Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10S2018036
Abstract:
A 15-year-old male neutered American Eskimo dog was referred for evaluation following falling down a flight of stairs resulting in nonambulatory tetraparesis. The patient was diagnosed with a C3-4 traumatic disk herniation and the owner elected nonsurgical management. The patient began rehabilitation sessions including acupuncture and showed motor improvement but was euthanized one month after the incident due to the anxiety of the patient. During the course of treatment, the patient also developed a soft tissue injury to the left elbow.
History and Presentation:
A 15-year-old male neutered American Eskimo dog was referred to the IndyVet Emergency and Specialty Hospital neurology service after falling down a flight of stairs resulting in nonambulatory tetraparesis. Prior to this event, the patient had a history of paraparesis of the pelvic limbs due to lumbosacral disease and bilateral hip pain which he had been undergoing rehabilitation for during the prior three months. Treatment at that time included laser therapy, controlled exercise, and underwater treadmill walking. He also had a history of nonsteroidal anti-inflammatory drug (NSAID) gastrointestinal sensitivity. The patient was believed to have a cervical myelopathy and magnetic resonance imaging (MRI) was performed which revealed a C3-4 traumatic disk herniation. The owner elected nonsurgical management and the patient was hospitalized for seven days with treatment consisting of laser therapy of the cervical spine and twice daily (BID) administration of omeprazole (1.4 mg/kg), famotidine (0.73 mg/kg), metronidazole (9.1 mg/kg), tramadol (5.1 mg/kg) and gabapentin (13.7 mg/kg). The patient had received injections of depo-medrol and dexamethasone from the referring veterinarian before presentation. Seven days after presentation, the patient was discharged and resumed treatment through the rehabilitation department. During the patient’s recovery, he began to frequently struggle to prop himself up in a sternal position which resulted in a soft tissue injury to the left elbow which was confirmed by radiographs taken of the limb. Due to the left elbow pain and the patient’s increasing anxiety, prednisolone (0.38 mg/kg) at a twice daily tapering dose and methocarbamol (19.2 -38.5 mg/kg) and trazodone (1.9 -3.8 mg/kg) at a two to three times daily frequency were also prescribed. Twice daily administration of carprofen (1.9 mg/kg) was begun once the patient had discontinued prednisolone due to the need for better pain control.
Physical Examination and Clinical Assessments:
Upon presentation to the neurology service, the patient was nonambulatory tetraparetic with normal motor of the left limbs and minimal motor of the right limbs with postural reactions absent in all but the left thoracic limb. In all limbs, spinal reflexes were normal to increased and deep pain sensation was intact. A cranial nerve exam noted an absent menace and decreased pupillary light response in both eyes due to mature cataracts and iris atrophy. The patient was determined to have a cervical myelopathy. MRI confirmed a C3-4 traumatic disk herniation with mild extradural compression. The patient also had a severe chronic disk herniation at T12-13 and mild disk protrusions at C4-5, C6-7, and T13-L1. Evaluation by the rehabilitation department after seven days of hospitalization had an unchanged neurologic examination with the addition of pain noted on palpation of the mid cervical spine and near the thoracolumbar junction. Musculoskeletal palpation revealed generalized muscle atrophy of the front and rear limbs with the supraspinatous, infraspinatous, deltoid, lateral and long heads of the triceps brachii, biceps brachii, sartorius, vastus lateralis, vastus medialis, rectus femoris, biceps femoris, semitendinosus, semimembranosus, superficial gluteal, and middle gluteal muscles most noted. Gentle palpation of the cervical spine revealed fasciculations of the trapezius muscle from approximately C3 to the cervicothoracic junction and along the spine from approximately T10-L1 with a thickened, tight muscular band palpable in the latissimus dorsi muscle on the right side at the level of T12/T13. Both triceps brachii muscles had a ropey quality with a trigger point in the proximal right long head palpable. A trigger point was also located in the middle of the right deltoideus muscle. In the pelvic limbs, the quadriceps femoris muscle groups had increased tone with hyperesthetic regions in the cranial aspect on the left leg and the middle aspect on the right leg. Two weeks into rehabilitative treatment, the patient began to exhibit left thoracic limb pain. The patient had full range of motion of the left elbow but overall, he kept the joint in extreme flexion and was uncomfortable on palpation of the joint. Trigger points were easily felt in the long head of the triceps brachii, biceps brachii, and deltoideus muscles and the long head of the triceps brachii also felt ropey and taut. The patient also seemed reactive to shoulder flexion with muscle fasciculations of the deltoideus and infraspinatous palpable. Overall, the patient’s discomfort was localized to the left elbow and was believed to have a soft tissue injury. Radiographs of the left thoracic limb showed soft tissue swelling cranial to the distal humerus.
Problem List:
The patient’s problems consisted of nonambulatory tetraparesis, cervical, thoracolumbar, bilateral hip and left elbow pain, generalized muscle atrophy, lumbosacral disease, NSAID sensitivity, mature cataracts, and iris atrophy.
Differential diagnoses for the patient’s nonambulatory tetraparesis included:
Vascular- fibrocartilaginous embolism; infectious-meningitis; neoplastic- nerve sheath tumor; degenerative- spondylosis; intoxication-strychnine poisoning; congenital- atlantoaxial instability; autoimmune- degenerative myelopathy; traumatic- acute cervical disk disease; endocrine/metabolic- hypothyroidism; myofascial: trapezius muscle trigger points
Differential diagnoses for the patient’s left elbow pain included:
Vascular- hypertrophic osteopathy; infectious- osteomyelitis; neoplastic- osteosarcoma; degenerative- osteoarthritis; iatrogenic/intoxication: hypervitaminosis A; congenital- elbow dysplasia; autoimmune- immune-mediated polyarthritis; traumatic- soft tissue injury; endocrine/metabolic- primary hyperparathyroidism; myofascia: triceps brachii trigger points
Definitive Diagnosis:
The patient’s nonambulatory tetraparesis was diagnosed as a C3-4 traumatic disk herniation with mild extradural compression. The patient also had a severe chronic disk herniation at T12-13 (historical T3-L3 signs) and mild disk protrusions at C4-5, C6-7, and T13-L1. The patient’s left elbow pain was a soft tissue sprain/strain near the cranial aspect of the distal humerus.
Medical Decision Making:
Acupuncture was recommended for this patient for its analgesic effects in order to address cervical, elbow, and thoracolumbar pain which were discernible through the palpation of myofascial restrictions, increased muscle tone, thickened/ropey musculature, and trigger points. This was an especially useful option with the patient’s NSAID sensitivity and the ability to influence endogenous opioid release was also helpful for the patient’s anxiety. Acupuncture was also recommended for its neuromodulatory effects since the patient had severe motor deficits and the owner elected nonsurgical management. Treatments were recommended at a frequency of three times weekly due to the severe motor deficits as well as the owner was allowing six weeks of further recovery before deciding on if the patient would be euthanized.
Medical Acupuncture and Related Techniques Used:
The patient received acupuncture two to three times weekly for a total of nine treatments. Points frequently selected for dry needling were HT-3, HT-7, GV-20, and PC-6. These points were picked for their autonomic nervous system (ANS) effects, particularly in their ability to address emotional stress and anxiety. HT-3 was also used for medial elbow pain. LI-11 and LI-4 were also appropriate ANS points with LI-11 addressing lateral elbow pain and LI-4 impacting sympathetic regulation. These points were needled using Seirin J type No.1, 0.16X30mm needles. ST-36 was needled for its relation to the fibular nerve and resulting parasympathomimetic effects as well as its impact on pelvic limb dysfunction and SI-3 for its impact on cervicothoracic pain. Cervical spinal nerve points as well as GV-14, Bai Hui, BL-10, BL-13, BL-14, BL-15, BL-21, BL-27, and BL-28 were selected due to their association with the central nervous system and corresponding spinal nerves in order to address pain and neurodysfunction of all limbs. GV-14 was important to address neck pain and thoracic limb weakness and Bai Hui for pelvic limb dysfunction. Baxie and Bafeng points were utilized on all limbs due to the patient being non-ambulatory tetraparetic and the ability of these points to impact nerve function recovery. BL-54 and GB-30 were peripheral nervous system points selected to address preexisting hip pain and SI-11, SI-12 and GB-21 were used for thoracic limb myofascial dysfunction due to the increased tension of the neck and elbow pain. These points, as well as any trigger points, were needled with Hwato Singles 0.20 X 25mm. Trigger points frequently treated were located in the left long head of the triceps brachii, biceps brachii, deltoideus, and supraspinatous as well as the trapezius near the cranial to mid cervical spine and the latissimus dorsi muscle at the thoracolumbar junction near the outer bladder line.
In addition to acupuncture, the patient received laser therapy, controlled exercise, and aquatic therapy at a frequency of two to three times weekly for ten sessions. Laser therapy (Grady Medical, 3W, 810nm, continuous wave) was performed along the cervical, thoracic, and lumbar spine as well as the left elbow, shoulder, and triceps brachii muscle. At each rehabilitation session, bicycling, toe tickles, proprioceptive toe drags, and flexion holds were performed on all limbs to maintain range of motion and muscle mass and to stimulate further sensory gains. The patient was also placed in the underwater treadmill for assisted gait training as well as standing and weight shifting exercises. At home, the owner completed the above mentioned exercises and also utilized thermotherapy, cryotherapy, and gentle massage of the neck, back, and left thoracic limb musculature in order to assist with pain and provide a mentally soothing effect.
Outcomes, Insights, and Discussions:
Throughout treatment, the patient showed steady improvement in both sensory and motor function of all limbs with the greatest change occurring to the left side. Acupuncture and laser therapy assisted with neuromodulation and nerve function repair as well as addressed the myofascial discomfort along the patient’s spine and left thoracic limb. The owner reported that the patient was most comfortable for one to two days following acupuncture. He was also less anxious during this time period which can be attributed to the ANS effects of some of the selected acupuncture points. Motor control improvement, though also assisted by the above mentioned acupuncture effects, was also impacted by controlled exercise. Through strengthening and gait patterning exercises, the patient was able to learn correct movement patterns. Unfortunately, as the patient regained motor control, his anxiety increased. The patient struggled to attempt to sit sternally which resulted in trauma to the left elbow. Due to the patient’s growing anxiety in combination with a projected prolonged recovery period, the owner elected euthanasia despite improvements in neurologic function. Possibilities for avoidance of this outcome could have been earlier and more aggressive sedation for the patient as well as intentionally timing acupuncture closer to the weekend as this was when he was the most stressed. The owner also could have had further instruction on how to properly support the patient when rotating him from side to side to limit the amount of harm he could impose upon himself. Electroacupuncture also could have been utilized to enhance anti-anxiety and pain regulating effects though it was not an available modality at the time of treatment.
Through this case, I learned the value of looking at the patient as a whole and that treatment plans must evolve with the needs of the patient. Though a cervical disc herniation was the reason for presentation, the patient’s anxiety and elbow pain was equally as important. This case also taught me the need for integrative approaches since surgery is often indicated but not always pursued. The choice for this patient to be managed through nonsurgical therapy despite severe neurologic deficits being present, created the need for both standard medical treatment as well as integrative approaches. Though this case ended adversely, the client frequently thanked us for the extra quality time that we provided her with her pet as she felt she would have euthanized much sooner without our treatments. Further research and inclusion of integrative approaches in cervical myelopathies should be performed so that more patients are given the best opportunity for recovery even without surgery.
References:
1. Hayashi, A. M., Matera, J. M., da Silva, T. S., Pinto, A. C., & Cortopassi, S. R. (2007). Electro-acupuncture and Chinese herbs for treatment of cervical intervertebral disk disease in a dog. Journal of veterinary science, 8(1), 95-8.
2. Liu, C. M., Chang, F. C., & Lin, C. T. (2016). Retrospective study of the clinical effects of acupuncture on cervical neurological diseases in dogs. Journal of veterinary science, 17(3), 337-45.
Photos and Videos:
1stAcupuncture (photo): First acupuncture treatment performed (7 days after injury).
LaserTherapy (photo): Laser therapy to the cervical spine (3.5 weeks after injury).
AssistedStand (photo): Assisted stand and weight shifting exercise (3.5 weeks after injury).
ConsultMotor (video): Movement capability of patient at first acupuncture session. Patient was excessively sedate though no alterations in medications had been made (1 week after injury).
UWT (video): Underwater treadmill walking five days before euthanasia (4 weeks after injury).