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When to refer Spinal Cases?

Ideally, any animal showing signs indicative of spinal pain and/ or neurological deficits should undergo thorough investigation to achieve a definitive diagnosis:    Only then can an accurate prognosis be offered, and rational advice be given, e.g.: non-surgical management of thoracolumbar disc disease (six weeks cage-rest) differs markedly from the management of ischemic myelopathy (early active physiotherapy), given that the two conditions often present with very similar signs. 

 

The decision to opt for surgical therapy is based primarily on the severity of the spinal lesion.  For a suspected thoracolumbar disc problem it is helpful to grade each case as below, as this will indicate the necessity for early referral and the likelihood of a successful outcome.

 

Clinical signs

Grade

Prognosis without surgery

Prognosis with surgery

 

 

Pain only

I

Good.  Requires cage-rest for a minimum of six weeks to reduce the risk of recurrence or worsening of grade.  Pain can often take 2-3 weeks to subside.

Suitable for cases with repeated bouts of (or unremitting) pain despite cage-rest.  Pain relief is usually rapid.  Post-operative cage-rest is not normally required.

Neurological deficits present, but still ambulatory

II

Good – see comments above.

As above.

 

Non-ambulatory, but urinary continent

III

Recovery is slower and occasionally less complete.  Deterioration of grade, despite cage-rest, is not uncommon.

Recovery is usually faster and more predictable.  Again, there is no necessity to cage-rest after surgery.

Urinary incontinent, but deep pain positive*

IV

Again, slow recovery, and risk of deteriorating grade.

Comments above apply.

 

 

No deep pain*

V(a)

Extremely guarded.  However, if surgery is not an option, a small minority of cases have recovered to grade II or better.  Requires prolonged, dedicated nursing.

If surgery is performed within 48hrs of the loss of deep pain, 50% of animals will improve to grade II or better.

No deep pain plus ascending loss of panniculus/ other spinal reflexes

V(b)

Euthanasia

Euthanasia

 

* - deep pain sensation should initially be assessed by squeezing the toes with a pair of artery forceps, until the animal shows distress by vocalising or turning towards the painful stimulus.  If the leg is withdrawn it is merely a demonstration that the local reflex arc is intact - seen even in cases where the cord has been completely transected.  Should no conscious reaction be seen, progress to using a pair of heavy-duty bone-holding forceps higher up the limb to firmly grasp a long bone.  It is possible to detect deep pain sensation in a significant number of cases that have shown no reaction to having the toes pinched.

 

In addition, it useful to is assess whether limb deficits are upper or lower motor neurone in character:

 

Signs

Upper motor neurone

Lower motor neurone

Limb muscle tone

Increased

Decreased

Spinal reflexes (e.g. patella/ withdrawal/ perineal)

Increased

Decreased

Urinary incontinence

Very full bladder – difficult to express

Bladder feels only part full, and is easily expressible

 

Irrespective of the grade or cause of the spinal lesion, animals with upper motor neurone signs have a significantly better chance of a full recovery, than those with lower motor neurone signs.

 

The use of steroid in spinal disease.

 

Quantitative evidence for a positive disease-modifying effect in the acute spinal patient has been demonstrated in humans, but only anecdotally in animals.  Current recommendations are to use 30mg/kg soluble methylprednisolone (Solu-medrone V, Pharmacia) slow i.v. within eight hours of the onset of signs, to be repeated up to two times, every eight hours.  The use of any other steroid preparation e.g. dexamethasone, will possibly have some mild analgesic effect, but may be deleterious to the cord, and GI tract.  It is better to resort to opiates, rather than low dose steroid/ NSAID’s, unless you can be sure the animal will not be referred for surgery.

 

 

 

 

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Last modified: December 08, 2003