Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2019015
Abstract: Spinal cord injuries are a common problem in dogs(1) that can lead to weakness, paralysis, pain, voiding disturbances and decreased quality of life. The most frequent causes include intervertebral disk disease, trauma or infarction (fibrocartilaginous emboli myelopathy or FCEM).(2) The patient in this study experienced paraparesis due to spinal cord injury which progressed rapidly despite traditional medical therapy. The purpose of this case study was to determine if the addition of manual acupuncture, LASER and electroacupuncture would improve proprioception, motor function and alleviate pain. After three sessions of therapy, the patient regained proprioception, he was able to ambulate unassisted and he was significantly more comfortable.
History: “Harley” is a 5-year-old neutered male, mixed breed canine that was evaluated for thoracolumbar pain and severe paraparesis. Prior patient history included chronic left hind limb lameness of unknown etiology (present upon adoption three years ago), severe back pain three months previously and acute ataxia three days before presentation. The first episode of back pain was treated by a local emergency hospital using oral gabapentin (7 mg/kg every 8 hours) and grapiprant (2 mg/kg every 24 hours) and resolved within days. When the patient subsequently presented to the hospital (July 29, 2019) for ataxia, he had a stiff, stilted gait and mild pain in the thoracolumbar region. His hind limb conscious proprioception was absent and although he would pivot his feet instead of stepping while turning, he did not require assistance to ambulate. The owners elected oral medical therapy again and he was treated with gabapentin (7 mg/kg q 12 hours) and prednisone (0.35 mg/kg q 12 hours). When his symptoms progressed three days later, he could only pull himself around with his front legs, and he was neither able to transition to a standing position, nor posture to urinate or defecate.
Physical Examination and Clinical Assessments: On presentation (August 1, 2019), the patient was bright and alert. His forelimbs appeared unaffected and with the support of a thoracic harness and a pelvic sling his owners were able to walk him into the office. He had minimal observable motor function to his pelvic limbs or tail and his left hind limb was adducted medially. His lumbar spine was kyphotic, he was knuckling on the pelvic limbs and he was and unable to support his weight. When in a sitting position, his back was arched with hind limbs extended. On myofascial examination, there were multiple areas of muscle pain and myofascial restriction between thoracic vertebra (T) 12 and the third lumbar vertebra (L), as well as myofascial restriction around L5. There was no pain elicited in the sacral spine. There was mild pain in the left adductor muscles and slightly decreased tone to the left gluteal muscles compared to the right. Both thoracic limbs were neurologically normal and did not have evidence of pain or myofascial dysfunction. Biceps, triceps, patellar and cranial tibial reflexes were normal. There was a crossed extensor reflex suggesting a lack of upper motor neuron inhibition.(8) Conscious proprioception was absent while withdrawal reflex and pain sensation was present in both pelvic limbs. There was normal anal tone. Radiographs were taken to rule out obvious signs of neoplasia and potentially note any disk compression. Radiographs revealed spondylosis deformans (SD) ventrally between T10 and T11, T12 and T13, L3 and L4 and between L7 and the first sacral vertebrae (S). On the left side, there was bridging between L2 and L3 as well as L6 and L7. The left femoral head was blunted, and the left acetabulum was flattened. There was significant osteophyte formation, sclerosis and remodeling of the joint surfaces. There was no radiographic evidence of neoplasia.(10) Aberrations on laboratory tests were consistent with musculoskeletal trauma with a slightly elevated ALP at 168 (normal 5-160) and creatinine kinase at 281 (normal 10-200). Complete blood count was normal.
Problem List: 1. Paraplegia with T3-L3 neuropathy
2. Chronic left hind lameness and coxofemoral DJD
Differential Diagnoses:
1. Paraplegia with T3-L3 neuropathy
a. Spondylosis Deformans (SD)
b. Intervertebral disk disease (IVDD)
c. Fibrocartilaginous Emboli Myelopathy (FCEM)
d. Degenerative Myelopathy (DM)
e. Neoplasia
2. Chronic left hind lameness and coxofemoral DJD
a. Developmental abnormality
b. Trauma
c. Previous surgery
d. Neoplasia
Putative Diagnoses: Based upon the clinical presentation and neurologic examination, it was clear that there was neurologic dysfunction and spinal cord compromise between segments T3 to L3. The most common causes of spinal cord compromise in dogs include IVDD, FCEM, or neoplasia.(1) Other possible differentials for the neurologic dysfunction in this case include SD and DM. There was radiographic evidence of SD in several areas along the thoracolumbar spine, but SD has always been considered an incidental finding,(8) contributing very little to clinical presentation. On the other hand, a recent study suggests that although vertebral fusion from SD stabilizes the fused vertebrae it may predispose dogs to adjacent segment disease and the development of compressive myelopathies such as IVDD.(9) There are two types of compressive disk diseases resulting from either disk extrusion or disk protrusion.(8) Disk extrusions (Hanson type 1) commonly affect small dogs over the age of 2, they typically happen acutely, and these patients usually have moderate to severe neurologic deficits and pain. Protrusions (Hanson type 2) on the other hand, affect larger middle-aged to older dogs and they tend to be chronic producing mild to moderate deficits and pain.(8) This patient’s episode of severe back pain months earlier suggests this problem may be chronic. With IVDD, 19% of dogs will experience a relapse.(7) The presence of SD and the subject of chronicity makes a compressive IVDD lesion most likely in this case. In contrast, FCEM usually happens acutely, is not typically associated with pain and it tends to be strongly asymmetric.(8) Although there was some asymmetry with this patient, the preexisting left hind lameness would account for the incongruity. Similarly, DM can be ruled out in this case as affected dogs are not usually painful8 and the condition is slowly rather than rapidly progressive. A neoplastic cause is less likely since there was no radiographic evidence of neoplasia,(10) and the patient did not exhibit other signs of illness such as weight loss, lethargy or poor appetite. For the second problem of chronic left hind limb lameness and radiographic coxofemoral DJD, the most probable cause is a developmental abnormality such as hip dysplasia. Trauma is also less likely the cause of DJD in this case. With a history of acute trauma, malunion or displacement would be expected and with chronic trauma, the opposite hip would likely also be affected. This is also doubtful to be the result of surgical intervention as there is no surgical procedure that would explain the radiographic appearance of the pelvis. The abnormal acetabulum as well as femoral head is most consistent with severe hip dysplasia resulting in degenerative joint disease. Neoplasia is questionable too because the radiographic criteria for bone cancer involving cortical bone destruction, periosteal proliferation and indistinct margins between normal and abnormal bone(10) are not satisfied in this case.
Medical Decision Making:
This patient’s rapid decline of function had a huge impact on the treatment protocol in this case. Not only were the owners concerned about quality of life, but personal and financial circumstances dictated that neither surgery nor extended nursing care would be possible. The steroid dose was increased from 0.35 mg/kg every 12 hours to 0.7 mg/kg every 12 hours for 3 additional days, and the client was instructed to taper to once a day for 3 doses, then to every other day for 3 final doses. Because multiple treatment modalities are crucial to the recovery outcome of spinal cord injury,(2) electroacupuncture, manual acupuncture and LASER therapy were added to this patient’s treatment plan. Electroacupuncture was chosen due to the abundance of research on electroacupuncture and its influence on fibroblast production, differentiation of astroglial cells and formation of new astrocytes in the spinal cord.(4) Prednisone was continued because of a study in dogs revealing the combination of corticosteroid and electroacupuncture was the most effective therapy for ambulatory paresis due to spinal cord injury in dogs.(3) Although electroacupuncture and steroids used independently provided more benefit than no treatment, the combination significantly shortened the patients’ recovery time.(3) Similarly, LASER was chosen in this case since phototherapy has demonstrated improved motor response in individuals with spinal cord injury(5) and decreased time to ambulation after hemilaminectomy.(6)
Medical Acupuncture and related techniques used:
Using a 12-watt class IV 980 nm wavelength Companion LASER, 3,012 joules were applied to the areas where pain was palpated on examination and where the lesion was localized with the neurologic examination. The total area that the LASER was applied spanned from T10 to L5. Manual acupuncture was also used in several acupoints. The point selection was based upon palpation of trigger points, areas of myofascial restriction as well as specific motor, sensory and autonomic nerve locations. The first points needled were along the governor vessel line. GV 20 was chosen to help with any agitation using 0.20 x 30 mm Seirin needles. Bai Hui was needled next for pelvic limb neurologic dysfunction using 0.20 x 40 mm Carbo needles preparing this area for electroacupuncture. The next points stimulated were BL 20 and BL 25 bilaterally using 0.20 x 40 mm Carbo needles and BL 60 on the left hind leg. BL 20 and 25 were chosen based upon points of myofascial restriction to target abnormal areas noted on radiographs and to include the caudal thoracic and mid lumbar spinal nerves. The first channel of the ITO ES-130 3-Channel Electro-Stimulation Unit stimulated BL 20 to BL 25 on the left side and the second channel attached BL 20 to BL 25 on the right side. Channel three was connected to Bai Hui and BL 60 on the left side. The rationale for that was to help stimulate the left pelvic limb because it appeared to be more severely affected. However, cross communication between the spine and the nerves of the pelvic limbs ensured that the right pelvic limb would also benefit. The electrostimulator delivered an 2.5 Hz frequency impulse for 20 minutes to all the channels.(11) Needles were also placed in BL 54 GB 29 and GB 30 using 0.20 and 0.16 x 30 mm Seirin needles to stimulate left gluteal, sciatic and femoral nerves and to help with the DJD of that hip joint. BaFeng points were also stimulated bilaterally, with 0.12 and 0.18 x 15 mm Seirin needles to help with neuropraxia. On the left hind limb ST 36 was stimulated for its anti-inflammatory functions and pelvic limb support. This protocol was repeated a total of three times during 30-minute sessions spaced 3 days apart (August 1, 2019; August 4, 2019; August 7, 2019). At session two (August 4) the prednisone was decreased to once a day and at session three (August 7) it was decreased to every other day. By the fourth and final session (August 13, 2019), the patient was not on any oral medication. The fourth and last session took place 12 days after the acute paraplegia episode and first acupuncture session. On the last session (August 13) the patient was not interested in sitting still. Therefore, manual acupuncture is all that was accomplished during that session. Using 0.16 and 0.20 x 30 mm Seirin needles, points stimulated included Yin Tang, GV 20 and GV 14 for calming effects. Based upon some mild latissimus pain and myofascial restriction, 0.20 x 30 mm Seirin needles were placed bilaterally in BL 15 and BL 25.
Outcome: After one session of acupuncture the patient was stronger but still required significant support to walk. His pain was improved and continued to improve with each session. After three sessions, the patient’s mobility was almost normal except he would lose his footing on slippery floors and had trouble climbing stairs. He was able to posture regularly to urinate and defecate. His right hind limb did not exhibit any conscious proprioceptive deficits, but his left hind limb was still slow to replace when knuckled. His interest in daily walks and play had significantly improved. After the fourth session, Harley was back to his usual self, resuming normal daily activity and his proprioceptive positioning was back to normal.
Discussion: Spinal cord disease can be an emotional, physical and financial burden to dogs and dog owners. There are multiple treatment options available ranging from spinal cord surgery, medication and rest to alternative therapies such as acupuncture and LASER. Above all, the well-being of the pet and the pet owner must always play a role in medical decision-making. Extenuating circumstances with the owners of this patient dictated that time to recovery was essential. Neither a costly, invasive surgery nor prolonged recovery time were a feasible option. Where medication alone failed “Harley”, acupuncture and LASER succeeded to produce results even after one session. After three sessions of acupuncture and LASER therapy, “Harley” was walking without assistance. Even his pre-existing left hip lameness was improved. Without the constraints of time, it may have been best not to increase the prednisone dose in order to better understand how acupuncture and LASER alone would have benefitted this patient. It is this author’s opinion that steroids alone would not have been enough to help this patient since rapid neurologic decline occurred despite steroids. The combination of LASER and acupuncture in this case provided a more rapid recovery than medication alone. These alternative therapies improved nerve repair and cellular regeneration, allowing pain relief, recovery of motor function and restored proprioception. Further study of electroacupuncture combined with photobiomodulation without the use of steroids would be a future consideration of study.
References:
- Webb AA, Ngan S, Fowler JD. Spinal Cord Injury I: A synopsis of the basic science. Canadian Veterinary Journal 2010; 51:485-492.
- McDonald JW, Sadowsky C. Spinal Cord Injury. The Lancet 2002;359: no. 9304: 417-425.
- Yang JW, Jeong SM, Seo KM, Yam TC. Effect of corticosteroid and electroacupuncture on experimental spinal cord injury in dogs. Journal of Veterinary Science 2003; 1: 97-101.
- Hayashi AM, Pinto ACBCF, Cortopassi SRG, et al. S100B Levels in CSF of non-ambulatory dogs with intervertebral disk disease treated with electroactupuncture. Journal of Veterinary Medicine 2013; ID 549058, 8 pages.
- Cordeiro da Silva F, Gomes AO, Da Costa Palacio PR, et al. Photobiomodulation improves motor response in patients with spinal cord injury submitted to electromyographic evaluation: randomized clinical trial. Lasers in Medical Science 2018; 33, issue 4: 883-890.
- Draper WE, Schubert TA, Clemmons RM, Miles SA. Low-level laser therapy reduces time to ambulation in dogs after hemilaminectomy: a preliminary study. Journal of Small Animal Practice 2012; 53: 465-469.
- Mayhew PD, McClear RC, Zeimer LS, et al. Risk factors for recurrence of clinical signs associated with thoracolumbar intervertebral disk herniation in dogs: 229 cases (1994-2000) 2004; 8: 1231-1236
- Dewey CW, da Costa RC, Practical guide to canine and feline neurology. Third edition. Wiley Blackwell 2015.
- Ortega M, Goncalves R, Haley A, et al. Spondylosis deformans and diffuse idiopathic skeletal hyperostosis (DISH) resulting in adjacent segment disease. Vet Radiol Utrasound. 2012; 53:128-134.
- Newton CD, Nunamaker DM, Thrall DE. Textbook of Small Animal Orthopaedics. Lippincott Co.1985.
- Silva JR, Silva ML, Prado WA. Analgesia induced by 2 or 100 Hz electroacupuncture in the rat tail-flick test depends on the activation of different descending pain inhibitory mechanisms. Journal of Pain 2011;1: 51-60.