Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 4S2018006
Abstract: Cooper is a two-year-old neutered male schnauzer mix who was seen for rehabilitation following a hemilaminectomy performed on March 30, 2018. Cooper was evaluated and treated once a week for 4 weeks. Treatment modalities included therapeutic exercises, acupuncture, electroacupuncture, laser and massage. Cooper improved significantly during the time period and continues to return for weekly sessions.
History: Cooper is a two-year-old neutered male schnauzer mix who suffered a traumatic spinal cord injury on March 29, 2018. The injury occurred as Cooper was playing with a housemate and he attempted to jump from a chair over to a couch. He hit the couch awkwardly and cried out, fell to the ground but got up and was limping on his left rear. The next morning, he was unable to ambulate on his rear limbs and his owners took him to the Veterinary Referral Center of East Dallas(VRCED). Cooper had been evaluated the previous day for acute onset diarrhea and treated with metronidazole, a probiotic, and a gastrointestinal diet after radiographs and examination did not reveal a specific cause. No musculoskeletal abnormalities were noted at the time of that exam. On March 30 Cooper’s examiner at the emergency clinic noted that he was painful overall and non-ambulatory in the pelvic limbs with absent conscious proprioceptive(CP) reflexes in both pelvic limbs as well as decreased panniculus at the second lumbar vertebra(L2). Cooper demonstrated good pain sensation and cranial nerve evaluation was normal. He was painful at the thirteenth thoracic(T13) and first lumbar vertebrae(L1). Cooper had normal withdrawal reflexes in both pelvic limbs and normal to slightly increased reflexes (it was not noted which reflexes but presumably patellar, tibial, and sciatic). His abdomen was tense. All other systems were noted as normal. A myelopathy between the third thoracic(T3) and third lumbar(L3) vertebrae was diagnosed. Cooper was transferred to Animal Imaging for magnetic resonance imaging(MRI) and then returned to VRCED. The MRI revealed abnormal vertebral formation with twelve thoracic and eight lumbar vertebrae present. A large amount of disc material over the twelfth thoracic(T12) to the first lumbar(L1) vertebrae site was found extending laterally and dorsally over the cord, from cranial T12 to caudal L1.
The surgeon at Veterinary Referral Center, evaluated Cooper upon his return at 5:15pm. Abnormalities noted were a large urinary bladder with overflow incontinence present, paraplegia with absent CPs in pelvic limbs and withdrawal present. Cooper had normal anal and tail tone and minimal muscle tone in both pelvic limbs.The surgeon noted bilateral patellar and sciatic hyperreflexia and a panniculus cutoff near L2 bilaterally. An intervertebral disc rupture at T12-L1 was diagnosed (left sided, dorsal extradural compressive lesion) and Cooper was taken to surgery. The surgeon performed a left-sided T12-L1 hemilaminectomy removing a large amount of degenerative disc material and hemorrhagic material. The spinal cord was found to be mildly edematous.
Cooper was kept at the VRCED for 3 days and discharged on April 2, 2018. He had regained bladder control but was very ataxic in both rear with continued negative CPs but his muscle tone had improved in both rear limbs. His therapeutic treatment to this point had included ice, sling walks, assisted and unassisted stands, passive range of motion(PROM) thirty repetitions on each leg four times a day. His medications included the following:
Tramadol, 50mg, 1/2 tablet every 8-12 hours for discomfort
Galliprant 20mg, 1/2 tablet every 24 hours
Gabapentin suspension 50mg/ml, 0.4mg every 8-12 hours for pain
Metronidazole 100mg, 1 tablet every 12 hours
Cooper’s home care instructions were to keep his activity restricted for six to ten weeks in a crate or small room and to utilize a sling to support him on walks to urinate and defecate three to four times daily. The PROM exercises were to be performed three times daily for five to ten minutes. Additionally, physical therapy was strongly encouraged.
On May 2, 2018 Cooper presented to me for initial evaluation and to begin therapy and rehabilitation. A video was taken as he moved around the room. (Attached) Since his release from VRCED his owners had been following all of the surgeons recommendations and Cooper was confined in a small crate. On exam I noted Cooper to have a markedly arched back at his thoracolumbar area. He could briefly support himself on both rear and advance a few steps to then slowly collapse on both rear. When at a stand he had a wide based stance with his weight shifted forward. The skin incision over the caudal thoracic to mid lumbar area was healing well and no pain was elicited over that area. His body condition score(BCS) was 4.5/9.0 and a pain scale of zero.
Cooper’s myofascial exam revealed tense areas bilaterally in the neck and shoulders with decreased tone in both rear limbs. His neurologic exam showed a cutaneous reflex present to the caudal lumbar area bilaterally and hyperreflexia of the right patellar reflex noted. He had delayed CP on the left rear with absent CP in the right rear, normal withdrawal present in both and absent crossed extensor reflex in all four. Normal anal and tail tone was noted.
Additional information noted was that Cooper’s lab work was all normal but his at home environment included a very active playmate who loved to run, jump and rough house with Cooper as well as mostly hardwood and tile flooring in the home. Cooper was spending almost his entire day in his crate to be separated from his playmate. He had been prescribed acepromazine, 25mg, and had received 1/4 tablet two hours prior to his appointment. All other medications had been discontinued. Cooper was also noted to have a fear of water per his owners.
Cooper’s diagnosis was an intervertebral disc herniation at T12-L1(with a spinal deformity noted of 12 thoracic and 8 lumbar vertebra present). He was 4 and one half weeks post-operative. He remained paretic in both rear limbs with prominent kyphosis present. No signs of myelomalacia were noted.
Initial treatment for Cooper included utilizing a figure eight sling to help shift his pelvis forward and facilitate better low back muscular function. We recommended increasing his walks by three minutes twice a week if he tolerated it. We began acupuncture the day of his initial evaluation to precipitate axonal regeneration, increase circulation to the operated tissues, and to decrease glial scarring.
Acupuncture was performed with the patient in sternal recumbency utilizing 0.16mm x 15mm (Serin coated for all points) at GV20 and GV 14 to stimulate vagal input(Autonomic) and 0.16 x 30mm at BL23, BL 25 for central nervous system input and at BL54, GB29, GB30 bilaterally to stimulate the sciatic input. Laser therapy utilizing a class IV Cutting Edge unit at 8j/cm2 for five minutes in scanning mode as well as
massage of Cooper’s neck, shoulders, hips and thighs was performed. Cooper tolerated the treatments well and enjoyed his special treat of peanut butter while he was receiving them. The owners were called the following day and reported that Cooper seemed tired following the treatment but the next morning he was very alert and was comfortable and able to stand for longer period of time, he wanted to walk in the grass and so they increased his walk time by a few minutes.
Cooper was returned to the surgeon for a 6-week post-op check up on May 10 where she noted that he had mildly delayed CP in both pelvic limbs with left faster than right, along with bilateral patellar hyperreflexia and moderate ataxia–improved in the figure eight sling and in grass but still significant. No paraspinal pain was noted. He was cleared for further rehab and therapy and acupuncture and it was noted that although he is improved, it is possible that he will always have some degree of neurologic deficits due to the spinal cord injury.
On the afternoon of May 10, Cooper was presented for treatment where I agreed with the above improvements but noted that he remained weak in both rear and markedly kyphotic. His treatment that day included acupuncture at GV20, GV14, GV4, BH, cranial and caudal to his spinal cord injury as well as BL18, BL23, BL25, BL27, BL28 using 0.18mm x 30mm needles and laser therapy at 8j/cm2 to tight, tense areas in his neck and shoulders and down both rear legs and the epaxial musculature from T10 to L7. This treatment addressed more of his myofascial issues including muscle shortening of his epaxial groups. Exercises included underwater treadmill with a technician in establishing and assisting gait in the rear limbs. It was noted from his attitude that Cooper would probably much more appreciate the land treadmill use and just walking outside in the future. Static stands for 30 seconds x 3, inflated green bone standing with cookie stretches, walk in grass outside with assistance in figure 8 pattern for 5 minutes. We discussed increasing his walks again by 3 minutes each week and adding in sit to stand exercises at home.
On May 16 Cooper returned for another session with a report that he continues to improve. Exam showed that his CPs continued to be delayed but his mobility and muscle tone in both rear limbs was improved. He remained markedly kyphotic but comfortable on palpation along the thoracolumbar spine.
We utilized the land treadmill at a very slow 0.5mph speed for 3 minutes which he tolerated well. Additionally, he handled planking on the inflated green bone along with cookie stretches and a wobble board session of 15 seconds x 4. We added stair stands with sways for 30 seconds x 4. His acupuncture session was electroacupuncture(8 channel Model JM-2A made by Wuxi Jiajian Medical Instrument, Inc) at 2 Hz x 10 minutes then 100 Hz x 10 minutes with 0.20mm x 30mm coated needles at BL 18 to BL23 bilaterally as well as other needles at GV20,GV14,GV4, BL27,BL28 and lateral neck areas of tenseness. I recommended that the owners try to find a way to allow Cooper more mobility at home away from his playmate (to avoid rough play and jumping). We cut sections of yoga mats and gave them to the owner to place on the floor in the kitchen which they feel that they can use a baby gate to help accomplish this set up at home.
On May 22 and 30 as well as June 6 Cooper was treated again utilizing the above and his mobility continues to improve. Video was taken on June 6 and is attached. His CP’s have returned and he is able to stand for much longer periods of time as well as walk with increased comfort. We continue to work on stretching, strengthening and lengthening his epaxials as well as core and rear limb strength. I do believe that acupuncture has hastened his recovery specifically with his returned motor and neurologic function and it has increased his comfort level.