Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2019003
Abstract
Farley is a 6 years old mix breed dog that had a left hemilaminectomy from T12 to L2 to decompress an intervertebral disc hernia at T13-L1 and L1-L2. After the surgery, Farley still had severe hind limbs deficit, with more deficit to the left hind limb. Acupuncture was performed twice weekly for 4 weeks. A significant improvement was seen after the treatments and Farley regained a fair motion of both hind limbs.
Farley is a 6 years old, spayed female, Jack Russel and Dachshund mix of 21 pounds. The actual owner adopted her at a young age after being relinquished for parvovirus infection. She recovered adequately from the infection and didn’t have any health problem until April 2019.
On April 19th, Farley stood up on her hind limbs, yelped and became ataxic and severely paraplegic from her hind limbs. She had severe proprioceptive deficit from both hind limbs. The thoracic limbs remained normal. Multiple diagnoses were considered including intervertebral disc disease, fracture, luxation, meningomyelitis and neoplasia. Considering the breed and the presentation, the intervertebral disc herniation was considered most likely. On April 19th, a blood work was performed. The ALT was increased at 227 mg/dL (normal range 0-120 U/l). No clinical sign is correlated with this finding and no specific treatment for the liver was started. To assess the pain and inflammation, Gabapentin at 10.5 mg/kg twice daily and Galliprant at 2 mg/kg once daily were started. Tramadol at 2.6 mg/kg two to three times daily was added on May 21st.
Two views radiographs of the thoracolumbar spine were taken on April 19th. On the review by Dr. Neuwirth, DVM, DACVR, several narrowed intervertebral disc spaces including T11-T12 through L1-L2 were visualized. At the L1-L2 spaces, there is faint soft tissue and mineral opacity in the ventral aspect of the intervertebral foramen. Mineralized intervertebral disc is visible at situ at several sites including T12-T13, L2-L3 and L6-L7. It was recommended to consult a surgeon and/or a neurologist to further assess Farley. Additional diagnostic tests including magnetic resonance imaging (MRI) or computerized tomography (CT) Scan were also recommended. The client decided to pursue with a neurologist and an MRI with contrast was performed. The MRI reveals a right-sided extradural compression at T13-L1. The ventrally material is consistent with intervertebral disc material. There are also signal changes to the cord suggesting spinal cord edema. Moreover, there is a compression at L1-L2, somewhat left-sided and less severe than the T13-L1 lesion. No other sites of significant spinal cord compression are noted. The MRI was reviewed by Dr. Tsuyoshi Murakami, DACVR.
Farley had surgery on April 22nd, 3 days after the injury. A hemilaminectomy from T12 to L2 was performed. A large amount of mineralized disc material was removed from T13-L1. Farley recovered well form anesthesia and the surgery went as expected. She was started on Omeprazole, Codeine, Amantadine and prednisone after a wash out period from the Galliprant administration. The Gabapentin was pursued.
After the surgery, Farley remained with severe proprioceptive deficit from both hind limbs. The owner who is a veterinarian, started to perform transcutaneous electrical nerve stimulation (TENS) daily on the gluteal and quadriceps muscles. Farley received 2 previous acupuncture treatments on Friday April 26th and Monday April 29th before the initial assessment. The acupuncture points used are unknown.
On May 3rd, 11 days after surgery, Farley started to have motor function to her right hind limb. The left hind limb remained severely paraplegic and no motor function was seen while walking. On the initial examination, Farley had a normal mental responsiveness, normal cranial nerves and normal thoracic limb proprioception. She had an ataxic gait from the hind limbs with minimal motor function from both hind limbs, the left side being more severely affected. She dragged the dorsal aspect of her left hind paw on the floor. Support with a sling was necessary to allow her to ambulate. She had a kyphotic posture in the thoracolumbar area. She was tense all along the spine with the thoracolumbar area being the most sensitive region. The patellar reflexes were present in both hind limbs as well as the withdrawal reflexes, although the left hind limb had a slightly decreased withdrawal pull. The trunk and anal reflexes were normal. From the literature, the combination of electroacupuncture and dry needling with prednisone is more effective than prednisone treatment alone to recover ambulation, relieve back pain and decrease relapse2. Therefore, this modality was added to Farley’s treatment protocol.
Farley May 3rd -2 Farley May 3rd
Farley received acupuncture twice weekly for a total of 7 treatments (9 with the 2 initial treatments received by another veterinarian). The acupuncture points were chosen according to her deficits. Autonomic, peripheral and local points were used at each treatment. Before each session, Farley had a full myofascial and neurologic exam to personalize each session accordingly and assess the improvement. The autonomic points selected are GB 14, Bai Hui and ST 36. Those points were performed at each session. The peripheral points used were the Bafeng, GB 29, GB 30, GB 31 and BL 54. Those points were chosen to stimulate the sciatic nerve and femoral nerve. At the 5th session, Farley was more reactive, and the Bafeng points on the right hind limb were not performed. The local points chosen were along the Bladder line. The points performed on the Bladder line were limited because the surgeon discouraged needling over the shaved surgical site. The area shaved was asymmetrical and BL 22, BL 23 and BL 25 were performed on the right side. With the nerves cross-communication, it was judged adequate to treat only this side. Moreover, BL 18 was performed bilaterally to address the increased liver value ALT. The BL 18 represents the Back Shu point of the liver. An average of 23 points were used at every treatment. Massage always followed the acupuncture treatment. The massage consisted to a gentle rolling over the neck and back, and petrissage of the hind limb for 3 to 5 minutes.
Carbo and Millennia needles were used according to the availability of the clinic. Needle’s size 0.16 mm x 30 mm was used first to needle GV 14 and Bai hui to assess the sensitivity of the patient. The rest of the first treatment and the next ones were performed with 0.2 mm x 30 mm needles. Only dry needling was used on Farley but electroacupuncture and laser could have been good modalities to add as well. The electroacupuncture was not used because this modality was not accessible at the facility where the treatments were given. The surgeon discouraged laser therapy over the shaved surgical area until the recheck 17 days after the surgery. This modality was not used after the recheck. TENS was used inconsistently by the owner throughout the treatment period.
Farley tolerated the acupuncture treatment well and received Gerber chicken baby food jar at each treatment. During a few treatments, she stopped eating the food and seemed to feel the needle working. She refused the food for the rest of the treatment during those sessions but continued to tolerate the needling.
Farley improved significantly with the acupuncture treatment. After the 2nd treatment on May 6th (4th treatment including the 2-initial ones performed by another veterinarian), Farley started to have motor function from the left hind limb. At every session after this one, Farley regained more and more motor function from both hind limbs and the owner was able to see the difference from the previous day. No adverse effect of fatigue was noticed by the owner, and Farley tolerated all the treatments well.
Farley May 13th -3 Farley May 13th -2 Farley may 13th Trim
Electroacupuncture combined with standard Western medical treatment was effective and resulted in shorter time to recover ambulation and deep pain perception than did use of Western treatment alone in dogs with signs of thoracolumbar intervertebral disk disease1. Although there is more evidence of success with the use of electroacupuncture than dry needling, it was considered an appropriate adjunctive treatment for Farley. She improved more rapidly when the acupuncture treatments were done twice weekly than just after the surgery on pain medication only.
References
1) Hayashi, A. M., Matera, J. M., & de Campos Fonseca Pinto, A. C. B. (2007). Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs. Journal of the American Veterinary Medical Association, 231(6), 913-918.
2) Han, H. J., Yoon, H. Y., Kim, J. Y., Jang, H. Y., Lee, B., Choi, S. H., & Jeong, S. W. (2010). Clinical effect of additional electroacupuncture on thoracolumbar intervertebral disc herniation in 80 paraplegic dogs. The American journal of Chinese medicine, 38(06), 1015-1025.