Description

Webinar 1) Common Neurological Emergencies – A Case Based Video Tour

A case based video tour looking at some common neurological emergencies you might encounter in practice and how best to deal with them. During this we will neuroanatomically localise, create a list of differential diagnoses and discuss diagnostic and treatment options. We will discuss what can be done if referral isn’t an option and what to expect prognostically. We will cover seizures, intervertebral disc disease and spinal fractures.

Webinar 2)Spinal Pain in the Young Dog

Emilie Royaux explores the causes and treatments of spinal pain in young dogs. Understand the various conditions that can lead to this problem, learn about available diagnostic tools, and discover the best ways to manage and treat spinal pain in your canine patients.

Transcription

Thanks very much, Anthony, and good to hear you're such a fan of Liverpool as a, as I am. So yeah, so as Antony was saying, this webinar is essentially just looking through a few cases of, I guess the more common, neurological emergencies that we tend to see in the referral setting. And, and essentially what I've tried to do is we do is to, to look at the case from from start to to end in terms of how they present.
How they appear from a neurological examination point of view, what our sort of differential diagnoses are, what the treatment options are and what we might expect from a prognostic, point of view as well. And I've tried to do it so that obviously there are both options in the first opinion practise setting, but also from a referral point of view. So if, you know, referral isn't an option, there's always things that you might be able to do in sort of your, your own practise, but also to give you a bit of an idea as to what we might do if they get get referred to ourselves.
And so essentially, each one will go through a different case and and sort of work through them. If at any point you have questions, feel free to type them out, and I can, can try and answer some of them at the end and and we'll see, see how we get on. So I thought we'd start with our first case.
He's an 8 year old male entire cocker spaniel called Jasper, and he presented initially with a 3 day history of progressive weakness in his pelvic limbs. . Both his owners and his referring vet thought that he was quite painful, and they started him on some meloxicam, but his signs continued to progress despite this, and otherwise, no real pertinent history, no history of trauma, just, just, quite an acute onset, but quite progressive, sort of paraparesis.
So this was Jasper when he first presented. And so from a neurological perspective, he is sort of non-ambulatory. He needs a sling to support his pelvic limbs.
When we have a non-ambulatory dog, we sort of try to see if there's any voluntary movement there at all. And you can get the impression there's some flickers of movement, particularly in that right hind limb. So he's a dog that we would call non-ambulatory parayretic.
If there was no voluntary movement, then we might say that he was paraplegic, but because there's some flickers of movement there, we term it parayretic. And then sort of knuckle over his paws and check for, any sort of postural reactions or really checking for his proprioception. And you can see in that right pelvic limb it was pretty absent, but in his right thoracic limb actually quite, quite normal, .
We then check his reflexes to see if they're present or absent. You can see he has a, an intact patella reflex there. And then we can also check his withdrawal reflex, which seems also intact.
He's pulling his leg back into his, into his belly, so that's present as well. So they're the main, I guess, findings from his examination. Just to help you out, his, like I say, his thoracic limbs were, were normal, his cranial nerves were normal, his mutation was appropriate, and so it was mainly just the sort of non-ambulatory paraparesis with absent postural reactions in his hind limbs, but his reflexes were intact.
So I guess the first question that we try to answer is where we might neuro anatomically localise his problem to and I've given you four options here. So either a C1, C5 myelopathy, a C6 T2 myelopathy, a T3, L3, or an L4S3 myopathy. So I don't know which of those you think it is, but for me, he was most consistent with a T3 L3 myelopathy.
And that was primarily because his thoracic limbs were normal, and his pelvic limbs were affected. So straight away we know it has to be either a T3, L3 myelopathy or an L4 S3 myelopathy. And then the way to differentiate between those two is to see if they have intact reflexes or not.
The fact that he had a normal patellar reflex and a normal withdrawal reflex makes it much more likely a T3 L3 myelopathy rather than an L4 S3. If he had a reduced patella or withdrawal, then I'd be thinking more an L4S3 myelopathy. So I guess if you were to summarise him as a case, he's an older cocker spaniel, with an acute, progressive, painful symmetrical T3L3 myelopathy.
We know it's painful. He had some discomfort on his back and his owners report that he was quite uncomfortable. It had progressed over the preceding days.
Both pelvic limbs were relatively equally affected, and as we just determined, it was more of a T3 L3 myopathy rather than anywhere else. The reason that we try to summarise these cases in such a way is to try to help us create a succinct list of, of differential diagnoses. I think we found more and more over the past few years, particularly in neurology, if you can summarise a case.
Like that and try and keep it as simple as possible. You end up really only having 2 or 3 primary differential diagnoses based on the history, the progression, the signalment, your neuroanatomical localization, the symmetry, and whether there's pain or not. And that can really help you determine what diagnostics need to be done, but also potentially what we might expect prognostically.
So for Jas, I've given you a list of differential diagnoses, I guess there's one, possibly two that I would have way out in front for him based on his summary, but I've given you a few to to consider, and we'll go through those in a little bit of detail as we go through the, the presentation. But for me, for Jasper, the most likely cause of his sort of progressive paraparesis would be an intervertebral disc extrusion. That would be quite way out in front, given he's a cocker spaniel, given he was painful, given the signs were progressive, given that it was affecting both pelvic climbs quite symmetrically, that'd be quite high up on the list.
I guess you could also put in something near plastic, given that he's a slightly older dog, and occasionally we can see that in these cases, but we see that relatively less frequently compared to, to slipped discs. In terms of the other differentials, a spinal fracture, there's no major history of any significant trauma, so I think that's very unlikely. The acute non-compressive nucleus pulposis extrusion or the fibrocartilagous embolism, they both present quite differently.
Normally they're much more sudden in onset, normally much more lateralizing and not normally that painful. . And often with those two conditions, whilst the signs are very sudden in onset, they're normally quite static and non-progressive.
So the fact that Jasper was acute, progressive, and painful, and with both back legs being sort of relatively equally affected, it makes those two differentials a lot less likely. A steroid responsive meningitis, arthritis, would be not really appropriate. Normally that's in dogs less than 2 years of age.
Normally they're pyrexic. They are painful, but they're not normally myelopathic. So they're normally walking normally just with neck pain and a pyrexia.
Any discospondylitis is possible, you might expect it to be a bit more of a, a longer history. They're normally pyrexic, and they don't often cause a a dog to be non-ambulatory, but, but they certainly can do if it progresses into the, the vertebral canal. And so for Jasper, we went ahead and did an MRI scan.
So on the left you can see this TG weighted sagittal, sorry, TG we transverse view of his vertebral column and you can see where the arrows pointing. That's sort of hyper intense, volume of material is consistent with a degenerative disc material that's compressing his, his spinal cord. I don't know if you can see my mouse, but the, the spinal cord is this sort of slightly more hyper intense area here being pushed over to the side and where the orange gyro is is the degenerative disc material.
The middle image is a a sagittal view, so again you can see the vertebral bodies, you can see the spinal cord and where the arrow is pointing is that really dark hyper intense degenerative disc that's compressing his, his spinal cord. And then the image on the right is essentially what we might be seeing if we're doing the hemilaminectomy. So essentially the window or bone has been removed and, and now we've got this very thin layer of sort of periosteal tissue remaining.
Behind that, you can see this sort of dark red, sort of black purplish material which is consistent with haemorrhage and and disc material as, as well. And so after his hemilaectomy, we had him in for a couple of days and you can see that he was much better. He was now ambulatory without support, he was more comfortable and he was able to.
To walk without a, a sling, so doing much much better, which was, which was good. I guess one of the questions that we often get asked is, you know, if we have these dogs that are non-ambulatory paraytic or or paraplegic, you know, if there are any other options other than, you know, MRI's and and surgeries. There and there certainly are in the sense that, you know.
With Jasper, obviously we would still consider the gold standard to to have an MRI scan and if there's a compressive disc to to decompress that and get his spinal cord back to its normal position. But certainly there's a lot more work, more recently, particularly in Dash hands where we found that, you know, conservatively managing these dogs is still a, a viable option, particularly if people can't afford or can't go down the route of MRI scans and and surgery. In terms of how to, to manage these patients.
Particularly if they're staying in your, in your practise, I guess there's 4 main things to, to consider. The first is to make sure that they are comfortable. So often with these dogs, I put them on a, a non-steroidal, so, so metaam or or Carrofen.
I often add in gabapentin, and then also some paracetamol if they're still a bit painful. And then I normally combine those three different medications with 4 weeks of, of strict rest. I normally start them on all 3 medications to begin with, and then I stopped the paracetamol first and then the the anti-inflammatory second, and then the gabapentin after about 3 weeks.
So then the 4th week of their rest, they're off all pain relief and we can see how comfortable they are. And depending on their progress, we then might be able to start to, to increase their activity. The most important thing with these dogs is to make sure that they're not using any steps or stairs or not jumping on and off furniture and really trying to make sure that they're strictly rested.
So I normally recommend getting a crate or a pen to keep them in pretty much the whole time whilst we're giving them pain relief and and rest. Depending on on their severity, often, you know, owners might need a sling either to go into their belly. Either a scarf or a thin towel will be fine, or you can buy these sort of dog slings off of the internet for not too much money just to help support their back half, particularly when, you know, they're trying to get them out to go to the toilet or get them up and about for whatever reason.
Depending on their severity, also you can get these sort of full body harnesses, you know, the help them up harnesses from, orthoppets are quite useful, particularly if you've got a dog that's got all four limbs affected, so a tetraparesis, and often that sort of full body harness can be really useful to, to keep them up and and mobile when you need to get them out for, for toileting. In terms of bladder management, those dogs that are particularly severe, so normally those paraplegic dogs, often they might need some help from a toileting perspective. If they're with you in the hospital, it's often easier just to place a urinary catheter to make sure that their bladder remains empty and not doesn't get too full.
If they are, or you're trying to get them home, then sort of seeing if you can manually express their bladder or do that easily. We've been teaching the owners to do that at home is certainly a possibility. As soon as these dogs get some movement back in their pelvic limbs, or if they never progressed to the point of, of losing it, often they can pass urine for themselves.
It's normally those dogs that have lost all voluntary movement where we have to be a bit more careful with their, with their bladder. And then the other question we often get asked is about physiotherapy and when to start that. It depends a lot on the individual, but those dogs that we operate on, I normally start the physio quite early, so normally the day after surgery or two days after surgery, and just start with some sort of light range of movement exercises.
And often what we do is try to give those exercises to the owners at home to then do over the subsequent weeks. If you're conservatively managing these dogs, you could also try to get a physiotherapist involved and see if they can start that process a little bit earlier just to try to help speed up their recovery. In terms of hydrotherapy, I normally wait a bit longer.
I normally try to have a week or two of rest before starting hydrotherapy, again, depending on the case. And normally I recommend underwater treadmill work rather than a free swimming. And then in terms of prognosis, again, it depends a little bit on whether we are operating on these dogs or whether we're sort of managing them conservatively.
And then it also depends on their grade and how severe they are. So you can see those dogs that are surgically managed. We would expect almost 95% of all those dogs to get back to walking.
The main. The thing that they need to retain is no susception. So if they've lost no susception or they've lost deep pain perception, then that percentage drops.
We reckon down to about 50% or 60%, depending on the breed. But even if they become paraplegic, so they've lost all voluntary movements, but they retain feeling in their back legs, then we reckon about 95% of those dogs we get back to to walking following surgical decompression. If we're conservatively managing these patients, so sort of providing them with pain relief and and rest, again, it depends a lot on the grade of paralysis, and it also depends on their progression.
But even then we reckon it varies obviously, but I mean, about 60 to 80% of those dogs, you know, we could get back to walking with just rest and pain relief and the appropriate care. If they lose deep pain perception and we're not operating, then we think that's even less, maybe about 10%. But the evidence behind that and the amount of research done in those dogs is pretty, pretty limited, so I'll take that with a, a pinch of salt.
So essentially. Surgical decompression is certainly still probably the the choice if, if possible, but if you've got owners that can't afford MRIs or surgery or don't want to do it for whatever reason, it's still worth giving these dogs a chance with pain relief and rest and, and seeing what sort of progress they can make, just by doing that over the next sort of 3 to 3 to 4 weeks. And in that case, the Jasper, he was obviously an intervertebral disc extrusion.
So it was a, a degenerative disc that had slipped out and that hit the spinal cord, and so bruised the spinal cord, but also actively compressed it with this sort of hard degenerative material. And I guess one thing that we mentioned as possible differentials. For him before we chose ours was whether he had an acute non-compressive nucleus proposis extrusion or a fibrocartilagous embolism.
And I guess I wanted to sort of use these two dogs to compare those two differential diagnoses. So. On our left is this dachshund, so our sort of poster child for the chondrodystrophic breeds, and his history was this acute, symmetrical, painful and progressive, paraparesis.
So you can see again he's non-ambulatory, he needs support. He's got very minimal movement, in those back legs because he's chondrodystrophic, because it's acute, both legs affected, he is a bit sore and he's progressively getting worse. He would fit most likely with a, a disc extrusion.
Where's the dog on the right. This was a different type of breed. It's a sort of medium or large breed.
He's a per acute onset, asymmetrical. You can see that left leg is working very well, whereas the right leg isn't doing much at all. He wasn't painful, so there's no discomfort there on spinal palpation.
And also he had very static signs, so he had an instantaneous, very lateralizing paraparesis that remained static and started to improve. And so he's much more consistent with a fibrocartilagous embolism or an acute non-compressive nucleus pulposis extrusion compared to a taxi on the left, which would be much more consistent with a slipped disc. And the reason I wanted to highlight, I guess those two and the differences in how they present, and also how they progress, is that ideally the Daxy on the left would have an MRI scan and surgery, not always needed, but often, often would be the, the gold standard choice.
Whereas the dog on the right, we can MRI them and often we might see either an FCE or an ANNPE, but significantly, both of those conditions are non-surgical. There's nothing that we need to do from a decompressive perspective because the injury is normally intrinsic to the spinal cord. So with the FCE it's more, it's an ischemic myelopathy, so the spinal cord has been deprived of of oxygen, whereas with the AN NPE it's more of a contucive.
So the disc slipped out and it hit the spinal cord and bruised it, but because that disc is still hydrated, because it's a, a normal breed, it's not a chondrodystrophic breed, they often have fluid centres to their discs, so it doesn't really compress the spinal cord itself. And so all those dogs with FCEs or ANMPEs can just be more conservatively managed and we would expect them to recover over time and they don't, they don't need surgery to, to recover. And so if in practise you're presented with a case on the right and the owners can't afford an MRI scan to, to confirm.
What we suspect, it's definitely fine to then rest those dogs, start some physiotherapy, and the majority will improve. So, if you've got a paraute lateralizing, non-painful and quite static slash improving paraparesis, then certainly give those dogs time because A, they often don't need surgery, and B, they all do quite well with them, with time. And then sticking with our theme with .
These particular daxis and and discs. I've got little Mabel, just to give you another example of a, of a slipped disc. So she came to us with quite an acute onset of, of neck pain, and that was mainly her issue.
Neurologically, otherwise, she was fine. She had good poor placement, cranial nerves were normal, but you can see she can't lift her head any higher than she is at the moment. Quite a low head carriage.
She's sort of quite crouched, and super painful. But as soon as she tried to lift her head up, she would yelp and scream out in, in discomfort. And as soon as you have either a Daxi or a French bulldog or a cocker spaniel, all those sorts of breeds, there's chondri dystrophic breeds with quite an acute painful low head carriage like that, sort of top of the list, in terms of differential diagnoses, would be an intervertebral disc extrusion in their, in their neck.
As we said before, SRMA, really unlikely, normally less than 2, normally pyrexic. She wasn't either of those. Neoplasia, possible, but she's not an old dog, and and so that'd be low on my list.
A discospodylitis, you'd normally expect them to be pyrexic, normally a bit more of a, a slightly chronic history. So certainly way out in front again would be a slipped disc in the neck. And this was the MRI scan of her, of her neck.
So you can see on the left is this TT weighted sagittal view of her of her neck. So this is the back of her brain here, and the spinal cord running down her neck. These are the vertebral bodies and the discs that sit in between them.
You can see that this disc here is quite degenerative, dehydrated. It's extruded up and it's compressing the spinal cord, from, from ventrally. And again here on the transverse TT weighted.
Image of that area. You can see her spinal cord should normally be in this area, but the disc from here has slipped up and is compressing the spinal cord, which is now wrapping around the, the disc itself. And so for for Mabel, we operated and we did an eventual slot.
So we go from underneath, so we operate underneath the neck. We sort of push the trachea over to the side. We avoid the oesophagus, we go through the muscle and we essentially bur a whole little corridor through the disc to get access to this part of the disc that's slipped out.
We then remove this with different instruments to try to suck it away from the spinal cord, and then the cord itself goes back to being in this space, back to its normal position. And then we close everything up. And the lovely thing about ventral slots, particularly with those dogs that just present with pain rather than the much else, is that quite soon afterwards they, they recover really quite quickly.
And so for her, ideally, the quicker resolution would be an MRI scan and and surgery. Again, if you can't, you can still do the same sort of principle as, as before. So, put them on pain relief, like I say, normally an anti-inflammatory, normally gabapentin, normally paracetamol.
For those dogs with neck pain, particularly French bulldogs, but other breeds as well, often they get quite . Sort of marks muscle fasciculations and, and spasms. So you can also add in there a muscle relaxant.
So I normally use diazepam, but occasionally methocarbamols as well. Rest them for 4 weeks. No steps or stairs, no jumping, just strict strict rest and, and pain relief, and, and no neck cleats, just use harnesses for them to, to get them up and, and about.
And then this is Mabel, I think this is the day after her, her surgery itself, so you can see her head carriage is much better, holding it much higher, much more comfortable. And I think she went home two days after her, her surgery. In terms of the ventral slot surgery, it's normally, normally pretty successful.
We reckon we see a slipped disc in the neck in about a quarter of all dogs with slipped discs and daxis, beagles, poodles, French bulldogs, cocker spaniels are normally the breeds that we tend to see, . The surgery itself is normally quite safe. There was a paper looking at sort of adverse events and found it in maybe about 10% of patients.
Some are minor, some are major. The main ones that they found were that some of these dogs can neurologically deteriorate following eventual slots. Normally it's those more chronic discs, so those discs that have been there for longer or those discs that have sort of protruded out rather than extruded out, .
Some dogs have sort of persistent pain following the surgery, and some dogs can, bleed quite a lot during the surgery itself. But normally, with those adverse effects, you know, there's nothing that's normally fatal. Some might require a second surgery, but normally it's pretty good.
And in reality, actually, it's quite a, a successful surgery. The vast majority of dogs do very well and, quite quickly, and, and we get them home quite quickly as well, which is, which is nice. Fine, so it was a little whistle stop tour of of slipped discs and how you might manage them in in first opinion, but also how we manage them in in referral.
We sort of skip to our. Our next case, so this is Maddie. She's a 4 year female neutered Labrador, that came to us with a quite an acute onset of, of seizure activity, about half an hour after coming back from her, her walk.
She was clustering, and when she arrived to us, she was in her status. . This was the video the owner took, at home when she got back from her walk, so you can see she's having sort of tonic clonic movements in, in later recumbency.
She has these sort of facial automatisms. She, is not conscious, she's not responsive. It's tricky to see here, but she's salivating.
There's a little patch of saliva there. And also the subsequent seizures, the owners reported that she often passed, urine and, and faeces during the seizure itself. So she ticks all the boxes for a generalised seizure in the sense that it was tonic clonic, natural recumbency, a loss of consciousness and some .
Sort of signs in terms of urinating, defecating and and salivating. And when she came to us, as I say, she was in status, and we define that as basically a generalised chronic seizure lasting for more than 5 minutes or 2 or more sort of more discrete seizures where there's an incomplete recovery of, of consciousness. And so if you've got a dog that's having severe clusters but never really recovering in between, then that would also be classed as a dog in status epilepticus.
And so I guess the next question I have for you is, if we've got a dog that is seizuring such as, such as her, where would you neuroanatomically localise? So I've give you four options. One is the forebrain, the second is the cerebellum, and the third is the brain stem, and then 4th, multifocal.
And I guess the thing just to remember, which you probably already know, is that if you've got a dog that is having generalised seizure activity or seizuring, then straight away we can localise that dog to, to the forebrain. You shouldn't get any seizure activity from the cerebellum brains or or any other area, so it would have to be the, the forebrain. And then in terms of differential diagnoses, there's obviously lots of things that can cause dogs to have seizures.
We often categorise them in different ways. Some people call them reactive or structural. Some people separate them into extracranial versus intracranial.
I guess the most important. The thing from our perspective is what is the most likely differential diagnosis. And so for her, she's a Labrador, that was perfectly normal up until, after her, her walk, and then she had quite an acute onset of severe seizure activity.
So I've given you four options, meningoencephalitis of unknown aetiology, and idiopathic epilepsy, intoxication, or a brain tumour. For me, out of those, it's probably more likely going to be an intoxication. And meningoencephalitis normally is a bit more sort of chronic in the progression of the signs.
So normally these dogs would be neurologically abnormal in between the seizures, but also preceding the seizure activity, and often they are sort of younger dogs, and certain types of, of breeds rather than Labradors. Idiopathic epilepsy is, is possible, but to have such a severe onset of clusters and status would be unusual for a dog that's idiopathic epileptic. Intoxication is, like I say, most likely for me based on the fact that it happens so suddenly, it happens so severely, and also happened after coming back from a walk.
A brain tumour obviously is always possible. Again, I might expect the owners to have maybe noticed some signs preceding such severe seizure activity, so it'd be slightly less likely, on my, on my list. And so I guess one thing that might be relevant to to you is, you know, if you have a dog come to your practise that arrives, in status, what to do and, and when to do it.
And I've sort of given you a little flow chart here as to, to the things to remember, based on how they progress and and how they present. So if you have a dog that sort of turns up, at your clinic. In that sort of condition where they're seizuring, the first thing to do is to get some rectal diazepam and and give that to them and administer that to them.
Normally one make the dose should do it, but you can repeat that if, if needed. Give them some oxygen if they require it. See if you can place an IV cannula and just do some basic blood work.
So, a PCV, a total solids, a biochem would be ideal. And I often start them on fluids quite quickly because often they can lose fluids due to the quite extensive seizure activity. So that'd be your first sort of checklist of things to, to do.
If the patient then continues to seizures, hopefully by that point, you have an IV cannula in place, you can repeat the diazepam, if you need to. If they continue to seizure, despite, you know, two doses of diazepam, then you can start to consider other anti-epileptics. I guess the most common we use is phenobarbital, and and often what I would then do would be to start with an initial dose of maybe 3 milligrammes per kilo IV.
And see how they respond to that. And then if they continue to seizure, I then tend to almost semi load them. So every time they seizure, I would add in an extra dose of 3 milligrammes per kilo of phenobarbital.
And you can keep on doing that until you reach a total dose of about 20 milligrammes per kilo within 24 hours. The reason I don't tend to go from nothing to 20 straight away is that if you go with such a high dose from the offset, those dogs will often become really quite obtund or stuporous because of the medication itself. And it can be then quite difficult to, to monitor for sort of progression or or other signs.
So I tend to semi load them just keep adding 3 and 3 and 3 until we get better control of, of the seizure activity. As you're doing that, you could also add in some levetiracetam, so some Keppra. And again, if I've got a dog that's that severe, I would start on the pheno, but then also add in some levoterracetam straight away.
And I normally give an initial dose of about 60 milligrammes per kilo. And then every 8 hours after that, I had about 20 milligrammes per kilo intravenously. So the first dose is normally quite high, and then every 8 hours just go down to 20 milligrammes per kilo and whilst you're seeing how they progress and how they respond.
If you've got a dog that you've sort of loaded with phenobarbital, you've started the levetiracetam and they're still continuing to seizure, that's when you start to consider some constant rate infusions. And normally I go with either midazolam, Dexmilatabidine or propofol, and then more recently start also to use some. Some ketamine.
I normally choose one of these to begin with and see if we can get things under control. It normally only takes one CRI. It'd be unusual to have to require two.
So it just depends on your personal preference and and what you're used to. And then normally when we get to this sort of stage, we can try and control their, their seizure activity. The difficulty, sort of difficult side of things sometimes is to try to wean them off the infusion, because often, particularly with propofol or midazolam, as you're trying to reduce the CRI, you're getting them off it.
They can often become quite dysphoric and can sometimes paddle or become disorientated, and often people think that is seizure activity, so then they go back on the medications again, so it can be quite tricky to to wean them off or know that they are stable to, to wean off. So in terms of of this Labrador, so we presumed initially that she was intoxicated. We gave her some rectal diazepam when she came, placed an IV and we gave her some intralipid as well, just in case there was a toxin, and we started her on some levetiracetam with a plan that if she continued to have more, we would give her some diazepam, no.
That we might have to start some phenobarbital. But luckily, she had two more seizures, and then she stabilised with the, with the above protocol. And, and then with time of about sort of 36, 48 hours, she became quite normal and, and we discharged her, two days later with some levetiracetam.
And she was certainly presumed to be a dog that had eaten something on her, her walk. Often when they come and they've been seizuring so aggressively for, for so long, they can be very post it to following the seizure activity. And often what we find with these dogs is that they can be quite a toxic.
They often have reduced or absent menace responses by. Naturally and and that takes time to, to improve. So I always warn owners after such severe seizure activity that they might be quite unusual for the first couple of days, they might bump into things, they might have reduced vision, but that should all improve with time.
The other question to maybe ask yourselves is, technically would we call Maddie epileptic and, and by the sort of definition from the consensus statements, we, we wouldn't. So an epileptic dog, certainly one with idiopathic epilepsy, you would need to have sort of more than 2 seizures greater than 24 hours apart. So she obviously had a cluster of seizures within 24 hours, which was because of her intoxication.
So she's not technically epileptic. That has to be sort of two seizures and more than 24 hours apart before we define a dog as being epileptic. And in terms of intoxication, I guess the thing to remember is that a lot of dogs that present so acutely with such severe seizure activity tend to be either because of intoxication, occasionally I've had it in dogs that have become suddenly hypoglycemic, but we often see.
In those dogs that have eaten something that they shouldn't. Obviously we do see it in other conditions as well. It just seems to be less likely, less common, and normally it's preceded by some other neurological abnormalities rather than just the seizures themselves.
And I guess sort of top tips in terms of having a dog that comes to you with such severe seizure activity is that if you start them on a CRI, particularly a propofol CRI, then it's always worth intubating them. They are a much higher risk of developing aspiration pneumonia, so by intubating them and keeping them as con controlled area as possible, that will hopefully reduce that risk. Always keep an eye on their temperature and turn them every 4 hours if you, if you need to.
It's always worth, worth placing a urinary catheter and monitoring their ins and outs just to make sure that they are stable. Obviously lubricate their eyes. Normally do it every sort of 2 to 4 hours if they are on a constant rate infusion, .
And the other thing just to remember that if you've got a dog coming and you can't or haven't got an IV cannula in, and it's difficult to control the seizures with the diazepam, you can give both phenobarbital and midazolam intramuscularly at the same dose if you, if you need to in a, in an emergency situation. Perfect. Right, OK, then we'll change tack and we will go on to our, our next case.
So this is Sky. She is a 5 year female neutered chihuahua. That came to us with again about 2 to 3 day history of sort of progressively worsening vestibular sites.
So this was how she presented, so she's quite severe in the sense that she is unable to ambulate for herself. She has a really quite marked left-sided head tilt, and she's also got a, a head turn. You can see her palpal reflex there was, was normal.
And you can see she's maybe obtunded but has some degree of alertness. You can see in her left eye, she has this sort of ventrilateral strabismus. You can see the position of that left eye is much lower compared to the right.
When we elevate her head, you can see there's some vertical nystagmus in that left eye and some horizontal nystagmus in her right eye. With the horizontal nystagmus, you can see the fast phase is to the right, . It's always tricky to do an exam in a dog that's so severe, but often we try to support them and and check their paw placements.
You can see in her right thoracic limb, she's got normal paw placement, same for her, her left thoracic limb. And then when we try to look at her pelvic limbs, you can see in her right pelvic climb, she's placing that quite, quite well. And then when we check on her left hind limb, from memory, I think there was a slight delay here, so she was sort of knuckling over on that pool, maybe slightly more than we would consider normal.
So my first question for you is, where would we neuroanatomically. Localised. So I guess just to summarise, she was non-ambulatory, mainly because she was so severely attaxic.
She had a left sided head tilt. She had a nystagmus, both vertical and horizontal nystagmus, and the horizontal nystagmus was a fast phase to the right. She had a ventrolateral strabismus in her, her left eye, and, and her left pelvic limb, had a slight partial deficit.
So based on the fact that she had a head tilt, she had some nystagmus, she was severely attaxic, and she had some strabismus, certainly we would localise her to the vestibular system. Because the head tilt was on the left and the strabismus was on the left, but her nystagmus had a fast phase to the right, we would then say that she had a left sided, vestibular disease. And then the question we always ask ourselves is whether this is peripheral or central.
All dogs that present to us with vestibular dysfunction will have 4 of the main key signs. So often they've got a head tilt, often they've got strabismus, often they are ataxic, and often they have some nystagmus. The reason or the way we try to differentiate whether these dogs have peripheral vestibular disease or central vestibular disease is whether they have any other signs.
So in dogs that have central, they might have a reduced mentation. They might have other cranial nerve deficits, or they might have some postural deficits. And in her case, she had a left pelvic limb postural deficit, and she also had maybe a slightly reduced mentation.
And so for me, she would localise to, a central vestibular, because of those, those signs. And so just to summarise, like I say, all dogs with the vestibular signs would have an ataxia, a head tilts, some nystagmus, and some strabismus. Once you've established, it's the vestibular system that is affected, then look at your ball placement, see if there's any deficits, look at your cranial nerves.
And assess their mentation, see if they are obtunded or stuporous, or whether it's any more than than just a disorientation. Often dogs with vestibular dysfunction will be disorientated, but what we're looking for is more than that. We want them to be obtunded or stuporous to suggest it's more essential.
If with those three questions your answer is no, then I'd say it's more likely peripheral. But if one of those things is abnormal, then maybe we're dealing with the essential vestibular dysfunction. Often people talk about the nystagmus and the nature of the nystagmus.
It is true that if they've got a horizontal nystagmus, then we might be leaning more towards peripheral, whereas if it's vertical or rotatory, we might, we might be thinking more central. And I guess the other thing just to consider is that there are a few exceptions in dogs with peripheral vestibular syndrome. So if they have an ear disease, or they've got obvious otitis external, that might make it more likely that they've got peripheral vestibular dysfunction.
If they've got a concurrent facial nerve paralysis, that doesn't mean that it's necessarily sensual because often, well, the facial nerve does run through the middle ear. So again, if they've got something affecting their inner and middle ear, it can give you vestibular dysfunction and their facial nerve paralysis. And that's also true for Horner's syndrome.
So occasionally we have dogs or cats that come to us with Horner's syndrome, a facial nerve paralysis, and vestibular dysfunction, and that would be more likely peripheral because of those peripheral nerves being in all quite a a similar location. And so in terms of differential diagnosis, so there's a few sort of things to have in mind when you have a dog with peripheral vestibular syndrome. So you've gotitis media or internal.
Often we see that in certain breeds more than others, so French bulldogs quite commonly, or cavaliers with primary secretory otitis media. You've got these acute idiopathic or geriatric, dogs with vestibular syndromes. They're normally older dogs with very per acute onset or peripheral vestibular signs.
You've got dogs that can have tumours in the middle or inner ear. Dogs that have had some ototoxic medications, so immunoglycosides, amorphrosmide, or any other medications into their ears can also cause a peripheral vestibular syndrome. And also on the list, but quite uncommon, but, an underactive thyroid can certainly give you signs of peripheral vestibular syndrome, but you'd also expect other signs, like normally they have other signs suggestive of a poly polyneuropathy.
Whereas if you've got a dog that you think is more likely a central vestibular patient, then your list of differentials is, is slightly different. And again, depending on their signalment, depending on their history, these would be the sorts of things to, to consider. So a neoplastic process, a tumour affecting the brain stem.
And remember, if you're talking about central vestibular, that's normally either going to be your brain stem or your cerebellar cerebellum that's gonna be, gonna be affected. So a tumour in either your brain stem or your cerebellum can certainly give you sensual vestibular signs, . A meningoencephalitis of unknown aetiology that can certainly affect your brain stem or cerebellum, and that can be progressive and give you sensual vestibular signs as well.
A brain infarct or an ischemic infarct to either your cerebellum or your brain stem can give you this sort of per acute onset of vestibular signs. Again, we see that in certain breeds more than others, so, cavaliers or greyhounds are quite commonly getting infarcts to the cerebellum that can give us vestibular signs. In metronidazole toxicity, so if these dogs have been on high doses of metronidazole or a prolonged course of metronidazole, then often we see them or they can develop these signs consistent with central vestibular syndrome, .
A thiamine deficient cat can often present with vestibular signs, and again, an underactive thyroid could technically give you some signs that might also show you central or be central vestibular in in nature. So going back to Little sky, now we've gone through that summary of a vestibular dysfunction. She's a young chihuahua with an acute sort of progressive and non-painful left sided, vestibular syndrome that we've said is likely or more likely central rather than peripheral.
And in terms of differential diagnosis, again, I've given you a little list to, to choose from. Two options for you would be either a brain tumour, a meningoencephalitis of unknown aetiology. A brain infarct, metronidazole toxicity, or a thiamine deficiency.
So if you were to work through these, a brain tumour possible, but she's quite a young dog, and so it'd be lower on my list for, for that reason in particular, but always possible. A meningoencephalitis of unknown ethology is probably my most favoured differential diagnosis for her, given she's a young chihuahua. We often see it in that particular breed.
Given the signs were progressive over a few days, that sort of fits with the history that we'd expect. And also the fact that it's a central vestibular condition. Often we see this affect the brain stem or, or the cerebellum.
A brain infarct for me is less likely. Normally in a brain infarct, it'd be a very sudden onset. So normally a per acute onset of vestibular signs.
Hs progressed over about 2 or 3 days. So I think that's less likely. It'd be unusual for a brain infarct to progress over that sort of time period.
She wasn't receiving metronidazole, so that's unlikely, and she had a normal diet, so again thiamine deficiency really unlikely, and she's a dog. And so we went ahead and did an MRI scan, and you can see there's sort of 4 images from her scan itself. So on the left is this TT weighted sagittal view, and we've got a TT weighted transverse, a flare transverse, and then a T1 weighted post contrast view.
And so I don't know if you can see, but it's pretty clearest on on this view here when the TT weighted transverse and the flare transverse, but there's just quite large focal. Sort of quite irregular but well defined, sort of T2 and flare, hyper intense lesion at the level of, I guess, where we'd probably expect her, her left cerebellar peduncle to be. So it's affecting exactly where we'd expect her, vestibular nuclei to be in the vestibular, central vestibular parts of her, her brain to be.
And it also fits it's on the left hand side, which is where we, localised her, her problem to be. We then did a spinal fluid tap, so we took some spinal fluid and sent off for analysis and her protein level was 68, but it should be less than 30, and she had quite a high cell count. So normally, we'd expect less than 5 cells, whereas I think hers was close to 200, and the majority of those were, were lymphocytes.
So she had a lymphocytic pleoytosis. And so that is all very consistent with the meningoencephalitis of unknown aetiology. And basically, these MUOs or MUAs, depending on what you call them, is essentially an umbrella term for lots of different subtypes of autoimmune inflammatory central nervous system diseases.
We often see it in young or middle aged dogs. And you might have heard of them as being called either GME or enemy. And there's essentially different subtypes that we see in different breeds affecting different parts of of the brain.
The only way we ever get a definitive diagnosis for this condition is if we do histopathology, which we don't often tend to do unless these dogs go for postmortem. So the diagnosis is based on the MRI scan, the spinal fluid tap, and obviously if it's consistent with the breed and the history and the and the progression. And the way we treat these dogs is normally by suppressing their immune system.
We think this is an autoimmune disease, and so we dampen that down and hopefully we see a reversal of their signs. So we start them on quite high doses of steroids. I normally give them some intravenous dexamethasone to begin with, and if they're doing well then sort of transition them to prednisolone.
If you've got quite severe cases, we might add in a second immunosuppressive agent. So normally we'd go for cytarabine, but, but you can also use azathioprine or cyclosporin or something else if, if needed. And then depending on how severe they are, we also try and do a bit of physiotherapy, just try to get them as normal as we can, and as quickly as we can.
And the prognosis for these patients is really quite variable. We reckon, or we say to owners that if they have a good initial response to treatment, then hopefully we're quite optimistic that they'll do well. But it can be one of those conditions that can be quite difficult to predict, and often these dogs are on medications for a long, long time and they can go up and down quite, quite quickly.
So it's just worth, keeping an open mind with them. And so this was after we started her on some steroids. This was a couple of days, I think, after she had some dexamethasone, and you can see she's much more, well, a bit more alert, a bit more responsive.
She can now walk for herself. Still has quite a marked head tilt, still quite ataxic, and still has some, obviously some vestibular signs, but, but slowly getting there. And I'd expect over the coming days and weeks for her signs to continue to improve.
I always warn owners that these dogs can often retain a slight tilt of the head, but everything else should hopefully hopefully improve. And so with those patients, if you have a young chihuahua or a young French bulldog or a young pug, or those, even Maltese, those sorts of breeds that have, you know, quite an acute but progressive history of intracranial signs, whether it's vestibular dysfunction or whether it's something else that's going on. And those owners can't afford to go for more or further diagnostics.
Always consider MUO, so meningoencephalitis as a, as a possibility because a lot of other differentials you can normally rule out with those dogs. And so if they're really strapped for cash or they can't go for more diagnostics, you can always try them on some sort of steroid to see if we see a clinical improvement based on your clinical suspicion. Perfect.
Right. And then we'll come on to our last case. So this is a bandit.
He is a 3 year old male and entire crossbreed. That came with an acute onset, quite progressive weakness, affecting all four of his legs. Initially it was worse in his fine limbs, and then it progressed to all 4.
The owners also noticed he had a bit of a change in the tone of his, his bark. So you can see here, he's, he's sort of non-ambulatory tetrapoetic, so he needs support to be able to walk, but he's still got movement in all four legs. He's better in his front legs than he is in his back.
Here you can see that I'm checking his withdrawal reflex, so giving a bit of a pinch to see if he pulls his leg back, but you can see he's not really able to, to withdraw his limb. You can also see here just checking his patella reflex, and that's completely absent. So at the moment we've got a non-ambulatory tetraporetic dog with absent withdrawal reflexes in all four limbs and an absent patellar reflex in both hind limbs.
I guess the other thing to know is that he was non-painful, so there's no discomfort. Identified anywhere and you couldn't really see it in this video, but when you check his paw placement, that was actually quite normal. So despite the fact that he couldn't walk, when you knuckle over his paws and you support him, he was able to place his paws back to to their normal position.
So based on that, again, a little question for you where you would neuroanatomically localise. So either a C1, C5, or C6 T2 myelopathy, or the neuromuscular system, or the brainstem. And out of all those 4, for me, it's more likely the neuromuscular system.
And essentially, if you've got a dog that is tetraporetic, so weak on all four limbs, a lot of people get confused or worried that this could be a problem affecting their neck, and certainly that can cause a dog to be tetraporetic. But the thing to check, or the two things to really check would be whether they've got postural deficits. So if you've got a dog that's tetraporetic, has normal paw placement, then certainly I'd be a bit suspicious this is more like the neuromuscular.
And secondly, check their reflexes. If you have a dog that's got reduced or absent withdrawal reflexes in all four limbs, or reduced or absent patella reflexes, but is unable to walk on all four limbs, then that certainly would make it more likely a neuromuscular problem. We can get dogs that have a C6 T2 myopathy that would have a reduced withdrawal reflex in the front limbs, but they should be normal in the hind limbs.
The fact that this dog and these dogs with neuromuscular conditions have a reduced reflex in all four limbs, makes that much more, much more likely. So if you were to summarise him, he's a cross breed with an acute, progressive, non-painful, really quite symmetrical problem affecting his neuromuscular system. And so in terms of differentials, I've given you a, a few to, to choose from.
So the first one is an acute idiopathic polyradicular neuritis. Number 2 is a myasthenia gravis, number 3 is botulism. Number 4 is a tick paralysis, or number 5 is a paraoplastic syndrome.
In reality, if you've got a dog that you think has a problem affecting the neuromuscular system, these are pretty much the main differentials to have on your list. It should be one of these. And in reality, actually, this is the, well, nearly the order that I would have, have them in.
So the most common reason we see dogs coming to us with your muscular problem is that they've got an acute idiopathic polyradicular neuritis. We also see quite a few dogs with myasthenia gravis. Botulism is really quite rare.
Normally you expect to have cranial nerve deficits, which this dog didn't have. Tick paralysis, certainly rare in the UK, more commonly Australia or other countries. And then you think to have the back of your mind as a paraoplastic process if they might have a tumour or cancer elsewhere, that's giving us a secondary neuromuscular problem.
So in reality, a neuromuscular dog think either a polypredicular neuritis or myasthenia gravis, but have in the back of your mind, maybe a paraplastic process. And so significantly with these dogs, and the most important thing is that they don't need an MRI scan. They don't have a problem affecting their spinal cord.
They have a problem affecting their neuromuscular system. When we define the neuromuscular system, we're essentially talking about the peripheral nerves, or the muscles, or the junctions between those peripheral nerves and the muscles themselves. So there's no need to do an MRI scan because there's not a problem affecting their spinal cord.
And so actually all our diagnostics are focused on looking or excluding other causes for a neuromuscular problem. So often what we do would be to a full haematology and biochemistry. I often check a T4 and TSH in dogs just to make sure they're not hypothyroid.
Then do some chest radiographs and then an ultrasound scan of their abdomen. And then also worth sending off some blood to check for anti-asty coding receptor antibodies. And this is the test that you do for.
My senior graph just to rule that out as a, as a possibility. And so in our, all the buds were normal, the imaging was normal, and the astoconium receptor antibodies were also normal. Other diagnostics you could consider but wouldn't be essential, be either electrodiagnostics.
So often we do this, normally after about sort of 5 to 10 days after the onset of their signs. So you can do electromyography, where you might see some fibrillation potentials or some positive sharp waves, and you can also check the conduction velocity in the nerves and see if they are reduced. Occasionally people take spinal fluid samples.
I think that's less useful in these conditions. You might expect a slightly elevated protein, but it's quite a non-specific change, so I'm not sure it's worth the the effort of getting it based on on the results we get. But essentially, when you do all these tests, and if they all come back relatively unremarkable, particularly the the astocholine receptor antibodies, then you're left with acute idiopathic polyradicular neuritis.
And that's the important thing to remember is that this is normally a diagnosis of exclusion. Once you've exclude excluded any tumours or cancers, once you've ruled out myasthenia gravis, then you're left with this, which is the most common sort of polyneuropathy that we see in in dogs. It typically affects the hind limbs first, but then it can also affect the thoracic limbs.
The cranial nerves are normally normal, but often owners comment that the dog's bark has changed, so they're a bit dysphonic. Often we don't see a megaesophagus, and that's different to myasthenia gravis. So that's another reason that the thoracic radiographs are quite useful because if you had a dog that had a megaesophagus, then maybe you'd be more thinking actually that you're dealing with a myasthenia gravius rather than a polyradicular neuritis.
So it's always worth doing those X-rays. And the other thing just to bear in mind with this condition is that it's always possible once we get them over this, that they have a a recurrence. You'd be unlucky, but occasionally we, we do see it.
And in terms of acute idiopathic polyprediction neuritis, obviously from the name, you can tell that we don't know really what, what causes it. There are a few theories. We often see it in certain breeds more than others.
So Jack Russells and and restes are slightly predisposed. There might be a seasonal component to it, so often we see it in the sort of autumn or winter time. Some people have found maybe a link with Kaylaactor.
So those cases with the polyprediction neuritis were found to be more likely positive for Campylobacter, and they were also more commonly fed raw food, particularly raw chicken. There's a few other papers here that might be, you might be interested in just to, to read a bit more, a bit more about it. And in terms of treatment, I guess the thing to remember is that there's no real effective treatment.
There's no real medication that we give to reverse these signs. A lot of it is just time and supportive care. So often we keep these dogs in, we just make sure that they are static and stable and not deteriorating.
Often we start some physiotherapy. The majority can urinate for themselves, but something that we often check. A subset of these dogs will progress to become tetraplegic, so they lose all movement in all four legs.
If they become tetraplegic, then there's always a concern that they also might progress further and stop being able to breathe. Those cases are obviously quite severe. Occasionally we put them on mechanical ventilators just for a few days so that we can then start to try to give them time to get over it.
But often if they get to that point, people elect to to put them to sleep. But the vast majority plateau before they get to that point. So they remain non-ambulatory.
We give them physio, support. Of care and then over the coming days and weeks, we expect them to improve. And the thing to remember about this condition is actually the prognosis, if they don't go into respiratory arrest is really quite good.
And I've never had a dog with polyradicular neuritis not get back to walking, and they all get back to walking. They just need time and support to, to get there. And so this was a bandit.
This was a few weeks back, through our rehab centre. This is Sarah, one of our physiotherapists, and you can see he's got his little help up harness on, but he is now ambulatory without too much support. He's able to sit and he's, much stronger in all four of his limbs.
. So he's doing quite well. He's still not completely normal. I think some of his reflexes were slightly reduced still, but overall, much improved, and the vast majority of these dogs will go back to normal within about 6 to 6 to 8 weeks.
And you can see here his withdrawal reflex now is much improved and back to normal, but I think his patellar reflex was still, still slightly reduced. So yeah, so it's a bit of a whistle stop tour of some, some different cases, I guess the more common ones that we tend to, to see and that you might see in, in practise. We tried to cover like a few different areas and different topics just to try and keep it interesting.
But yeah, I'm very happy to answer any questions if anyone has them about particular cases that I've shown you or particular cases that you've had in practise that you want to ask about, feel free to, to ask away. Thank you so much, Alex. I don't know if you want to come on with your video, up to you.
Just while we're letting people get some questions in, we're getting some, really nice feedback. Amanda said that was brilliant, thank you. Those of you who are enjoying this, obviously we've still got tomorrow, so if you've got friends and colleagues who you think would enjoy coming to our, to our final day, which I just need to re-remind myself, is on.
Is on endocrinology, of course it is. So if if any of your friends would like to go on that, please feel free to talk about this on social media with a photograph of one of the slides or something. And of course the hashtag VVC24.
As always, I'm always interested to know where you're listening from. Simon's just said thanks Alex, really good. So do put that in the chat box, whereabouts in the world you're listening from.
Kyle, and Dana are always asking me to mention the goodie bag. Some of our sponsors have made this possible for this to be a free conference. And of course there's some really nice, offers there.
So do look at the goody bag, and Kyle, when before the next talk starts, we'll put that up for you. So yeah, let's go through some questions. I've also got 5 minutes where I just want to tell you about the fantastic sustainability summit we had yesterday, and the opportunities we've got for, to make a real difference as a veterinary profession and also for, for you guys to be educated at a reduced level.
So if we've got time for that, I'm gonna just show that for 5 minutes. But let's make sure we get questions done first and . I really enjoyed that, that presentation personally, Alex.
It was great to see all the different types of diseases, and it, it was really a sort of almost like a Disney story because there was that hero's journey and thank goodness, we had lots of er successful outcomes at the end, er particularly Badger there, so thanks for giving us some good news stories er in neurology. So why, how quickly should you see any improvement in a dog with FCE? So you said .
Fibrocartilaginous embolism. What, what's your impression with that? That's a question from Carolina.
Yeah, that one really varies in the sense that, like I said, those ones with FCEs or ANPs normally very sudden onsets, only very lateralizing. The main thing I look out for in the 1st 2 or 3 days is that they're not getting worse. So often they remain quite static and quite stable.
Some improve that quickly, but normally they remain quite stable. And then after the 1st 3 days, I would expect to see some subtle improvements. It won't be.
Quick, it still can take quite a few, days or few weeks, depending on how severe they are. But as long as they're not getting worse in the first few days is the main thing. And then after that, it can take a, a few weeks.
Often, the most affected limb will always be slightly weak long term. But it just depends a bit on how severe the spinal cord was injured as to how long it might take for them to, to recover. But definitely worth giving them time because they all almost always get back to walking.
Yeah, I think everybody's a bit fascinated about this because we didn't talk about it to a huge extent, and I think it is relatively common, isn't it? Maria saying, what about urination in fibrocartilaginous embolisms? Yeah, again, it depends a bit on their severity, so it's similar principle in that if you've still got some voluntary movement, then the vast majority of dogs will be able to urinate .
Despite being, you know, quite severely affected, because of the nature of that disease and because they're normally quite asymmetrical, we normally retain movement at least in one of the limbs or one side of the body. And so often I would give those dogs a chance to, to urinate because the majority will. If you're unsure, best just to catheterize them or express the bladder, but as long as there's some voluntary movement, then the vast majority will, will be able to pass urine.
Occasionally we get FCEs or ANNPs that are severe where they are either, you know, paraplegic or have lost all movement. If they're like that, then, then certainly they might need some help from a bladder perspective. So just look for any movement and then that would then decide things.
Couple of people, Miriam and Katerina asking about ketamine, Miriam's saying that she'd heard that ketamine can cause seizures in predisposed dogs. Is that right or wrong? And then, Katerina was saying, could ketamine be used in cramps?
So yeah, so ketamine, I think there's a lot of sort of past discussion about whether it can cause worsening of seizure activity in dogs that are have an underlying cause or predisposed. I don't tend to worry about that anymore. We often use it, I, yeah, use it for dogs that we are struggling to control their seizure activity, and even those dogs sometimes that have an intracranial pathology that's causing them to seizure, occasionally we'll use it in those dogs as well.
So I wouldn't worry too much about it making any seizure activity worse. Like I said, it's not my go to for CRIs for dogs that are in status or clustering. I normally go for the sort of midazolam and meatomidine first and then maybe propofol or ketamine second.
That's something that people are starting to try sort of more and more. And then what was the second question, sorry? The second question was around, can you use ketamine with cramping dogs.
Cramping dogs. Yeah, so it depends a little bit on why they're cramping. So we can see sort of epileptoid cramping syndrome, particularly in a terriers.
But we think of that as more of a sort of paroxysmal dyskinesia or like a movement disorder, and we wouldn't use it in that particular instance. Norm. Those dogs with those sorts of cramping dyskinesias will spontaneously improve without much intervention.
Occasionally if it's prolonged and might give them a benzodiazepine, so maybe diazepam or midazolam or even a metocarbool. But in reality, those dogs with, well, those border terriers with epilepsyid cramping, we think might be diet related, so often change their diet to a gluten free one. And then if it's not that, then often we consider it as a, a movement disorder, so I wouldn't tend to use ketamine in those cases.
Fantastic. Emma's saying we don't have IV levetiracetam. So she was, wondering if you could use Keppra solution rectally, but I suppose, if you're missing one of the drugs, Venobarb, is that still kind of.
One of your major go to's. Yeah, exactly, yeah. So I think as long as you've got phenobarbital present, and particularly the one that you can give intravenously, that's probably the most useful.
Leviterraim, it's nice to have an IV sort of prep in in your clinic, so you've got it, it's a bit faster acting. But if they've got only the oral solution. You could certainly try out per like rectally and see, or obviously you could try it already if the dog is, is able to take it.
But but yeah, if you've got pheno, if you haven't got levitratum IV I would then use your pheno IV in that sort of emergency setting, and then you can always use one or both rectally if you need to in the, in the future. Kelly's asking how long between the seizure episodes would you wait before continuously topping up with phenobarbitone IV that was my case. Yeah, so it depends a little bit, so I would normally, if I've got a dog that's having clusters of seizures, I would give them the diazepam straight away to stop that current seizure and then I would give them that sort of first dose of phenobarbital.
If they then have a, a second seizure. If it's within the next 10 minutes, I probably wouldn't be too worried, but if there's one again in maybe 1520 minutes or half an hour, that's when then I would do, adding a second pheno dose, just keep on adding it as the, if the seizures continue. You can always keep on giving additional Diazepam doses.
Get them out of that seizure quite quickly while you're topping up the pheno. But yeah, normally give it a bit of time because occasionally, once you're given the pheno, if they're going into a second seizure, it's probably before that pheno's had any effect. So it's worth giving a bit of time before you start to top it up too much.
Katerina's got a very interesting question here, which er I wasn't really aware of. In human medicine they use head movements to correct what they call crystal disease, which I think is vestibular disease. Can one use head movements to fasten vestibular crystals in dogs?
That sounds very exciting. Yeah. So it's, it's, so yeah, in people they get vestibular dysfunction, they cause it, they call it normally like mini Air's disease, I think they call it.
And it's essentially these little auto lifts in your semicircular canals in your inner ear that get dislodged and then disrupt your balance. And there's a different manoeuvres, I think one's called the EPA manoeuvre where they put you on your back and turn your head and, and, and position or move you around to try and get that little otolith back into the, the right spot and remove it from the the abnormal area. I think that's one of the most common reasons people get the similar disease.
In dogs, there is a paper where they tried it, I think, on 12 dogs and questionably not too successful, and I think the consensus at the moment actually dogs don't tend to get vestibular disease because of those little crystals or otoliths. It's normally because of a different underlying pathology, and so we don't tend to try that manoeuvre, really at all. One of the physiotherapists at work is, is quite keen to, to always try that and give it a go.
And we've done it in a couple of dogs, but it's not something that we tend to do because I think the underlying pathology is different between dogs and, and people. The thing that I have found useful is those dogs that have Vestibular dysfunction, particularly those dogs that have idiopathic vestibular syndrome, they can get quite a marked head tilt, and that can often persist, even once you've got everything else sorted. I found more recently that if we get some physiotherapy for those dogs, particularly with their head movements, it can stop.
Having a, a long term head tilt just as some exercises, cos I think a lot of it is to do with the muscle changing rather than the actual vestibular dysfunction. So it's always worth getting some physio input for those dogs, I think, just for getting them up and about and trying to normalise their, their posture. Thanks Alex.
Er Caterina and Lisa are quite concerned about the metronize or toxicity. Is that reversible once the drug is stopped? Yeah, so that's, it's one of those nice conditions.
In terms of why some dogs get it and others don't, it's not just because of dose or duration, some dogs just seem to be more susceptible. We don't know exactly why some dogs get it and others don't. We think it's to do with some GABA receptors and their calcium channels.
The thing with it is to stop the the metronidazole straight away, . Get them on some fluids, but also we start them on diazepam, and I normally give them 0.5 a milligramme per kilo of diazepam every 8 hours for about 3 days.
And every dog I've had within 3 days, pretty much with that treatment has gone back to being normal quite quickly. So, so yeah, it's quite an easy fix. Once you stop it, start some fluids, give them some diazepam, and they'll be, much improved by about 3 days' time.
Fantastic. I think we should move on. I'm keen to get people out just on 9 o'clock.
So, Alex, thank you so much for that. That was fantastic. As many people have said, a really, enjoyable and, visual presentation, so Miriam's just saying that I enjoyed the topic and the presentation very much.
So that that's the only problem, Alex, with webinars, you can't hear the tumultuous applause, but are being much appreciated by everyone who's present and making comments. So thank you so much for that. No worries, thank you for having me.
Good evening. Welcome to my presentation about spinal pain in young dogs. My name is Emily Rayo and I work as a veterinary neurologist in Davis Veterinary Specialist in HN.
So first I classify young dogs as dogs less than 2 years old. Dogs with spinal pain can present with neck or back pain. Dogs with neck pain can present with a low head carriage, reluctant to move their head, reluctant to jump or to the stairs.
Screaming episode is a common sign in dogs with neck pain. Some dogs have small muscle twitches in the neck or the shoulder area, and some dogs are lame or lift a thoracic leg. We also call this a nerve-w signature.
Typical signs of dogs with back pain are a hunched posture, reluctance to jump or to do stairs. Also dogs with back pain can have screaming episodes, but we see that less often in dogs with back pain. And also they can have intermittent lameness or lifting of a pelvic leg.
So on this slide, I made a summary of the most common causes for spinal pain in dogs in young dogs. Vascular disease is typical not painful. Infectious and noninfectious inflammatory conditions are very important differentials for young dogs with spinal pain.
Trauma angioplasia. Can happen at any age, so also in young dogs, and certain congenital diseases such as atlantoaxial instability and also associated cervical spondylomyelopathy need to be considered in certain dog breeds. It is very important to remember that in dogs less than 2 years old.
Introvertebral disc disease is very rare. So In the next part of my presentation, we'll discuss the most common diseases that cause spinal pain in young dogs by discussing some of the cases that I have seen in the clinic. The first case today is Scooby, and Scooby is a 4 month old Stafford, a Cherbo terrier, and I saw her for the first time in September because she had a recent onset of pain of unknown origin.
So the owner described that Skookie was sometimes having yelping episodes or and that she was also sometimes reluctant to put her head down to it. Scooby might have hurt herself when playing a bit wild with another dog? And she was seen actually already by the local vet.
The local vet did a general blood test which revealed a mild anaemia, which was most likely age related, a mild neutrophilia and monocytosis. The reactive protein was mildly increased. Chest radiographs and ultrasound of the abdomen were normal.
So I started just with a physical examination which was normal. Also, the neurological examination was normal. During the consult, I could not find any obvious back or neck pain.
But Skooky yelled once when the owners picked her up to put her on the table. So in a young dog with screaming or yelping episodes some . Spinal disease is an important differential, and for me, my main differentials were steroid responsive meningitis, arthritis, discos spondylitis or another type of infection like a slumbar abscess or an osteomyelitis, and, and trauma was also an important differential.
Neoplasia and congenital vertebral formations were possible as well, but luckily less likely. . And we discussed with Fiona the differentials and the different options.
So we gave the option to say we will first try a little bit of rest and painkillers, and if there is no improvement, . We can then do further investigations or we can go for an MRI scan of the neck and the back if necessary. So the owners decided to go for conservative management first.
So Sky initially responded well. She did quite well for 6 weeks. She became more comfortable.
But after 6 weeks, we got a phone call that Sky was painful again. So I asked the owners to send me some videos of how school he was at home when she was . Painful.
So the owners are asking her to to come down a couple of stairs and we can see that she appears a little bit hunched. She's holding her head a little bit low, and she's doing the the stairs, but she's hesitant. When she goes in the house, you will see that she's also hesitant to do the little step to get into the house.
And then on this slide, we can see that a Scooby is eating from a ball and the owner is. Lifting the ball a little bit to make it easier for Scooby to eat. And we could see that as soon as the owner was holding the ball a little bit lower that Scooby stopped eating.
So we invited him back for a reexamination and on the day of the second consult he had a fever at 13.8 degrees and she also appeared painful on ventroflexion of the neck. So my main differentials for a young dog with neck pain and fever.
Where non-infectious inflammatory conditions such as SRMA and IMPA, but infectious diseases such as discospondylitis, osteomyelitis, abscesses where possible as well. So as based on my examination, I localised the problem in the neck, and therefore we decided to start with an MRI scan of the neck. So we did an MRI of the neck and we always include the craniothoracic vertebral column.
And I was actually quite lucky that day because just on the edge of the scan, we could see that the intervertebral disc at T5T T6 appeared abnormal. So the intervertebral disc space appeared collapsed, and had an abnormal intensity. And we could also see that .
The end plates of a D5D6 were actually irregular, and there was a mild compression of the spinal cord as we lose the dorsal and the ventral CSF column. So based on the MRI scan we diagnosed Sky with discospoylitis at T5D6. So just .
I added some more images for you. So this the one weighted transverse image at the level of T5D6 is a pre-contrast image and this is a T1 weighted post contrast image. At the same level, so 25 to 6 and we can see that .
At that level, the intervertebral disc and the surrounding soft tissue structures are contrast enhancing, which means there is inflammation going on of the intervertebral discs and the surrounding soft tissue structures as we had a suspicion of discospondelitis. We have formed a lone culture to try to identify the underlying pathogen. The blood culture returned with a positive culture for coliform species?
And the antibiogram showed that the pathogen was sensitive to amoxicillin clavulanic acid. Therefore, we started Scoy on a long course of Simulox actually. So we advised a course of 6 months of amoxiclo 20 mg per cake twice daily.
The dogs that we diagnosed with this coonyitis. We always keep them on a very long course of antibiotics, between 6 months and a year, and that is mainly because of the risk of relapse when stopping the antibiotics early. So so far, Scui is doing well, and she has become more comfortable again, and so she seems to respond well to the treatment.
So in the following slides, we will just go into a little bit more detail about discospondylitis. So discospondylitis is an infection of the intervertebral disc and artisan in place. This can affect dogs of any breed or age?
German shepherd dogs are predisposed and typical signs of discospoolysis are severe spinal pain and fever. Discospondelitis can affect every intervertebral disc, but L7S1 is the most common affected site. Discospondylitis can be diagnosed with radiographs, CT or MRI.
So on the radio car, we can recognise this cosponolysis by . Irregular implates. And often there is some sclerosis, so widening actually of the end plates, and there is collapse of the invertible disc space.
So the invertible disc space is very narrow if you compare it. With the other invertible disc spaces. So the advantage of radio cars is that it is not so expensive and that you can take radiographs under sedation.
The only disadvantage is that in the initial stage, the radiograph can be normal and it can take up to 2 weeks before the changes are visible. So you can also diagnose this spondylisis on CT. And typically you will see again abnormal irregular in plates.
You can also see osteolysis. And you can also see. Periosal proliferation adjacent to the end plates.
That's what we see here. And then with MRI scan, you can also diagnose that discospoylitis. It's our most sensitive tool to to detect discospoylitis.
Ty, the intervertebral disc. And the implas have an increased signal intensity on T2. We can often see contrast enhancement of the invertebrate disc and surrounding tissues.
The main actually disadvantage of MRI is the need for general anaesthesia and the high cost of the MRI scan. So when dogs diagnosed with discosinylisis and recommend to do urine and blood culture to try to identify an underlying pathogen. Unfortunately, only an approximately 30% of the cases diagnosed with discosinylysis will have a positive plot of urine culture.
So you often get into a false or negative. Another option would be to take a sample directly from the impact of this. You can do this ultrasound guided or do the fluoroscope.
Culture of the invertebrate is positive in approximately 40% of the cases. As discussed previously, a very long course of antibiotics is recommended. In one large retrospective study, the average duration of treatment was 53 weeks.
Choice of antibiotics is ideally based on an antibiotin that if the cultures are negative, syphalosporins or amox plaque are a good first choice of antibiotics. Ideally, intravenous antibiotics are given the 1st 5 to 7 days. If the dog does not show any improvement after 1 week of treatment, a second antibiotic that is active against anaerobic bacteria can be added to the treatment.
As this was formulitis is a very painful condition, analgesia is an important part of the treatment. In general, the prognosis is good, but relapse can happen at any time. So quick case 2 is about Luna.
She is a 1 year old female Burmese mountain dog, and she has a 2-week history of neck pain and fever, despite a treatment with meloxicam. So in this video, We can see that Luna has a low head carriage. And is reluctant to look at the left and the right.
So she has a typical postures of a dog with neck pain. You can see that her eyes are moving but her head is barely moving. So, on Luna's general physical examination, Luna had a fever.
And on the neurological examination, . We could found some neck pain. So the main differentials were inflammatory and infectious diseases.
We started with blood tests. Haematology revealed a mild neutrophilia. Thereafter we did some radiographs of the neck and the back to rule out a discospondelitis.
The radio cars were normal. To finish, we did a spinal tap. The examination of the cerebrospinal fluid revealed a mild increase in total protein, an increase in nucleated cell count with 139 cells per microliter, and normally we allow up to 5 cells per microliter.
And on the cytology we could see a mixed neutrophilic pleocytosis. And this confirmed our suspicion of SRMA. So we can see the neutrophils here in the CSF and then occasionally mononuclear cells, but mainly the neutrophils.
So SRMA stands for steroid responsive meningitis arthritis, which means inflammation of the meninges and arteries. SRA is an autoimmune disease. Sarrama typically affects dogs between 6 months and 18 months of age, and it becomes extremely rare in dogs older than 2 years.
Medium and large dog breeds are predisposed for SRMA, but it can affect actually any breeds, especially the Boxer Border collie and Bernice's mountain dog and beagle are predisposed. Dogs present with neck pain, sometimes also with back pain or multifocal spinal pain and yaxia. So we recommend normally the following tests for dogs where we suspect SRA.
So we recommend some blood tests, imaging of the vertebral column, and the spinal tap. So in the blood test we expect to see a neutrophilia. And If we do biochemistry and if we also run a C reactive protein, which is a marker for inflammation, we can see that the CRP is often increased.
Unfortunately, an increased CRP is a very non-specific finding, so we can also see that in dogs, for example, with discospoelitis. For the spinal tap, we actually recommend to do a cisternal and lumbar puncture, as these studies have shown that this increases the chance of a diagnosis. On the CSF analysis typically reveals a neutrophilic pleocytosis.
It is very important to warn the owners of dogs with suspected SRMA that a CSF tap carries an increased risk of haemorrhage due to arthritis. So imaging of the neck plus minus the back is important to rule out other conditions that can cause similar signs. Disco spondylitis or other types of of spinal infections such as osteomyelitis or supplear abscess are important to rule out as treatment with corticosteroids can worsen the infection.
In small breeds. It is also important to rule out an Atlantoaxial instability before doing a CSF tap, as flexing of the neck in a young dog with Atlantoaxial instability can cause severe neurological signs. Radiograph CT or MRI scan can be used as a screening tool.
MRI is often our most sensitive tool to pick up problems but unfortunately also the most expensive. Typical dogs with MRI dogs with SRMA have normal radiographs and CT scan of the vertebral column. On MRI, we can see that the meninges are taking up contrast.
The articular facets and muscles surrounding the vertebra can also show contrast enhancements. So these are MRI images of a dog with a CRA. On the left there is a T1 way that transfers pre-contrast image at a level of C3.
And on the right side, we have the same images but after a contrast administration. On the post-contrast image, we can see a contrast uptake of the muscles surrounding the vertebrae. As SRMA is a non-infectious immune-mediated inflammatory disease, corticosteroids are the preferred treatment for SRMA.
So we start with high immunosuppressive doses and slowly taper down. It is very important to treat talks with SRMA for a long time, as this can help to avoid relapses. Most dogs grow out of the disease when they reach the age of 2.
I've just provided a prednisolone schedule that I often use to treat my patients. So I often start with 4 milk per kg of prednisolone, once daily for 2 days, and then I reduce to 2 milk per cake, once daily for 2 weeks. Then I reduced to 1.5 mg per kg once daily for 4 weeks, then to 1 mg per kg once daily for 4 weeks and then I continued to slowly taper down the dose of prednisolone with 25% every 6 weeks.
Unfortunately, dogs who are treated with such a high dose of prednisolone develop significant side effects such as PPD, polyphagia, hair loss, and weight gain, and it is very important to warn the owners for that and to explain to them that the side effects will get better with time. So in some scientific articles, nonsteroidal anti-inflammatory drugs are mentioned as a possible treatment. For SMA in dogs who are particularly mildly affected and have a low nucleated cell count in the CSF analysis.
It is important to monitor these dogs closely if you treat them at NSAIDs. If they don't improve or they get worse, then it is important to switch to treatment with corticosteroids. We often get questions about a second immunosuppressive drugs.
Personally, I think I rarely need them for dogs with SRMA, but, sometimes it can be necessary if a dog suffers from frequent relapses or if the side effects of the corticosteroids are too bad that the quality of life of the dog is affected. There is a nice review article on SRMA, . That you can access where the doses of the different .
Immunosuppressive drugs are summarised. And this is the title of the article, and you can find more information about dosage in back in this article. So in general, the prognosis for SMA is good.
As we mentioned before, most dogs grow out of the disease when they become 2 years old. A mortality rate of 4 to 8% has been described in studies, and the reason for that or euthanasia or frequent relapses, haemorrhage, or complications secondary to immunosuppressive medication. Relapse rates of 15 to 60% have been described.
That is That that is 60% is quite high, but I think relapses can be avoided if you start with high enough doses of prednisolone and you treat for a long enough time. One, particular complication of SMA is haemorrhage. So some dogs with severe SMA developed a haemorrhage in the central nervous system.
This can just happen spontaneous or associated with a spinal tap. The haemorrhage can result in severe neck pain and sometimes in severe neurological deficits, such as tetraparesis or tetaplegia. Treatment of such a haemorrhage is most often conservative with corticosteroids and pain relief and good nursing care.
Most of the time, these dogs slowly recover with time. In literature, surgical treatment to remove the haemorrhage has been described as well. So the general prognosis for dogs who develop a haemorrhage is regarded.
Because of the severity of the signs and the line of recovery. So this here is a T2 star transverse image at the level of C1 from a dog that developed a haemorrhage secondary to SRA. So it's important to know that T2 star is a specific sequences that they used in MRI to look for haemorrhage.
Typical haemorrhage appears flat on Tar images, and on this image. You can see haemorrhage, dorsal and ventral to the spinal cord. So this dog, we treated him conservatively with steroids, and good nursing care, and lots of pain relief and rest, and in the, in the end, the dog was fine.
So our next case is Rosie. She is a 5 month old female entire cover group, and we saw her because of a 5 month history of collapsing episodes. You told us that the episode was typically triggered by an exercise of excitement.
And when Rosy had an episode. She, Appeared in severe pain, so was sometimes feeling on the outing, and she collapsed on her side with her limbs extended. During the recovery, Rosy appeared a taxic on her legs, and the owners also described that Roy, sometimes was cyanotic during a collapsing his legs.
So the first, so there are 2 videos. The first video is of all the main collapsing episode. She appears very vacant.
She's laying on her side. I think the owners are checking it if, if Rosa is still alive. Looks like she's gasping for air, and you can see that she has a very abnormal colour of tongue.
And then the 2nd episode, in the 2nd video is taken after the episode of collapse. So Rosie, her mentation is much better being around, but she does appear and a bit attack it on her for legs. Neon told us that often this just gradually improved the game in the hours after the episode.
So during the consult, the general physical examination was normal. Rosie initially was able to walk unaided, but during the neurological examination, Rosie had a collapsing episode where she screamed, she lied in later incumbency and became cyanotic. So after the collapsing episode, Rosie remained no and that rotator parity.
And based on the neurological document. Examination and localise the problem in the summonsified spinal cord segments. So my main differences at that time were syncopey due to cardiac or metabolic problem.
Congenital veral malformation, resulting in, one or axial instability, and, I could not fill out a very atypical epileptic seizure. As you know, epileptic seizures are typically wet dog is at rest and are not triggered by excitement or exercise. So we just started with a general blood test, which was normal.
And then we did a cardio workup, we, our cardiologist did an echo and also performed holter monitoring, and that was all normal. So, After that, we went for a CT scan and we could see on the CT scan that . There was a luxation at C1 C2, so there was dorsal displacement of C2 compared to C1.
And the dance of C2 appeared short and flattened. So just a bit more information about Atlanto axial instability. So Atlan of actual instability is the result of congenital vertebral malformation.
There can be hypoplasia or aplasia of the dance of C2 which we also call the axis. And sometimes there is absence or lexicity of the ligament a support of the dent. So this is a photo of a normal C2, also called axis.
And in this photo on the right, we can see how the axis articulates with the atlas so C1. So in this C2 the the length of the axis is normal. And it articulates ventrally with the floor with the ventral floor of the canal of C1.
So, small dogs, so typically the toy miniature dog breeds are predisposed for atlantoaxial instability. The dogs are often less than 2 years old when they develop clinical signs. Typical signs of neck pain, and sometimes they have neurological deficits such as tetaparessis and tetaplegia.
And in severe cases such as in Rose's case, we can see respiratory depression. So, Atlantoaxial instability is not so difficult to diagnose. You can use a radiograph, CT scan or MRI scan.
If you would consider surgery, CT scan is important for your surgical planning. So on the left, there is a lateral radiograph of the neck of a normal dog, and on the right, there is a lateral radiograph of a dog with Atlantoaxial instability. On the photo on the right, we can see that C2 is dorsally displaced compared to C1.
So there is a big gap between the roof of C1 and the spinous process of C2. So here we can see that the roof of C1 and the spinous process of C2 are nicely aligned. So, this is, the CT scan of, a normal dog again on the left with a normal dense of C2 and a nice alignment between C1 and C2.
And this is the CT scan of Rosie again, where we could see that C2 was dorsally displaced, from C1, and the dents at C2 was short and flat. And then to finish, I'll just show you an MRI scan. So this is a situated the sagittal image of the neck of a dog with a normal atlantoaxial joint.
And this is a 2 image of a dog with Atlantoaxial instability, where we can see that C2 is dorsal displaced compared to C1, and it's causing pressure on the spinal cord. The spinal cord also appears a little bit hyperintensive, which means that the spinal cord is confused. So atlantoaxial instability can be treated.
Conservative by resting the dog strictly, giving pain relief, and sometimes we put a neck brace. Unfortunately, Some dogs do not tolerate a neck brace very well, so you cannot always use a neck brace. Surgical treatment is often the preferred treatment.
During surgery, the atlanto a joint is stabilised. Lots of different techniques have been described, but the most common technique is, with a ventral approach to C1 and C2 and C1 and C2 are stabilised with scruce pins or pins and bone cement. Unfortunately, this asserted that does carry a high risk of complications.
And the main reason for that is that the vertebra of these dogs are so small. That blind placement of the screws is difficult, and there is a risk that the screws end up in the spinal canal. Luckily, there have been some developments and now it is Now it is possible to order 3D printed drill guides specific for your patients, and they can be extremely helpful to place the screws correctly.
So here we have some photos of surgical planning for an Atlantoaxial instability surgery. So these are the drill guides we use and they are made based on the images of the CT scan. So, this is actually a three dimensional reconstruction of a rosis CT scan post surgery.
So we stabilised the atlantoaxial joint with screws and a bone cement also called PMMA. So the alignment of C2 and C1 and C2 is good again. So Rosie actually did very well after her surgery and so far I think almost 2 years later, she, she never had an episode again.
So, case 4 is, . It's about Wayne and Wayne is a 1.5 year old lurcher, was presented because of a 1 month history of neck pain.
This started after running into a tree on a rock. Physical and neurological examination was normal except for neck pain. So we because of the suspicion that the trauma was the cause of the neck pain, we decided to do a CT scan and the CT scan of the neck revealed actually a complete transverse fracture of the vertebral body of C2.
Typically dogs with a fracture at C2, C3, they're extremely painful. So, after the diagnosis, we discussed the treatment with the owners and we discussed conservative treatment versus surgical. To help us to make a decision to go for conservative or surgical treatment, we often use the three compartment model.
So in the three compartment model, we divide the vertebral column in a ventral, a middle, and a dorsal compartments. So in the ventral compartment there is the ventral part of the vertebral body. The ventral longitudinal ligaments and the ventral part of the anallus of the disc.
In the middle compartment there is the dorsal part of the ventrial vertebral body, the dorsal longitudinal ligament. And the dorsal part of the analy. And then in the dorsal compartment, there is a spinous process, .
The lamina and the pedicles and the articular facets. And the, the recommendation is normally when 2 parts, 2 or more parts. Are affected, we see that we see that the spinal fracture is unstable and normally then surgical treatment would be the preferred Treatment choice.
So, in Wayne's case, we actually recommended surgical treatment, knowing that it would not be easy because we were already one month after the The fracture? But the owners, declined a surgical treatment. Our physios were very helpful, and they actually made a brace, especially for a way to help him to not move his head too much, and we advised to keep him strictly rested for another 6 weeks and then to start very gradually to build up his exercise.
I remember that in the first month, there was still an occasional pain episodes, but thereafter, Wayne recovered actually well, and I think now 6 or 7 months after his injury, he's still doing really well. So, conservative treatment. It's always an option, even dogs with a severe spinal fracture.
So our, last case is about Inta. She's a case I saw actually in December, just before Christmas, and she's a 2 month old giant Snzer. And she literally just moved to her new owners from the breather.
And one day after they got in fact, we noticed she became a bit quiet and that her her pelvic legs started to appear weak. And the weakness in her pelvic legs rapidly got worse. So on the, on the day of the consult, Inca appeared already parad and she also had a fever.
So there's a little video of Inca on the day of, the consult. So Inca did not have any movement at all left in her pelvic legs? And we also thought that she had a bit of a short strided cape in her thoracic legs.
I show you the video once more. She was also incontinent. And she also had a very flaccid tail.
So on the neurological examination, as you can see, Inca was quiet, but she was responsive. For she was paraplegic and as we discussed, she has a short strident gate of the thoracic legs. Examination of the cranial nerve was normal, .
And the spinal reflexes were normal, but we had a doubt about a presence of no deception. Posstrope reactions were absent in the pelvic legs, and we could find some back pain in the thoracic area on examination. So based on .
The neurological examination paraplegia with intact spinal reflexes, we localised the problem in the T3 3 spinal cord segments. Possible differentials also keeping in mind that she had a fever, where inflammatory and infectious conditions were probably highest on the list, but we could not rule out a congenital problem or neoplasia. The trauma was very unlikely as the owners had been with the puppy all the time and had not seen any trauma.
So we decided to do an MRI scan of Inca's back. On the left, image, you can see a T2 way the surge image of, the thoracic vertebral column. And on the right there is a T .
The one weighted transverse post contrast image at the level of T4. So on the image on the left we can see that the spinal cord is slightly swollen . Between T3, T4 until approximately T7 because we're losing the dorsal and ventral CSF column.
And also we can see a slight bulging of The disc here. On this post contrast the weighted images, we can see that there is a lot of contrast enhancement surrounding the. The vertebra but also at the level of the vertebra.
Which indicates that there's probably an inflammation or maybe an infection going on. So, for us, the MRI scan was compatible with inflammation or an infection, starting in the dorsal mediastinum and extending in the thoracic vertebral canal. Urine culture was negative, blood culture was positive for an unusual bacteria called erratia mics.
And, in the anti antibiogram, we could see that there was sensitivity to cephalexins. So we started to treat Inca with . Antibiotics, pain relief.
We also, she started some doing lots of physiotherapy, and, I think after a week, we started seeing a little bit of improvement and the owner took her home. Now 5 weeks later, Inca came back for the examination. To see her physios as well.
And luckily she was doing already much better. So, she recovered some good movement in her pelvic legs. She was actually at home almost able and.
To do a few steps. That's fine. Very well done.
Let me go back this way. She was still incontinent and I'm quite hopeful that this will just improve with time. So we'll keep her on on on antibiotics, probably for another.
3 months and once she's completely normal we might consider to stop the antibiotics knowing that there's a risk of a relapse. So Thank you so much for joining me in this presentation, and I hope you enjoyed it, and if you have any questions, you can always send me an email.

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