous fluids given to
replace losses. A high index of suspicion should be maintained for pancreatitis (see below) and aspiration pneumonia (especially in recumbent animals). Drugs used to
355
356
intake and non-essential drugs are stopped and symptomatic therapy is started. Misoprostol is indicated for
NSAID-induced GI ulceration. It would also seem to be
the logical therapy for corticosteroid-induced bleeding.
However, it does not reduce the incidence of GI hemorrhage caused by corticosteroids; omeprazole, cimetidine and sucralfate are also ineffective (Hanson et al.,
1997; Neiger et al., 2000). The lack of a suitable pharmacological agent emphasizes the importance of prevention, supportive care and dietary management. Barium
sulfate may work to stop GI bleeding or diarrhea when
all else fails.
Colonic and gastroduodenal perforation carry the
highest mortality rate of all GI complications. Furthermore,
Drug**
Species
Dose
Antiemetic
Metoclopramide
0.20.5 mg/kg SQ q8 h
Antiemetic
Chlorpromazine
0.5 mg/kg IM q8 h
Hypotension, seizures
Ulceration
Ranitidine
Dog
Cat
Ulceration
Famotidine
Dog
Cat
Ulceration
Sucralfate
0.251.0 g per
animalPO q8 h
Ulceration
Omeprazole
0.50.7 mg/kg
PO q24 h
NSAID-induced ulceration
Misoprostol
Dog
Cat
15 g/kg PO q8 h
Unknown
Diarrhea, abortion
Diarrhea
Loperamide
0.08 mg/kg PO q8 h
Narcotic overdose
Diarrhea
Bismuth salicylate
Dog
0.25 ml/kg PO q6 h
Cat
Not recommended
Barium sulfate
0.5 ml/kg q 24 h,
max. 3 doses
Constipation
Aspiration
Constipation
Bisacodyl
510 mg PO q24 h
per animal
Laxative
Constipation
Psyllium
Postoperative care
Pancreatitis
Acute pancreatitis has a high mortality rate. It should
be considered along with GI perforation in any neurological patient that develops a sudden onset of vomiting,
collapse and pyrexia during its postoperative course.
Some dogs show a more insidious onset of signs. High
doses of corticosteroids do seem to predispose dogs to
pancreatitis, particularly those with neurological disease (Strombeck and Guilford, 1990; Williams, 1995).
Diagnosis can be difficult; serum amylase and lipase
are not specific but may help if markedly elevated and
abdominal ultrasound can also be very useful (Hess et al.,
1998). Treatment entails withholding all oral intake for
5 days until the clinical signs are in remission. Intravenous
fluid therapy must keep up with fluid losses, which can
be dramatic, and urine output should also be monitored. Metabolic acidosis and electrolyte derangements
are common and warrant regular blood gas and electrolyte measurements. An anti-emetic such as chlorpromazine should be used at the lowest possible dose to
control vomiting. Metaclopramide is not recommended.
Procaine penicillin and an aminoglycoside are the antibiotics of choice (Strombeck and Guilford, 1990). The
prognosis is guarded.
Urine scald
Urine scald is an important cause of dermatitis and also
predisposes to decubital ulcer formation. Any dog that
soils itself with urine or feces must have the affected
Wound complications
Wound complications have been recorded in as many
as 14% of dogs undergoing spinal surgery (36/264).
Surgical time over 90 min and use of multifilament,
absorbable suture material increase the complication
rate; monofilament, absorbable material is therefore
recommended for wound closure. The most common
357
358
Decubital ulcers
Decubital ulcers result mainly from unrelieved compression of tissue between a hard surface and a bony
prominence (15.3615.39). Even small paraplegic animals can develop decubital ulcers (15.37).
The skin should be kept clean and dry at all times and
in recumbent animals the bony prominences should be
examined at least daily for the onset of decubitus. The
15.36 The area over the ischiatic tuberosity in the early stages of
decubitus formation, to show edema and the onset of hair loss. At
a more advanced stage, areas of decubitus may appear simply as
a wet area on the hair coat due to the exudation of serum.
Postoperative care
An appropriate flooring material (15.315.7) is essential to prevent, or at least retard, the onset of decubitus.
Resolution of established decubitus is obviously difficult
until the inciting cause is eliminated. Relief of pressure
is an important principle of treatment, which has been
reviewed in detail (Swaim et al., 1996). Neurological
patients are at particular risk due to the high potential
for urine and fecal soiling, which must be minimized
by regular bathing and drying (15.17, 15.20). Prompt
removal of devitalized tissue and regular irrigation with
an antiseptic solution (such as 0.4% chlorhexidine or
Domeboro solution (Domeboro Astringent Solution,
Bayer, Morristown, NJ)) are recommended. Surgical
debridement and primary closure, possibly using skin
flaps or grafts, may be required to resolve an indolent
ulcer, even after neurological function returns (Swaim
et al., 1996) (15.11).
Miscellaneous
A number of other problems can arise during the postoperative period. These include:
Self-mutilation can occur in some animals with
paresthesia or absent deep pain (2.26, 15.7).
Some male dogs with severe UMN lesions develop
permanent erections; this can also lead to selfmutilation or the exposed penis may simply get
traumatized (Olby et al., 2003). Gabapentin
(page 343) has been used to treat spasticity in
humans with chronic spinal cord injuries (Gruenthal
et al., 1997); it may help to reduce the muscle
spasm contributing to erection in dogs. Elizabethan
collars or other restraint devices may also be helpful.
In humans, prolonged recumbency combined with
inactivity increases significantly the risk of deep vein
thrombosis and pulmonary thromboembolism. These
are almost certainly under-recognized as causes of
morbidity and mortality in veterinary neurosurgical
patients (Feldman, 1986). Treatment is difficult so
every effort should be directed toward avoiding
circulatory stasis by providing adequate
physiotherapy and intake of fluids (LaRue and
Murtaugh, 1990). Aspirin may be protective.
Some problems are more likely to develop after
surgery for specific disorders. Myelomalacia
develops in some dogs with thoracolumbar disc
disease (see page 128); pathological fractures can
occur in dogs with spinal tumors; pneumonia and
gastric dilation or torsion are more likely in
recumbent, tetraparetic dogs after cervical surgery.
Some complications can be prevented by a
thorough presurgical evaluation (15.40).
Finally, an animals mental status should not be overlooked in the recovery process. Affection from nursing
359
360
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Index
Anaphylaxis 85
Anatomical location of the injury
295297
Anatomical specimens 73, 74
Anatomy
blood supply 1417
nervous tissue 16
skeleton 614
urinary system 350351
Anesthesia
complications 86
CSF collection 64
induction 85
maintenance 85
premedication 85
recovery 8586
side-effects 85
Angiotensin converting enzyme
(ACE) inhibitors 85
Angled bur guard 77
Anomalous spinal disease 36
Antibiotics see also specific drugs
drug side-effects 85, 355
prophylactic 83, 309, 327, 331,
355, 357
wound infection 357
Anticlinal vertebra 9
Anti-coagulant drugs 82, 99, 333,
342
Anti-convulsants 343
Anti-emetics 356, 357
Anti-infective agents 85
Anti-inflammatory drugs see also
Corticosteroids; Non-steroidal
anti-inflammatory drugs
cervical disc disease 96
CSM 218
hypervitaminosis A 326
lumbosacral disease 188
palliative 254
side-effects 83, 85, 341342
thoracolumbar disc disease 123
ventral slot surgery 102
Antiseptic, urinary 352
Anulus fibrosus
approach to ventral neck 115
364
Index
Beagle
chondrodystrophy 13
meningitis 329
Bedding (postoperative) 346
BenceJones proteinuria 42
Bernese mountain dog (meningitis) 329
Bethanechol 352
Bile duct rupture 19, 282
Biomechanics of spinal fixation
286290
Biopsies
core 79
needle 6162, 275
tumors 6162, 251252, 275, 276
Bisacodyl 356
Bismuth salicylate 356
Bladder
assisted emptying 131, 343, 344,
352, 353
dysfunction 351352
innervation 351
leakage 20
neurological screening 20
rupture 282
Blastomycoides dermatidis 330
Bleeding disorders see also Von
Willebrand disease
aspirin-induced 99
bleeding time test 217
blood clots 99
cervical disc surgery 99
cervical myelopathy 82
CSF analysis 65
CSM 217, 224, 225, 229, 234
epidural 57
gastrointestinal 83, 84, 229, 342,
356
Hemoclips 78
hypoventilation 82
laminectomy 98, 138, 146
neurovascular bundles 241
preoperative assessment 213, 217
prevention 138
respiratory 82
spinal cord 51, 94, 281, 333
subdural 57
surgical complications 98, 128,
224, 225, 229
thyroid hormone supplementation
217
venous plexus 99, 146, 234
Von Willebrand factor 42, 82, 217,
229, 360
Blood cell counts
CSF 44, 45
routine laboratory analysis 41
white blood cells 42, 329
Blood contamination 44
Blood gas analysis 42
Blood supply 1417
see also Vascular system
Body position
CSF collection 66
head position 29, 94
imaging 46, 47, 54, 55, 56
patient examination 2025, 2528
paw position 20, 22
perception of 5, 6, 22, 23, 348
position for radiography 46
postoperative 225, 228229, 343,
344, 345346
Body weight (cement bar thickness)
314
Bone diseases
CSM 211, 212
DISH 326
lumbosacral 183, 184
mimicking spinal disease 20
neurological patient 81
osteoarthritis 20
osteochondritis dissecans 20, 36,
37, 183
osteochondritis 20, 36, 37, 183
osteoporosis 38, 122, 326
scintigraphy 5960
tumors 94, 248, 249, 260
Bone physiology
composition 7
demineralized matrix 292
production 209
Bone surgery
allograft 117, 220, 221, 274, 292
atlantoaxial subluxation 168,
177178
autograft 117
bleeding from cancellous bone 142
bone vessel plug 77
bone wax 77, 142, 313, 314
cement 238, 314
CSM 223, 232, 235, 238240,
245
decompression 117, 203, 243
external fixation 290292
facetectomy 203
fragments 51
fusion 234
hemilaminectomy 1, 143, 268,
269
infection risk 301
instrumentation 77, 79
laminectomy 195, 198, 200, 208,
272
lumbosacral disease 191, 198,
200
Index
tachycardia 85
vascular diseases 20, 36, 329,
332333
Carprofen 341, 343
Cartilaginous exostoses 36, 323
Cart (paraplegic) 350
Catheters 353354
Cats
analgesic drugs 340, 343
anti-inflammatory drugs 342
atlantoaxial subluxation 169170
cervical disc disease 35, 103
feline immunodeficiency virus
81, 262
feline infectious peritonitis 35,
330
feline leukemia virus 81, 262, 263
gastrointestinal tract 356
Horners syndrome 25
hypervitaminosis A 326
ischemic myelopathy 37, 38
ischemic neuromyopathy 281,
332333
lymphoma 263
Manx 322
pharmacology 340, 342, 343, 352,
356
sacrocaudal dysgenesis 322
spinal trauma 36, 37, 169, 287,
297, 301302, 305
thoracolumbar disc disease 10,
127, 128, 129, 133
tumors 261263
urinary tract 302, 352
Cauda equina
compression 181182
disc fenestration 202
functional anatomy 3
lumbosacral laminectomy 199,
200
nerve roots 3
neuritis 36, 37, 184
Caudal vertebra
lumbosacral disease 183
sacrocaudal dysgenesis 322
tail injuries 296297
Cauterization 75, 83, 275
Cavalier King Charles spaniel
(syringomyelia) 322323
Cefadroxil 357
Cefalosporin 83, 85, 355
Cefazolin 83, 327, 357
Cellulose surgical spears 77
Cement plugs
CSM 218, 219, 220223, 226,
237239
ventral decompression 117
vertebral distractionstabilization
221223
Central cord syndrome 29
Cerebellar disease 29
Cerebellomedullary cistern (CMC)
CSF collection 64, 6568, 85
injection of contrast medium 53, 71
Cerebrospinal fluid (CSF)
cell counts 44, 45
cervical disc disease 94, 99
collection 43, 6469, 85
examination 44, 45
functional anatomy 45
meningitis 329
neutrophils 43
sedimentation chambers 44
thoracolumbar disc disease 122
ventral recumbancy 69
xanthochromia 45
Cervical disc disease 93120 see also
Cervical spondylomyelopathy
cats 103104
diagnosis 3537, 9496
clinical signs 37, 9394
decision-making algorithm 97
palpation 24
dorsal decompression 98
laryngeal nerve paralysis 99
non-surgical treatment 96
pain 37, 94
postoperative care 102
prognosis 102103
surgical treatment
approach to ventral neck
106109
complications 98102
distractionstabilization 117118
dorsal decompression 98
dorsal laminectomy 120
fenestration 96, 109110
hemilaminectomy 119, 266270
indications 96
locking plate 220
paramedian approach to ventral
neck 232233
postoperative care 102
ventral decompression 9698,
111118
Cervical fibrotic stenosis 212
Cervical spine
blood supply 15
diagnosis 3537
anatomical location of injury
295297
myelography 38, 70, 72
radiography 46, 49
ligaments 14
365
366
Index
Cisapride 352
Cisplatin 254
Claudication,
intermittent 38, 334
neurogenic 36
Clavulanic acid 344, 355
Cleanliness, postoperative 343344
Client communication 88
Client consent form 88
Clindamycin 327, 331
Closed collection system 354355
Cloxacillin 327
Coccidioides imitis 330
Cocker spaniel
kyphosis 131
thoracic tumor 250
Codeine 340
Cod-piece 307
Collar (head) 237, 239, 295
Column splitting 52
Computerized tomography (CT)
imaging 5557 see also Magnetic
resonance imaging
atlantoaxial subluxation 164
body position 55, 56
cervical disc disease 9596
comparison to MRI 57
CSM 214216
disc extrusion 56, 57, 94
dorsal recumbency 55
neoplasia 251
preoperative assessment 82
spinal cord expansion 57
thoracolumbar disc disease 56, 123
trauma 284285
Confinement (cage) 125, 126, 131,
228, 288, 305
Congenital diseases
arachnoid cyst 122,
atlantoaxial instability 281
myopathy 38
vertebral anomalies 37, 212,
321322
Consent form 88
Conservative treatment
anti-inflammatory drugs 96
atlantoaxial subluxation 164165,
166167
cervical disc disease 96
complications 166167
CSM 218
decompression 124, 125
fenestration 124, 125
immobilization 282
lumbosacral disease 188, 192
recovery times 124, 125
rest 123, 124, 125, 192, 282
Constipation 356
Contrast meda
absorbtion 53
discography 50
epidural leakage 71
epidurography 50
hand position 70
iohexol 43, 49, 86
myelography 49, 72
poor filling 53
spinal cord parenchyma 54
sterile meningitis 4243
Coonhound paralysis 38
Cord dorsum potentials 61
Corpectomy 58, 149, 147
Corticosteroids see also Antiinflammatory drugs
canine distemper virus infection
330
CSM 218
drug side-effects 355, 356, 357
fungal infections 331
GME 330
meningitis 329
meningomyelitis 331
MPSS 8384, 133, 217, 257, 282,
293, 332, 342
osteoporosis 326
preoperative assessment 8384
thoracolumbar disc disease 125,
126, 131, 133
wound infection 83, 357
Costs of surgery 88
Coupage 344
Coxofemoral arthritis 184
Cranial nerves 20, 21, 25
Creatine kinase (CK) 42
Creatinine 82
Crossed extensor reflex 32
Cross-pin fixation see also Pin
fixation; Screw fixation
atlantoaxial subluxation 180
dorsal 180
spinal trauma 282
Cruciate ligament rupture 20, 184
Cryoprecipitate, bleeding disorders
217
Cryptococcus neoformans 42, 330
Curettage 236
Curettes 75, 79
bone graft collection 79
House 75, 144
Shea 75
Cushings disease
osteoporosis 326
preoperative assessment 82
wound infection risk 83
Index
Cushings syndrome 81
Cutaneous trunci reflex 20, 24, 2627
Cuticle bleeding time 217
Cyclosporin 85
Cystocentesis, postoperative 297
Cysts
arachnoid 29, 37, 51, 122, 212,
297, 300, 301, 321, 323326
cystocentesis 297
dermoid sinus 184, 212, 323
epidermoid 36, 212, 323
kidney 55
marsupialization 244
subarachnoid 324
synovial 36, 37, 52, 94, 122, 183,
215, 245, 320
tube cystostomy 355
Cytosine arabinoside 254
D
Dachshund
cervical disc extrusion 93
chondroid metamorphosis 12
hemilaminectomy 344
L4/S3 lesions 38
thoracolumbar disc disease
treatment 126
thoracolumbar mid-bodies 10
ventral slot decompression 116
Dalmatian (L2/L7 defects) 2829
DAMNIT scheme 21, 35, 36
Dantrolene 352
Decision-making algorithms
atlantoaxial subluxation 165
cervical disc disease 97
cervical spondylomyelopathy 223
lumbosacral disease 189
neoplasia 256
thoracolumbar disc disease 124
trauma 293, 294
Decompression (dorsal) for CSM
218, 219
see also Ventral decompression
Decubital ulcers 339, 347, 358359
Decubitus 127, 167, 297
Deep pain sensation see also
Nociception; Pain
after durotomy 293
after hemilaminectomy 150
lack of 293
malacia 293294
neurological examination 21
spinal fracture 87
thoracolumbar disc disease 125
trauma 293295, 301302
Deep vein thrombosis (DVT) 127, 359
microbiology 42, 45
serology 42
urinalysis 42
Diaphragm
herniation 282
paralysis 82
Diarrhea 339, 356
Diazepam
analgesia 85, 96, 102, 343
lower urinary tract effects 352
micturition disorders 352
post-myelographic seizure
prevention 216
Disc anatomy 1213
Disc degeneration 12, 36, 183, 184,
281, 320
Disc extrusion (bulge) see also
Intervertebral discs; specific
spinal regions
age related 59
atlantoaxial 163
cervical 93, 94, 99
definition 13
diagnosis 56, 57, 94, 212
dorsolateral hemilaminectomy
144145
Hansen type 13
intervertebral foramen 96
protrusion 59
surgical complications 127, 129,
131
surgical indications 219
thoracolumbar 122, 127, 129, 131,
136
Disc herniation see also Intervertebral
discs
CSM 211, 219
dorsal hemilaminectomy 119
Hansen type 12, 37
lumbosacral 186, 200
myelographic abnormalities 51
surgical indications 219
terminology 58
thoracic 123
thoracolumbar 36
traumatic 285
Disc mineralization 59
Discogenic pain 184
Discography 50
Discospondylitis 326328
atlantoaxial subluxation 163
CSM 212, 225, 228
differential diagnosis 36, 122
fungal infection 328
localization of signs 37
lumbosacral disease 183, 184
myelographic abnormalities 51
367
368
Index
butorphanol 340
codeine 340
dantrolene 352
fentanyl 8485, 341
glycopyrrolate 85
halothane 85
iohexol 86
ivermectin 85
ketoconazole 85
ketoprofen 342
loperamide 356
metronidazole 85
misoprostol 356
morphine 340, 341
MPSS 84
nitrous oxide 85
non-steroidal 83, 85, 341342
opiates 8485, 340, 341
oxymorphone 340
phenoxybenzamine 352
prazosin 352
sedatives 282
steroids 83, 85, 326, 357
sucralfate 356
terazosin 352
trimethoprimsulfonamide 85
Dura
dorsolateral hemilaminectomy
incision 148
herniation 191
lesions 51
stay suture 279
tears 36, 122, 281
Durotomy
dorsolateral hemilaminectomy 148
patients with no deep pain
sensation 293
preoperative assessment 87
thoracolumbar disc disease 132,
149
Dysgenesis, sacrocaudal 322
Dyspnea 82, 99, 167
Dysplasia
antlantooccipital 36, 37
myelodysplasia 36, 212, 322
Dysraphism (spinal) 36, 212, 322
F waves 61
gastrocnemius muscle 60
neoplasia 250251
spinal cord evoked response
6061
Electrosurgery
cautery 83
instruments 75
Embolism
aortic 332333
fat 297
fibrocartilaginous 35, 37, 212, 281,
332
Empyema, epidural 36, 328329
Endocarditis 20
Endotracheal tube 85
End-plate failure 225, 227, 238
Enrofloxacin 85
Ependymoma 51, 248, 252
Epidermoid cyst 36, 212, 323 36
Epidural abscess 51, 122, 212, 225
Epidural empyema 328329
Epidural fibrosis 183
Epidural hemorrhage 57
Epidural leakage 49, 53, 71
Epidural lipomatosis 36
Epidural steatitis 330331
Epidurography 50
Epineurium 276
Erections 359
Erythrophagocytosis 45
Escherichia coli 327
Esophagus disease 98, 99
Etodolac 341
Euthanasia 229, 293
Euthyroidism 217
Evoked response, spinal cord 6061
Exercise intolerance 3637, 222
Exostoses, cartilaginous 36, 323
Extensor postural thrust 23
External fixation 237, 316318,
328
External splints 239, 290, 305, 306
Extradural tumors 248250,
259263
Eye function 21
Edema 99
Ehrlichia 38, 42, 330
Electric drill 77
Electrocardiogram (ECG) 213, 282
Electrocautery 83
Electromyography (EMG) 6061
Electrophysiology
cord dorsum potentials 61
Index
Fat graft
autogenous fat 8687
dorsolateral hemilaminectomy 149
fenestration of disc extrusion 201
foraminal decompression and
facetectomy 202
free fat 8687
laminectomy 208
minimization of scarring 8687
necrosis 38
postoperative complications 127,
128, 129
thoracolumbar disc disease 127,
128, 129
Fecal incontinence 131, 183
Feline diseases see also Cats
thoracolumbar disc disease 127,
128, 129
FeLV-associated lymphoma 262
feline immunodeficiency virus
(FIV) 81, 262
feline infectious peritonitis (FIP)
35, 330
feline leukemia virus (FeLV) 81,
263
Femoral nerves 127
Fenestration and disc removal
bulging disc 202
cervical disc disease 96, 109111
comparison to ventral slot 97
CSM 221, 227
fenestration 127, 154159
hemilaminectomy 149, 159
instrumentation 75
laminectomy 201
pediculectomy 159
postoperative complications 130,
221, 227
thoracolumbar disc disease 124,
127, 130, 154159
Fentanyl 84, 340, 341
Fever 339
Fibrocartilaginous embolism (FCE)
35, 36, 37, 212, 281, 331332
Fibroid metamorphosis 12
Fibrosarcoma 38, 248, 249, 260
Fibrosis
cervical 36, 37, 212
epidural 183, 190
peridural 131
restrictive 225, 273
Fine needle aspiration 61
FIP (feline infectious peritonitis) 35,
330
Fistula, cutaneous 127
Fixation devices
biomechanics 289290
external 290291
internal 291
multiple implant 166
Fixationstabilization
atlantoaxial subluxation 166167
caudal disc extrusion 96
cervical disc disease 117118
Flexor (withdrawal) reflex 27
Floating limb gait 28, 212
Flooring (cage) 345346, 359
Fluconazole 331
Fluid intake 85, 343, 344345, 355
Focal granulomatous
meningoencephalomyelitis
(GME) 248
Food intake 343, 344, 356
Forage (CSM surgery) 221, 232,
235
Foramen magnum 179
Foraminal decompression 192, 202
Foreign body migration 36
Free radicals 84
Fungal infection 42, 328, 330
Fusionfixation
atlantoaxial subluxation 166,
167168
lumbosacral disease 189, 192
new bone production 209
sacral subluxation 204
F waves 61
G
Gabapentin 343
Gadoteridol 58
Gagging 20
Gait abnormalities
disconnected 212
floating limb 28, 212
neurological examination 20
Gallstones 38, 122
Gastrocnemius muscle 60
Gastrointestinal tract disturbances
bleeding 83, 84, 342, 356
diarrhea 339, 356
drug-induced 83, 84, 341, 342,
356
melena 339, 356
parasites 38, 122
perforation 83
pharmacology 356
postoperative 339, 355357
ulceration 127, 297, 341, 356
vomiting 339, 356
Gelatin sponge 78
Gelfoam 36, 78, 86, 99, 269
Gentamicin 327
German shepherd
chronic degenerative
radiculomyelopathy 319320
fungal discospondylitis 328
lumbosacral disease 38, 185, 186,
190
nuclear bone scan 60
sacral subluxation 182
thoracic tumor 250
German short-haired pointer 4
Giant breed dogs (CSM) 211, 222,
223
see also Large breed dogs; specific
breeds
Glioma
myelographic abnormalities 51
poorly differentiated 252
tumor classification 248
Glucocorticoids 217
Glucose metabolism 20, 38
Glycopyrrolate 85
GME (focal granulomatous
meningoencephalomyelitis) 248
Golden retriever
bulbous dilation of dorsal arachnoid
space 324
left hemiparesis 29
myelomalacia 61
thoracolumbar spinal cord segments
3
vertebral bone loss 61
Golf-tee pattern 52
Gracilis contracture 20, 184
Grafts
bone 117, 220, 221, 274, 292
fat 38, 8687, 127, 128, 129, 149,
201, 202, 208,
Granulomatous
meningoencephalomyelitis
(GME) 330
Great Dane
CSM 36, 211, 213, 222224, 228,
246
dyspnea after imaging 82
hypothyroidism 217
postoperative complications 228
Gunshot injury 36, 331
H
Halothane 85
Halti head collar 237, 239, 295
Hansen-type disc herniation 12, 13,
182, 183
Harnesses 218, 237, 239, 347
Headlight 73, 74
Head movements 29, 94
369
370
Index
Heart disease
arrest 167
cardiomyopathy 213
cardiopulmonary arrest 99
differential diagnosis 20, 38
neurological patient 81
rhythm disorders 85, 86, 282, 297
Heat therapy 347
Helminths 330
Hemangiosarcoma 248, 261
Hematoma
cervical disc surgery 99
CSM 212, 225, 229
extradural 99
postoperative complications 99,
225, 229
prognosis 284
spinal cord 36, 37 212, 333
spinal trauma 284
Hemilaminectomy see also Minihemilaminectomy
cervical disc disease 98, 119,
266270
dorsolateral 136150
marsupialization 326
neoplasia 266270
nerve sheath tumor 275279
spinal trauma 294
thoracolumbar disc disease 125,
126, 151154
Hemiparesis 94
Hemivertebra 320321
Hemoclips 78
Hemocytometer 44
Hemogram 41
Hemorrhage see also Bleeding
disorders
aspirin-induced 99
cervical 82, 99
CSF analysis 65
CSM 224, 225, 229, 234
diaphragm paralysis 82
epidural 57
gastrointestinal 229
Hemoclips 78
hypoventilation 82
prevention 138
psoas muscle 38, 281
respiratory 82
spinal cord 51, 94, 281, 333
subdural 57
surgical 98, 128, 138, 146, 224,
225, 229
thoracolumbar 128
venous plexus 99, 146, 234
Hemostasis 81, 82
Hemostat 77
Index
Intertransverse ligaments 14
Intervertebral discs see also Disc
herniation
anatomy 12
disc removal 75
functional anatomy 1113
fusion 220, 221
Intervertebral foramen 3, 11, 96
Intracranial disease 163
lesions 94
raised pressure 64
Intraduralextramedullary lesions
29, 51, 52, 53, 248
Intraduralextramedullary tumors
248252, 259263
Intraoperative complications
cervical disc disease 9899
CSM surgery 224226
thoracolumbar disc disease 127
trauma surgery 297, 297299
tumor surgery 258
Intubation 85
Intumescence 2, 3, 258
Iohexol 43, 49, 86
Ischemic injury 225
Ischemic myelopathy 35, 36, 51,
122, 184, 281
Ischemic neuromyopathy 20, 38,
122, 212, 281, 332333
Ischemic neuropathy 281,
332333
Ischemic spinal cord 86
Isoflurane 85
Itraconazole 331
Ivermectin 85
J
Jamshidi needle 79
Jaw tone 20
Joint capsule proliferation 211
Joint pain 36, 122, 184, 320
Jugular vein 69, 278
Junctionopathy 20
K
Ketoconazole 85
Ketoprofen 341, 342
Kidney disease
calculi 38
cysts 55
nephroblastoma 249250
neurological patient 81
pain 122
worms 38, 122
Kirschner wires 178
Lhasa Apso 94
Ligamentous hypertrophy 211
Ligaments
cruciate 20
dorsal longitudinal 14
functional anatomy 1314
ligamentum flavum 197, 199
nuchal 242
ventral longitudinal 14
vertebral 1314
Limb disorders
functional assessment 2526
gait, attitude and posture 212
lameness 183, 184, 204
neurological examination 28
Lipomatosis, epidural 36
Liver disease 81
Locking plates 219, 220, 220, 221,
223
Locomotor status 20, 20, 22
Lomustine 254
Longissimus tendon 271
Longus colli muscles 109, 112, 173
Loperamide 356
Lower motor neurons (LMN)
bladder function 24, 351
diagnostic pitfalls 29
differentiation of abnormalities 26
EMG 60
lesion severity 3132
limb function 2526
motor system function 26
muscle atrophy 26
reflexes 5, 26
thoracolumbar disc disease 121
Lumbar arteries 16
Lumbar cord segments 3
Lumbar disc disease see also
Lumbosacral disease
anatomical location of the injury
296
CSF collection 6869
differential diagnosis 15, 35, 37
lumbar puncture 68, 69, 72
myelography 71
radiography 4748, 4950
Lumbar nerve roots 3
Lumbar nutrient foramen 9
Lumbodorsal fascia 154
Lumbosacral anatomy 11, 182
Lumbosacral disease 181209
see also Lumbar disc disease
diagnosis
clinical signs 183
CT 186188
decision-making algorithm 189
differential 36, 184
371
372
Index
Index
Myelomalacia
malacia 148
postoperative 127, 359
secondary to disc extrusion 333
thoracolumbar disc disease 127, 128
Myelopathy
brachial plexus 36
cervical 38, 82, 212
degenerative 37, 184, 209
differential diagnosis 184, 212
fibrocartilaginous embolic 212
hemorrhage 82
hypoventilation 82
hereditary 36
ischemic 35, 37, 51, 184
lumbosacral disease 184
myelographic abnormalities 51
Myelotomy 87
Myesthenia gravis 38
Myopathy 20, 38
Myositis 20, 38
Myxoma 260
N
Narcotic agents 85, 96, 340
Necrosis
aseptic 259
fat graft 36
Needle biopsy 275
Neoplasia 247279 see also specific
tumor types
diagnosis
biopsy 251252, 262
classification 248
clinical signs 247248
differential 35, 163, 281
electrophysiology 250251
imaging 250251
localization of signs 37
staging 252254
extradural 248249, 259
extramedullary 249250, 259261
fibrosarcoma 38
intradural 38, 249250, 259261
intramedullary 250, 261
lumbosacral 184
nerve root tumors 251, 275, 279
nerve sheath tumor 257, 275279
neurological patients 81
prognosis 259261, 263
spinal 248, 261263
spinal cord 59, 257258
treatment
decision-making algorithm 256
non-surgical treatment 254255,
262263
373
374
Index
Non-surgical treatment
anti-inflammatory drugs 96
atlantoaxial subluxation 164165,
166167
cervical disc disease 96
complications 166167
CSM 218
decompression 124, 125
fenestration 124, 125
immobilization 282
lumbosacral disease 188, 192
recovery times 124, 125
rest 125, 126, 131, 192, 228, 282,
288, 305
thoracolumbar disc disease 123,
124, 125
trauma 282, 289290, 305309
Nuchal ligament 241, 242
Nucleus pulposus 13, 111, 152, 156
Nursing care, postoperative 343345
see also Postoperative complications
Nutrient foramen 9
Nutrition see also Food intake
hypervitaminosis A 36, 37, 326
postoperative nursing care
344345
vitamin disorders 36, 37, 217, 326
O
Obesity 83
Occipital artery 15
Occipital protuberance 178
Oculovestibular response 20
Odontoidectomy 171, 177
Oligodendroglioma 252
Omeprazole 356, 356
Operating loupes 73, 74
Operating microscope 73, 74
Operation duration 83
Opioid analgesics 340341, 343, 356
side-effects 8485, 340, 341
Organophosphate toxicity 38, 42
Oropharyngeal pain 94
Orthopedic disease
CSM 211, 212
DISH 326
fracture 122
lumbosacral 183, 184
neurological patients 81
mimicking spinal disease 20
tumors 248, 249, 260
Osteoarthritis 20
Osteochondritis dissecans (OCD)
20, 36, 37, 183
Osteophytes 211
Osteoporosis 38, 326
Index
Periodontal disease 83
Periosteal elevator 75, 136, 197, 235
Peritonitis 330
Peroneal nerve 31
Pharynx pain 94
Pheochromocytoma 20
Phenobarbitone 217
Phenoxybenzamine 343, 352
Physical examination 1920
see also Neurological examination
Physical therapy 131, 343, 346350
Pilonidal sinus (dermoid sinus) 36,
37, 184, 212, 323
Pin fixation 78 see also Cross-pin
fixation; Screw fixation
angles for fixation 311, 312
entry points and trajectory 312
external fixation 292
failure rates 169
insertion 76
metal and cement fixation 309
stapling technique 315316
Steinmann pins 221, 290292,
296, 298, 310, 314, 315
vertebral distractionstabilization
221
Pinscher, miniature 118
Placing test 23
Plasma cell tumor 259, 260
Platelets 82, 342
Pleocytosis 44, 45, 49, 329, 330
Pleuritic pain 94
Pneumatic system 77
Pneumomediastinum 225
Pneumonia 99, 297
Pneumothorax 127, 130, 158, 297
Polyarthritis 20, 38, 94, 122
Polymyositis 38, 94, 122, 163
Polyradiculoneuritis 38, 184
Poodle
atlantoaxial subluxation 161, 163,
168
dens hypoplasia 164
Position (perception of)
anatomy 5
nerve compression 6
neurological examination 22
postoperative sensory stimulation
348
reflex step 23
Positive profile pins 78
Postoperative care 339360
analgesia 339343
atlantoaxial subluxation 169
cervical disc disease 102
cleanliness 343344
CSM 228229
375
376
Index
Radiography (contd.)
lesions (contd.)
lumbar 4950
neoplasia 250
thoracolumbar 122
trauma 283
postoperative care 344
Ranitidine 356
Recovery times, thoracolumbar
surgery 125
Recumbency
CSF collection 59
imaging 47, 55
postoperative 225, 228229, 344
Red blood cell counts 44, 45
Reflexes 2627
anal 183, 185
crossed extensor 32
cutaneous trunci 20, 24, 24, 2627
hock flexion 27, 30, 182
LMN 5, 26
palpebral 20
panniculus 21
patellar 20, 2627
perineal 20
postural 20
pseudohyperreflexia 27, 183
pupillary 20
reflex step 23
SchiffSherrington sign 32
spinal 20, 21, 87
UMN 6, 26
withdrawal 20, 27, 28, 31
Renal disease
calculi 38
cysts 55
nephroblastoma 249250
neurological patients 81
pain 122
worms 38, 122
Respiratory disorders
dyspnea after imaging 82
fentanyl-induced 84
hypoventilation 82
pneumomediastinum 225
pneumonia 99, 297
pneumothorax 127, 130, 158,
297
postoperative 168
pulmonary edema 167
respiratory arrest 167
upper airway disease 20, 38
Rest see also Non-surgical treatment
cage confinement 125, 126, 131,
228, 288, 305
lumbosacral surgery 192
spinal trauma 282, 288
Index
Sharpei 60
Shih Tzu
chondrodystrophy 12
disc extrusion 94
L4/S3 neurological defects 30
neck pain 94
Shock
septic 83
spinal 32, 282
Silky terrier (disc extrusion) 102
Sinus (pilonidal) 36, 37, 184, 212, 323
Skeletal hyperostosis 36, 326
Skeleton 614
Slings and harnesses 346, 347, 349
Small breed dogs see also Miniature
dogs; Toy breed dogs
atlantoaxial subluxation 161
thoracolumbar disc disease 151
Soft tissue tumors 94
Spears 77
Specific gravity (CSF) 45
Sphincter tone 191
Spina bifida 36, 37, 184, 322
Spinal arteries 16
Spinal cord
anatomy 1, 16, 24
blood supply 16
evoked responses 6061
nerve fibers 6
segments 13
ultrasound examination 55
white matter tracts 56
Spinal cord disease
compression 227, 228
expansion 57
hematoma 36, 37, 94, 212,
333334
hemorrhage 36, 51, 94, 281,
333334
herniation 147, 273
infection 330
injury 87
ischemia 86
liquification 132
malacia 287
swelling 127
tethering 36, 37, 149, 184, 322
tumors 59, 257258
Spinal dysraphism (myelodysplasia)
36, 212, 322
Spinal ganglion 3
Spinalis muscle 267
Spinal nerves 3, 183, 191, 277,
278
Spinal palpation 2425
Splints, external 239, 290, 305, 306
Spondylitis 326328
Syringohydromyelia 163
Syringomyelia 36, 37, 51, 94, 163,
212, 297, 311, 322
T
Tail defects
lumbosacral disease 183
sacrocaudal dysgenesis 322
Tail injuries 296297
Tartar scrapers 76
Technical errors 258
Temperature, pulse, respiratory rate
(TPR) 343, 344
Temporal muscle mass 20
Temporomandibular joint lesion 94
Tendonitis 20
Tendons 20, 271
Terazosin 352
Tetanus 38
Tethered spinal cord 36, 37, 149,
184, 322
Tetracyline antibiotics 331
Thalamic pain syndrome 38
Thiamine deficiency 36
Thoracic spine
anatomy 89
aorta 10
blood supply 15
localization of injury 296
mid-bodies 10
radiography 4748
spinal cord segments 3
Thoracolumbar disc disease
diagnosis
clinical signs 121122
CSF analysis 122
decision-making algorithm 124
differential 122
imaging techniques 56, 122123
kyphosis 131
non-surgical treatment 123126
prognosis 132133
surgery
complications 127, 129,
130132
disc extrusion 127, 129, 131
decompression 124, 126127,
130
fenestration 127, 154159
hemilaminectomy 126,
126127, 136150,151154
kyphosis 131
laminectomy 126, 270273
pediculectomy 126, 127,
151154
recovery times 124125
377
378
Index
Thoracolumbar vertebrae
T1/T13, 1
T2, 36
T3/L3, 15, 28, 36, 37
Thrombin 99
Thrombocytopenia 82
Thromboembolism 359
Thrombosis (iliac) 332333
Thyroid gland 20, 172, 217
Thyroid hormone supplementation
217
Thyroid-stimulating hormone (TSH)
217
Tibial crest avulsion 20
Tibial nerve 31
Tick paralysis 38
Toxicity
organophosphate 38, 42
toxic disease 36
toxic myopathy 38
zinc 358
Toxoplasma gondii (toxoplasmosis)
42, 330
Toy breed dogs 165, 325
see also Miniature dogs
TPR (temperature, pulse, respiratory
rate) 343, 344
Trachea 108, 171
Traction (response to) 213, 214,
223, 224
Transverse foramen 7, 8
Transverse ligament of the atlas
14
Trauma 281318 see also
Atlantoaxial subluxation
bile duct rupture 19
biomechanics 286289
diagnosis
anatomical location of the injury
295297
decision-making algorithm 293,
294
differential 36, 184
imaging techniques 283,
283286
initial assessment 281282
neurological signs 28, 282283,
293295
fracture 21, 36, 87, 286289
gunshot injury 36, 331
neurology
deep pain sensation 293295
examination 21
pathophysiology 289292
psoas muscle 331
prognosis 301302
recovery 87
spinal region
cervical 295297
lumbar 296
lumbosacral 184
sacral 36, 296297
thoracic 282, 296
treatment
bone grafts 292
choice 293295
complications 297301
fixation 2890291, 316318
metal and bone cement
291292, 309316
modified segmental 291
non-surgical treatment 289290,
305309
postoperative care 297
urinary tract 282
Traumatic feline ischemic myelopathy
36, 37, 281
Trimethoprimsulfonamide 85, 331,
343, 355
Tube cystostomy 355
Tumoral calcinosis (calcinosis
circumscripta) 36, 37, 122, 212,
326
Tumors 252254 see also Neoplasia;
specific types of tumor
biopsy 6162
classification 248, 253
seeding 276
spinal 59, 257258, 261263
U
Ulcer formation
decubital 339, 358359
gastrointestinal 127, 297, 341,
356
Ulnar nerve 31
Ultrasonography 5455, 250
Ultrasound therapy 347
Upper airway disease 20, 38
Upper motor neurons (UMN); see
also Lower motor neurons
bladder function 20, 24, 351
crossed extensor reflex 32
EMG 60
motor evaluation 2526
reflexes 6, 26
severity 3132
thoracolumbar disc disease 121
Ureter calculi 38, 122
Urethra
innervation 351
neoplasia 184
tumor 38
Index
Ventral fissure 16
Vertebrae (general)
anticlinal 9
blood supply 1417
column splitting 52
congenital anomalies 321322
functional anatomy 115
intervertebral discs 1112
ligaments 1314
spinal cord segments 23
synovial articulations 911
Vertebral buttress 287289
Vertebral canal 7, 8
cauda equina compression 181
CSM 211, 219
differential diagnosis 36
tumors 253
type I disc extrusion 14
Vertebral column 1417
Vertebral distraction/stabilization
218, 219, 221223
see also Fixationstabilization;
Internal fixation devices; Metal
and cement fixation
Vertebral foramen 141
Vertebral fracture 225, 331
Vertebral instability 211
Vertebral plexus 15, 269, 273
Vertebral tumors 253, 255257
Vertebrectomy 255, 273274
Vestibular disease 85
Viral infections 330
Visual function
blindness 85
neurological examination 20, 21
placing test 23
ptosis 25
Vitamin A 36, 37, 326
Vitamin E 217, 257
379