Spinal Cord Diseases - Bush Veterinary Neurology Service...Vertebral Malformations • Many...

Spinal Cord DiseasesPart 2

Casey P. Neary, DVM, DACVIM (Neurology)Neurology/Neurosurgery8/20/17

• V – Vascular • I – Infectious / Inflammatory• T – Trauma• A – Anomalous• M – Metabolic• I – Idiopathic• N – Neoplasia• D – Degenerative

Anomalous• Vertebral malformations• Cysts / Diverticula• Cervical spondylomyelopathy (Wobbler)

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiTmejS6NjSAhWBeyYKHf_CAmoQjRwIBw&url=https%3A%2F%2Fwww.researchgate.net%2Fpublication%2F264937237_Surgical_treatment_of_dorsal_hemivertebrae_associated_with_kyphosis_by_spinal_segmental_stabilization_with_o_without_decompression&psig=AFQjCNEfa1l5XgoEAJYqvn9O3oyzOrk17w&ust=1489677818800380https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiTmejS6NjSAhWBeyYKHf_CAmoQjRwIBw&url=https%3A%2F%2Fwww.researchgate.net%2Fpublication%2F264937237_Surgical_treatment_of_dorsal_hemivertebrae_associated_with_kyphosis_by_spinal_segmental_stabilization_with_o_without_decompression&psig=AFQjCNEfa1l5XgoEAJYqvn9O3oyzOrk17w&ust=1489677818800380

Vertebral Malformations• Variety of neurologic symptoms Myelopathy Radiculopathy

• However… VAST majority are incidental findings / clinically

insignificant

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj_5dXghdvSAhUF6yYKHT-nCaUQjRwIBw&url=https%3A%2F%2Fwww.bonbonfrenchies.com%2Fbonbon-french-bulldog-maryland-frenchies&bvm=bv.149397726,d.amc&psig=AFQjCNEwAJ5gL0bkOs1umarB5xrC_VGv_w&ust=1489754270838031https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj_5dXghdvSAhUF6yYKHT-nCaUQjRwIBw&url=https%3A%2F%2Fwww.bonbonfrenchies.com%2Fbonbon-french-bulldog-maryland-frenchies&bvm=bv.149397726,d.amc&psig=AFQjCNEwAJ5gL0bkOs1umarB5xrC_VGv_w&ust=1489754270838031

Vertebral Malformations• Generally breed-associated• Exception Mucolipidosis

• Bulldog overrepresented Also…

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiml5GTh9vSAhXG1CYKHVkJAAUQjRwIBw&url=http%3A%2F%2Fwww.georgiadogs.com%2Fuga%2F&bvm=bv.149397726,d.amc&psig=AFQjCNHCRTKISJ-FKkuARGWKh3LlegI8zw&ust=1489754763582035http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiml5GTh9vSAhXG1CYKHVkJAAUQjRwIBw&url=http%3A%2F%2Fwww.georgiadogs.com%2Fuga%2F&bvm=bv.149397726,d.amc&psig=AFQjCNHCRTKISJ-FKkuARGWKh3LlegI8zw&ust=1489754763582035http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjUr6Wph9vSAhUHJiYKHbzJBiAQjRwIBw&url=http%3A%2F%2Fthehappypooch.com%2Fbest-dog-foods-for-pugs%2F&bvm=bv.149397726,d.amc&psig=AFQjCNHTOQQj8FuflIprZB4a0jyH-84ROw&ust=1489754809394948http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjUr6Wph9vSAhUHJiYKHbzJBiAQjRwIBw&url=http%3A%2F%2Fthehappypooch.com%2Fbest-dog-foods-for-pugs%2F&bvm=bv.149397726,d.amc&psig=AFQjCNHTOQQj8FuflIprZB4a0jyH-84ROw&ust=1489754809394948https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiU8bHEh9vSAhXC6CYKHWO9AOYQjRwIBw&url=https%3A%2F%2Fwww.theodysseyonline.com%2F13-reasons-boston-terrier&bvm=bv.149397726,d.amc&psig=AFQjCNERMvdp6b0lwuri_nrUs8m-si3MYw&ust=1489754874648730https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiU8bHEh9vSAhXC6CYKHWO9AOYQjRwIBw&url=https%3A%2F%2Fwww.theodysseyonline.com%2F13-reasons-boston-terrier&bvm=bv.149397726,d.amc&psig=AFQjCNERMvdp6b0lwuri_nrUs8m-si3MYw&ust=1489754874648730

Vertebral Malformations• Many different classification systems Stage of development

• Embryonic– Hemivertebrae– Wedge vertebrae– Butterfly vertebrae

• Fetal– Block vertebrae– Articular process hypoplasia

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjouOjPj-XSAhXHhFQKHdgtAdMQjRwIBw&url=http%3A%2F%2Fradiologyimages.blogspot.com%2F2011%2F01%2Fbutterfly-vertebra.html&psig=AFQjCNGu3qpoMgAtCXIfu_SkiTwj2T08Rg&ust=1490100611937752http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjouOjPj-XSAhXHhFQKHdgtAdMQjRwIBw&url=http%3A%2F%2Fradiologyimages.blogspot.com%2F2011%2F01%2Fbutterfly-vertebra.html&psig=AFQjCNGu3qpoMgAtCXIfu_SkiTwj2T08Rg&ust=1490100611937752

Vertebral Malformations

http://rad.washington.edu/about-us/academic-sections/musculoskeletal-radiology/teaching-materials/online-musculoskeletal-radiology-book/scoliosis/

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwj0rOGwj9vSAhXF4SYKHej0BskQjRwIBw&url=http%3A%2F%2Frad.washington.edu%2Fabout-us%2Facademic-sections%2Fmusculoskeletal-radiology%2Fteaching-materials%2Fonline-musculoskeletal-radiology-book%2Fscoliosis%2F&psig=AFQjCNEKO1sgZ7MoCj48EsAsjcnXizhw_w&ust=1489756970439178http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwj0rOGwj9vSAhXF4SYKHej0BskQjRwIBw&url=http%3A%2F%2Frad.washington.edu%2Fabout-us%2Facademic-sections%2Fmusculoskeletal-radiology%2Fteaching-materials%2Fonline-musculoskeletal-radiology-book%2Fscoliosis%2F&psig=AFQjCNEKO1sgZ7MoCj48EsAsjcnXizhw_w&ust=1489756970439178

Articular Process Hypoplasia• Hypoplasia or aplasia• Pugs

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjCwq6LpODSAhUGOSYKHbMtBLcQjRwIBw&url=http%3A%2F%2Fwww.andrewmoultonmd.com%2Fspine-anatomy.php&bvm=bv.149760088,d.eWE&psig=AFQjCNGxw1Tzm7sXtZ1dYC-O6JHuBJJm6Q&ust=1489934182235339http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjCwq6LpODSAhUGOSYKHbMtBLcQjRwIBw&url=http%3A%2F%2Fwww.andrewmoultonmd.com%2Fspine-anatomy.php&bvm=bv.149760088,d.eWE&psig=AFQjCNGxw1Tzm7sXtZ1dYC-O6JHuBJJm6Q&ust=1489934182235339

Articular Process Hypoplasia• “Pug Myelopathy”• Hypoplasia / aplasia of

caudal articular facets Thoracolumbar region

• Leads to chronicinstability and secondaryfibrous band Constrictive

myelopathy(J Am Vet Med Assoc 2013;242:223–229)

Vertebral Malformations• Diagnostics Radiography

• Most are easily identified MRI

• Cross-sectional analysis• Spinal cord compression• Other abnormalities

– Disc– Cyst / diverticula

Vertebral Malformations• Treatment Dependent on…

• Significance• Type• Number• Severity• Stability

Vertebral Malformations• Treatment Medical management

• Strict confinement• NSAIDs vs. steroids• Analgesic therapy

Surgery• Rarely performed…

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwi98_vqjeDSAhVRgSYKHXSGAaIQjRwIBw&url=https%3A%2F%2Fwww.amazon.com%2FCarlson-Secure-Compact-Single-Metal%2Fdp%2FB00MYDZIBM&psig=AFQjCNEgjS2npYe2vyVWAPA0ao_A4Jb9lQ&ust=1489928355000178https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwi98_vqjeDSAhVRgSYKHXSGAaIQjRwIBw&url=https%3A%2F%2Fwww.amazon.com%2FCarlson-Secure-Compact-Single-Metal%2Fdp%2FB00MYDZIBM&psig=AFQjCNEgjS2npYe2vyVWAPA0ao_A4Jb9lQ&ust=1489928355000178

Vertebral Malformations• Surgical Management More common to address secondary disease

• Block vertebrae– Disc

• Hemivertebrae– Cyst / diverticula

Vertebral Malformations• Surgical Management Simple

• Dorsal laminectomy• Hemilaminectomy

Complex• Requiring stabilization

“Chewy”

• 4 month old Chihuahua mix

• Weak / wobbly in PL since adoption

“Chewy”

“Chewy” MRI

“Chewy” CT

T6-7 T13

“Chewy”

Chewy’s 3D model

“Chewy”

Post-op radiographs

Right lateral

VD

Vertebral Malformations

• The 4 Questions Onset?

• Chronic– Months to years

Progression?• Slowly progressive

Symmetry?• Usually symmetric

Painful?• No

Spinal Arachnoid Diverticula• Focal dilations of the subarachnoid space• Formerly known as cysts• More common in brain

https://www.researchgate.net/figure/262810151_fig2_Transverse-plane-CT-myelogram-CT-image-showing-the-focal-accumulation-of-contrast-medium

Spinal Arachnoid Diverticula• Compressive myelopathy• Most common symptom Proprioceptive ataxia

• Two groups of dogs Cervical

• Large breed dogs– Rottweiler

Thoracolumbar***• Frenchies and Pugs

Spinal Arachnoid Diverticula• Corkscrew tail breeds• Very common to have concurrent disease

adjacent to SAD

Spinal Arachnoid Diverticula• Diagnostics CT / myelogram? MRI!!

• Diagnosis– FLAIR

• Also…– Cord changes

» Edema, gliosis

– Concurrent diseases

“Francisco”

Spinal Arachnoid Diverticula• Treatment Medical management

• Prednisone (low dose)• Omeprazole• +/- furosemide, acetazolamide

Surgery• Laminectomy• Durotomy• Marsupialization

Spinal Arachnoid Diverticula• Prognosis Medical therapy

• Unknown – no studies to date• “Guarded”

Surgery• ~63% - improved• ~37% - worsened

Spinal Arachnoid Diverticula


• Chronic– Months to years

Progression?• Slowly progressive


Painful?• No

Cervical Spondylomyelopathy• “Wobbler syndrome”• Condition of large and giant breed dogs• Static or dynamic compression Spinal cord Nerve roots pain and spinal cord dysfunction

• Causes Genetic, congenital, conformational, nutritional

Cervical Spondylomyelopathy• Breeds Great Dane, Doberman,

Basset

• Pathogenesis Multifactorial Canal stenosis from disc,

ligament, joint capsule, bone, vertebral instability, among others…

Cervical Spondylomyelopathy• Two forms Doberman

• Older dogs (6.8 years)• Caudal cervical• Disc-associated

Great Dane• Younger dogs (3.8 years)• Cranial-to-mid cervical• Osseous-associated

Cervical Spondylomyelopathy• Basset hound Unique form of disease JVIM, 2012, De Decker et. Al Dorsal lamina & spinous

process hypertrophy leads to ligamentum

flavum hypertrophy

Basset Spondylomyelopathy

“George” – 5 mo Basset Hound

Cervical Spondylomyelopathy• Diagnostics CT / Myelography MRI

• Diagnosis• Dynamic vs. static• Cord changes***

“Fitz” – 2 yo MN Great Dane

Cervical Spondylomyelopathy• Treatment Medical

• Prednisone!• Gabapentin• Controlled exercise

Surgery• Dependent on type, extent, severity• Ventral slot, dorsal laminectomy• +/- stabilization• Disc replacement??

http://dogquality.com/blogs/senior-dog-blog/18091711-cervical-disc-replacement-in-dogs

Cervical Spondylomyelopathy• The 4 Questions Onset?

• Chronic, Acute-on-Chronic

Progression?• Progressive


Painful?• Osseous-associated

– 50/50• Disc-associated

– Yes!

Neoplasia• Primary Arising from the spinal cord or meninges

• Secondary Adjacent

Primary SC Neoplasia

• Can be broken into 2 categories Intramedullary Intradural, extramedullary

http://sevneurology.com/lupa-spinal-tumor/

Intramedullary SC Neoplasia

• Uncommon ~15% of spinal cord tumors

• 2/3 are primary Neuroepithelial

• Glial cells• Ependyma

• 1/3 are secondary Metastatic


• Primary tumors More common…

• Young dogs• Cervical spinal cord

• Secondary More common…

• Older dogs• Thoracolumbar spinal cord

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjk6daZv-DSAhVLOiYKHWtMCB4QjRwIBw&url=http%3A%2F%2Fjournal.frontiersin.org%2Farticle%2F10.3389%2Ffvets.2015.00039%2Ffull&bvm=bv.149760088,d.amc&psig=AFQjCNFGavszNk5l_4kfp6HrkkZZ7cie_A&ust=1489941607221577http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjk6daZv-DSAhVLOiYKHWtMCB4QjRwIBw&url=http%3A%2F%2Fjournal.frontiersin.org%2Farticle%2F10.3389%2Ffvets.2015.00039%2Ffull&bvm=bv.149760088,d.amc&psig=AFQjCNFGavszNk5l_4kfp6HrkkZZ7cie_A&ust=1489941607221577


• Primary tumors Mean age is 5.9 years Most common is ependymoma

• Followed by– Astrocytoma– Oligodendroglioma

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiztITzv-DSAhVCOyYKHXZwAIYQjRwIBw&url=http%3A%2F%2Femedicine.medscape.com%2Farticle%2F1744030-overview&bvm=bv.149760088,d.amc&psig=AFQjCNEo8rP0EJ11-rK2DxK8OAO6-SHHgQ&ust=1489941800300339http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiztITzv-DSAhVCOyYKHXZwAIYQjRwIBw&url=http%3A%2F%2Femedicine.medscape.com%2Farticle%2F1744030-overview&bvm=bv.149760088,d.amc&psig=AFQjCNEo8rP0EJ11-rK2DxK8OAO6-SHHgQ&ust=1489941800300339


• Secondary / metastatic tumors Mean age is 10.8 years Most common…

• Hemangiosarcoma• TCC• Prostatic carcinoma• LSA?

Intramedullary Neoplasia


• Acute-to-chronic


Symmetry?• Often symmetric

Painful?• Nope!!

Intradural, Extramedullary

http://www.neuroradiologycases.com/2011/08/nerve-sheath-tumour.html


• Meningioma Most common in dogs Arises from arachnoid granulation of meninges

• Locations– Cervical most common

Grades• I-III

Types• Numerous!!

Transitional Meningioma

Sturges et. al. J Vet Intern Med 2008;22:586–595

Meningothelial Meningioma


Angiomatous Meningioma


Microcystic Meningioma


Meningioma

• Treatment Palliative care Oral chemotherapy

• Hydroxyurea Surgery alone

• 1410-1440 days (Levy et. al 1997)• 19 months (Petersen et. al 2008)

Surgery + Radiation• ??? Likely longer…


• Nerve sheath tumors Types

• Schwannomas• Neurofibromas• Neurofibrosarcomas

Nerve Sheath Tumors

Nerve Sheath Tumors

• Treatment Palliative care Radiation

• 371 ± 30 days Surgery alone

• 6-9 months Surgery + Radiation

• ??? Likely longer…

Nephroblastoma

• “Thoracolumbar tumor of young dogs”• Embryonal tumors of the kidneys• Neoplastic transformation of blastemal cells Retroperitoneal primary renal tumor Within dura spinal tumor

• T10-L3• GSD, Golden retrievers

Nephroblastoma

• Age at onset 5-48 months

• Median 14 months

• Progressive symptoms T3-L3 Paraparesis / ataxia to

paraplegia

Nephroblastoma

Nephroblastoma

• Treatment Medical management Surgery

• Dorsal / hemilaminectomy• Durotomy

• Prognosis Poor

• MST 30 days in all dogs• Surgical resection

– MST 70.5 days

Extradural Tumors

• Vertebral tumors Osteosarcoma Fibrosarcoma Chondrosarcoma Multiple myeloma Lymphoma Metastatic…

Extradural Tumors

• Other sites Soft tissue Abdominal Retroperitoneal Esophageal

ID-EM and Extradural Tumors


• Acute-to-chronic


Symmetry?• ED Symmetric • ID-EM Asymmetric

Painful?• Most are…

– Meninges, nerve, muscle

Degenerative• Intervertebral disc disease (IVDD)• Degenerative myelopathy (DM)

Max,7 yr, MN Dachshund

Max – The Situation

• 2 days ago – sudden onset not walking, painful

• 1 day ago – pcDVM - paralyzed and no deep pain

• Your exam – quite the same

• Diagnosis ? Prognosis?

Max – The truth

• Came in through ER (~8PM)• Plegic, DPP (NEGATIVE)

• Advised to wait til AM to have MRI

• 8AM• Exam unchanged.

Outcome

• Left hemilaminectomy at T12-T13 with removal of massive amount of paste-like disc

• Grossly normal spinal cord

• Weakly ambulatory at discharge 2 ½ days later

Ito D, et. al. Prognostic value of magnetic resonance imaging in dogs with paraplegia caused by thoracolumbar intervertebral disc extrusion: 77 cases (2000-2003). J Am Vet Med Assoc. 2005; 227: 1454-60

Deep Pain Negative & Hemilaminectomy

T2 Signal Changes

Number Recovered

Success Rate

None noted 13/13 100%

< 3x length L2 4/6 66%

> 3 x length L2 1/10 10%

Totals 18/29 62%

Deep Pain Positive & Hemilaminectomy

T2 Signal Changes

Number Recovered

SuccessRate

None noted 31/31 100%

< 3x length L2 11/12 92%

> 3 x length L2 2/5 40%

Totals 44/48 92%

• MRI findings best predictor of outcome in paraplegic dogs

• Generally success rates are 92% and 62%, in DPP+, DPP – respectively

MRI as predictor of outcome

• Allows for evaluation of SC health• Without MRI Prognoses range from 10-100%

• “50/50”

• MRI allows for… Establishment of diagnosis Accurate prognosis!

Why wait??

• Our beliefs Diagnostic and prognostic value of MRI is worth the wait CT / myelogram?? Little harm in waiting

• 2 components of injury caused by disc rupture 1) Concussive internal injury sustained at moment

of impact• Most important / fate is sealed at time of rupture

2) Ongoing compression

Why MRI for Type I Disc Disease?

• MRI consistently superior to myelography for determining lesion localization and lateralization (Bos)

• Correlation between MRI and surgical findings is 100% for lesion localization and lateralization (Besalti, Naude )

• Superior to deep pain status in determining outcome in paraplegic dogs

Besalti, O, et. al. Can Vt J. 2005: 46: 814-20.Bos AS. University of Guelph. 2008: 113-49Naude SH, JAVMA 2008; 232: 702-8.

No harm in waiting…

• JAVMA 2016 Jeffery et. al

• Goals of study Identify factors associated with recovery of

locomotion

• 78 dogs that underwent spinal surgery for IVDD Iowa State, TAMU, UK

JAVMA 2016 cont.

• Results No evidence that prognosis for recovery of

ambulation was related to time from onset of non-ambulatory state or loss of DPP

• Conclusion “Immediacy of surgical treatment had no

apparent association with outcome” Rather, the prognosis strongly influenced by

nature of initiating injury

Further Evidence…

• JAVMA 2003 Olby et. al Study on spinal trauma

• Including IVDD, HBC, etc. Outcome was not associated with duration of

paraplegia Additionally, 0% of DPP(-) dogs recovered that

had suffered “trauma” (fracture, subluxation, etc.)

Further Evidence…

• JSAP 1999 Scott, McKee No statistical significance to show duration of loss

of DPP impacted the prognosis

• JAVMA 2005 Ito et. al Duration of clinical signs

• Not associated with outcome

However….

• We do still recommend prompt establishment of diagnosis and prognosis

• Surgical intervention (if indicated) Sooner rather than later.

Type I Disc Disease

Intervertebral Disc Degeneration

Brisson, B. Vet Clin Small Anim. 2010; 40:829-858.

Type I - Breeds

• Overall prevalence = 2% (Bray, 1998)• Dachshunds (20%), Pekingese, beagle, cocker

Type I – Age

• Chondrodystrophic: 3-7 years• Non-chondrodystrophic: 6-8 years

- Large breed dogs: mixed, German Shepherd, Labrador, Rottweiler, Dalmatian, Doberman

Surgery vs. Medical Management?

• In general with an isolated disc rupture… Surgery

• Prognosis with surgery is >95%• Quicker recovery• Low recurrence with fenestration

– ~8%

Medical management• Fair prognosis• Recurrence rates

– 30-50%

Medical

• What are we trying to accomplish?

• Rest is key!!!! All medically managed cases

will be more likely to fail if not rested.

• So, rest (not medication) is more important!

NSAIDS > Steroids

• NSAID therapy associated with higher satisfaction (better pain control, fewer side effects) via questionnaire (Levine)

• Administration of steroid is associated with higher rate of GI and urinary complications causing increased hospital stay

• NSAIDS lower recurrence rate than prednisone (Mann)• Steroids impair healing (annulus)

Levine JM, et. al. Vet Surg.2007; 36: 482-91.Mann FA, et. al. J Emer Crit Care. 2007; 17: 53-60.

Medical

• My preference NSAID

• Meloxicam, Carprofen Gabapentin Tramadol Muscle relaxer

• Other Urinary status

Surgery

• Best if done sooner…• If delayed >2 weeks Prognosis could worsen Why?

• Disc material analogy• If delayed…

– Adhered to dura, vessels– More challenging– More dangerous

Type 1 Disc Summary

• Not as time sensitive as once thought. Down ≠ Down n’ Out

• Recommend referral in all dogs with suspected disc disease Establish diagnosis and PROGNOSIS

• Educate owners of risks associated with medical management Recurrence Surgery for chronic discs

Type 1 Disc


• Peracute-to-acute


Symmetry?• Often subtly asymmetric

Painful?• Yes!

Disc Disease – Type 2

• Signalment Large breed dogs 6-8 years GSD, Lab, Golden

Disease Physiology

• Disc degeneration• Fibrous form of

metaplasia nucleus pulposus

replaced with fibrocartilage

weakening of the dorsal annulus

protrusion, bulging of annulus

Type 2 - Signs / Progression • Lumbosacral (L7-S1) disc protrusions

• Slow to rise / sit• Paraparesis• Poor reflexes• Incontinence• Tail abnormalities• Pain

• Low cervical disc protrusions (Disc associated Wobbler’s syndrome or DAWS)• Tetraparesis• Tetra-ataxia• Pain

Surgery and L7-S1 Type II Disc

• Dorsal laminectomy with fenestration• 131 cases, GSD, painful / reluctant to jump, rise, climb

stairs, 93% improved, 17% recurrence rate (Danielsson)• 69 cases, various grades, 78% good outcome (De Risio)

- Urinary or fecal incontinence has a worse prognosis - Chronic urinary incontinence predicts poor outcome

• DO NOT confuse with orthopedic disease and wait to address the problem until incontinent

Danielsson F, et al Vet Surg 1999;28(2):91-98.De Risio L, et al. JAVMA 2001;219(5):624-628.

Type 2 Disc


• Chronic



Painful?• Yes

IVDD in Cats??

• Yes!• Far less common• Older• Lumbar disc disease L4-L5

• Type 1 > Type 2• Outcome similar to dogs

“Amy” – 11 yo FS Balinese

Degenerative Myelopathy

• First described in 1973 Non-specific degeneration

• Most dogs in initial reports were GSD

• However, common in several other breeds Overall prevalence of

0.19%


• Cause Mutation in superoxide dismutase 1 gene

• SOD1• Antioxidant / free radical scavenger

Amyotrophic lateral sclerosis• ALS / Lou Gehrig’s disease• Differences

– Neuron vs. axon


• Progressive disease in older dogs 8-14 years

• Large breed dogs GSD, Boxer, CBR Mean age of 9 yo

• PWC Mean age of 11 yo.


• Clinical Progression Spectrum of symptoms

• Proprioceptive ataxia, paraparesis

– T3-L3 spinal cord segments

• Progress to non-ambulatory state (6-20 months)

– LMN paraplegia– tetraplegia– brainstem signs


• Antemortem Diagnostics MRI

• Diagnosis of exclusion / presumptive diagnosis

– Normal MRI– Cord atrophy

CSF• Normal• High protein


• Genetic test Mizzou OFA

• Samples Cheek swab Whole blood

• Results

• Treatment? No definitive treatment Supportive care

• Exercise/physical therapy• Vitamin supplementation?

Good nutrition Weight control




• Chronic!


Symmetry?• Often symmetric

Painful?• No.

Take Home Points

• MRI is the best diagnostic modality to evaluate spinal cord health, determine an accurate prognosis and to plan appropriate therapy

• Not everything is a disc!!!

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Any Questions??

�Spinal Cord Diseases�Part 2�Slide Number 2AnomalousVertebral MalformationsVertebral MalformationsVertebral MalformationsVertebral MalformationsArticular Process HypoplasiaArticular Process HypoplasiaVertebral MalformationsVertebral MalformationsVertebral MalformationsVertebral MalformationsVertebral Malformations“Chewy”“Chewy”“Chewy” MRI “Chewy” CT“Chewy”Chewy’s 3D model“Chewy”Post-op radiographsVertebral MalformationsSpinal Arachnoid DiverticulaSpinal Arachnoid DiverticulaSpinal Arachnoid DiverticulaSpinal Arachnoid Diverticula“Francisco”“Francisco”Spinal Arachnoid DiverticulaSpinal Arachnoid DiverticulaSpinal Arachnoid DiverticulaCervical SpondylomyelopathyCervical SpondylomyelopathyCervical SpondylomyelopathyCervical SpondylomyelopathyBasset SpondylomyelopathyBasset Spondylomyelopathy“George” – 5 mo Basset HoundCervical Spondylomyelopathy“Fitz” – 2 yo MN Great DaneCervical SpondylomyelopathyCervical SpondylomyelopathySlide Number 44NeoplasiaPrimary SC NeoplasiaIntramedullary SC NeoplasiaIntramedullary SC NeoplasiaIntramedullary SC NeoplasiaIntramedullary SC NeoplasiaIntramedullary NeoplasiaIntradural, ExtramedullaryIntradural, ExtramedullaryTransitional MeningiomaMeningothelial MeningiomaAngiomatous MeningiomaMicrocystic MeningiomaSlide Number 58Slide Number 59MeningiomaIntradural, ExtramedullaryNerve Sheath TumorsNerve Sheath TumorsNephroblastomaNephroblastomaNephroblastomaSlide Number 67Slide Number 68NephroblastomaExtradural TumorsSlide Number 71Slide Number 72Extradural TumorsID-EM and Extradural TumorsSlide Number 75DegenerativeMax,� 7 yr, MN DachshundMax – The SituationMax – The truthMRIOutcomeSlide Number 82MRI as predictor of outcomeWhy wait??Why MRI for Type I Disc Disease? No harm in waiting…JAVMA 2016 cont.Further Evidence…Further Evidence…However….Type I Disc DiseaseIntervertebral Disc DegenerationType I - Breeds�Type I – Age Surgery vs. Medical Management?MedicalNSAIDS > SteroidsMedicalSurgeryType 1 Disc SummaryType 1 DiscDisc Disease – Type 2Disease PhysiologyType 2 - Signs / Progression Slide Number 105Surgery and L7-S1 Type II Disc Type 2 DiscIVDD in Cats??“Amy” – 11 yo FS BalineseDegenerative MyelopathyDegenerative MyelopathyDegenerative MyelopathyDegenerative MyelopathyDegenerative MyelopathyDegenerative MyelopathySlide Number 116Degenerative MyelopathyTake Home PointsReferencesReferencesAny Questions??

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