Description

Neck pain is common sign of spinal disease in dogs and can be due to multiple causes. Diagnosis involves the use of imaging, CSF tap and systemic investigation. Treatment needs to be specific for the disease itself and can be medical or surgical, as well as symptomatic aiming to relive the pain. In this session, we will review the most common causes of neck pain in dogs, how to diagnose the specific conditions and how to directly and symptomatically manage the conditions.

Transcription

OK, many thanks for that introduction and just checking you can still hear me before I get started? Yep, I can, yeah, we can hear you crystal clear. Perfect.
All right. Thank you. Thank you very much.
Thank you for that introduction. Thanks to Laurent for that last lecture, and, happy to take over for those of you who are still staying up into the small hours. We're gonna talk now about, how we investigate and manage, pain, neck pain in young dogs, can be quite a common problem in practise, and we're gonna end up hopefully coming up with a cheat sheet in, .
In, the end of this lecture that helps you identify what are the main things we should be considering, what are the differential diagnoses. Firstly, this is, like the last lecture, sponsored by Hallmark Veterinary Imaging. Many thanks to them for that.
And just to disclose, they don't have any relevant financial or non-financial relationships with products or services described. So moving on, we're gonna start this with a case where you so to, to highlight the fact that sometimes we can do neurology without an MRI or without CSF. We can look at creating a differential diagnosis list based on our lesion localization.
So we examine our patient, we find out where we think the disease is, and, based on the presence of pain or not. Then we can come up with what's possible, and then manage based on that, and that disease list, the differential diagnosis list is narrowed down based on the signal and and the presenting complaint history. So are you a chronic progressive?
Are you an acute onset? Are you lateralized or not? Are you a young dog, old dog?
So those sort of things. And we'll, we'll emphasise that as we go through. But this, so this case is to highlight then how we're going to approach the diseases that we'll talk about during this lecture.
This is a 10 month old bull terrier, and as you can see, has a slight problem, presents with, a problem with motor function in all four limbs and As we, as we get the dog up, you'll see that's readily apparent and obviously in severe pain, you can see with just the minor minor movements this dog has. A neck, head posture that suggests discomfort here, and has, a reduced motor capacity, both front and pelvic limbs, a lot of increased tone going on there in the pelvic limbs. Dog's trying to move his neck and head around, but you can see there's a lot of discomfort there.
In essence, this may be where you can stop. You can say that is the dog normal? No, is he neurologic?
Well, he has some reduced. To function. And we know that he's in severe pain.
It seems to localise pretty specifically to the neck. So we could stop there. Moving this dog around any further may, if we have, we don't have any history ruling out trauma may actually make things worse, obviously.
So, we're going to focus on, the, the dog having a cervical spinal lesion localization. We don't really need to go much further with our exam. If we have a dog presenting to us in pain.
we're gonna talk about those, the differentials that are, can be responsible for that. So, when we have a list here of vitamin D coming up as a pneumonic that we use to help us remember the diseases that can be responsible for nervous system disease, we have V for vascular, which is very rarely responsible for discomfort in the spinal cord. In the shape of fibrocartilaginous emboli, it can certainly be responsible for weakness, paresis, plegia.
I for inflammation, so this is our first possible disease that we'll consider, set of diseases actually, that can affect either the bone in the shape of osteomyelitis or discos spinylitis, or, immune-mediated and infectious diseases of the nervous system, at least involving the meninges. If you have neck pain and you're thinking about inflammation, then the disease must in some way affect the meninges, either by compressing on them. Or involving them directly.
And in this case, with inflammation, they'll be involved directly. Then we've got trauma, hopefully some history to help us out with that. So maybe a fracture or luxation, subluxation that is compressing the nerve roots and meninges.
Toxins, well, these don't really result in neck pain, so we can rule them out. Anomalous developmental. For the neck, or back, if we're considering something causing pain, well, we have a lot of conditions that the animals can be born with.
So vertebral anomalies, for instance, such as hemivertebra, butterfly vertebra, and block. Spina bifida. I mean, these things don't necessarily result in a painful situation, but things that go along with them, such as secondary disc disease, such as compression of the spinal cord due to kyphosis, then these can cause pain.
Another anomalous condition that we could consider in the mainly thraculum, but also cervical spine, is that of a subarachnoid cyst, most commonly now called subarachnoid diverticulum, an expansion of the subarachnoid space. But again, it's not often a very painful situation. So, where do we end up in summary with anomalous disease?
The one condition you should think about for the neck is Going to be atlantoaxial subluxation. And that's what we'll talk about. No real metabolic diseases that end up causing pain.
You could argue that something affecting the parathyroids could cause some type of osseous breakdown, and we could have a fracture, but that's gonna come straight back to trauma. So we're gonna say no to metabolic. There's no idiopathic neck pain syndrome, so we can rule that out.
Neoplasia, that is a big cause of concern. Perhaps less so in young dogs, which is the focus of this talk, but it certainly is something that we would have to put on every list. Every time we'll say, Well, this dog's one year old, so he shouldn't have cancer.
That would obviously be the dog that will come back and trick you and and does have cancer. So it has to be on the list. Maybe in young dogs it's going to be at the bottom of the list.
That could be Neoplasia of the bone, it could be of the nerve, and nerve root, could be the meninges. We'll talk a bit more about that as we move through this talk. Nutritional disease is not really gonna cause pain again, and then degenerative diseases, really we're talking about disc disease.
So what we're gonna talk about in this session is, we're faced with a 10 month old dog, as you saw in that video that has neck pain. We have now a differential diagnosis list here, inflammation, trauma, maybe anomalous disease in the shape of alantoaxial subluxation, maybe neoplasia, maybe disc disease. We're going to narrow that down based on our signalment, how the animal presents, and we're going to talk a little bit about how you can narrow those things down based on some tests, depending on how much money the owners have.
So, we're gonna talk specifically about, about those diseases. If we're looking at investigating this 10 month old dog as an example, what can we do when we think that the dog has spinal disease? There's several ways of, of looking for the underlying cause.
CSF, so spinal fluid can certainly sensitively look for an inflammatory disease affecting the meninges and nerve roots. So any type of meningitis, could be picked up with CSF. Survey radiographs, well, they may help if you have a a vertebral involvement.
So if you have subluxation, for instance, if you have a fracture, if you have disco spondylitis or tumour in the later stages causing lysis, we might get some help with those. We'll talk more about that shortly. Myelography, fallen a bit by the wayside with the passage of time, but certainly still can help you identify some abnormalities in the spinal cord.
Nowadays we're more commonly looking at MRI scanning and CT scanning. To help us identify structural lesions that are associated with the spinal cord, and in some places, centigraphy exists to identify changes in blood flow. And so if we have, a bone abnormality that's changed the blood flow, whether it's in, whether it's inflammation or tumour, then scentigraphy can pick that up, sometimes way before radiology or even MRI scanning can.
So let's talk about some of the specific diseases. So at first on that list, was I for inflammation, and when we're thinking about where inflammation could take hold, we're thinking certainly of the vertebrae. Now, oddly enough, osteomyelitis is not common in .
In, dogs, most of the time, then we're actually thinking, that we're dealing with a discospilisis, so the bacteria will, will migrate to the end plate there. That's where the loops of capillaries are. And those are things which, are gonna actually cause sedimentation of those bacteria.
So for just an odd reason that we'll end up having endplate inflammation due to bacteria. And bacteria is the most common cause of a, disco spondylitis. Occasionally, we can see fungal causes, particularly in German Shepherd dogs.
Aspergillus is, is quite common in those dogs because of an immuno immuno sufficiency. And so most of the time we're going to consider that German shepherd dogs can have a problem with IGA, and that can usually protect you from any mucosal invaders which aspergillusis. So, fungal disease is a possibility.
For bodies as well, grass seeds, are a possibility that often they'll drag in both, both, bacteria and fungal diseases. Most of the time though, bacteria and most time it's staph, which helps us because if we don't know, based on any tests, that, that we're doing, what the cause is, we could say, well, 8 out of 10 probability, we know what it is, staph, and that means we can 8 out of 10 times use the correct antibiotics. So how do we diagnose this?
Well, it is some, somewhat simple, in many cases, but because we can perform a radiograph and we can see lysis of the end plates and proliferation of the bone, sclerosis. And that's something which then is fairly definitive for, Discuss spondylitis. However, it can take a couple of weeks to be detected.
And so in our bulldog, when I tell you a little bit of history, then you'll know that the dog only had pain for 3 days. We take a radiograph of that dog and it's completely normal, so we can't rule out discus spondylitis at this stage. Early onset.
Clinical signs mean that, we're, we are unable, to, rule these conditions out. So we have to keep that, they have to keep this on the burner as a possibility. What is this disease really?
How is it causing signs? Well, you can get compression of the nervous tissue, with soft tissue involvement. So disc really, dorsal longitudinal ligament that when it becomes inflamed with infectious processes, such as, bacteria, maybe fungus, as we said, can end up causing compression of the nervous tissue.
And therefore, it's ultimately a medical disease. How seriously the animals are affected, we first treat this as a medical condition, and we've seen dogs who've been paralysed with back pain due to disco spondylitis that have had a dramatic turnaround of neurologic signs within several days in response to just antibiotics. So, firstly, always consider a medical condition.
Systemic antibiotics though are necessary, and they're going to be necessary for at least 8 weeks. These are, these are, after all, bone infections. So we're gonna need bone penetrating antibiotics.
We're gonna need them for a long period of time, and they can be expensive, particularly in large breed dogs. Improvement, as we said, can be very quick. And obviously, in conjunction with the antibiotics, we're gonna need, some pain relief, and we're have in it, we have in this, situation to use non-steroidals, maybe in conjunction with muscle relaxants, maybe in conjunction with gabapentin, opioids, but we've got to veer away from steroids.
And although we love to use anti-inflammatory steroids for back pain in many cases, as we'll talk about, it's not, something that's gonna help us with discoyelitis, in fact, may make things worse. So pain relief is necessary. Overall, the prognosis is very good, but, sorry, we have a.
Screenshot problem. OK, here, hopefully everyone can see this now. The prognosis is very good, but in certain cases, we can have a a need for very long term antibiotic therapy.
So we will judge the, the, requirement for antibiotics based on the resolution of lysis and proliferation on radiographs. If we can see that there is some resolution radiographically, we will then say after 8 weeks, we could stop the antibiotics. But if we get a recurrence of signs, then we're gonna put them back on for a further 88 weeks, and that can be, obviously extremely expensive.
So, one thing just to mention though, is however rare it is. We should test these dogs for Bruella, because Bruucella is a zoonotic disease and it can cause discospodylitis in the absence of other signs. So, remember, take home message for discospodylitis, besides it being something that can be treated well and can be diagnosed cheaply, it is a disease which, sometimes can be very nasty if the underlying aetiology is Bruceella.
Right, keeping with the theme of I for inflammatory, we're now gonna look at the inflammation that's affecting the nervous system via meningitis. And the meningitis just being, inflammation of the meninges. So that would just present as neck pain.
If it involves the spinal cord as well, then we'll call it, meningomyelitis. So there's just a terminology thing here. So we'll think of inflammation affecting, the, the nervous system.
Now, origins of this can be either infectious or immune-mediated. And this is a problem, presents a conundrum to us because We may not be able to identify the underlying cause and have to choose whether we go with an antibiotic type approach, or whether we go with an immunosuppressive approach. And obviously that would be, the latter would be contraindicated if you had any infectious agents.
When you think about the infectious agents that could be responsible, yes, we could think about viral disease, in cats, for instance, we might think about FIP in dogs. Distemper when it affects the nervous system rarely affects the meninges, so we're we're gonna be less interested in that. Protozoa, well, yeah, that's a possibility.
Toxoplasma and Neospra, they're things which can affect the nervous system, not often painful, but should consider it. Fungal diseases depends on where you live, but yeah, fungal diseases can cause, as well as osseous disease can cause some, nervous system problems, may well be systemic depending on what it is. So you may have to look for respiratory conditions, skin conditions, bone disease.
Bacterial disease, that can be a consideration. In addition to discus myelitis, we may have spread into and around the nervous system that can be Myema, where that's, that's the, that's defined as pus within a, cavity, and that can be the spinal canal, or it may just be bacteria that have spread to the nervous system because of of sepsis, of local infection getting in there, or even a bite injury, sending bacteria locally. Theketial disease, so Rocky Mountain spied fever, lia, those things depend on, are, are going to be prevalent in certain areas of the world.
So, so their significance depends on where you live, but certainly can be responsible for pain in the neck and back. Can present any of these can present as a focal problem, and, . Just neck pain, or they can be multifocal and involve the nervous system as well.
So, always be on, on the lookout for, inflammation, being responsible for a variety of signs. Not always, though, they're responsible for pyrexia or sepsis. And so you may have an otherwise healthy dog, which seems odd, but make sure you consider inflammation on every list, essentially.
Progressive diseases, and multifocal, so we need to make sure that we remember that once you see this bull terrier that's 10 months old, if it is an inflammatory disease, it's not getting better on its own, it's gonna get worse and can be and can rapidly get worse as well. So, do we treat with antibiotics or do we treat with immunosuppressives? So let's deal with that in a second, because, our, infectious diseases, as, as we've said, not always para septics.
We're not really able to detect systemic diseases, systemic signs with them. They'd be responsible many times to combinations of antibiotics. You're rarely gonna know what infectious aetiology is responsible.
So we'll go with. Something, a combination which covers aerobes, anaerobes, gramme positives, gramme negative bacteria. So we're gonna go with sulphur drugs, for instance, at 15 milligrammes per kilogramme twice daily.
We'll go with clindamycin, 10 milligrammes per kilogramme twice daily, and that's a good combination to use. You might want to use doxycycline, particularly if you live in a place that may have tick-borne diseases. It's very lipophilic and loves to get into the nervous system.
Versus metronidazole, very, potent drug for anaerobic infections, particularly bacterial infections and those that, that get in the nervous system. It's very lipophilic as well. So you can use a combination and should use a combination of drugs if you think that you have an infectious disease.
So these antibiotics are the ones that we consider that get into the nervous system. In red are the ones that you could use in the first few days. After that, the blood brain barrier, blood spinal barrier, it's gonna probably get in the way of entry of these antibiotics.
So ampicillin, claviinated amoxicillin. These things don't do a good job of getting into the nervous system. So we can only use them initially and then after that, we're going to use others.
So most of the time. We just ignore them completely and go straight to, the fluoroquinolones. Good, obviously gramme negatives, pretty good for streps, so it's a good thing to use, can get into the nervous system.
Third generation cephalosporins. The first generation's not so good and can't penetrate blood brain barrier, so nothing that we're gonna really be interested in. But 3rd generations, yes.
Uhole we've mentioned, trimethamine sulphur drugs, great for getting in the nervous system, very potent, broad spectrum. Great for protozoa. You might not like them because they have some side effects, but if you have a dog with nervous system infection, then the pros and cons really are gonna, are gonna lean more towards the use of trimethrine than against it.
Doxycycline, then, as also we've mentioned, this, very lipophilic, great for Rickettsial diseases, but good for overall, antibiotic, treatment of the nervous system. These are our antibiotic options. We're going to use multiple of them because we're not often going to know what's there, but we could take a step back and say we're not actually sure, in many cases, whether, whether if it is a nervous system problem rather than a bone problem, whether an infection exists at all, and it may be an immune mediated problem, which means what do we do about steroids, so.
You would think intuitively, as we said for disco spondylitis, we shouldn't be using steroids when we think of a bacterial infection. If we have an immune-mediated inflammation, as we'll talk about in a second, we're gonna want to use immunosuppressives. Now, if we use immunosuppressive doses of steroids in the face of a bacterial infection, any type of infectious disease, we may end up with a serious progression.
So, if we think that there's a chance of infection, what we will do is use combination of antibiotics. And that combination of antibiotics will also be used with anti-inflammatory steroids for 234 days, because your clinical signs of pain and nervous system dysfunction are related to the inflammation in the nervous system. And so anti-inflammatory steroids are actually, are actually not contraindicated with infectious disease, but remember, Anti-inflammatory doses, no higher, so half to maximum 1 mg per gig per day, and.
Short term, 3 to 5 days maximum, because we don't want, to potentiate the infectious process and its progression with dampening down immune response. Now. On the other side of this, we have meningitis of unknown aetiology, which is an umbrella term.
It depends where you live as to how you spell aetiology. You might spell it with an A, you might spell it with just an E, you might say unknown origin. Really, it just means that after 30 to 40 years of research into this area, no one.
Knows what is going on. Not very comforting to the owners. Really, this, this umbrella term covers multiple diseases such as GME, granulomatous meningoencephalitis, necrotizing diseases such as necrotizing leukoencephalitis, necrotizing meningoencephalitis.
And most of the time, this is referring to brain disease, but a surprisingly high number of dogs will present initially with just spinal pain, neck more than thorac a lumbar and lumbar sacral. So although we often think of these as brain dysfunctions, And that they're multifocal, do not rule them out if you have a dog with neck pain. So who do they affect?
Because as we said at the start, we can narrow down our list of possible causes of neck pain based on our signalment and presenting signs, and particularly when they started and where they progressive. So who do you affect? Well you often, if you are a meningitis of unknown aetiology, are gonna affect small, young, pure breed dogs.
What do we mean by young? So we often mean 2 to 4 years of age, and who are you if you're a pure bred? Well, often you are a small white fluffy like this, so you are Maltese, you are West Island white, Lsa, so, Bon frise, toy poodles, Jack Russell terriers.
And so you see these come in and they're young, and this should be top of the list. There are a few other breeds that can be affected by by these diseases, again, purebreds, particularly French bulldogs, but also Chihuahuas, Yorkshire terriers, Maltese, and pugs. These are breeds that have a familial association with these inflammations, so it seems to be potentially a genetic predisposition.
In addition to the neck pain, they may well have neurosciences. We said, they could be brain and spinal cord, but may initially just be spinal cord. Rarely though, any systemic signs.
And so if you see any systemic signs and you think inflammation is a possibility, then we're really narrowing it down to an infectious disease. As we said, infectious diseases may not have systemic signs either, but if you have an animal who does have systemic signs, then we're gonna say it's more likely infectious than the immune mediated. They're progressive, they're multifocal, they're nasty and left untreated, they're gonna be fatal.
And really the treatment is some type of immunomodulatory therapy, which often initially is immunosuppressive steroids. And we're talking here, high doses, 4 milligrammes per kilogramme per. Day for a couple of days.
That's a high dose. And then we're gonna reduce that dose to 2 milligrammes per kilogramme per day for maybe 2 weeks, and then 1 milligramme per kilogramme per day for, for maybe 4 weeks. We're tapering down to effect.
Other drugs that we can use, either as sole agents, as first therapies, or as adjunctive therapies, are gonna be cytosine. And there's a fairly complicated dosing regime involved with administrating that. But it's a very potent drug.
Azathioprine, simple way to administer that, but has a lot of side effects, cyclosporin, but also, in addition to that, we've got mycophenolate. So there are some other immunomodulatory drugs, which all work in slightly different manners. So different Mechanisms of action, which mean that they can be synergistic with each other.
It's not unusual for us to have a dog on 2 to 3 of these drugs. It's a nasty set of diseases, and we're just guessing, unfortunately, which is going to be the best therapy in an individual case. So this is, I outlined a more logical approach to how we deal with the SWF, which is the the small white fluffy, not the single white female, this is the small white fluffy.
We're treating for the treatable in this case, and the reason for highlighting that is that you may not have CSF. You may not have MRI. You are just fa.
With a dog with neck pain. Now, based on the signalment, so particularly the age and the breed, we're looking at the likelihood of an infectious versus an immune mediated disease. If you think it's an infectious disease, and you think you have time on your hands, as we see here, then we could go with let's start antibiotics and anti-inflammatory steroids.
We start that and we will see that you can potentially have improvement and that may be just masking the signs, but all of a sudden, 345 days later, the dog has improved. And in that situation, we'll withdraw the steroids after 345 days, continue with antibiotics for up to 4 weeks, and potentially you have success, or you have relapse. Regardless of that, if you didn't get a response in the first place, then this approach tells us that potentially we've got more likely in new mediated dysfunction.
You could, if you have time on your hands still, alter the antibiotics and see if you can get a better effect. Time on your hands means that the dog just has neck pain and is not looking like he's having such rapid progression of nervous system dysfunction, you think you may actually lose the patient. And so this is the approach that we will take if we're not sure what the underlying cause is and if we have some time.
The bottom line is that 8 out of 10 dogs overall in the northern hemisphere will have immune-mediated dysfunction as a cause of their inflammatory disease. So 8 out of 10, remember when we said in discosinellitis, 8 out of 10 causes related to Staphylococcus infection. That's a useful perspective.
Well, 8 out of 10 immune media 8 out of 10 inflammatory conditions that . We see causing nervous system dysfunction are actually immune mediated rather than infectious. And so we could move straight to the right side of this slide or treat the dogs immediately with what we're going to talk about immunoexpressive treatment, if we think they are ticking time bomb, meaning that these patients are going to get worse rapidly and we are worried about spending some time on.
Antibiotics and anti-inflammatory steroids when it's the least common cause of inflammation affecting the nervous system. What do we do? We use a high dose of immunosuppressive steroids, as I've described, and then we look again for a response.
Initially, we may see tremendous response. So we will, step down that dose as we talked about 4 to 2 to 1 to 2. We're telling the owners that each time we step down, we may have clinical signs that come back, in which case we've got to step back up and and take out the duration of that dosage a little bit longer.
We may successfully step down, but we may have some steroid side effects, and so we may have some problems with the dogs becoming overweight, thin skinned, alopeciic. Extremely polyphagic may start to affect endocrine function. So some serious long-term side effects, so we may have steroids spare.
If that immunosuppressive steroid regime did not work, then, we have to think of several things. Number one is, the role of a second drug, and we made brief mention of those being azathioprine, mycophenolate, cyclosporin. Site in raveno side, those are things which we would consider.
Nothing against using those as first line approaches to treatment, but it it personally, I'll always use immunosuppressive sides. At the same time as considering a second drug, so a drug added on to immunosuppressive steroids, we may consider having another chat with the owners because we need to make sure that they recognise that this is. Not a good disease and that potentially the dog, could die in the next few hours to days.
It can be that serious. Even if we get some resolution of clinical signs, there can be progression. Overall, with different treatments that are available, these dogs can potentially have a good quality of life for 2 to 3 years, but most of the time, they will relapse.
So they are significantly, serious diseases. One of the inflammations of unknown origin that we also deal with is this steroid responsive meningitis, which does deserve its own place really for us to discuss more more specifically. Steroid responsive meningitis may perhaps be the worst name for any disease in the nervous system, because most neuro neurologic dysfunction, pain will respond to steroids.
So it's not a great name, . But we, that's what we're stuck with right now. It is a specific condition.
It is a condition which affects pure bred dogs, most commonly beagles, Bernese mountain dogs, boxers, they're the top three. A few of the breeds trying to get in on the act, these include German shorthaired pointers, Nova Scotia duck toiling retrievers, Weimarana, greyhounds, golden retrievers as well. So a few breeds trying to get in on the act here, and so pure bred dogs that present with just neck pain.
Remember we said shortly ago that meningitis means neck pain. We have to have meningomyelitis to have nervous system dysfunction. So this is a disease which purely causes neck pain.
No nervous system dysfunction. The minute you have nervous system dysfunction, think of another disease. The other piece of the jigsaw that helps you suspect this condition is the fact that they are young, 6 to 18 months of age.
So, there's no real gender pre. For these dogs, but they are 6 to 18 months of age. So if you've got one of these breeds coming in, or really any pure bred dog that just had neck pain, no neuro dysfunction at this age, we'd start to put this on the list.
It is something which can be successfully treated with high doses of steroids, and here we have outlined the regime that I talked about, in a couple of slides ago, 4 Migs per gig, once a day. If they're eating, you can give it orally. If they're very depressed, they can't eat, then we'll give it intravenously, and we treat for two days.
And then we give 2 mgs per kg for us for a couple of weeks. 1 mg per kg, once a day for a month. So we're tapering down and as we said, initial, additional immunosuppressives may be warranted, but in this condition, it rarely is warranted.
Most of the time steroids will do the trick. We can add azathiopride in conjunction if we. Want a steroids spare, but most of the time, they'll at least respond to this.
We've got to go aggressively though, unfortunately, we can't use anti-inflammatory doses because this disease will become chronic and nasty, and we won't be able to turn it around. So, unfortunately, early aggressive treatment is necessary. All right, so that was I for inflammation.
We talked about discoonellitis, we talked about meningitis. We talked about infectious causes of meningitis and immune-mediated causes, and the immune mediated being the meningitis of unknown aetiology, and then the steroid responsive meningitis. Now we're gonna look, we're gonna turn our attention to anomalous diseases and In anomalous diseases we've mentioned that we are going to focus on atlantoaxial or subluxation, but it's worthwhile paying attention to this scenario.
Kiri like malformation and string of myelia, rarely responsible for such overt pain as you saw in the video with the bull terrier, but certainly can be responsible for dull pain or episodic bouts of pain. Scratching, depending on which breed we're dealing with. Kiri-like malformation and syringomyelia are two distinct diseases, so different diseases, but often occur in conjunction, so can be related.
So we're going to explain what they are. Here's a dog with chiari-like malformation. It's an indentation of The cerebellum and his syringomyelia, which is expansion of fluid in the spinal cord, and so we're gonna look at some definitions, talk about when to suspect to this.
Chilli malformation then is, is some type of deformation of the back of the skull. Usually it's what's called a hypoplasia, so it's just too small, and that results on indentation of the structures which it surrounds, which essentially is the cerebellum. So we're looking at this .
So-called suboccipital bone here. Sometimes it can be so severe that when it presses on the cerebellum, it will actually cause her herniation of the cerebellum, herniation on a chronic basis, and so we're not talking about the herniation that we see with brain trauma, for instance, or with tumours. So it's a chronic thing.
Very difficult though to actually diagnose this. We certainly really can't with any sensitivity, palpate the abnormality, and radiographs are not great also at identifying the osteo abnormality. So we need to rely on advanced imaging, particularly MRI.
Here we see a normal MRI so we can see a nice round cerebellum here with the skull around it, plenty of subarachnoid space here. Compared to an indented cerebellum. This is occipital hypoplasia, small occipital bone, suboccipital bone.
See how the cerebellum's much flatter now compared to this normal version, and we can also see here some syrinx formation, which we'll talk about in a second. And in this case, we've not only got flatting and indentation of the cerebellum, but we've got a slight herniation here. And so this is the most serious form of QRE-like malformation.
On its own, Qia-like malformation can be responsible for a dull, aching pain which can be intermittent, sometimes causing burning and sensations over the back of the head and the neck, based on what we know of its occurrence in people. But what it does that's more significant is alter CSF flow. So if you have a flat back of the skull that's compressing your cerebellum, it's also pushing the cerebellum downwards.
And you can see in this normal case here that CSF can flow out of the skull into and around the spinal cord. Well that's not the case when you have a flat back of the skull. So it alters CSF dynamics.
Ultimately, it's like putting your thumb on the end of a hose pipe. Fluid is going to be created daily in the ventricles. In fact, the ventricles will create CSF volume, replenished CSF volume 5 times in a day.
So it's a dramatically open tap. Here we have fluid produced lateral ventricles, which is gonna flow out of the lateral ventricles and it's gonna move towards the back of the skull. Now, the flat back of the skull is a thumb now on that hose pipe.
The tap leading the fluid down the hosepipe. Put your thumb on. Hose pipe and that fluid now comes out with more pressure and rips into the spinal cord, but does it on a very chronic basis.
And this is syringomyelia. So the, the expansion of fluid in that spinal cord, syringomyelia, sometimes called syringohydromyelia, but most of the time SM or syringomyelia. This is a fluid cavity, a syrinx or cyst in there.
So this is the obviously thumb on the hosepipe. There is some complex physics that's been, investigated to work out why this happens. It's very similar to Bernoui's principle where just increased prep or increased pressure will actually tear the spinal cord open and force fluid in there.
Overall, the brain is just too big for the skull. There's a very flat back of the skull. And that that changes those fluid dynamics.
We don't know how long it takes, but we suspect, multiple months to years, so we can see a dog with chiari at 6 months of age, and it may not have any evidence syrinx filled up for 234 years, and that's Problem because as you're probably well aware, this is a set of conditions which will affect pure breed dogs, cavaliers being the poster child for this, and 2 or 3 years of age is too late for the diagnosis in the breeder's eyes because they want to have bred those dogs by then. So this is a problem for us. We can't often detect which dogs with QRE will ultimately end up having.
Syringomyelia. Now in the cavalier breed, 95% or more of that breed actually has re-like malformation. So we're just going to assume that you have it.
Only maximum 60% of that breed end up developing syrinxes, and not all of the dogs that develop syrinxes develop clinical signs. So, there, there, there is a progression here, but there isn't a guarantee that you will end up having clinical signs. Besides the Cavalier and Charles, there are several other breeds that will see Brussels Griffon, for instance, Chihuahuas, Pomeranians, French Bulldogs, often the small toy breed dogs.
And the most prominent signs are surprisingly actually pain-related scratching, sometimes called phantom scratching due to pain, episodic pain. They may yelp out in pain, and when you examine them, you can't find any pain, or it's a dull aching pain rather than a sharp pain, which they're they're trying to tell you about. More rarely, we're gonna see, a change in spinal column shape.
We can have scoliosis, kind of deviation of the neck. We can have obvious pain on palpation. We can see progressive spinal cord signs, ataxiaparesis.
Things which you actually would think would be more common if you've got a huge cyst in your spinal cord, you would think you may actually be very weak and drunken. Maybe be paralysed, but that's very, that's not so common, and it's not so common because you only actually need about 10% of your spinal cord to walk. So we can see this expanding cyst, syrinx in the spinal cord in a basically normal do, which is quite concerning.
Worthwhile emphasis and what I've said, and that is that not all dogs with syringomyelia may have clinical signs, up to about a third of them will have clinical signs. Most common in the cavalier scratching. But that's not the case in other breeds.
Other breeds may not manifest as scratching, they may manifest as just neck pain. But Not usually is, is it ever as severe as you saw in the bull terrier in the first video. That's, that type of pain is not what we're often used to seeing.
It's an episodic type of discomfort. It's an irritation, like a burning sensation that can come and go. Here's an example of a cavalier, which many of you may have seen with this phantom scratching called phantom scratching because they'll rarely connect with the skin.
It can be very debilitating because it can occur multiple times throughout the day, often stimulated by excitement or more commonly a more commonly a collar being placed on or the owners touching them. Some type of, some type of sensory stimulus will set this off where they become irritated. But as you can see, they can walk normally until all of a sudden they want to scratch.
So they have good motor function, rarely are attaic in the initial stages, and will just present with this scratching, and then can yell out in pain occasionally, and when, when, as we said, when you examine them can be completely, normal. How do we treat them? Well, the analogy of the hosepipe may help with this in that we've got a tap that's turned on constantly, and the thumb is over the end of the hose pipe here.
We can try and turn the tap down first, so reduce the buildup of CSF in these cases. Similar to the treatment of the hydrocephalus, we're going to use diuretics like rosamide. So you're gonna use 1 to 2 migs per gig twice a day.
If that's inadequate, which often it is, we're gonna add prednisone, an anti-inflammatory dose of steroids can actually reduce your, CSF production. If it's inadequate, in combination with rosamide, we can have gabapentin. This is, as you probably well know, a miscellaneous, analgesic, meaning that we're not quite sure what why it works, but it tends to take away any pain associated with nervous, structural functional abnormalities.
Other things to consider, omeprazole, the proton pump inhibitor, none of its relatives seem to work, but omeprazole as, as a sole agent seems to reduce. CSF production that may help. Tramadol maybe is not as successful in dogs, to reduce pain as, as, as was once thought, but maybe something you you like to use.
Amantadine takes away chronic pain. SSRIs should also be considered. The serotonin, the selective serotonin reuptake inhibitors.
These can take away pain too. So never be afraid to use a combination of pain relieving drugs. And last resort is surgery.
We talk about reducing the fluid production, but we don't talk about taking the thumb off the end of the hose pipe. And so, the last resort is indeed surgery. Take the thumb off the end of the hose pipe, which means taking the back off the skull.
So it's a very radical treatment. This is a suboccipital craniectomy. In addition, a C1 laminectomy, where we're taking the bit of the roof off here.
This opens up the nervous system and so it can free the cerebellum, changes the CSF dynamics back to normal. Potentially, some people say, open up the, the, the spinal cord and, and drain the cyst, although there's some morbidity that can be associated with all of this surgery, so we have to be cautious, with that. This is, this, this has some risk, without doubt.
And there's also a risk of no improvement, so a very expensive procedure, and potentially there's no improvement because we may be doing something after the horse has already bolted here. We've got production of CSF which is, which is normal. We've got flow of CSF which is abnormal, creates cystic accumulations in the spinal cord, and taking the back of the skull off is not gonna take away those cystic accumulations.
It may alter CSF flow such that we don't get progression. But it may well not affect in any way, the CSF buildup in the spinal cord. There's a risk of recurrence which approaches half of these cases.
So, again, a concern in children that have this surgery, they're often committed to 3 or 4 revision surgeries, because the scar tissue that's laid down where we've removed bone from. It's gonna just then recreate the pressure situation, so. Is a problem.
Now, I've gone through this because it is a common scenario in some breeds, and it often gets discussed and it can be complicated. So hopefully try to try to simplify it, but the one take home message is it's very rare to have constant severe pain as a result of this disease. The pain that comes from this disease is more episodic, it is not often severe, it's sometimes barely detectable on, on physical examination.
Is a cause of pain, but a but a totally different type of pain. Another consideration under the title of anomalous disease is atlantoaxial subluxation. Again, there's a signalment here which may help us.
What this means is that we've got a problem with C1 and C2, where for some reason, where the dorsal aspect can be seen to subluxate away, mainly because of ventral structure abnormalities, and the ventral structures can start to compress the spinal cord and cause pain. Often in toy bred dogs, very young dogs, most of them are less than a year of age. Occasionally can be in adults, but that's usually secondary to trauma.
So, these are, are, are, are often the breed the breeds that you may be affected by GME or the meningitis of unknown origin. Top of the list, Yorkshire terriers, so half of the AA subluxations that are seen on Yorkshire terriers. It will cause some type of gate dysfunction in many of these cases.
So ataxia tetrapoesis may be a full-on, recumbency with, tetraplegia, although that's less common. 2/3 of the dogs will have neck pain as well. Maybe that's their only sign, combination of other signs can be seen, such as, deviation of the neck, so torticollis.
Very rarely, but it's worth considering, intracranial signs can be seen with a spinal condition like this, because it will affect blood flow, and most commonly the intracranial signs are vestibular related. So we, we're looking really for some congenital anomaly here that's leading to subluxation and most of the time, it's actually a problem of the dens or the odontoid process here of C2. The peg that, that keeps the C1, C2 structures together.
There are ligaments going over this, which is called the transverse ligament which allow full movement of the two vertebra, but won't allow them to dorsally separate too much. So many times we've got some odontoid process abnormality. Up to half of cases can have aplasia or hypoplasia of the dens.
There can be even in some cases, a failure of fusion, maybe even a fracture, and angulation of the dents, and that's a serious problem because if you get subluxation of those two vertebrae and you have angulation of the dens, then you can get significant spinal cord compression resulting from it. So, difficult sometimes to know what it is that's predisposed, but the, these, based on studies of, of multiple case series, have been the main causes.Es problems, whether it be an absence or reduction of size and angulation of dense fracture of dents, or ligamentous abnormalities, occasionally.
Ossification issues, the atlas and blocked vertebra, particularly of C2 and C3. So multiple things can lead to this, but you're often going to see these cases when they present with subluxation of C1 to C2. Here we see normal structure, here we see a tearing of the alanttoaxial ligament here, because there's a lack of dens, there's no support structures here ventrally.
Here we have the dens, but it's a dorsally angulated dens and so it's gonna immediately cause compression. Here we have a failure of osseous fusion of the dens, so again, a lack of support structures ventrally. Radiographs can be enough in these cases to help us outdo the disease, as we can see in a fairly neutral position here, you have separation of C1, C2, and on the VD view, you can see a lack of adontoid process here.
So, radiographs can be very helpful. It's rare, rare that we would need to be so . Aggressive in flexing the neck as we can see here, and we probably should keep it as neutral as possible because this may, particularly if you have an angulated dens, really exacerbate the neurologic signs.
So if you're going to flex the neck to try to highlight a subluxation, do it very minimally, potentially do it under fluoroscopy, because that type of subluxation that you see on radiographs may be diagnostic, but unfortunately may make the situation a lot worse. CT can be very useful for this condition. As we said, radiographs there may be all you need to diagnose it, but if you're going to take it further and treat these cases, then you're gonna need some assessment of the structures that are involved and that are abnormal, and the size of those structures.
CT is very good in in transverse, images of showing structures of bone and position of the adontoid process. Here we see a subluxation, but it's also good at helping us measure the bone. Because we want to put implants in if we're gonna actually fix this and so we're gonna need to measure.
MRI adds an additional perspective here and that is potentially what's going on within the nervous system. So here we can see the bone, here's C1. Here's the joint space, and here's C2.
I mean, see the, the dens ordontoid process compressing the spinal cord to a sliver of nervous tissue compared to what's behind it and in front of it here. And so, that's fairly diagnostic as well, and helps us identify if there are any concurrent abnormalities within the nervous system. As we can see here, again, significant compression.
But what we also see in this case is that he's got dilation of his ventricular system. And the reason for being interested in what's going on in the nervous system is that many of these cases occur in small or toy breed dogs, which can have concurrent anomalous diseases like chiari, as we've mentioned. So as you can see in this dog has.
Like hydrocephalus, as we can see in this dog too. So we're looking for concurrent abnormalities, not necessarily to fix them at the same time, but to inform the owners that these may affect our prognosis. What we're often looking to do is try to realign the verge, and that can be attempted on a conservative basis by sedating or even putting the animal under an anaesthesia and trying to get them realigned in extension, putting a splint ventrally and wrapping the head and neck in this external coaptation attempt here.
This is something which may be viewed as a cheaper option, obviously to surgery, but that's falsehood, unfortunately, because these wraps need to be in place for 6 to 8 weeks, and they will only lead to a fibrous fusion. There's no osseous fusion that's that's resulting from this. There's no exposed bone surfaces.
Which are gonna cause, fusion. It's a fibrous, fusion that you're gonna see. No osteo fusion, which means it could happen again.
And that's what's been seen in these studies, that, that up to 4 out of 10 dogs, will have a successful outcome long term, but 6 out of 10, therefore will have repeat signs. So external coaptation. May be successful.
If you've got a very young dog, 3 or 4 months of age that you don't want to put through surgery, maybe it's the only option. But it isn't something unfortunately that is cheap because you've got to change this wrap every week for 8 weeks, probably under anaesthesia. You can't leave this wrap on with a splint in place because you can get skin problems that are due to the pressure of the splint, pressure of the bandage.
You can get dermatitis due to the moisture that can get in here and also food getting in on the rostral aspect of this bandage. You can get ventilator problems, and many times these little dogs just want to give up and will lie in lateral recumbency, so it's not a great option. If it's an acute onset, maybe there's a better chance of, of a successful outcome with this, but unfortunately, many times this is a surgical disease.
Multiple fixation techniques have been described, both, both dorsal and ventral fixation. Pros and cons. Potentially, you still need to involve some external coaptations, so we may need to neck wrap them, but many times if we're happy with the fixation, we won't do that because these dogs will do a lot better if they're not wrapped, in a half body wrap as we've seen.
Success rate vary. In the literature from 50% to 90%, many times we would suggest that with people that are comfortable doing this surgery, 8 out of 10 of these dogs will do well long term. Often better in young dogs and in dogs that have had, more acute signs than chronic as well.
We may, want to keep these dogs strictly rested, however secure we think the fixation technique has been because we're waiting for osteous fusion, and that's the advantage of a surgical approach to this subluxation. When we can get in there, if we do a ventral fixation, we can actually expose the cartilage ventrally. And encourage osseous fusion.
Dorsal techniques such as this one where we wire from C2 underneath C1, and loop it back and and tie that off. They have been described, but unfortunately, they don't also encourage any osseous fusion, so not that successful. You may think that that is an easier approach going.
Through some dorsal cervical muscles, but you're more likely to injure the spinal cord because, probably not a shock to many of you, but where this wire is going here, is where the spinal cord sits. And so this is going to be, a rather delicate procedure which can in many cases, risk further neurologic deterioration. Complications overall of this surgery have been well described, and they can include misalignment or malalignment of the vertebra, implant failure, so fracture, for instance, migration of the implants, soft tissue, neurologic tissue damage, so locally, they ventrally, particularly, we have a lot of soft tissues we want to avoid upper upper respiratory, upper GI tract issues, that potentially we can make worse when we're putting implants in.
Respiratory compromise in this region, and, and 1 out of 10 of these in some studies will, will die due to the intervention in this region of the nervous system. Remember, C1, C2, very close to the brain stem, which is where his respiratory centres live. And so any spread of edoema can cause a respiratory problem.
Here's just a few techniques outlined. Here's a transarticular screws or lag screw technique, which has been described and is pretty successful. However, in very small dogs, it is very difficult.
So not something that we like to do, because if you break the bone, as you're trying to secure the screw in here, you really only have one shot. Most of the time we'll try to do a multiple implant procedure where we're putting screws in the bodies of seed. 2 and C1 and transarticular pins and we'll cover it all with methyl methacrylate or some acrylic cement here.
So you can see the cement covering these multiple implants and the vertebrae are now aligned. The advantage of a multiple implant approach is that if we get any fractures, migration of the implants, we're still able to rely on others that are in place. So, most of the time we'll go with the ventral approach because we can expose the cartilage of the articulation and encourage osteo fusion.
And we get a better access to putting implants in the body. So we've talked about inflammatory disease, we've talked about anomalous disease, and, we're now going to talk about neoplasia here because that certainly can, can result in significant spinal pain, on palpation or just, obviously with observation as we saw in that young dog. Vertebral tumours, intrajoal tumours, intramodullary tumours, are the three types of tumours that we need to consider.
So if you say spinal tumour, what you're really saying is that you could have a tumour in the body of the bone itself, so the vertebra. And this in fact is the most common area to have a tumour. You could have a tumour within the intradural cavity or sarachnoid space, or you could have a tumour within the spinal cord itself.
So 50% of tumours affecting the spinal cord are actually vertical tumours. Extradural so-called tumours in the vertebral body here or in or in the dorsal processes here. And these are solitary tumours most of the time, that could be metastatic.
But osteosars, fibrosars, hemangiocars, these are the most common. Occasionally lymphoma, multiple myeloma will, will be responsible, which is why we're always gonna have to consider this in young dogs. So they may be primary bone tumours.
Most common cause of spinal tumour. Intradural tumours, so they're ones that exist in the subarachnoid space, that end up compressing the spinal cord. Again, lymphomas on that list, but nerve sheath tumours, so maybe causing brachial plexus-related signs and then neck pain, and meningioma.
So tumours of the meninges compressing the nerve, the, spinal cord, and it's most common in cervical spine rather than thorac a lumbar spine. . About 3 to 4 out of 10 cases are intradural, and which leaves us with 1 out of 10 cases which are intramedullary.
So actual spinal cord tumours, which can be metastatic or primary spinal cord tumours, these initially are not painful, but as they grow in size and the spinal cord expands and stretches the meninges, then they can become uncomfortable. They're not painful initially because there are no sensory nerve endings in the spinal cord. So you can have something in there, that's quite nasty and, and it exists, in a non-painful situation.
So many times we're actually thinking about tumours on the outside of the spinal cord when we're thinking about painful disease. Here's an example of that sort of situation we have we have a we have an 8 year old greyhound, presenting with, with obviously severe pain, we can see ventral flexion of the neck. It is ambulatory, as you can see, the age of the dog, the fact that this dog presented, 3 to 4 weeks after the onset of pain and the pain was initially intermittent and then became progressive.
and constant made us start to put tumour at the top of the list. . We're going to talk about that dog in a second again.
How do we investigate tumours? Well, certainly radiographs can help us, but they just are things which can detect issues which essentially are the tip of the iceberg, as you can see here, you've got lysis of the vertebrae here. Doesn't cross into other vertebrae, so you think, well that could be tumour more likely than infection.
On MRI you can see the lesion that is in that dorsal process and it and you can now see how it affects the spinal cord here. We can see on transverse view, the extent of that lesion here, compress it. So really the tip of the iceberg is what radiographs will show us MRI is gonna show us a whole lot more detail on how it actually involves the spinal cord, which is gonna be essential if we needed to do any surgical therapy.
What type of tumours we've mentioned there osteosarco and fibrocyte, well, what's your prognosis? Well, this is pretty bad. There are not many studies out there, but based on these studies and, and our, our experience, you can do some very aggressive treatment, surgery, radiation therapy.
And overall results are poor, meaning that for, in this case, 4 months, median survival time. And, and that's for multiple reasons. One is that as we move back a slide, you can see the extent of this tumour in the vertebral body, and it's gonna be impossible to take all of that out.
So you're always gonna leave some tumour in the bone, and tumour in bone is extremely painful. The second reason is that most tumour surgery is going to be success. With margins, and you're never gonna get margins in these cases because that would involve resecting the spinal cord.
So at this stage, we're not able to actually take all the tumour out, which means the overall prognosis is good. Sometimes surgery can decompress the nervous system, successfully take away pain for a period of time. So I'm not suggesting that we shouldn't do it, but we need to, make owners aware that this is a very bad disease, and it may require stabilisation of the vertebra, because, again, going back, the more tumour that's in the bone that you take out, the less structure of the bone remains, the less stability of that vertebral unit exists.
And so we're gonna need to actually replace that with some artificial stabilisation, such as screws and cement. Meningiomas are slightly different in a better prognosis for them. These are remember are intradural or subarachnoid type of tumours.
Boxes and golden retrievers are overrepresented here, and have a much better medium survival time if you give them treatment, surgery and radiation. So it can be 19 months. Remember, the osseous tumour is more like 4 months.
Myelography, as you can see here, a bit outdated but can show us that we have expansion of the spinal cord, suggestive of, of meningioma. A location based on one study more, more common for them to be, cervical and more common for them to be cranial cervical. MRI, and this is the MRI of that greyhound that you saw, shows a, a, shows a very well delineated.
Mass affecting the spinal cord. It's actually compressing the spinal cord, it's not inside the spinal cord, but taking that out can obviously result in some spinal cord damage. And then we come on to the last about diseases causing neck pain, and that is disc disease.
Now, we're often used to talking about disc disease when we talk about thorac a lumbar pain, but cervical disc disease is, is, although not as common, is, a similar problem which initially manifests as pain and then can Obviously cause neurologic dysfunction. Neurologic dysfunction is not as severe as in thoracol lumbar, spinal column abnormalities, just because there's more room in the neck for the spinal cord to move away from the disc. So we don't often see such severe thing signs as we see in tracolamba space.
Obviously, any breed can be affected by neck disease. The age is a factor. There's a mean age of 6 years.
This is helpful because we in our first slide, our video of that young bull terrier, saw a 10 month old dog with neck pain, and this disease is on the list. So, so we're gonna say likelihood is low based on age here. So it's important to use these signal months to help us out.
Incidence of cervical invertral disc disease a lot lower than thoracolluba, so 2 to 34 out of 10 maximum, and it's most common acutely in the cranial cervical area. So, we need to do, come around full circle back to our bull terrier and try to summarise this talk. Any dog that presents you with neck pain has several possible differentials.
If we go through the vitamin D list, we go with I for inflammatory, and that could be disco. It could be meningitis or meningomyelitis, which, as you see, could be infectious or immune-mediated. Obviously, trauma such as fracture is a possibility.
When we think about anomalous disease, well, it could be chiari and syringomyelia or it could be atlantoaxial subluxation. We also have to think about neoplasia and disc disease. So several differentials.
When we consider who we're dealing with a 10 month old bull terrier with significant neuro dysfunction that's been progressive over the last 2 to 3 days. Then we think, OK, inflammatory disease is a possibility. You're not, you're not a typical breed for immune-mediated disease of your nervous system.
You're quite young for that, but it's still a possibility. You could have infectious disease, so you could have disco spondylitis. There's no history of trauma in this dog, so we could move on.
Anomalous disease. Well, also an acute onset in this dog and very progressive. AA subluxation is always a possibility.
There's no history of anything like falling off a bed or a couch. It's always a possibility, but then you look at the breed and say that's less likely in this sort of breed. Tumour, well, that's a possibility in any dog, but we're going to put that low on the list as well because of its age, and then we think about this disease, well, I'm going to put that low on the list as well because of age.
So we're left in this dog thinking that inflammatory disease is most likely. Now, we do, as we say, have several tests that we could start to consider to help us confirm both location of disease and what it is. However, when the owner comes and says, this is my dog and I have no money to go any further, you're faced with a challenge.
And what you're going to do is use those signalments and the history and the possibilities of those conditions to develop that list and rank the list. And in this, in this case, we ranked infectious disease highest on the list. And we also thought we had some time on our hands because we still had some motor function.
So we put the dog on antibiotics, and we first thought that infectious disease may be in the boat. Cervical radiographs were normal, which the owners allowed us to do. And we started the dog on cephalexin, we also put him on a fentanyl patch, as you'll see, the hair has been clipped, where a fentanyl patch was, and we put him on anti-inflammatory medications, non-steroidals in this dog's case, because we thought just because spondylitis was a possibility.
And then monitored. This is the dog then 2 weeks later into those antibiotics. Obviously, you can see dramatically improved.
And so we've got nervous system function. It's even pulling on the leash here, so, perhaps that shouldn't happen 2 weeks into this condition. But it's a good test for neck pain.
If your dog pulls on a leash, you think, well, you're pretty comfortable, so that's a success. So we're gonna say that this dog is dramatically better on non-steroidals now and cephalexin. Now, if the dog had not improved so dramatically, then, or had got worse, we may then go to some immunomodulatory therapy.
So what we're doing is guessing without the addition of any tests, based on own. Finances, and then we're looking at the response to treatment to see if we need to change treatment. So we're gonna go with antibiotics in this case first in anti-inflammatories.
We got success and we ended up having long term success in this dog by keeping them on antibiotics for 8 weeks, presumptive disco spondylitis, but not confirmed. At the end of the day, that's less important, obviously than resolution of the condition. So, I want to thank you for your attention and time, listening to this.
Hopefully we've been able to present this, so that you now have a cheat sheet for neck pain in younger dogs, that which includes inflammatory conditions, infectious and immune mediated. Anomalous conditions, disc disease, obviously always considered trauma, and outside chance of, of tumour. I want to thank Hallmark again for sponsoring this condition, and, and give a shout out to our Facebook site, which is the veterinary neurology Facebook that I do with Laurent.
Who spoke earlier, obviously this, this evening, it's a free for you to sign up, to like that site, and we all do often do teaching, cases, and, updates on, breaking news, so feel free to get involved in that. Again, thank you very much. Happy to take any questions that you have now.
Simon, thank you so much, really excellent webinar. We have had some questions come in already and I'd just like to remind everyone if you do have any questions, just to put them down in the Q&A box, at the bottom of your screen. First cut came in from Audrey.
I love potentiated cellphone minds, but as they have disappeared, have now had to get human version. What do you use? Yes, good point, and we do use the human version, anything we can get hold of, though it doesn't seem to be really any relation to the type of sulfonamide you use with trimethoprine, in terms of, in terms of positive effect.
So anything that we can get hold of that is the, you know, is generic human version, obviously off-label use. But it's a crisis situation at the end of the day, because if you do have infectious disease in the nervous system, you are days away from having a potentially paralysed dog and a dead dog. So, obviously there are issues with the use of that.
Antibiotic, but it is a very potent drug for the nervous system and can be very successful too. So bottom line is, anything that you can get a hold of that has trimethprine in, and the version of sulfonamide that you can use doesn't seem to have any impact on success. OK, thank you.
And then just from Jill, just regarding the AA subluxation is the wrap only soft dressings or is a splint added? Oh, great point. Yeah, there's a splint added.
You can just go with it, with a soft wrap. We often just will use gauze and then, then, a lot of cotton wool or soft ban and then vet wrap around it. But, most of the time it's wise to use a ventral splint of sorts.
You may be able to mould to the splint to the fibreglass type of splint. That you can mould while they're under anaesthesia, so it conforms better to the neck. But if you, that will hopefully keep them in extension.
So you go from the sternum all the way to just underneath, the, the The rostral aspect of the, of the mandible, and keeping it ventral, and it midline is sometimes tough in those little dogs, and they can, you can think you've done a good job and they wake up and it's off to the side all of a sudden. And so, it can create multiple problems. But we try, if possible, to use a ventral splint to keep them in extension as they heal.
Brilliant. And then, really it's just so many comments coming in about how good the the lecture was, great visuals and presentation, really clear and helpful lecture. Thank you.
Jill's always also said that she's looking forward to hitting the Facebook. Right. And then from Craig, thank you.
Well worth staying up till after midnight, better than going to the pub. So I know, definitely from us at the webinar that we're really grateful. It was a really great session this evening from both you and Laurent.
I can't see any more questions coming in, and it is a very late night for everyone. So I just want to thank again, Hallmark Veterinary Imaging for sponsoring the neurology session. And just thank you, Simon, for, for such a great lecture.
OK, thanks very much. If any other questions later today, I'm happy to send the answers to you by email, but thanks to everyone for staying up so late, and I will speak to you again soon.

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