Written by a CuraCore Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 4S2018039
Lucy is an approximately one-year-old spayed female domestic medium-haired cat who presented in June 2018 for a second opinion regarding her limp. She was front-declawed at her previous clinic in January 2018 and has experienced thoracic limb discomfort since then. Several courses of opioids, steroids, and antibiotics were prescribed, and were temporarily helpful, but ultimately ineffective. Lucy’s guardian hoped for a longer-term resolution to her pain, and also wished for increased function in her forelimbs. After several months of a more integrative approach, including acupuncture, electroacupuncture, pharmaceuticals, the Assisi loop, and laser therapy, Lucy has regained use of both forelimbs, and no longer requires pharmacologic intervention on a regular basis to control pain.
History and Presentation
Lucy was adopted with a largely unknown history in fall 2017 from an urban municipal shelter. She was spayed just after her stray holding period during her shelter stay. She presented to her family veterinarian for an onychectomy in January 2018. She is one of eight indoor-only cats in her new home, the rest of whom are also forepaw-declawed by the same family veterinarian.
Onychectomy (commonly known as declaw surgery) is the removal of the third digital phalanx and is generally an elective surgery to prevent unwanted scratching behavior. There are a few medically necessary scenarios in which onychectomy is indicated as well, like nail bed infection and neoplasm, such as squamous cell carcinoma, melanoma, soft tissue sarcoma, osteosarcoma, and mast cell tumor.
Lucy had an onychectomy performed on both thoracic limbs at her family veterinary clinic. There are several recognized methods/approaches, and Lucy received the dissection technique using a scalpel blade. Dissection onychectomy is the most common approach, and can be done with a scalpel blade, radiofrequency, or carbon dioxide laser. “Nail clipper” onychectomy is done with a guillotine type of nail clipper around the digit between the second and third phalanges at the distal interphalangeal joint line.
There are many immediate and longer-term recognized complications of elective onychectomy, and because of these, the procedure is no longer recognized as legal in several countries and states. Hemorrhage, infection, lameness, claw regrowth, ischemia/tissue necrosis, neuropraxia, immediate pain, and second phalanx protrusion are common, occurring in up to 50% of patients.
Chronic pain is also common, and can be evidenced not only by obvious lameness, but also by changes in behavior, such as litterbox avoidance, increased biting behavior, and decreased activity. These, in turn, can lead to yet more sequelae, such as rehoming, euthanasia, diabetes, degenerative joint disease, and inability to groom.
Wind-up pain can result from inadequate or inappropriate perioperative analgesia. The radial, median, and ulnar nerves lead to dorsal and palmar branches, eventually terminating in digital nerves, providing sensory and motor innervation to the paw. It is recommended to provide local nerve blocks with 0.5% bupivacaine to four sites when performing onychectomy or other distal paw procedures. This is known as a digital or ring block. Multimodal systemic perioperative analgesia should also be provided, as well as post-operative close management on a case-by-case basis. Lucy received a routine ring block using 1mg/kg bupivacaine and 1mg/kg lidocaine. She had been pre-medicated with 0.15mL dexmedetomidine, 0.1mL ketamine, and 0.04mL butorphanol intramuscularly. (Concentrations were not recorded.)
Lucy’s pre-surgical bloodwork was within normal limits (complete blood count and chemistry/electrolyte 15 panel). Lucy tested negative for feline immunodeficiency virus and feline leukemia virus on 12/8/17 via ELISA snap combo testing. She presented for declaw surgery on 1/24/18. It was noted that that surgery was routine, and that a five-day course of buprenorphine was dispensed post-operatively. The prescription was for buprenorphine (0.5mg/mL) give 0.15mL transmucosally every 12 hours for 5 days. On 2/20/18, Lucy presented to her family veterinarian for ongoing pain post-declaw, and buprenorphine was again dispensed. On 2/26/18, Lucy’s guardians called the family clinic, indicating that the pain came back after discontinuing buprenorphine. She was told that post-operative pain can last 6-8 weeks in some cases, and to monitor vigilantly. On 3/8/18, Lucy presented to her family veterinarian for ongoing pain, and prednisolone (5mg/mL concentration – give 0.5mL by mouth once daily for 10 days, then 0.25mL once daily for 7 days, then discontinue) was dispensed after taking reportedly normal carpi radiographs. On 4/3/18, the owner called the family veterinarian and reported than on the higher prednisolone dose, Lucy was doing slightly better, so another course of prednisolone was initiated for a 2-week course.
Physical Examination and Clinical Assessments
Lucy presented to the Cat Care Clinic for a second opinion of her chronic pain and dysfunction. Her initial physical exam showed bilateral thoracic limb lameness. She was non-weight-bearing on her right forelimb, and toe-touching on her left forelimb. Neither obvious evidence of infection nor claw regrowth were noted on exam. She was very sensitive to touch on her front legs but had an overall extremely affectionate disposition. Myofascial exam revealed atrophied biceps and triceps groups bilaterally, as well as trigger points bilaterally in the long head of the triceps muscle and in the left supraspinatus muscle. Rear limb musculature was overdeveloped and tight. There was significant pain in the distal thoracic limbs, and the initial exam was limited in this area. The remainder of her physical exam was unremarkable.
Neurologic assessment revealed intact flexion reflex on the left pelvic limb, but no response to deep pain via traditional hemostatic testing on the left. Biceps brachii peripheral nerve reflex was intact bilaterally. Proprioceptive deficits were noted in both forelimbs. Rear limb neurologic exam was within normal limits.
Further diagnostics, such as imaging and labwork were declined at that time.
The differential diagnoses were limited in Lucy’s case to intra- and post-surgical complications related to forelimb onychectomy. It is entirely conceivable that the surgery and perisurgical analgesia were performed according to the gold standards of the veterinary surgical and anesthetic industry. Regardless, optimal surgical and anesthetic/analgesic techniques do not necessarily predict a desirable outcome.
Definitive (or Putative) Diagnosis (or Diagnoses)
Given that Lucy was not experiencing pain and forelimb lameness prior to onychectomy, it was concluded that the cause of her symptoms was indeed surgery-related.
Medical Decision Making
There were a number of factors that influenced the treatment approach, including the owner’s goals, Lucy’s extensive pain, the chronicity of the damage, and owner finances. The primary goals were to decrease pain and increase function of the forelimbs. A secondary goal was to increase Lucy’s comfort level at the veterinary clinic as her guardians noticed an increase in in-clinic fractious behavior since they started dealing with post-operative pain. Acupuncture was selected as the primary treatment modality, and was supplemented with pharmaceuticals, massage, range-of-motion physical therapy, laser therapy, Assisi loop, and electroacupuncture. Gabapentin, an anticonvulsant and neuropathic pain analgesic, as well as meloxicam, a non-steroidal anti-inflammatory drug, were initiated at conservative dosages as an adjunctive to acupuncture.
The goal of acupuncture was to neuromodulate the radial and ulnar nerve pathways to decrease wind-up pain and overall inflammation.
Integrative medicine sessions included acupuncture (both dry needling and electroacupuncture), Assisi loop application, massage, as well as photobiomodulation therapy. Not every session included all modalities. At first, sessions were once every 3-4 days for a month, then once weekly for another month, then every two weeks for 2 months. Currently, sessions are held as needed when Lucy has a flare-up of symptoms.
Dry needling was used primarily in an effort to stimulate nerve regrowth, motor function, and to dampen the wind-up pathways in existence. Seirin J-type 0.14 x 15mm needles were used initially to gauge Lucy’s reaction and get a feel for her particular myofascial qualities. We quickly moved to 0.16 and 0.2 x 15-30mm needles once we both knew what to expect. Acupuncture points elected included the following points:
• Radial nerve focus: Lung (LU) 5, LU 7, LU 9, Large intestine (LI) 4, LI 10, LI 11, Small intestine (SI) 9, Triple heater (TH) 3, and TH 5.
• Ulnar nerve focus: SI 3, SI 8, Heart (HT) 3, HT 7, and HT 8.
• Suprascapular nerve focus: SI 11 and SI 12.
• Median nerve focus: Pericardium (PC) 3, PC 6, and PC 8.
• Spinal accessory nerve focus: Gallbladder (GB) 21.
• Cervicothoracic spinal nerve focus: Governor vessel (GV) 14 and cervical spinal nerve roots.
• Digital nerve focus: Baxie.
An Ito ES-130 electrotherapy unit was used during several sessions to couple various points along the same nerve pathway, such as LI 10 – LI 11 and SI 11 – SI 12. Low frequency was used with no more than level 4Hz per pair. A 10cm Assisi loop was placed on the thoracic feet during most sessions and twice daily at home. A Companion 6W 932nm laser unit was employed in a contact fashion at low wattage (1.0-1.5W) in a continuous operation mode at the end of the sessions for 3-5 minutes, focusing on elbows, shoulders, and nail beds. Following therapy sessions as well as once daily at home, gentle massage was used on the tighter musculature of the rearlimbs (hamstrings and quadriceps groups) as well as neck and shoulders of the forelimbs (biceps, triceps, supraspinatus, infraspinatus, latissimus, pectorals, and strappy shoulder extensors of the neck).
Outcomes, Discussions, and References
Though Lucy has not regained full function of both forelimbs, her overall mobility and comfort level have come a long way since initial presentation. She has a slight limp on her left front leg, the leg that was always most severely affected. On rare occasions, she also is vocal when landing from a long vertical descent but is quick to recover. We achieved our main goals of increasing function and decreasing pain. I attribute these achievements to an integrative therapy approach since the steroid, narcotic, gabapentin, and non-steroidal anti-inflammatory medications were all gradually decreased over the course of her sessions. Despite reduced pharmaceuticals, Lucy has maintained good limb function without experiencing excessive pain. Additionally, our clinic is committed to a fear-free, consenting, and transparent approach. Using this philosophy, Lucy’s in-clinic behavior has improved significantly. Lucy’s long-term prognosis is unknown, but her owners and I remain hopeful. We’ve done extensive nutrition coaching, focusing on a slender body condition to reduce joint stress, as well as anti-inflammatory additives like omega 3 fatty acids. Additionally, we’ve emphasized intercat safety and harmony in the household. Her owners are considering starting a glucosamine/chondroitin supplement, as well as polysulfated glycosaminoglycans in the near future. She will not go outside unsupervised, and her owners are committed to keeping future feline acquisitions clawed.
Lucy was my first acupuncture patient, and she helped me as much as I helped her. Not only did I gain practical and logistical tips for future patients, but I felt that I was able to incorporate many facets of what I learned at CuraCore into this case. Lucy challenged me to think outside the conventional pharmaceutical box where I’m most comfortable.
I have encountered many onychectomized cats with post-surgical concerns, but Lucy was one of the most severe cases I have seen. Without the immediate “go-to” complications of incomplete excision and/or infection, Lucy became the perfect patient for exploration of my newfound acupuncture skills. There is a growing field of research focused on alternatives to declaw and the negative effects of declaw, as well as ever-evolving legislation regarding this ethical issue. There is a dearth of research, however, regarding the potential role of acupuncture and other complimentary modalities in treatment/management of post-onychectomy pain. Given the industry’s specific neuroanatomical understanding of onychectomy, I feel that there is great potential for furthering our understanding of managing pain in these patients. As long as some veterinarians are still performing this surgery, we need to continue striving to find safe approaches to related pain prevention, management, and treatment.