Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 4374
Abstract: Shrimp, a Dutch rabbit, presented with progressive marked paraparesis, suspected to be related to degenerative disc disease at the lumbosacral (LS) junction. He became ambulatory and pain free with treatment, greatly improving his quality of life.
History and Presentation: Shrimp, a 10 year old male castrated Dutch rabbit, presented for a 3 week history of progressive paraparesis, left worse than right. When he lay down, he could only extend his right hind leg. He was eating well and had no previous history of mobility issues or changes in his environment. He had a dedicated carpeted room for him to roam freely and was an only pet. He previously used a litter box but could no longer crawl in it. He was taking gabapentin 5 mg/kg and tramadol 5 mg/kg every 12 hours. He had a previous history of aortic stenosis, enucleation of the right eye and dental abnormalities.
Physical Examination and Clinical Assessments: On presentation, Shrimp was bright, alert and responsive with normal vitals. His weight was 2.34 kg and body condition score (BCS) of 6/9. He had a Grade IV/VI parasternal systolic murmur. Shrimp was non-ambulatory paraparetic with minimal motor in the left hind and moderate in the right hind. He sat with his weight shifted forward and to the right with his back flat. He was unable to hold a tucked position and sat with his tarsotibial joints extended and weight bearing on flexed phalanges. He was unable to fully stand. He had moderate discomfort on lumbosacral palpation (pain score 2/4). He had deep pain sensation in both hind limbs, conscious proprioceptive deficits, with a decreased withdraw reflex on the left and increased tone on the right. He was able to move his tail and his cranial nerve exam was unremarkable. On myofascial palpation, Shrimp had moderate muscle tension in his cervical epaxials and brachiocephalicus bilaterally, triceps, hip flexors, hamstrings and adductors. His left hind had limited extension of the stifle and hip due to shortening of the gastrocnemius and hamstrings. He had moderate hypertrophy of the cervical musculature, biceps and triceps but moderate atrophy of the thoraco-lumbar, pelvic and hind limb musculature. Radiology Report: Moderate to severe lumbar and lumbosacral degenerate vertebral changes. Narrowed disc spaces suggest degenerative disc disease. MRI was declined by the owner.
Medical Decision Making: The goals of treatment included analgesia, reduce muscle spasm, and improve activation of existing/remaining viable nerves. Specific points used were immune modulating points (ST 36, LR 3, GV 14), distal points on the affected limbs (BL 60, LR 3, ST 36, ST 34, Bafeng), trigger points and relaxation points (GV 20, GV 14 and Bai Hui). This was done with dry needling only (electrical acupuncture not available). Treatment started with smaller needles in relaxation points and the affected limbs. As the response was positive, the needle size was increased and front end points were also included.
Differential Diagnoses: Shrimp presented with an L4-S1 myelopathy. The most likely differentials were intervertebral disc disease (IVDD), LS stenosis or neoplasia. There was no evidence of LS diskospondylitis, coxofemoral arthritis, congenital vertebral anomalies or pelvic/ sacral fractures or luxations on radiographs, or history or spinal trauma.
Definitive (or Putative) Diagnosis (or Diagnoses): L4-S1 myelopathy due to suspected IVDD at the LS junction due to LS pain on palpation, neurologic deficits and radiographic findings.
Acupuncture Treatments: Shrimp’s acupuncture treatments included Seirin J-type (coated) needles, starting with 0.12 x 15 mm and gradually increasing to 0.20 x 15 mm to maximize nerve stimulation. Relaxation points were initiated to calm, including GV 20, GV 14 and Bai Hui. Bai Hui was also used to improve LS discomfort. The left hind limb was targeted as it was the most affected (and most accessible) using BL 60, LR 3, ST 34, ST 36, GB 29, GB 30, BL 39 and Bafeng. The first treatment was tolerated well and gradually over the subsequent 4 treatments the following points were added: GB 21 (right & left), SI 9 & SI 12 (left), BL 15 (left and right), tricep trigger points on both sides (including TH 10), as well as BL 27 & BL 28 bilaterally. All treatments were done using dry needling techniques for 10 minutes due to the sensitivity of rabbits. His treatments also included transcutaneous electrical nerve stimulation (TENS) across his LS junction, laser therapy over his LS region and left hind, and a generalized massage. Home recommendations included increasing gabapentin to 7.5 mg/kg every 12 hours, add warm towel wraps followed by a generalized massage, and passive range of motion of the hind limbs.
Outcomes, Discussions, and References: Shrimp showed significant improvement after his third treatment. He became ambulatory, his pain score dropped to 0/4 and his posture improved. His weight increased from 2.04 kg to 2.1 kg with a palpable improvement in his hind end musculature. He had improved motor in the left hind and even tried to scratch with it when his ear was rubbed and was able to climb into his cage. He continued to improve with subsequent treatments in his comfort level, mobility, and compensatory muscle discomfort. Unfortunately, Shrimp ran into a bout of GI stasis about a week after his last treatment. He became weak and lethargic with a decreased appetite and urinary incontinence. He became paraplegic with no deep pain in the left hind and decreased anal tone. His owners elected to humanely euthanize.