So first of all, thank you for coming back. I was discussing with Ed that we're quite, quite surprised and pleasantly surprised to see such a big interest in neurology. So we're going to start with, a discussion about the most common disorders that we see in young animals or, puppies, and I'm really going to try to stay to stand here now because I was told off in the first lecture that I was.
Standing next to it, so I still work at the RVC which is still the number one vet school in the world, as you all know. I will only repeat this a few more times today. So puppies can be very challenging because, as you might know, puppies are not necessarily cooperative, so it's very difficult, especially when you see puppies of only like 12 weeks old or 30 weeks old.
It's very challenging to assess their gaits because they are very bouncy anyway. They scream and squeak with whatever you touch them. They don't listen to you anyway, so it's very difficult to say if they have abnormal behaviour or they're not responsive.
And also what is sometimes challenging is they are. The body is not yet fully matured, so they're not skeletically mature, and that's something that we typically see, for example, when they have a trauma and you take a radiograph, all those vertebrae still have separate ossification centres. It's completely impossible to see if there's a Fracture laxation or whatever, and also some parts of the clinical examination is not yet developed in the prime example is for example the menace response that typically only occurs after periods around 12 weeks.
So when we talk about puppies and we take. What type of diseases should you expect in puppies? Of course, when you have young animals, same as with young children, young children are very prone for infectious disorders.
I have to say in England also in Western Europe, it's very, very rare to see infectious diseases. I think in 10 years neurology I've only seen once a dog with distemper virus. It's very rare for us to see dogs with neospirosis like this little puppy here.
So that's not really something I'm going to discuss today. Also you have all these very unique wonderful, metabolic disorders such as Limooric disease also very rare and I don't think very practical for you. So what we see definitely more often is what can be considered congenital disorders and what is one of the really unique things in veterinary medicines that we see these, these very specific breeds some.
Do not resemble wolves that much anymore, and some of these breeds are actually very specific congenital abnormalities. Also what we see quite common of course are poemic shunts, but they are worked up where I work by the medicine service, so I'm not really in a good position to. Discussed that, but what we see more common and it's definitely different than when I started neurology, what is now very popular is alternative diets, such as raw meat diets, self-cooked diets.
So unfortunately we see much more than previously, . Metabolic disorders such as secondary hyperparidoidism like this cat, it's very popular in Bengals. You see the quality of the bone.
This cat is osteopenic and it has a pathological fracture right here and also timing deficiency. These things I would like almost never see 5 years ago, but now we see that much more regularly. Fortunately, so like I said, I'm going to discuss just a few cases with you.
I hope that we go to 4 cases, and probably those represent the 4 most common disorders that we see in young animals. They're all very easy, so I'm sure you will recognise most of them. So the first one is, Toby, a 7 month old male neutered beagle, since one week.
He's lethargic, inhabitant. He has a pyrexia. All fine.
You feel very comfortable, but then suddenly he develops cervical hypersthesia. You don't like it because that smells like neurology. So Toby is referred to us when we do a general physical examination.
He has quite a high temperature, 40 °C, and his blood work reveals a neutrophilia. So when we look at him, So it's quite reluctant to walk, Toby. You can maybe say it's quite of a stiff gait and especially when he turns, you will see it's not really turning his head.
So again, what we discussed in the first lecture this morning, from just observing these animals, you can see because you also see when he tries to look up, he moves his eyes, but he does not really move his neck. So this is like a classic example of a dog with like a stiff guarded neck poster and quite a stiff gait. When we do the neuro exam.
When we test things like pro perception. Again, quite unremarkable, but you see again that Toby is very reluctant to move his head. So my, my colleague is, is Spanish.
She's often a little bit very determined. Mhm. Also she's checking for joint pain.
Which is not the case. So like I said in the first, like some systemic disorders like polyarthritis can really mimic neurological disease. So it's very important also like when you see a case like this, to do a limited orthopaedic examination.
And then when we start doing spinal palpation. He's not too bothered when we do when we palpate historic columbo limbosacal spine. But from the moment we reach his neck, you see, he flinches immediately and like I discussed, we start with a gentle palpation if the dog already responds now.
We're only very carefully trying to move his head, you see, he really doesn't like his neck. So this is for us a very common clinical presentation that we see quite common in. Neurologist, so these are dogs that are neurologically we could call them normal because they don't have a gait abnormality.
They don't have propriceptive deficits, but they have quite severe cervical hy prosthesia and we often summarise this as neurologically normal with cervical hy prosthesia. Now for me, This dog's clinical presentation is extremely suggestive for a disease. It's called steroid responsive meningitis arthritis.
This is, this condition has multiple names in the literature. It was first discovered in beagles in the laboratory setting, so it first was called a beagle pain syndrome. Other names that you will find is a necrotizing vasculitis, a juvenile polyarthride.
What is important is systemic. Immune disorder, so you can also see, so it's it's kind of a vasculitis with a predisposition for the vessels in the superachate space, but you can also see signs of vasculitis in other parts of the the body. So sometimes you, for example, can have some fresh blood in the stools.
This is like very likely an immune mediated condition with the breed predisposition, so it has strongly been suggested that there's some genetic predisposition. Like I said, it's also a more unusual, a rare form, which is the chronic form. In that chronic form, you can see gait abnormalities such as ataxia and increases.
So, The question is, of course, like like neur being neurologically normal with cervical hypersthesia is something that we see every week at our neurology service, but how common is steroid responsive meningitis as a diagnosis? And then of course the second question is, how can you guys in in private practise can make a presumptive diagnosis? So the first question.
Is the common condition, definitely. So this is a paper, I don't think I've read because it's only available early online, that describes the characteristics of 185 dogs with cervical hypersthesia without neurological deficits. .
You see the vertebral disc extrusure was the most common, but er responsive meningitis, arthritis was the second most common cause of cervical hypersthesia, so it's definitely a very important condition. And then of course, the second question is, how can you recognise this? Luckily, I think this is one of the conditions that has a very specific clinical characteristics that you can recognise in practising the you can also use to differentiate, for example, from intervertible disc extrusion.
So these dogs are typically very young, much younger than dogs with intervertible disc extrusion. So we typically say younger than 2, but dogs of 78 months old is very typical. Susceptible breeds, like beagles, boxers, border collies, we typically every breed that starts with a B is prone for steroid responsive meningitis, but also Nova Scot.
Duck tolling retriever and Jack Russells. What I find quite typical is that this is probably one of the only neurological conditions where it's very, very, very consistently you will find pyrexia. In other infectious inflammatory disorders, it is very uncommon even in dogs with disco spondylitis, bacterial meningitis.
It's more uncommon to find parrexia, but. Pyrexia for me is a very strong indicator for SRMA. Also this is one of the own, because I said it's it's, it's a systemic disorder.
It's a systemic vasculitis. So also on blood work you typically find abnormalities such as a neutrophilia, and often these os are very painful. Often when you really try forcefully to bend their neck, they start screaming.
It's one of the most painful conditions that we typically see. So of course, you know, I'm, I'm a big fan of clinical reasoning and using these five finger rules. So we also really force or brainwash our students and interns and residents to use this.
So this is an abstract that was presented yesterday. Sure all of you were there by Nick who will start his residency in July, and he wanted to see if you use those clinical characteristics that are easy to recognise, how likely can you predict a diagnosis, for example, of. And one thing that I found very similar to the previous study I showed that in its steric responsive meningitis archer is a very common cause of cervical hy prosthesia.
Again, it was the 2nd most common cause of intervertebral disc extrusion and SRMA, it's a very important condition. And now if you take that all in kind of a statistical model, because of course it's really nice that I tell you, oh you have the 5 finger rule and then you use everything and then you can predict the diagnosis, but of course it's important to try to see this actually makes sense from a statistical point of view. When we look at steroid responsive meningitis arteries, what does predict this diagnosis statistically?
Especially pyrexia, if you really see the odds ratio, if you have pyrexia, it's actually with an odds rate of almost 160 that your door with cervical hypersthesia SRMA. And also a factor that takes it out is the abnormalities on blood work on all the other conditions, it's very unusual to have abnormalities on blood work, and it's also really my feeling that those two abnormalities are very strongly associated with the diagnosis of SRMA. So how do we make a diagnosis because they have such a, typical clinical presentations.
These are not talks that we take to MRI. We. Almost never do MRI in these, in these cases when we have a suspicion of SRMA.
Some of my colleagues first take a take a radiograph to see if there are no other congenital abnormalities or something else. Others go immediately to a to a spinal tap, and when you talk about the spinal tap in collecting cerebrospinal fluid in right, you have to know normally cerebrospinal fluid, it's just water. There are no cells.
There are no proteins. There's nothing. So less than 5 cells are considered acceptable, but when you increase above those 5 cells or when you have abnormal protein, your spinal tap is considered abnormal.
In SRMA you will find in most cases very typical abnormalities and often these cell counts are dramatically increased. It's not like borderline abnormal. It's really like hundreds of abnormal cells, even thousands of abnormal cells.
Protein is really high. And what is very particular for SRMA is that the cells. Come out of it are very specific.
They are non-degenerate neutrophils, and often we get the question about how useful is it to do a spinal tap in practise. I'm in general not a big fan of it because a lot of people believe that an abnormal spinal tap is diagnostic for inflammatory brain or inflammatory spinal disease. That's Absolutely not true.
And to give you an example of, for example, dogs with tora columba intervertebral dis disease, half of these dogs will have an abnormal spinal tap. Dogs with idiopathic epilepsy, dogs can have an abnormal spinal tap. So spinal tap as the only diagnostic procedure, is only rarely of clinical use.
For me, probably the only exception in dogs. Would be a dog where you have a very high suspicion of SRMA because it gives those quite specific abnormalities. So even where I work, where all our clients have very deep pockets, we have MRI, we have CT, we have everything.
This is what we do and it's so it's quite cheap and straightforward to reach a diagnosis, . Treatment is often when I discuss treatment with the clients, I often discuss with them that it's good news and bad news. The good news is that the dog dogs often respond to treatment.
Often when you give an injection of dexamethasone, that's of course why it's called steroid responsive. They're much better the next day. It's often also a self-limiting disorder, so you give a prolonged course of steroids and then it they.
They should be cured, but of course the bad news is if you have such a young puppy and you have to put him on steroids for 6 months, they will have traumatic side effects. So, all of you know the side effects of steroids, which is PPD, . Polyphagia but also sometimes abnormal behaviour.
People on steroids are often a little bit irritable, and we hear from owners that the dogs become less responsive. They are not really interactive with other dogs and cats. They become exercise intolerant, and I've seen multiple owners where Because we have to know that owners don't have a medical background, so for them it's very challenging.
To make the difference between the clinical signs of steroid responsive meningitis arthritis and the side effects of steroids, and some clients really believe it's a continuation of the disease. Also it's very important of course to give these dogs a prolonged course. So if you don't discuss with them beforehand that those side effects will occur, they will not be happy to continue this treatment.
There will not be any complaint of these cases, and I've seen. Many clients that were not instructed about the side effects that are now very reluctant to continue treatment. I thought it is very interesting in all of immune-mediated diseases, there's a lot of research in how can we replace the steroids by any other immunosuppressant drugs like azathioprine, cyclosperm with less side effects.
It's very, very little data in these conditions. So also we still use steroids for this condition. So, like I said, the good news is dogs typically improve very quick, so this is to be, only 24 hours later.
You see it's already much, much happier at this point. So I think this is a really nice it's, it's a very common condition. It has a condition with very characteristic clinical.
Characteristics, you can hopefully reach a presumptive diagnosis yourself. These talks, they respond very well often to treatment, but unfortunately, you have to discuss this prolonged steroid treatment with your clients. I say it's, it's much more comfortable.
So this is typically how it goes when they come to us. We have a presumptive diagnosis of SRMA, we do spinal tap, we give an injection of dexamethasone. The next day they are like this and they go home.
So prognosis in general is good, but the big problem with this condition are relapses. And again it's very, there's no data about risk factors for relapses if it's because of non-aggressive treatment, not prolonged treatment, wrong treatment protoc. There's no evidence to make any recommendations here.
The literature suggests 16 to 32% of cases who have a relapse, which is very unfortunate because then if you're tapering down those steroids, it really sets you back, quite a big, step. So the second case is blue. So Blue is an 8 month old male chihuahua.
For the last 14 days, he's occasionally yelping when he's picked up by the owner. But in the last 4 days, Blue is quite reluctant to walk and has difficulties walking. And also now he starts to walk quite stiff and he's again reluctant to move his head.
When you see the video, it's quite clear. Just from looking at blue that again blue doesn't want to move his sorry I have to stay here that blue doesn't want to move and for me of course I'm a neurologist, this clinical presentation is really very different from that of from that of the previous door because blue has an abnormal gait so it has some tetraparesis combined with ataxia and as you can see, he really doesn't want to move his neck. Again, it's quite similar here from the side.
He has a low head carriage, and he doesn't want to move at all. Also what is quite different for blue, when we did a neuro exam, we do find some neurological abnormalities, so we did find some propriceptive deficits in his thoracic and his pelvic limbs. His spinal reflexes were intact.
So this will be a case that we localise to the C1, C5 spinal cord segments, and, and I said why is blue for me already very different than than Toby. Because he has gait abnormalities, and this is something that we discussed in the first lecture this morning. So in the spinal cord parenchyma, there are no pain receptors.
So if the condition affects the spinal cord itself, it will not be painful. While on those those structures surrounding the spinal cord like the meninges, the nerves, the vertebrate, the discs, they have an abundance of pain receptors. So if you have pain, and also blue have pain, sorry doesn't mention it.
One of these structures should be involved, but on the other hand, if you want to have neurological deficits, such as ataxia, paresis, per perceptive deficits, something has to affect the spinal cord. So that's why, for example, when in a, in a meningitis. That only affects the meninges, you will typically not have neurological deficits and when we summarise his clinical presentation, we would say that he has an acute onset, progressive, painful symmetrical C1, C5 myelopathy.
So for me. That would be again very suggestive for a specific condition, and that would be Atlanta axial superxation and again these talks have quite a typical clinical presentation. They are only 8 months old, they have these these gait abnormals.
This would be again a case when they come to draw veni College despite us having all the tools and our clients have all the money. These are cases where we don't do an MRI scan. So what we typically do, we start with radiographs, with radiographs, you sometimes have to do a gentle flexion and then you really see this gap opening between the Atlas, which is the first and the axis, the second, so you see this distance really gets bigger and also Atlanta axis differentation is kind of defined.
As the atlas moving in a cranial dorsal direction into the atlas. And that's typically what you see here, that the axis moves dorsally and also moves cranially into the vertebral canal. What is important, This isn't this is from from referring vet.
This is excellent. The vet the referring vet only did some gentle flexion because if you do excessive flexion, they can have life threatening consequences because of course if this moves cranially and dorsally and you flex, it's even possible that the dents goes into the brain stem and animals can. At best deteriorate neurologically, but at worst can even die when you do prolonged or excessive flexion during those studies.
So this is, this is very well performed. So what is a little bit atlantoaxial supplexation. So the most cervical vertebrae have a very similar shape in anatomy with the exception of the first two.
Like I said, the first is the atlas, the second is the axis, and they communicate a little bit by this structure, which is the dense. And then they also communicate with all these very specific ligamentous structures. So what we typically see with Atlantoaxisplexation is really all that is dents, it's not developed like an aplasia which it's underdeveloped, a hypoplasia, all those ligaments are not developed or weaker.
So what you can also see is most dogs present in the first months of life, but it can also happen that. It needs a little bit of a minor trauma for everything to set off, to set off. So Atlanta axial instability, typically young miniature and toy breeds, but actually can also occur later in life, sometimes after minor trauma.
They can present quite variable. We see them as as emergencies like acute onset non-ambulatory teapparesis. We also see them as more chronic cases where the owner says he has intermittent episodes of, of screaming, and also those clinical signs they can really.
Can be quite variable. It can go from cervical hypersthesia to an ambulatory tetraparesis like in blue to even vestibular signs or brain stem signs because if the atlas the axis really moves cranially and then goes like that, it can compress the brain stem. So most typically we set normalities like said that bony structure, the dents or abnormalities of those ligamentous structures that keep the dents and the axis at the same place.
So it's quite important is when we have these cases that we have a high clinical suspicion. Is that we try to diagnose or rule out it as soon as possible and also discuss this with the person who's doing the anaesthesia because of course like I said, if you do excessive flexion or extension, everything starts moving. They can have really devastating consequences.
So if during intubation you kind of pull the dog's neck apart, they can have devastating consequences. So one of the reasons why we don't often do MRI is because if they are in the wrong position, and the MRI of course takes much longer than a CT scan. These talks can be much worse after diagnostics.
So typically we do CT. In CT it's not generally necessary to do these dynamic studies. So in CT we just do neutral studies, we do a CT scan.
And in my experience, this is almost always diagnostic. So here you see a normal one, beautiful connection. This is like I said, typically where the axis has moved cranially and dorsally and you can imagine if you do extensive flexion, that this comes up and squeezes everything.
And here you see, again a bigage where you see this bony structure here, the dense. It's not present here anymore, so that's also kind of a classic school, school book example where you have aplasia of the dance. Another reason why we do, CT is because the CT really helps us in surgical surgical planning, how we have to place spins, screws, and things like that now.
I think from all spinal disorders, and I have a very big interest in spinal disorders, this is one of the most challenging to treat even for experienced spinal surgeons. So with a lot of these conditions, it's not much known about medical management. There are suggestions that when you have younger dogs with short clinical size, you can try medical management with an external splint for a prolonged period of time.
It's also one of these conditions where there are multiple surgical techniques described, but the reason why this is so challenging because it really affects the wrong dog. The anatomy of the, the atlas and axis is already very complex with with a lot of blood vessels, the brain semi is very close, of course the anatomy is also abnormal, but then it's immature dogs, so often the Actually when you place pins or screws, it's not even bone, and to make it all worse, it typically affects young toy breed dogs like chihuahuas, so they are often like 1.5 kg, 2 kg, which complicates everything more, but I think what is.
On the other hand, too, if surgery is successful, technically successful, prognosis is often very good and like dogs like blue, when we do surgery and it goes well, often they can leave the hospital already after 1 or 2 days because they feel immediately much better. So when you do medical management, it's not, it's not easy, . And there's definitely one person in the room that knows this is not easy.
What is important, when you place an external splint for these cases, if most people intuitively will place a splint from here to there. Then you make it even much worse because if you make a splint like that, then even there will be more stress on the Atlanta axial joint. So you definitely have to include the ears.
But again, if you have this very small dog, it's very challenging those splints have to be replaced at least once a week. You can have complications in the long term it's also not that that cheap. So surgery.
There are multiple surgeries. This is until probably a year ago what I typically did, but I think I really like this radiograph because it really illustrates the challenge of this condition because you see here's a microchip. You know how big a microchip is, and a microchip is as big as the dog's vertebrae.
So placing two pins and 4 screws in vertebrae that are as big as a microchip, it's quite challenging. So. This is one of the conditions where we are really interested in novel techniques and luckily for us there's this gentleman, it's Doctor Bill Oxley, who now started the company in 3D printing devices.
So this is one of the conditions where we typically use now 3D printed technology. So, we print, of course, the models of the vertebrae, but also, we define the. The optimum trajectories of those implants and then what comes out of it are these 3D printed drill guides and those drill guides really click on the individual vertebrae and that gives us much more confidence of drilling next to all these important structures.
So in surgery. It looks a bit. Like this.
So this is what you get like a 3D printed drill guide, one for the Atlas and one for the axis. It really clicks on the anatomy of that vertebrae, and it really helps you to place all these screws with much more confidence that you're not drilling into the vertebral canal or in the vertebral artery. Or any of those are quite important structures.
So that's a little bit how a little bit I think what Rick was saying in the previous lectures like like there's a shift of baseline, and I think using things like 3D printer technology is becoming much more the norm these days. So 3. Is Sasha, a very cute fluffy 14 week old, female Pekinese, not normal since birth, as much as a Pekinese can be normal since birth.
But the problems has become progressively worse, and the dog is showing increasingly abnormal behaviour with tendency to circle, and I do appreciate that a lot of people don't like neurology, but. I'm confident that all of you can see that this behaviour of Sasha is not normal. So Sasha is only walking in circles.
Of course Iana complains that she's not responsive, but I'm not sure how responsive a 40 week old Pekinese should be, but it was definitely clear, she was always walking in circles, . Like I said, menace, absent in both eyes, but it's very challenging because Sasha is only 14 weeks old, so we know the menace should only appear when they are 12 weeks old. So it's a bit difficult to say if this is 100% true abnormal or not.
Otherwise not really creating a nerve deficits, but what is very interesting is when you look at her eyes is that she has a bilateral ventral strabismus which was always present, and we'll come back to that in a second. It's something that that's makes neurologists very excited, propriceptive deficits, she didn't have propriceptive deficits, hopping power placement, that was all considered normal, so. Let me summarise in her exam.
Maybe she was not as responsive. Definitely abnormal behaviour that circling is not normal. Sometimes she also had a tendency to fall to either side of her body, absent menace response, but this is very interesting.
Is that she has this bilateral strabismus. Ventrilateral and, and I hope you're all still interested in neurology at 5:30 tonight because I we're going to discuss vestibular disease. This is not the vestibular trabismus because vestibular strabismus is positional.
So in vestibular strabism is the eyes have a normal position and only when you turn the head, you will see the strabismus. So this is kind of a resting strabismus which is not associated with vestibular disease like that this is something that makes neurologists really excited. Maybe you don't share my enthusiasm, but at the end we, we, localised to the forebrain.
And Sasha had probably where you could have guessed hydrocephalus. I think from all congenital brain disorders, this is definitely the most common that we see. So as you see, this is a normal dog.
Even if you're not a radiologist, I think you can see the difference between both MRI scans. So in hydrocephalus you have a dilation of the ventricular system with excessive, with excessive fluids. So on this MRI scan everything is fluid.
It looks white or hyper intense and of course that causes a rupture of neurons, increased intracranial pressure, loss of neurons, all these things. It can be we see most common congenital hydrocephalus. You can see it's acquired, for example, if here is a tumour obstructing that CSF flow, all the CSF will start to accumulate, so that's acquired, .
Very typical and again those young toy breeds like Chihuahuas are again the most commonly affected, but also Pekinese, shih-tzu, pucks, English bulldogs, especially here in the UK. Clinical science can again be a bit variable, and they do not always relate to fore brain disease because of course if here, as you see here, also the cerebellum and the brain stem get involved, so sometimes these dogs present with vestibular disease. What is interesting is that these dogs, because they are still growing.
And of course their heads is completely filling with fluids, is that it can also affect the development of the development of the skull and that's definitely not something that we saw in, what we saw in what we noticed in Sasha. So especially when she was clipped, it was more difficult to sit with all her hair is that she has a dome shaped skull and this, although there are multiple theories. It suggested that this ventrolateral strabism it is not a problem with the innovation to eyes, but it's just a deformation of the orbits where the skull gets deformed, so there that it's not a strabismus.
That's also why it's also present during rest. This phenomenon where you have this ventrolateral strabismus in dogs with hydrocephalus has also been sometimes referred to as a setting sun sign. So I I think if I would see a dog with this clinical or physical characteristics, I would have a high suspicion of hydrocephalus.
So, diagnosis can be challenging. And the reason why diagnosis can be challenging is because what we typically see is that all breeds that we see have a different anatomy, and also different anatomical abnormalities that we consider normal in the specific breeds. So what we consider normal in, for example, Chihuahuas, perks, English bulldogs, and, cafe king spaniels that their lateral ventricles, these white structures here are way bigger than in other breeds, so this is a Labrador and this is, .
Caveat in Charles Spaniel, so that complicates really making a diagnosis for us, and that brings us a little bit if you ask what is the diagnostic modality of choice, I would say MRI in this case in the previous cases we discussed radiographs just a spinal tap CT scan, is better than doing an MRI and. Of course extreme cases can be diagnosed with a CT. Last week I've even done a surgery only with a CT without an MRI scan.
But there are very specific guidelines published and evaluated to make the difference between these just ventricles that are too big, breach related to what we call ventriculargaly or clinically relevant hydrocephalus. So this is definitely something that helps neurology specialists, but what is important even for specialists, it's often challenging to make the difference between normal and abnormal anatomy. So treatments, again can be two types.
One would be medical treatments and the aim of the medical treatment would be to give something that decreases the production of cerebrospinal fluids. And of course the favourite drug of every neurologist is steroids, so we use it much less than like 20 years ago. But this is a condition where we definitely use steroids, not necessarily for its anti-inflammatory effects, but steroids decrease the production of cerebrospinal fluids.
There are in the literature, you might find some other drugs such as acetazolamide or omeprazole, but recent studies suggest that they are not necessarily effective in decreasing cerebrospinal fluid. Classically. People suggest that medical treatment in these cases would only be temporarily to get some improvement before surgery is considered, but I'll discuss with you in a minute there's evidence that maybe it can also have a longer lasting positive effect with medical management.
Surgery is a ventricular painal shunt where we place a shunt here in the brain. Yeah in the ventricles, it's attached to a valve, and when the pressure gets too high, it gets shunted to the to the body. The surgery has a bit of a reputation of being a surgeon that's flat with a lot of complications.
I have to say it's. Not like major brain surgery, and dogs typically recover very quick from the surgery, so it's not unusual for us to do this surgery and dogs are discharged after 2 or 3 days after surgery. We see complications in approximately 25% of cases, but.
Quite surprised that most of these complications can be treated very successfully, even with revision surgeries that only last like 20-30 minutes just to replace the shunts a little bit. So I think the reputation of the surgery of being so flood with all these complications, is not necessarily not necessarily true. Outcome is a bit challenging.
I think these are, two big studies. This is from the group of, Munich, and Munich in Germany they are kind of the centre of excellence when we talk about hydrocephalus. They discussed that, 36 despite surgery, 1 in 3 of these talks are ultimately put to sleep for neurological disease.
That's quite a big number, but on the other hand, 72%. Demonstrates an improvement after surgery. This is a paper that we published, last week.
It's originally was in a final year student project from Zoe, and one of our residents has written it up, and our main aim was to see what happens to the medical management because what's very often in neurology that we consider a lot of conditions like surgical conditions. But we don't know anything about medical management and although this is a relatively small study and you can debate the scientific value, I think it's interesting just to see what happened to these dogs. We have 12 medically treated dogs, but half of them actually don't do that bad, and I have multiple cases that are on prolonged steroids or intermittent steroids.
But still have a very good quality of life. The clinical sciences finally stabilise. It's presented a bit different, but our results are a bit similar for surgery as the other group where we see long term.
So over the years we see in the short term that most doctors after VP shunt placement improve immediately. But long term, that only 55 54% shows and sustains clinical improvement which is a little bit disappointing. So I think in summary, and maybe that also reflects a little bit my personal experience is that the surgery is relatively low morbidity.
We almost never see complications during the surgery. Dogs leave the hospital quite soon. Most talks improve very quick after the surgery.
It's very unusual to see complete clinical resolution. So for example, in Sasha, I would expect that she would always have a bit of tendency to circle. Most of these complications can be easily corrected, but what is very interesting is that despite that we feel that our surgery has very good short term success and it's quite easy to perform.
That approximately 36 to 42% of these dogs are put to sleep for this condition, and it's a bit unclear if they develop shunt-related complications later in life or still kind of a neurological deterioration because of all the neurons they have lost previously and of course it's only 12 dogs, but maybe medical management can be considered in selected cases. So the last case, because I'm not sure how I'm doing with time. Are you fine?
OK, so the last case, I'll be quick, it's one of our favourites now. It's a young puck, with a chronic progressive parasis and ataxia. It doesn't seem to be painful and it's not responsive to, NSAIDs, where you see walking like a very typical chronic myelopathy.
You see the dog is, is dragging its feet. Why you see quite often in these chronic disorders, chronic spinal disorders are a very different beast than acute spinal disorders, so you don't necessarily see. Perceptive deficits although you see that he has worn toenails when you see it again here.
And now he's having absent pro perception, so he's disagreeing with me already. So in general we see quite often pucks with chronic spinal disease that can be young pucks or older pugs and are a few puck specific abnormalities, one would be hemivertebra with. Very specific article process displays a really constructive myelopathy and also what we see quite often, probably the most common condition would be a spinal arachno diverticula where perks are predisposed for.
So I think what is important. When you take radiographs of these small brachycephalic dogs yourself, it's extremely, extremely common to see hemivertebrae. It's even common to see kyphosis in neurologically normal animals that will never develop clinical signs.
So it's one of these situations where radiographs can be quite misleading for you. So in this paper that we published, what was quite interesting. That if you take neurologically normal French bulldogs, 94% will have a hemivertebra, while it's only 17% in pucks.
But when pucks have a hemivertebra, it's much more likely to be clinically relevant. So when we say what are the risk factors to develop clinical signs with a hemivertebra it would be pucks, presence of severe kyphosis. So if the vertebrate commas like this, it's fine, but if it's like this, it's much more likely resulting in clinical signs.
Maybe the hemivertebra subtype, and there's no evidence to support that, for example, having 7 hemivertebra that we often see in French bulldogs is more likely associated with clinical signs. So like I said. A severe kyphosis is much more likely associated with clinical signs.
So, treatment is extremely challenging. It's again one of these conditions where there has been a lot of controversy, also very little data, and one of the reasons is because it is such an uncommon condition. Even at us we see more than 2000 neurology patients every year.
We only see 2 or 3 talks with clinically relevant hemivertebrae. Historically it was always that if they have mild clinical signs, you can do medical management and then they will stabilise when it becomes litally mature. More, more recent studies are not that positive, so, so it has.
We're starting to accept a little bit that maybe surgery is the treatment of choice, which is extremely challenging because of small young breeds. The thorax is a very specific anatomic region. The anatomy is abnormal in these talks anyway.
So it is a paper that one of our residents published together with Liverpool and. Glasgow University, only 13 dogs, but the outcome was very consistent. None of these dogs did well on medical management.
We had unfortunately a 0% success rate with progression of clinical science to non-ambulatory status in all dogs. Surgeries are two approaches. You will not find a lot of surgeons that have a lot of experience with this because it's so, uncommon.
One of them is Doctor Massimo Baroni, who was doing this already in 2007. He does an intrathoracic approach, of course, for most neurosurgeons. These structures make you very uncomfortable, which, which, which are big blood vessels, which is a thorax, but it has very good results.
So we again use here 3D printed technology to use a dorsal approach. This, constrictive myelopathy. So this is a normal vertebra and what you can see in parks is that they miss here, the articular processes, and the theory is that it starts changing a little bit and then you get fibrosis formation with hair.
Spinal cord compression again, a condition that is very difficult to treat. We don't know what happens with medical management. We don't know the clinical progression, but the results of surgery have been poor so far, but I do expect more publications quite soon because it is quite a hot topic in the veterinary society.
Again, the challenge is if you're really good in radiographs, you can diagnose on your radiographs that these talks have absent articular processes, but again, in 97% of neurologically normal pers, we will see abnormalities of the articular process. Unfortunately, PUs French bulldogs are by definition abnormal, which complicates our diagnostic decision making. So the diagnosis in the.
Like you said, in an MRI fluid is white, you see here a dilation of his torso oragno space, which is a spinal arach diverticulum, which typically results in this slowly progressive clinical signs. It's often more obvious on the myelogram, where you see like a teardrop, tear shaped dilation of the supragnoid space causing chronic spinal cord compression. Bugs are definitely predisposed.
It's not the most common breed to be affected by this condition. Medical management can result in improvement in 40% in 30% of cases, while surgery has a much better prognosis with improvement in 82%. But unfortunately for PAs, It seems that POCs have a much worse prognosis after surgery for this condition than other breeds, with much higher prevalence of recurrence of clinical signs.
Now it's the last thing I say, and it's more kind of academic, . In the neurology community there is this big discussion of spinach diverticula and parks in young dogs and older dogs should be considered different clinical entities, and we also have the experience that when you do the surgery in all the parks, they don't necessarily have such a good prognosis. So as usual time to reflect and I don't know if there's time for questions.
Unfortunately, I don't think we do have any time for any questions if people do want to change to another hall, but I'd encourage you to stay for the next session, which will start at, about a couple of minutes. Thanks.