1

Practical NeurologyPains in the Neckand Back 3

Wendy Blount, DVM

Intervertebral Disc Disease

Prognosis – Type I Disc Dz• Very few outcome studies on medically

managed dogs• No deep pain

– 40-50% will walk again with medical treatment (stats before rehab)

– 60-80% will walk again with surgery– 33% of those that walk again will have

intermittent incontinence– Recovery of deep pain within 2 weeks

carries a good prognosis

• Length of time between loss of deep pain and surgery– Surgery sooner is better than later– 48 hour rule – no longer widely accepted

Intervertebral Disc Disease

Prognosis – Type I Disc Dz• Non-ambulatory with pain sensation

– 80-95% success with surgery

• Mean time from surgery to ambulation– 10-13 days for small dogs

– Much longer for large dogs

• Mean 7 weeks to ambulation

• 62% walking in 4 weeks

• 92% walking within 12 weeks

• Longer for older, heavier patients

• Back pain alone without neuro deficits– 24 of 25 of dogs improved with surgery

Intervertebral Disc Disease

Prognosis - Type I Disc Dz• More acute paralysis carries worse

prognosis– Those that go from walking to paralyzed in

less than one hour don’t do as well

– Those who go down gradually (1-2 days) have better prognosis

• Respiratory compromise– (Prognosis same with a ventilator)

– Prognosis grave without ventilator

• Dogs non-ambulatory from type II disease over weeks to months have worse prognosis than type I

Intervertebral Disc Disease

Prognosis - Type I Disc Dz• 20% of dogs who have back surgery

will have another episode of back pain with neuro deficits– Most do not require surgery

– Re-operate rate is <10%

– 40% recurrence when treated medically

• Dogs with 5 or more mineralized discs at surgery have 50% recurrence rate

Intervertebral Disc Disease

Prognosis - Type I Disc Dz• Ambulatory patients – Severe Cervical

Pain– 50-70% respond to medical therapy

– 30% will relapse within 2 years

– 15-20% will need surgery

• Ambulatory patients – Severe TL Pain– Nearly 100% respond to medical therapy

– 30-50% relapse within 2 years

– Relapse more common with prednisone than with NSAIDs or high dose MPSS

2

Intervertebral Disc Disease

Prognosis - Type II Disc Dz• Typically managed medically

– Injection of proteolytic enzymes into the disc holds promise (chymopapain)

• No outcome studies on surgical intervention– 10-15% success

Intervertebral Disc Disease

Progressive Myelomalacia• 5-10% of dog who lose deep pain

• Hemorrhagic necrosis and melting of the spinal cord

• Ascends and descends through the spinal cord (first sign?)

• HINT: cranial migration of panniculus

• Flaccid abdominal muscles

• Migrating flaccid paralysis

• Eventual respiratory paralysis

• Grave prognosis

Toby

• 3 yr M English bulldog– Owner seeks a second opinion for

difficulty breathing– Her regular vet did not refer her, and

in fact told me to be “very careful” with her when I called him

– Owner shows “high dollar” English Bulldogs and is a practicing attorney at 78 years of age

– Work-up for respiratory disease shows chronic aspiration pneumonia, which we are treating

– One his evening walk on Friday evening, Toby cannot rise to go outside

Toby

• Neurologic exam– Elevated respiratory rate and

hunched posture– Able to stand with assistance, but

not walk– Lower Lumbar Back pain– Normal front legs– 3+ patellar reflexes, crossed

extensor reflexes, minimal vol motor• Lesion localization: TL spinal cord• Radiographs

Toby

• Neurologic exam– Elevated respiratory rate and

hunched posture– Able to stand with assistance, but

not walk– Lower Lumbar Back pain– Normal front legs– 3+ patellar reflexes, crossed

extensor reflexes, minimal vol. motor• Lesion localization: TL spinal cord• Radiographs – hemivertebrae, butterfly

vertebrae• Dr. Mike Herron is the surgeon on call

– “I would not touch this surgery with a 10 foot pole”

Toby

• Toby does well with cage rest and analgesics– Respirations return to normal as

pain is controlled• He goes home walking in 2 weeks• Owner had just gotten off probation for

selling children– https://www.nytimes.com/1992/05/21/us/wo

man-gets-60-years-in-bid-to-sell-children.html

• Two years later, she had her own Justice Files episode

3

Congenital Spinal Malformation

Hemivertebrae

• wedge shaped – lateral, dorsal, ventral

Congenital Spinal Malformation

Butterfly vertebrae

• Central vertebral body fails to form

Congenital Spinal Malformation

Block vertebrae

• Fusion of two or more vertebrae

Congenital Spinal Malformation

Stenotic vertebral canal

Transitional vertebrae

• vertebrae of one spinal segment take on characteristics of another

• Thoracic vertebrae normally have ribs

• Sacral vertebrae normally are fused

• C, L and Co vertebrae are neither

• Results in different number of C, T, L or S vertebrae than usual

Congenital Spinal Malformation

• Common in “Screwtail breeds”– English Bulldogs, French Bulldogs

– Boston terriers, Pugs

• Some malformations are incidental findings – correlate with the neuro exam

• Much like Type II Disc Disease or Wobbler– If symptomatic, usually progressive

– Occasional acute decompensation

Congenital Spinal Malformation

Treatment

• Medical treatment if pain only or ambulatory with mild to moderate neuro deficits

• Surgery if non-ambulatory

• Because of abnormal anatomy of hemivertebrae, some surgeons think that surgery carries increased risk of destabilization

• Some surgeons won’t cut as long as there is voluntary motor, unless medical therapy has failed for a really long time

4

Chief

7 yr M GSD• Has gradually developed difficulty

rising in the rear limbs• Has gotten worse over the past year,

despite NSAIDs and joint supplements• CBC, GHP, UA, HW – NSAF• Exam – hair worn off the tops of the

toes on the rear feet, scabs, worn nails• Neuro Exam:

Chief

7 yr M GSD• Has gradually developed difficulty

rising in the rear limbs• Has gotten worse over the past year,

despite NSAIDs and joint supplements• CBC, GHP, UA, HW – NSAF• Exam – hair worn off the tops of the

toes on the rear feet, scabs, worn nails• Neuro Exam: gait

Chief

7 yr M GSD• Has gradually developed difficulty

rising in the rear limbs• Has gotten worse over the past year,

despite NSAIDs and joint supplements• CBC, GHP, UA, HW – NSAF• Exam – hair worn off the tops of the

toes on the rear feet, scabs, worn nails• Neuro Exam: gait

– Front limbs normal– Weak, swaying, stumbling gait in the

rear, short swing phase– Hops with rear legs at a run– Muscle atrophy in the rear limbs

Chief

• Neuro Exam: – Normal hopping on front legs– Short, weak hops on rear legs– CP deficits rear limbs– Cranial nerve and front limb reflexes

normal– Cutaneous trunci normal– Rear limb reflexes 0-1– No urinary or fecal incontinence

• Lesion Localization: lower SC• Spinal Rads: normal• Working Dx: Degenerative Myelopathy

Degenerative Myelopathy• Ascending axon and myelin

degeneration of the spinal cord

• Unknown initial cause - heritable

• GSDs and Boxer most commonly affected

• Postural tremor is common

• Paraparesis progresses to paraplegia, then incontinence

• DNA Test based on SOD1 mutation is available from a number of labs– U of Missouri

– OFA

– Optigen

– www.vetdnacenter.com – not for Bernese Mt Dogs

Degenerative Myelopathy

• Treatment – mixed results in clinical trials

– Aminocaproic acid 15 mg/kg or 500 mg/dog PO TID

– N-acetylcysteine 25 mg/kg PO q8h x 2 wks, then q8h QOD. The 20% solution should be diluted to 5% with chicken broth or suitable diluent

– (Prednisone 0.5-1 mg/lb/day x 10d, then QOD)

– Vitamins B, C (1g PO BID) and E (1000 IU PO BID)

• Aggressive PT can delay muscle atrophy and extend mobility

• Definitive Dx is necropsy histopath

5

Causes of Progressive Rear End Weakness without Pain

• LMN Reflexes– Degenerative Myelopathy

– Hypothyroidism Polyneuropathy

– Diabetic neuropathy

– Botulism

– Coonhound paralysis

– Tick paralysis

– End stage myasthenia gravis

• UMN Reflexes– Rottweiler Leukoencaphalomyelopathy

– Hereditary Ataxia of Jack Russell Terriers

– Afghan Hound Myelopathy

Petunia

• Sig – 4 year old SF DMH cat, outdoor• CC – can no longer jump up to reach

food bowl, seems wobbly• PE and Neuro

Dr. Girard Beekman

Petunia

• Sig – 4 year old SF DMH cat, outdoor• CC – can no longer jump up to reach

food bowl, seems wobbly• PE and Neuro

– Normal front limbs– Increase stride in the rear limbs w/ ataxia– Hyperreflexive patellar and ischiatic reflexes– Drags toes in the rear limbs – CP deficits– She bites you hard when you palpate TL

spine – neuro exam over

• Dx Plan – TL films

Petunia

• Sig – 4 year old SF DMH cat, outdoor• CC – can no longer jump up to reach

food bowl, seems wobbly• PE and Neuro

– Normal front limbs– Increase stride in the rear limbs w/ ataxia– Hyperreflexive patellar and ischiatic reflexes– Drags toes in the rear limbs – CP deficits– She bites you hard when you palpate TL

spine – neuro exam over

• Dx Plan – TL films normal

Petunia

• Owner declines referral, but approves lumbar CSF tap & FeLV Test– Increased microprotein, normal cell counts

– CSF Culture negative, FeLV Ag Negative

• Dx – likely neoplasia– LSA most likely

• Tx– Prednisone 10 mg daily

– Declines chemo or oncology referral

• Asymptomatic for one month– Then symptoms return, and progress to

paraplegia

– euthanized

– Necropsy confirms SC lymphoma

NeoplasiaPrimary Spinal Cord Neoplasia• Glioma

• Meningioma

• Nerve sheath tumors– Hemangiopericytoma, Schwannoma

– nephroblastoma - rare

• Lymphoma (most common in cats)

• PUSS (MFH)

Metastatic Spinal Cord Neoplasia• Lymphoma

• Carcinoma (mammary, prostate, TCC)

• Epidural mets – OSA, HSA

• Melanoma

• Lipoma, liposarcoma, myelolipoma

6

Neoplasia

Spinal Cord Neoplasia

• Dx

– Radiographs usually normal

• Unless tumor is mineralized

• Or invades bone

• Or is a nerve sheath rumor, enlarging the IV foramen

Suzy

• Sig – 10 year old SF Chi-MinPin mix• CC – coughing again• Hx – chronic bronchitis

–

• PE – TL spinal pain• Neuro – CP deficits rear legs• Dx plan

– CBC, GHP, lytes, UA – normal– TL spine radiographs

Suzy

• Sig – 10 year old SF Chi-MinPin mix• CC – coughing again• Hx – chronic bronchitis

–

• PE – TL spinal pain• Neuro – CP deficits rear legs• Dx plan

– CBC, GHP, lytes, UA – normal– TL spine radiographs

• DDx – osteomyelitis, neoplasia– Thoracic radiographs

Suzy

• Sig – 10 year old SF Chi-MinPin mix• CC – coughing again• Hx – chronic bronchitis

– PDA coil placed 10 years ago

• PE – TL spinal pain• Neuro – CP deficits rear legs• Dx plan

– CBC, GHP, lytes, UA – normal– TL spine radiographs

• DDx – osteomyelitis, neoplasia– Thoracic radiographs

• Large Solitary lung mass• PDA coil

Suzy

• Dx Plan– US guided aspirate of lung mass

– Cytology + culture

– Squamous cell carcinoma

– No need for culture

The same symptoms can develop a new cause

Always take 2 views

Neoplasia

Primary Vertebral neoplasia

• Osteosarcoma

• Chondrosarcoma

• Myeloma (plasma cell tumor)

Metastatic Vertebral Neoplasia

7

Neoplasia

Primary Vertebral neoplasia – less common

• Osteosarcoma**

• Chondrosarcoma

• Myeloma (plasma cell tumor)

• Fibrosarcoma

• hemangiosarcoma

Metastatic Vertebral Neoplasia – more common

• Distant metastasis– Carcinoma (prostate, mammary, lung)**

• Local invasion from sublumbar LN– Bladder carcinoma

– Anal sac tumor, perianal gland tumor

Neoplasia

Primary Vertebral Neoplasia – more common

• Osteosarcoma**

• Chondrosarcoma

• Myeloma (plasma cell tumor)

• Fibrosarcoma

• hemangiosarcoma

Metastatic Vertebral Neoplasia - less common

• Distant metastasis– Carcinoma (prostate, mammary, lung)**

• Local invasion from sublumbar LN– Bladder carcinoma

– Anal sac tumor, perianal gland tumor

Neoplasia

Presentation

• Usually middle aged to older

• Young dogs or cats– Lymphoma (median age 2-3 year)

– Nephroblastoma (6 months to 3 years)

– GSD

– Labrador Retrievers

• Onset usually progressive– Lymphoma sometimes acute

• Severe pain precedes motor deficits for cord tumors

• Neuro deficits come earlier for vertebral tumors

NeoplasiaDiagnosis

• Signalment– Cats with severe TL pain progressing to

neuro deficits - LSA

• Hyperglobulinemia and proteinuria with myeloma

• Bony tumors seen on survey rads

• CSF tap– Very rarely see neoplastic cells

– Increased protein without increased cells

– for LSA – send to CSU for flow and PARR

• SC tumors often require advanced imaging– (Myelogram, epidurogram), CT, MRI

Neoplasia

Treatment

• Anti-inflammatories for cord edema– Prednisone 0.5 mg/kg PO BID, taper

• Analgesics

• Chemotherapy for LSA or myeloma– Palliative piroxicam for carcinomas

• Decompressive surgery ????

• Palliative radiation

Neoplasia

Prognosis

• Grave for bony neoplasia

• Poor for cord neoplasias treated supportively– Short term can be good

• Days to weeks to months

– Grave long term

• Long term remissions sometimes possible with meningioma in some cats – Prognosis may not be determined without

histopath

• Most euthanized within weeks to months

8

Neoplasia

Monoparesis – Left Front, possible bilateral rear limb weakness

Dr. Amelia Foster

Neoplasia

Nerve Sheath Tumor

Curtis Dewey, DVM

Belle

Sig – 3 year old female Pit Bull Terrier

CC – laying around, eating fine, owner has $150

PE & neuro exam – mid-thoracic pain

Dx Plan – 1 lateral radiograph thoracic spine without sedation - normal

Tx Plan 1 –

• Deramaxx SID x 7 days and cage rest x 2 weeks

Belle

3 day follow-up call – back to normal, still doing cage rest

10 days after first visit – laying around again refuses to move, won’t eat

PE & neuro – pain at same spot is worse

Dx Plan – T spine films with sedation

Belle

3 day follow-up call – back to normal, still doing cage rest

10 days after first visit – laying around again refuses to move, won’t eat

PE & neuro – pain at same spot is worse

Dx Plan – T spine films with sedation

Dx – discospondylitis

Radiographs can be normal early in the course of discospondylitis

They don’t always have a fever

Belle

• Tx Plan 2 –– Baytril 5 mg/kg PO BID x 3 weeks

• Follow-up call in 2 weeks – Belle back to normal

• 3 months later – Belle won’t move again

• PE & Neuro – Temp 104oF, LS pain

• Dx Plan – lumbosacral radiograph with sedation, Brucella titer, urine culture

9

Belle

• Tx Plan 3 –– Baytril 5 mg/kg PO BID x 3 weeks

• Follow-up call in 2 weeks – Belle back to normal

• 3 months later – Belle won’t move again

• PE & Neuro – Temp 104oF, LS pain

• Dx Plan – lumbosacral radiograph with sedation, Brucella titer, urine culture– Brucella card test, IFA, TA all +

– Urine Culture no growth

• Ames, IA for culture confirmation & speciation (TVMDL will forward)

Belle

• Tx Plan 4

– OHE

– Streptomycin and tetracycline x 30 days, then recheck spinal rads

• Recheck spinal rads normal

• Many relapses – never could clear the infection, infection would move from IVS to IVS

• Belle was eventually euthanized

Belle

• Tx Plan 4

– OHE

– Streptomycin and tetracycline x 30 days, then recheck spinal rads

• Recheck spinal rads normal

• Many relapses – never could clear the infection, infection would move from IVS to IVS

• Belle was eventually euthanized

Discospondylitis

Infection of the Intervertebral discs & vertebral end plates

• Bacterial– Staphylococcus spp.– Brucella canis– Many others

• Less commonly Fungal• L7-S1 most common• If ambulatory, prognosis good for all

but Brucella– relapsing, chronic discospondylitis

• Diagnosis – radiographs, urine culture, Brucella serology, CSF culture, LS aspiration cytology & culture

Marti – “Doc’s Spicy Martini”

• Sig – 4 month old female golden retriever

• Stiffness, sore, was fine yesterday

• PE & Neuro – neck pain – rest of neuro exam normal, possible muscular pain, possible joint pain

• CBC – grans 20,600/ul, monos 2,000/ul, HCT 30%

• GHP/Lytes – phos 8.1

• UA – USG 1.003

• DDx– myositis, polyarthritis, meningitis, unnoticed

trauma, neoplasia

Marti – “Doc’s Spicy Martini”

• Dx Plan 2– Cervical rads with sedation – normal

– CPK – normal

• DDx– Meningitis, polyarthritis, neoplasia

• Rickettsial disease

• immune mediated

• Bacterial

• Fungal

• Neospora/Toxoplasma

• Lymphoma

• (Hepatozoon)

10

Marti – “Doc’s Spicy Martini”

• Tx Plan– Doxycycline 10 mg/kg divided BID x 3 weeks

– Clindamycin 15 mg/kg PO BID x 3 weeks

– Deramaxx 1 mg/lb PO SID

– Tramadol 3 mg/lg q 8hrs PRN for pain

3 days later….

• Marti is laterally recumbent & unwilling to move, but neuro exam normal, Temp 103.5oF– Immobility due to pain, neck pain suspected

– Joint pain can not be ruled out

• CBC, GHP, lytes, UA – no change

Marti – “Doc’s Spicy Martini”

• Dx Plan– CSF Tap

• Grossly normal

• Culture negative

Marti – “Doc’s Spicy Martini”• Dx Plan

– CSF Tap

• Grossly normal

• Culture negative

• Cytology – neutrophilic pleocytosis, hypersegmented segs, increased protein

• Fungal Ag (Histoplasma spp, Cryptococcus spp, Aspergillus spp, Blastomyces spp) - neg

– Joint Taps of stifles and elbows

– Urine culture – negative

– Hepatozoon PCR – negative

– Tick Panel – RMSF, Lyme, Ehrlichia – neg

– Toxoplasma/Neospora Titers – negative (Dx?)

• Diagnosis – Steroid Responsive Meningitis-Arteritis

Marti – “Doc’s Spicy Martini”

• Tx Plan– Prednisone 1 mg/lb (30 mg) PO divided BID x 2

weeks– Prednisone 10 mg PO BID x 4 weeks– Prednisone 10 mg PO SID x 4 weeks– Prednisone 10 mg PO QOD x 4 weeks– Prednisone 5 mg PO QOD x 2 weeks– If only partial response to 1 mg/lb divided

BID, go to 1 mg/lb PO BID x 1-2 weeks– Wean off pred very slowly over 4+ months– If any relapse of symptoms, inc. to previous

dose, repeat interval and try again to reduce– 50% will need lifelong pred at some dose, or

intermittently– If incomplete response to pred, can try

azathioprine, cyclosporine or other immunosuppressives

Immune Mediated Meningitis

Similar CSF results

• Culture negative

• Neutrophilic pleocytosis

• Elevated protein

All respond to immunosuppression

Different histopath on necropsy

Steroid Responsive Meningitis-Arteritis (SRMA)

Aka Aseptic Meningitis

• Nova Scotia Duck Tolling Retrievers (“Tollers”)

Immune Mediated Meningitis

• Nova Scotia Duck Tolling Retrievers (“Tollers”)

11

Immune Mediated Meningitis

Necrotizing vasculitis• Prognosis not as good as SRMA• Bernese Mt Dog, Beagle, GSP• “Beagle Pain Syndrome”Pyogranulomatous ME• Rapidly progressive, neck pain, brain

stem lesions, seizures, vomiting• PointersAseptic meningitis/polyarthritis of Akitas

Osteomyelitis

DDx• bacterial• FungalDx – FNA – cytology, C&S

Dr. Gary Old

Summary

PowerPoints• .pptx• .pdf – 1 slide per page• .pdf – 6 slides per page

Laboratory Information• CSU – Advanced Lymphoma

Diagnostics Submission Form

Summary

Client Handouts• Degenerative Myelopathy• Discospondylitis• Intervertebral Disc Disease• Nerve Sheath Tumors• Steroid Responsive Meningitis

Summary

Client Drug Handouts• Acetaminophen• Amantadine• Aminocaproic Acid• Amitriptyline• Bethenachol• Carprofen• Clopidogrel• Deracoxib• Dexamethasone• Doxycycline• Enrofloxacin • Famotidine• Firocoxib

• Fish Oil• Gabapentin

• Joint Supplements• Meloxicam• Methocarbamol• Omeprazole• Phenoxybenzamine• Prazosin• Prednisone• Sucralfate• Tramadol

• Tetracycline

Acknowledgements

Curtis Dewey, ACVIM (Neurology)Ronaldo C de Costa• Practical Guide to Canine and Feline

Neurology, 3rd ed. 2016.

Michael Connolly, DVM• Nacogdoches TX

Ann Katherman, ACVIM (Neurology)• Feline Neurology – VIN 2019

12

Acknowledgements

Amelia Foster, DVM• Naples FL

Girard Beekman, DVM• York ME