Written by a Medical Acupuncture for Veterinarians course graduate.  Author’s name available upon request.  Signed release obtained from client/author.  4388

 

Abstract: Acute onset of severe pain and neurologic deficits associated with lumbosacral stenosis and cauda equina syndrome in a dog.  Patient did not initially respond to medical/pharmaceutical therapy including NSAID treatment, but has returned to near normal mobility and comfort following medical acupuncture and therapeutic laser treatment.

History and Presentation: Patient is a 12 year old SF Airedale cross weighing 43 pounds. She has been remarkably healthy, only presenting for routine wellness exams, dental cleanings and vaccines annually.  Senior blood screening performed before her dental in January 2017 revealed slight renal azotemia, at which time the patient was started on Prescription k/d diet.

Patient presented on 7/27/2017 to my associate for pain and non-weight bearing (NWB) lameness right hind. There was no injury or incident leading up to this visit. Radiographs were taken which revealed lumbosacral spondylosis.  She started the dog on grapiprant (Galliprant) at 1.5 mg/kg once daily and performed a therapeutic laser (using the Arthritis pre-set on Companion Therapy Laser machine).

Physical Examination and Clinical Assessments: The patient returned 8/8/2017 with more severe pain, weakness in the left hind as well as continued NWB lameness in the right hind. Exam on this date revealed severe pain (subjective) and reluctance to relax/extend the right hind leg.  She could support herself on her left leg to some extent, but it was very weak and her tendency was to fall to the left.  It was difficult to assess conscious proprioception (CP) at this time, as she would not extend her right leg to the ground.  The CP was estimated to be slightly decreased on the left, but this was also difficult to assess, as I was supporting most of her body weight.  There was normal range of motion in all joints of the right hind leg. She didn’t seem particularly painful to manipulation or palpation. There was normal withdrawal reflex, no crossed extensor reflex and the patellar reflex was estimated to be slightly decreased, although nearly normal.

Differential Diagnoses:

L-S spondylosis resulting in potential nerve root impingement

Tumor/Mass – spinal cord or bone (Osteosarcoma)

IVDD

Spinal cord compression from mass or arthritis

Cauda Equina Syndrome

Cranial cruciate injury

This list was compiled from the exam findings and initial radiograph findings.  Cruciate injury was less likely, but included until further radiographs could be assessed.

Definitive (or Putative) Diagnosis (or Diagnoses):  The patient was referred for a CT scan, which led to the definitive diagnosis.  Results were L-S spinal canal stenosis, Cauda equina and nerve root compression due to degenerative IVDD and osteoarthritis

Medical Decision Making: Once the definitive diagnosis was reached, I increased the Galliprant dosage to one 60 mg tablet once daily, which is slightly higher than the label dose, but within the dosing “table” that is provided by the manufacturer.  I also started the dog on gabapentin at 5 mg/kg BID.  She continues on both of these medications to this day.

My goal with acupuncture treatment was to decrease pain and improve her neurologic function, particularly of the right hind leg.  Via particular acupuncture points, I would be stimulating nerve endings and cause release of neurotransmitters, which will have a central effect on the dorsal horn of the spinal cord.  At the cellular level, stimulation of fibroblasts will increase blood flow, release growth factors which aid in healing, and increase metabolic activity overall which will speed healing of affected tissues.  Treatment of trigger points and tight bands within the muscles will result in connective tissue stretch and nuclear remodeling.  I started with one treatment weekly, as this was the most frequent the owner could get the dog in along with therapeutic laser treatments and the medical/pharmaceutical therapy noted above.

Acupuncture Treatments: Once weekly treatments started within 4 days of CT scan which provided the definitive diagnosis.  The clients were traveling internationally, so I had to wait until the pet sitter could bring the dog in. I used dry needling and electroacupuncture, along with therapeutic laser.  For electroacupuncture, I used a Pantheon unit set on mixed frequency with 2 leads (4 points) treated with each session.  I have indicated points I used E-stim on, although I didn’t use all points at each treatment.

These are the points I used and rationale:

GV 14 – for associated neck and back pain (compensatory) and improved immunologic function

Bai Hui – for lumbosacral pain, pelvic limb pain and neurologic dysfunction *E-stim

Right hip triad (BL54, GB29,30) – for sciatic nerve pain, hip pain and pelvic limb dysfunction *E-stim

ST36 – for parasympathetic support (right side only)

BL40 – for pelvic limp pain/paresis, low back support (right side only)

BL23 – for lumbar and pelvic pain (bilateral) *E-stim

BL25 – lumbosacral pain, digestive support (bilateral) *E-stim

BL27 – sacral parasympathetic support, sacroiliac support (bilateral) *E-stim

BL28 – sacroiliac support, pelvic limp pain/paresis (bilateral) *E-stim

Trigger points and tight bands along lumbar spine and bilateral hind limbs – mostly lateral and caudal thigh

Outcomes, Discussions, and References: At the time of the first treatment, the patient was still quite unstable on the right hind and minimal weight bearing.  The medical/pharmaceutical therapy (gabapentin and Galliprant) had been quite helpful, but she still had fairly significant dysfunction.

I believe acupuncture and laser helped significantly in this case.  The owner is also convinced and wishes to continue treatment every week to 10 days indefinitely.  I noted improved coordination, particularly of the right hind leg.  She never did knuckle specifically, but she is placing her foot normally now.  She is able to rise comfortably from lying down, has no trouble with stairs and is able to jump onto furniture and into vehicles as needed (she had not been able to perform any of these tasks prior to treatment).

Describe Your Medical Acupuncture Experience: This case so far had been my most rewarding case.  I’m 100% convinced that acupuncture provided the most benefit and likely saved this patient from euthanasia.  I continue to learn from this patient with each subsequent treatment, based on how she responded to the previous treatment, new information that the owner provides and from my myofascial palpation prior to and during each treatment.

This patient has definitely improved my palpation skills, as she is calm, very sweet, and allows me to “feel her up” in any way I want.  She is never growly or shy, but does let me know when something is tender.  I only hope that I continue to have such patients that I can not only help, but learn from.

I would definitely benefit from and learn from additional research.  My current problem is TIME! I have listed some references that I used, in addition to the plethora of information provide to us during the online portion of the course via CuraCore.  I was not able to specifically find references for Cauda Equina syndrome in particular, but obviously many of the references are very relevant to this condition.

Acupuncture for Veterinary Neurologic Conditions

65th Convention of the Canadian Veterinary Medical Association, 2013

Allen M. Schoen, MS, DVM, PhD (Hon.)

Kline K, Caplan E, Joseph R. Acupuncture for neurologic disorders. In Schoen AM (ed), Veterinary Acupuncture, Ancient Art to Modern Medicine. Mosby, 2001. 179–192.

Clemmons R. How I treat degenerative myelopathy. In: Xie H, Chrisman C, Trevisanello L, eds. Traditional Chinese Veterinary Medicine for Neurological Diseases. Jing Tang Publ.;2011:347–354

Describe Your Related Medical Experience: I definitely saw the benefit of CT scan in this case.  We now have it readily available in our area, so I will be using it quite often.  Without that, I’m not sure my approach would have changed significantly, but I may have been reluctant to use laser, not knowing if neoplasia was a possibility.  I have also fully realized the benefit of Galliprant and gabapentin used together for pain relief.  The patient is now pain free and thanks to acupuncture, very functional!

Describe your feelings about this case:

Fun, rewarding, exciting!

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