Written by a CuraCore Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 4S2018045

Abstract
Maverick, an 11 year old male neutered Border Collie has been hiking his left hip into flexion during walks, which is suspected to be secondary to femoral nerve impingement due to severe compression of the disc space between his fifth and sixth lumbar vertebrae (L5-L6). After adjusting activity at home to very short leashed walks, no stairs, no jumping, and performing acupuncture with myofascial treatments for a few weeks, the hip hiking episodes lessened but have not resolved.

History and Presentation
Maverick is an eleven year old male neutered Border Collie. He started hiking his left hip into flexion during walks about three weeks prior to presentation (June 2018). These episodes are intermittent and occur randomly during walks where he will lift his left hip into flexion and stop to stand still, almost like a spasm. His owner has been stretching his left hind limb into extension when this happens, which helps end the episodes and his owner reports there is no thunk or any other abnormal type of sound or feeling noted. Maverick has also been slowly losing weight over the last couple months. His appetite has remained normal and his owner increased the amount fed, but he has not gained any weight back. He has also not continued to lose weight. Maverick has a history of suspect hip arthritis versus hip dysplasia per his owner, however this was never confirmed, but was suspected due to intermittent right hind lameness.

Maverick lives in a home with carpet. He goes on short ten minute walks two to three times daily. He does not have any stairs to do at home, but he does go on and off of furniture. His diet is Just Food For Dogs fish and sweet potato; he eats two cups twice daily.

The medications and supplements that he takes are Gabapentin100 milligram capsules and is given one capsule by mouth (PO) twice daily (BID), Shen Calmer biscuits and is given one biscuit PO BID, Prozyme powder and is given half of a teaspoon PO BID, Psyllium husk and he is given1/8 teaspoon PO once daily (SID) at night, and Welactin at one soft gel PO SID at night.

Physical Examination and Clinical Assessments
Maverick is bright, alert and responsive. His body condition score is four out of nine, which is ideal. His eyes are both clear with no ocular discharge. His ears are both clean and free of debris. His mucous membranes are pink and moist with a capillary refill time of less than two seconds. He has mild dental calculus. All of his peripheral lymph nodes are within normal limits. His heart rate is 120 beats per minute with no noted murmur or arrhythmia and strong synchronous pulses. His lungs are clear with no crackles or wheezes on auscultation. There are no obvious masses or organomegaly noted on abdominal palpation and his abdomen is soft and non-painful. His skin is within normal limits. On his neurologic examination, his conscious proprioception is within normal limits in all four limbs, he has no cranial nerve deficits noted, and he has hyperreflexes in both of his pelvic limbs (patellar reflex, tibial reflex). Maverick has grade four out of five ataxia in all four limbs with narrow hind limb gait and grade one out of four right pelvic limb lameness. He alternates off weighting of both pelvic limbs (right more than left). There was no hip hiking noted during his gait assessment. He holds his head low to neutral, which can indicate some cervical discomfort. Maverick has mild caudal cervical discomfort on spinal palpation, mild to moderate pain from his eleventh thoracic vertebra to his second lumbar vertebra, marked pain from his fifth to his sixth lumbar vertebrae, and mild to moderate lumbosacral pain. His right stifle is painful with drawer testing, but drawer is negative and it is thicker than his left stifle. He guards right hip extension, does not tolerate left hip extension and guards hip abduction bilaterally. On myofascial examination, Maverick’s fur is more flat over the lumbar and lumbosacral region (from the disc space of his second lumbar vertebra down to his lumbosacral space) indicating that there is likely some myofascial disruption causing the skin to be tighter and therefore the fur to lay down flatter. He has moderate tightness in his triceps (left more than right), moderate to marked restrictions in his quadriceps and Sartorius muscle groups (left more than right), mild tightness in his latissimus dorsi bilaterally (left more than right), and moderate tightness of his omotransversarius muscles (right more than left). I suspect that Maverick has nerve impingement on the left hip, as he doesn’t just guard left hip extension, but does not tolerate it.

I recommended that the owner have spinal, hip, and stifle radiographs performed. Radiographs were taken a few days later with Maverick’s regular veterinarian and revealed severely compressed L5-L6 disc space, normal coxofemoral joints bilaterally, and his spleen was subjectively enlarged. I recommended following up with an abdominal ultrasound to further assess weight loss and suspect splenomegaly; his owner will consider.

Differential Diagnoses
Left hip hike – rule out femoral nerve impingement, hip degenerative joint disease (DJD), focal seizure, other
Right hind lameness – rule out stifle DJD, hip DJD, old cranial cruciate ligament injury, nerve impingement, other
Weight loss – rule out primary gastrointestinal disease, renal disease, hepatic disease, neoplasia, other
Spinal pain (see above for segments) – rule out compensatory, intervertebral disc disease (IVDD), other
Ataxia – rule out IVDD, multifocal compressive lesions, other
Pelvic limb hyperreflexia – rule out multifocal compressive lesions, upper motor neuron spinal compression (myelopathy from 3rd thoracic to 3rd lumbar vertebra), other
Low head carriage – rule out cervical pain, tight cervical muscles, other
Flat lumbar/lumbosacral fur – rule out IVDD, compensatory, other
Muscle tightness (see above for which muscles) – rule out compensatory, other
Mild dental calculus

Definitive Diagnosis
I am suspecting femoral nerve impingement as cause for left hip hike due to radiographic findings revealing compressed disc space L5-L6. He likely has IVDD, possibly multifocally due to spinal pain in other areas as well, which is the cause of the narrowed disc space. The femoral nerve arises from spinal segments of lumbar vertebra four through six, which is consistent with the narrowing of Maverick’s L5-L6 space. The IVDD likely caused narrowing of this disc space, which therefore compressed the femoral nerve and is contributing to these episodes that are being witnessed by his owner. I also suspect femoral nerve impingement because Maverick does not tolerate left hip extension and suddenly jerks his leg back if I try extending his left hip. His right pelvic limb lameness is likely due to a chronic stifle injury versus DJD, but I cannot rule out some impingement from L5-L6 affecting his right hind limb as well.

Medical Decision Making
Due to suspect nerve impingement, my acupuncture approach is stimulation of the femoral nerve as well as sciatic nerve in attempts to relieve the impingement and nerve pain. I also used gentle massage over the lumbar and lumbosacral area near the compressed disc and the flat fur pattern to release tension in the muscles and fascia, which should help with pain from the tightness but also potentially decrease impingement by releasing the underlying tissues. Massage to the quads, as well as triceps, latissimus dorsi, and omotransversarius will help release tightness and trigger points from compensation and weight shifting. The massage and acupuncture to these areas should also increase blood flow to the areas, helping to wake up the tissues and help decrease pain.

Video1KristaWelsh  kristawelshtrimmed2

Acupuncture Treatments
Points used – GV 20, GV 14, SI 9, LI 10-11, GB 21, BL 21, BL 23, BH, BL 25, jian jiao, BL 54, GB 29-30, ST 36, GB 34, KID3/BL60, LIV 3
The points that were used were for calming purposes (GV 20), local muscle tension and pain (GV 14, GB 21, BL points along spine), general forelimb points for compensation (SI 9, LI 10-11), hip points for possible DJD vs. impingement (jian jiao, BL 54, GB 29-30), stifle points particularly for right stifle (GB 34, ST 36), distal nerve stimulation points (KID3/BL 60, LIV 3).
Acupuncture frequency – once to twice weekly, dry needling
Needle information – Energy Flo (uncoated) 0.25 x 30 mm and Seirin (uncoated) 0.20 x 15 mm (combination)

Outcomes, Discussions, and References
After the acupuncture and myofascial treatments, Maverick was still hiking the left hip occasionally on walks, but it was less and his owner realized it happened more when he went on slightly longer walks. When we went longer than one week intervals for acupuncture treatments, Maverick would have one day where his back was more arched and the left hip hiking would happen more often. He would improve the next day if this were to happen. His myofascial examination improved slightly with each treatment. His triceps were less tight bilaterally and overall his cervical muscles improved.
We would need to continue acupuncture once weekly for now in order to maintain and try to gain more improvement in the frequency of these episodes. Eventually the goal would be to taper how often he needs the treatments. Due to the extent of compression at L5-L6, we may not be able to get him to stop having episodes completely but we could potentially lessen the frequency.
I learned that nerve impingement can improve with acupuncture treatments, but may need chronic treatments in order to maintain the patient. Through some research I found that treatment of nerve impingement is highly variable between individuals. Similarly to sciatica responding to acupuncture in humans, nerve impingement in dogs can respond as well, but studies do show that more evidence is needed.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4631886/
https://aim.bmj.com/content/acupmed/29/2/108.full.pdf

My Impressions
My impression of this experience is due to the extent of disc compression in this patient likely secondary to IVDD, it is difficult to completely eliminate the hip hiking episodes because we cannot reverse the damage already done to that disc. However acupuncture can help lessen it and hopefully prevent the impingement from worsening. It can also help prevent compensatory tightness and soreness and help treat the spinal pain associated with his disc disease.


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