Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10S2017035
Sienna had an episode of acute paresis. Without a prior history of lameness or neurologic episodes, we treated for spinal cord impingement. Incorporating acupuncture and laser along with anti-inflammatories and pain medications, Sienna improved over the following weeks. On recheck, her ataxia is 80% improved and the owner said they have difficulty keeping her calm. She is improving every day and is on a maintenance plan for acupuncture to control her presumed intervertebral disc disease (IVDD). Acupuncture is an effective way to control pain and help with nerve conductance in IVDD patients.
History and Presentation:
Sierra, a 8.5kg 8-year-old Shih Tzu, has been a patient at our hospital since 2015. She is a house dog and has limited activity. She stays in her house and does go on short (1/4 mile) walks. She does not play with other dogs or go to dog parks. Her history here is primarily wellness care. She has been seen here for vaccines, dental procedures, and atopy (which is controlled with daily apoquel). Other than her spay 7 years ago, she has not undergone any surgical procedure. She has not had a history of lameness or pain. No history in her record of a comprehensive myofascial examination.
She presented on 3/7/18 for “hip issues.” She was walking on rocks and seemed to have “twisted” and then had difficulty walking. There were no indications of cause of injury (no jumping, slipping, falling) or pain (no yelping, crying). Owner picked her up then brought home. Last night and this morning, she was given Rimadyl (18.75mg) and Tramadol (50mg) from a prior dental. She doesn’t want to walk but is acting fine otherwise. She is eating, drinking, and urinating on her own (owner does have to pick her up to bring her to the appropriate places). She is not defecating.
Physical Examination and Clinical Assessments:
When presented, she was sitting and reluctant to stand with her hindlimbs. She can support herself with her hindlimbs for short periods of time (5-10 seconds) but then sits. When supported, she had moderate kyphosis, conscious proprioceptive were present but slow in hindlimbs (forelimbs were normal), and hindlimbs crossed. She was painful along the cranial lumbar area. She would not walk, she would just sit despite trying to call and coaxing her.
Cranial nerves unremarkable (mentation, menace, pupillary light reflex, no strabismus or
Thoracic reflexes bilaterally appropriate (triceps, withdrawal, crossed extensor)
o Hindlimb reflexes bilaterally:
▪ Patella- hyper-responsive
▪ Withdrawal- slow and insensitive
▪ Crossed extensor- present
o Anal reflex present
o Panniculus response positive but decreased/absent caudal to lumbar areas
The remainder of the physical exam was unremarkable.
Medical Decision Making:
Discussed with owner possible causes for paresis. Owner is retired and finances are very limited. Explained that ideally, imaging and bloodwork are helpful but we had to choose between diagnostics and treatment. We are focusing on treatment for nerve impingement based on her acute presentation of kyphosis, pain in her cranial lumbar area, and hindlimb nerve deficits. Acupuncture was vital to treatment to allow pain relief and muscle relaxation in her back/lumbar area (thoracolumbar spinal n). The muscles were very tense in the back trying to compensate for the instability of the vertebrae. By using acupuncture, the neuronal firing of the muscles was normalized and allowed the muscles to relax. Electroacupuncture was used to assist pain
management by enkephalin and dynorphin release. It also is cumulative at lower Hertz and has longer lasting effects than standard acupuncture. Laser therapy was also utilized because it promotes healing by decreasing inflammation and allowing nutrients to flow in and waste to move out of the tissue.
Electroacupuncture was also utilized for nerve stimulation in hindlimbs (we focused on fibular n, tibial n, digital n). As the spinal cord is impinged, it doesn’t allow nerve full nerve conductance from the spinal cord segment. By using electroacupuncture, we can increase nerve conductance to the spinal cord to promote nerve activity.
After evaluating, discussed concern for spinal nerve compromise. Although she had no obvious trauma, possibility include, but not limited to: FCE, meningitis, Guillain-barre, myasthenia gravis, neoplasia of the spinal cord, spinal cord impingement, polyradiculitis, endocrine related weakness (ie diabetic), toxins, and tick paralysis.
Definitive (or Putative) Diagnosis (or Diagnoses):
Although there are many differentials and no diagnostics able to be performed, top differential is spinal cord impingement because painful on lumbar palpation, deficits are in hindlimbs and not generalized, and minimal ticks in this arid environment.
Acupuncture treatments were based on:
-Relaxation points: Yintang, BaiHui
-Tension in paralumbar muscles, particularly those associated with area of kyphosis:
BL18, 19, 20, 21, 22, 23, 25. BL 21 point was very tense and the needle was bending
-Since she had decreased sensory function in her hindlimbs, acupuncture needles placed in the points bilaterally: Bafeng, K1, and ST36.
Electroacupuncture between K1 and ST36 bilaterally and between BL 21 and BL23. The stimulator used was ITO ES-160. The setting was 4Hz, 175us, continuous for 10 minutes. The intensity (which ranged from 2-4) was set for visible muscle twitching and was reduced to just below twitching. Needle choice for relaxation points were Seirin J type 0.2mm diameter and 30mm length Muscle strain and stimulation were Hwato 0.25mm diameter and 30mm in length for the bladder, K1, and ST 36 and 13mm in length for the Bafeng points The acupuncture treatments were repeated approximately every 12 hours for 4 treatments total.
Additional medical treatments
Laser therapy- class IV (4W for 3 minutes for 3 treatments total over 72 hours) on area surrounding cranial lumbar, the suspected location of lesion,
Anti-inflammatory- solumedrol 30mg/kg then two subsequent doses of 15mg/kg then switched to prednisone 5mg q12 hours for 7 days then tapered to 5mg q24 hours for 7 days then 5mg EOD until recheck, Gastroprotectant- pantoprazole (1mg/kg) then omeprazole (10mg), Muscle relaxer- methocarbamol (125mg), and Pain medication- gabapentin (100mg) and CRI of ketamine 0.2mg/kg/hr and lidocaine 2.5mg/kg/hr for the initial 12 hours then tapered. Tramadol ((50mg)when finished ketamine/lidocaine CRI).
Outcomes, Discussions, and References:
Sienna improved drastically during her treatment course. After the first acupuncture session, her kyphosis improved 25%. As the first day progressed, she became less anxious, more comfortable, and engaging. Her neurologic status was evaluated every 12 hours by veterinarians and every 24 hours by her primary care veterinarian. Re-evaluation 24 hours after her initial presentation, her kyphosis was 50% improved, she was able to stand for 30 seconds and was more stable. She is still not able or willing to ambulate on her own and she had CP deficits. Treatment continued and after the 72 hours of treatment, she was able to ambulate but some crossing of her hindlimbs. She was discharged at that point due to accruing costs. She was instructed to perform physical therapy at home by getting her to stand as long as possible for 5 minutes total three times daily. We also engaged her muscles and nerves by using treats to get her to sit and stand repeatedly during 5 minutes increments. When at rest, we massaged her hindlimbs and tickling her toes to stimulate movement. On recheck 7 days later, her ambulation is much improved. She is more stable when walking, her kyphosis has resolved, and her muscles are less tense. She is still in good spirits and does not realize her deficits.
Reference: 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. Joaquim JG