Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2018062
ABSTRACT
A dachshund presented to the clinic with initial signs of intervertebral disc disease with no neurologic deficits. Patient progressed to neurologic deficits despite medical management, and thus had a hemi-laminectomy performed at a referral center. He presented 2 weeks post-surgery for acupuncture management. Over the course of 9 months, he has shown steady improvement from nonambulatory and urinary incontinent to satisfactorily ambulatory and significantly improved urinary continence. He is currently having acupuncture performed every 3 weeks.
HISTORY AND PRESENTATION
Copper is a 7 year old, male, neutered, miniature Dachshund that presented initially on August 21st after one week of crying when picked up, and episodes of hiding. The initial examination and treatments were performed by another associate. Relevant findings from the exam was pain elicited on flexion of the neck to the left, lumbar spinal pain, and a tense abdomen. Radiographs of the spine showed narrowing of T12-T13, T13-L1, and degenerative joint disease of the stifles. A complete blood cell count (CBC) and chemistry were unremarkable. A heartworm/Lyme/ehrlichia/anaplasma test was negative for all conditions. Copper was sent home with grapiprant (20mg every 24 hours) and gabapentin (50mg every 12 hours). Owners reported on August 24th that Copper had delayed conscious proprioception, but was still ambulatory. Referral was recommended at that time. Copper was transitioned from grapiprant to prednisone on a tapering schedule, and methocarbamol (500mg every 12 hours for 5 days, then 250mg for 5 days) was added. Copper presented to a referral center for assessment. The day of presentation, Copper’s owners reported that he was acutely down that day, and unable to stand. The referral veterinarian reported Copper to be paraparetic, with deep pain present and hyperreflexive patellar, cranial tibial, and gastrocnemius nerves (bilaterally). An MRI was recommended, or myelogram as a more cost effective option, to assess the disc spaces prior to surgery. Owners elected a myelogram and surgical correction. Compression was noted at the T12-T13 disc space, and a dorsal laminectomy was performed on the T12-T13 disc space. Post-surgery, Copper was still paraparetic and urinary incontinent post-surgery. Copper presented for his first acupuncture session on September 20th, 2 weeks post-surgery.
Owners reported minimal to no improvement post-surgery with regards to ambulation. His pain was well managed per owner at that time. He was urinary incontinent with minimal urinary retention. His owners elected to try acupuncture, as they were concerned for what they felt was progressive weakness in the rear muscles. On examination, Copper was nonambulatory in the rear limbs, with minimal attempts at walking when placed in a standing position. If held steady, he could bear weight on his rear limbs when placed in a standing position. Copper had muscle tension along much of the epaxial musculature of the thoracic and lumbar spine. The caudal cervical musculature was moderately tense secondary to compensation of his condition. Neurologically, Copper was hemi-paralytic, with deep pain present, absent conscious proprioception, crossed extensor reflexes present bilaterally, and hyper-reflexive patellar, cranial tibial and gastrocnemius nerves bilaterally. Subjectively, Copper was weaker on the left rear limb versus the right.
DIFFERENTIAL DIAGNOSIS
Intervertebral disc disease (IVDD), Fibrocartilaginous embolism (FCE), degenerative myelopathy, unknown trauma, neoplasia
DEFINITIVE DIAGNOSIS
Intervertebral disc disease was the most likely diagnosis based on Copper’s neurologic signs and response to treatment. Dachshunds are an over-represented breed for IVDD. Based on a report by R. M. A. Packer et. al, dachshunds are 10-12 times more likely than other breeds to develop IVDD, with 19-24% of them experiencing symptoms of IVDD (“DachsLife 2015: an investigation of lifestyle associations with the risk of intervertebral disc disease in Dachshunds.” Packer, R.M.A, et.al. Canine Genet. Epidemiol. January 2016.). Copper had a myelogram to confirm IVDD. A myelogram cannot completely rule out FCE or degenerative myelopathy. Neoplasia was considered unlikely due to no evidence on radiographs. Copper was officially diagnosed with intervertebral disc disease based upon plain radiographs and subsequent myelogram. IVDD is caused by degenerative changes with the disc that leads to disc extrusion. This disc extrusion leads to trauma and inflammation of the spinal cord. Copper also experienced myofascial tension secondary to the surgery, as well as from his attempts at ambulation and using his body incorrectly to compensate for his condition.
MEDICAL DECISION MAKING
Central: GV14 and Bai Hui were utilized to stimulate the parasympathetic nervous system and reduce overall windup pain.
Peripheral: BL40 and BL 60 were utilized to stimulate the sciatic nerve in both rear limbs. Ba Feng points were utilized to simulate the interdigital nerves. ST 45 and ST 41 were utilized to stimulate the deep fibular nerve. ST34 and ST36 were utilized to stimulate the proprioception of the stifle (tibial nerve). KI3 and SP6 were utilized to stimulate the fibular nerve.
Autonomic: GV20 and Bai Hui were utilized to stimulate the nucleus tractus solitaries via the trigeminal nerve and parasympathetic nervous system.
Myofascial trigger points: Trigger points, particularly along the Bladder meridian near the surgical site, were treated. Points primarily utilized were BL 15, BL18, BL22, and BL 24. Triceps trigger points were treated as needed throughout his course of acupuncture. Treating these points released tension along the inner and outer epaxial muscles and triceps muscles through stimulation of Golgi tendon organs.
MEDICAL ACUPUNCTURE
The goals with Copper’s acupuncture treatment was primarily to restore mobility and urinary continence, as well as to relieve compensatory muscle tension and pain. Initially, Copper was anxious during treatment, but began to accept and seemingly enjoy the treatments. As he became more tolerant, electrical stimulation (e-stim) was added using a Pantheon 4Pro. Needles used were Seirin J-type 0.16×15 and 0.16×30.
The primary points that were of focus was along the Bladder line (BL). Points used were BL 15, BL18, BL22, BL 27, BL28, and BL54 bilaterally, as well as BL40 and BL60 (rotated each session left and right). Additional points to stimulate rear limb function included Ba Feng points, Bai Hui, and Kidney 3 (KI3). Points were also chosen to encourage bladder control, and included Spleen 6 (SP6) and Liver 2 (LR2). To balance out the autonomic nervous system, Governor Vessel 20(GV20) was utilized, as well as intermittently, Heart 7 (HT7) and GV14. E-stim was utilized along the Bladder line BL15 or 18 to BL22 on both lines. It was also used on a rotating left and right bases from BL54 to BL60. Later in treatment, this changed to BL54 to BL40 or BL60, GB29-GB30 and ST34-ST36.
Copper had treatment twice weekly from 9/20/18-11/16/18, then was treated once weekly from 11/16/18-2/28/19. He recently has decreased to every 3 week treatment.
OUTCOMES, DISCUSSIONS AND REFERENCES
Copper presented nonambulatory and urinary incontinent prior to starting the acupuncture treatment. He is currently ambulatory, although still quite ataxic in the rear limbs. He has control of his bladder if given the opportunity to urinate routinely, as he will leak if he becomes excited or tense with a fuller bladder. Copper quickly came to enjoy his acupuncture sessions, rapidly falling asleep as needles were placed. His owners have been pleased that he is able to be mobile, and can mostly control his bladder. We saw initial great improvement with each treatment session, but Copper did plateau for several weeks. He would not tolerate at home physical therapy, as he would not even attempt to move his legs with sling walking. Copper only did therapy on his terms. Once the weather improved, he has gained rapidly with his mobility with the self-governed physical therapy of outside walking. We do feel that Copper recovered initially much more rapidly with acupuncture than with just the surgery, as he had no improvement following the first two weeks post operatively. Acupuncture combined with medical therapy has been shown to be more effective than with medical management alone (Clinical Effect of Additional Electroacupuncture on Thoracolumbar Intervertebral Disc Herniation in 80 dogs, Han, Hyun-Jung et.al. in The American Journal of Chinese Medicine 38(06), 1015-1025, 2010). If Copper was initially started on acupuncture, he potentially may have avoided surgery based on these findings. He was acutely painful, and acupuncture can significantly reduce this pain (Analgesic effects of acupuncture in thoracolumbar disc disease in dogs. Jan Still, Journal of Small Animal Practice 30 (5), 298-301, 1989.) Overall he has improved to have a great quality of life and his owners are pleased with his progress.