Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10S2018030
Abstract
Bogey is a 6-year-old male neutered Dachshund, who is deep pain negative following two prior hemilamminectomies. Acupuncture was added to the physical rehabilitation plan with the goal of improving gait quality. After three treatments, we found improved pelvic limb motor quality, including less dragging of the right pelvic limb.
History and Presentation
Bogey, a 6-year-old male neutered Dachshund, initially presented on 9/6/18. He was being treated prior for a 1 week history of difficulty walking with conservative management for suspected Intervertebral Disc Disease (IVDD). The morning of presentation he was dragging both pelvic limbs and was referred for a neurology consultation. A magnetic resonance imaging (MRI) scan was performed that showed a herniated intervertebral disc at L3-L4, and a L3-L4 right-sided hemilaminectomy was performed. Bogey recovered well, but continued to have negative nociception of bilateral pelvic limbs and tail. Due to his lack of improvement following the first surgery, repeated imaging was recommended. A computerized tomography (CT) scan showed a left-sided L3-L4 compressive lesion, and a left-sided hemilaminectomy was performed. Motor function continued to improve slightly after discharge. He began his physical rehabilitation program on 9-28-18. This program included a home exercise program with various exercises completed three times daily and once to twice weekly in-hospital sessions, consisting of therapeutic exercises, underwater treadmill and LASER therapy treatments. He improved during this program. Bogey began to walk on his own without assistance on 11-15-18, but continued to be nociception negative. His walk was functional, but involved dragging of the right. Bogey’s owners were interested in adding acupuncture to his treatment plan to help fine tune his pelvic limb gait.
Physical Examination and Clinical Assessments:
Body condition score (1-9): 5
Pain Score (0-4): 0
Pulse quality: Strong, synchronous
Mucous membranes: pink, <2 seconds.
Hydration status: Hydrated
Eyes: Clear. Normal eyelid margins. Fundic examination: Not performed.
Ears: Normal pinnae. No otic discharge.
Nose/nasopharyngeal passage: Normal nasal planum. No nasal discharge. Normal airflow through both nostrils. No evidence of stertor.
Oral cavity: Normal dentition. Mild dental calculus.
Cardiovascular: Normal heart rate.
Respiratory: Normal respiratory rate and effort.
Abdomen: Soft and non-painful. No distinct masses or organomegaly palpated.
Rectal examination: Not performed.
Integument and musculoskeletal: Normal hair coat. Symmetrical pelvic limb muscle atrophy
Neurologic:
Mentation: alert and appropriate
Cranial Nerves: intact menace with normal pupillary light reflex, palpebral and vestibular eye movements; no nystagmus
Gait: motor bilateral pelvic limbs, drags right pelvic limb, high extensor tone
Conscious Proprioception: absent bilateral HLs
Nociception: negative bilateral pelvic limbs and tail
Reflexes: decreased patellar bilateral pelvic limbs, normal withdrawal bilateral pelvic limbs, cutaneous trunci cut off T13
Myofascial: Taut bands- triceps, cervical musculature, thoracolumbar epaxials, quadriceps
Problem List:
Proprioceptive ataxia
Deep pain negative
Muscle atrophy bilateral pelvic limbs
Taut bands- triceps, cervical musculature, thoracolumbar epaxials, quadriceps
Differential Diagnoses
Proprioceptive ataxia
Vascular- embolus
Infectious- discospondylitis
Neoplastic- spinal cord tumor
Degenerative- degenerative disc material
Iatrogenic/Intoxication
Congenital- hemivertebrae
Autoimmune- autoimmune meningomyelitis
Traumatic- Acute non-compressive nucleus pulposus extrusion secondary to a fall or other trauma
Endocrine/Metabolic- hypothyroidism
Myofascia- restrictions in myofascia
Absent nociception
Vascular- embolus
Infectious- discospondylitis
Neoplastic- spinal cord tumor
Degenerative- degenerative disc material
Iatrogenic/Intoxication
Congenital- hemivertebrae
Autoimmune- autoimmune meningomyelitis
Traumatic- Acute non-compressive nucleus pulposus extrusion secondary to a fall or other trauma
Endocrine/Metabolic- hypothyroidism
Myofascia- restrictions in myofascia
Definitive Diagnosis
Based on the history, the clinical signs of proprioceptive ataxia and absent nociception are both explained by persistent damage to the spinal cord from intervertebral disc disease, even though this was treated surgically.
Medical Decision Making
After discussion with the owner, we elected to try one to two sessions per week of acupuncture. Our point selection would include points for pelvic limb dysfunction (e.g. ST 36 and GB 30) and points to treat myofascial discomfort (e.g. BL 21, BL 23).
Medical Acupuncture and Related Techniques
12-15-18 First treatment:
Points: GV 20, GV14, Bai Hui, ST 36 Right, GB 29 Right, GB 30 Right, BL 18 bilateral, BL 23 bilateral, Bafeng bilateral
Technique: dry needling
Needle selection: All Seirin J type 0.16 diameter 30mm length
12-19-18:
Points: GV 20, GV14, Bai Hui, ST 36 Right, ST 34 Right, GB 29 Right, GB 30 Right, BL 18 bilateral, BL 23 bilateral, Bafeng bilateral
Technique: dry needling
Needle selection: All Seirin J type 0.20 diameter 30mm length
12-26-18:
Points: GV 20, GV14, Bai Hui, ST 36 Right, ST 34 Right, BL 18 bilateral, BL 19 bilateral, BL 23 bilateral, Bafeng bilateral
Technique: dry needling
Needle selection: Seirin J type 0.20 diameter 30mm length (GV 20, GV14, Bai Hui, BL 18, BL 19, BL 23) and Hwato 0.20 diameter 25mm length (ST 36, ST 34, Bafeng)
12-29-18:
Points: GV 20, GV14, Bai Hui, ST 36 Right, ST 34 Right, GB 29 bilateral, GB 30 bilateral, BL 18 bilateral, BL 19 bilateral, BL 23 bilateral, Bafeng bilateral
Technique: dry needling
Needle selection: Seirin J type 0.20 diameter 30mm length (GV 20, GV14,) and Hwato 0.20 diameter 25mm length (Bai Hui, BL 18, BL 19, BL 23, GB 29, GB 30, ST 36, ST 34)
Outcomes
The addition of acupuncture to Bogey’s recovery has been very beneficial. By the third session, his owner reported that she found his gait pattern to be normalizing. He was also more playful with the other dog at home. On examination, he was supporting himself with his right pelvic limb better when walking. On video comparison, it is easy to see that he is not dragging his right pelvic limb as much. This change in his gait is likely related to the acupuncture alone, since we did not utilize any other modalities at the time of these treatments.
Discussion
The addition of acupuncture in this case helped to quickly improve the gait quality of this patient. One of the challenges during treatments has been keeping Bogey still during his sessions. We have been experimenting with different treat options to try to keep him still for his sessions. The most successful has been using a bully bone. Now that we are finding a way of keeping Bogey still, we will begin to utilize electroacupuncture in his future sessions.
We have been able to see significant progress utilizing dry needling alone, but the hope is that in future sessions we will be able to see even more significant progress with the utilization of electroacupuncture. It will be interesting to see if the absent nociception returns with the use of this modality. Joaquim et al. provides us with hope that we will continue to see improvement in this case. Their results that showed a significant improvement in deep pain perception in dogs treated with both decompressive surgery and electroacupuncture after six months. This paper was still lacking in sample size. The comparison of decompressive surgery alone and electroacupuncture alone provides interesting discussion points for future cases. Although not statistically significant, it sets up the potential for using electroacupuncture as a conservative management for deep pain negative dogs that do not undergo surgery immediately. This conservative management technique was described separately by Hayashi et al. They found that dogs that underwent conservative management with electroacupuncture had a faster return of function and a faster return of deep pain sensation compared to conservative management alone. Both these studies highlight the need for more randomized controlled studies in this area, so that we have more evidence behind recommending these options as a potential first line of therapy.
As for our present case, we have been able to see in a short period of time an improvement in motor quality. Only time will tell if he will fall into the group that regains pain sensation that was described by Joaquim et al.
References
Comparison of decompressive surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long-standing severe neurologic deficits. Jean G. F. Joaquim, Stelio P. L. Luna, Juliana T. Brondani, Sandra R. Torelli, Sheila C. Rahal, and Fernando de Paula Freitas Journal of the American Veterinary Medical Association, June 1, 2010, Vol. 236, No. 11 , Pages 1225-1229
Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs
Ayne Murata Hayashi, Julia Maria Matera, and Ana Carolina Brandão de Campos Fonseca Pinto
Journal of the American Veterinary Medical Association, September 15, 2007, Vol. 231, No. 6 , Pages 913-918