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Written by a Medical Acupuncture for Veterinarians course graduate.  Author’s name available upon request.  Signed release obtained from client/author/4393.

Abstract: A four year old female spayed Irish Wolfhound was presented for evaluation of cervical pain and ambulatory tetraparesis. CT myelogram of the cervical spine was performed. There were multiple intradural extramedullary filling defects observed over C2 and C3. The differentials for intradural extramedullary pathology are: idiopathic hypertrophic cervical pachymeningitis, dural neoplasia (lymphoma, histiocytic sarcoma, meningioma) or hemorrhage. There was no underlying cause identified on cerebrospinal fluid analysis, complete blood count, serum biochemistry, radiographs, abdominal ultrasound and infectious disease titres. There was a return to near normal function with immunomodulatory treatment (corticosteroids and cytosine arabinoside), acupuncture (manual and electroacupuncture), and physical rehabilitation. During the course of treatment the patient developed a decubitus ulcer, intermittent SVT and decrease in kidney function and was treated with acupuncture and traditional medical management for those conditions.

History Presentation: A four year 9 month old female spayed Irish Wolfhound was presented for cervical pain, suspected headache, and mild ambulatory tetraparesis. Approximately two years ago the patient had acute neck pain without tetraparesis and was treated conservatively with restriction from high impact activities, oral Prednisone, Gabapentin, and Methocarbamol. Spinal radiographs, CBC, and chemistry were WNL. The UA showed 2+proteinuria. The UPC was normal and subsequent recheck UPCs were normal.

Physical Examination and Clinical Assessments: The patient was BAR, and in good body condition with a BCS of 4.5/9. Vitals were normal. Cranial nerves were normal. Gait assessment revealed mild tetraparesis (neurologic grade 2). The patient carried her neck in ventroflexion and resisted active lateral ROM. Both hind limbs were ataxic, but the right side appeared worse than the left. Conscious proprioception was absent on the right hind limb (0), and slow (1) on the left hind limb. Conscious proprioception was normal on the front limbs, although was difficult to assess due to patient size. The patellar reflex was mildly hyperreflexic on the right hind limb. All other reflexes were normal. Cervical pathology, specifically cervical spondylomyelopathy, was suspected. Empirical treatment, including oral Prednisone on a tapering dose, Amantidine, and fish oils were started because of the wait time to get in for neurology consult.

There was mild cervical pain present (2/10). There were multiple triggers in the cervical musculature. The lumbar region was reactive, especially the iliocostalis muscles. The gracilis was tight on the right hind limb. There was muscle atrophy with both hind limbs, although the right was worse than left (47.5 cm right and 50cm on the left). Mild crepitus was palpated when placing the right tarsus through PROM, but there was no pain, or effusion present.

A CBC, and chemistry panel were WNL.  The UA showed 3+ protein. The UPC was normal at 0.4. The urinalysis was normal and the patient was able to concentrate her urine. An abdominal ultrasound, completed prior to CT, showed mild renal pelvis dilation. Spinal radiographs showed spondylosis at multiple points of the thoracic spine, arthritic changes from L2-L4, and possible tipping of C5. Chest radiographs showed dynamic pectus excavatum which was believed to be an incidental finding.

CT myelogram was completed and showed multiple intradural extramedullary filling defects observed over C2 and C3. The differentials for intradural extramedullary pathology were: idiopathic hypertrophic cervical pachymeningitis, dural neoplasia (lymphoma, histiocytic sarcoma, meningioma) or hemorrhage. CSF showed a non-specific increase in protein. No neoplastic cells were visualized in the fluid. The patient was on a low dose of Prednisone at the time of testing, so Prednisone withdrawal was recommended with retesting of the CSF fluid and PARR testing.  The CSF collected two weeks later was normal. Cervical spinal pain returned 3 weeks after discontinuing Prednisone, so the patient was started back on Prednsione and Cytarabine Arabinoside.

During treatment the patient demonstrated intermittent SVT. The echo was normal, and the cardiologist did not recommend treatment for the occasional arrhythmia. The patient showed elevation in UPC (4.0) and increased SDMA, so the patient was started on a kidney sparing diet and Benazepril.

Medical Decision Making: There were many problems to address in this case. The initial problems that were addressed with acupuncture were neck pain, compensatory strain from the pain and abnormal ambulation, providing sensory afferent stimulation to the hind paws, and autonomic neuromodulation to help with the patient’s distress. As the case progressed, the patient developed intermittent SVT, kidney dysfunction, and a decubital ulcer. The heart shu point and PC6 were added for the arrhythmia. The “kidney tiara” was used to neuromodulate the kidneys to improve function. The decubitus ulcer was addressed with circling the dragon. Acupuncture was also utilized to improve immune function during Prednisone and Cytarabine treatment.

Acupuncture Treatment: Manual stimulation to GV20 was used for suspected headache and for autonomic neuromodulation. Manual stimulation to GV14 was selected for neck pain. Manual stimulation of Bai Hui was used for neurologic dysfunction of the pelvic limbs. Electroacupuncture (Dense disperse 4-100Hz) was used between ST36 and Bafeng points for pelvic limb dysfunction and a modality to provide sensory afferent stimulation to the hind paws. sT36 was also important for immune modulation. Manual stimulation of KI1 was used for additional sensory stimulation to the hind paws. Electroacupuncture (Dense disperse 4-100Hz) was also used between BL 10 and BL11 bilaterally for neck pain. Manual stimulation of GB20 and GB21 were used for neck pain. LI4 was manually stimulated for head and neck pain. Additional trigger points were treated in the neck based on myofascial exam. Points between BL12-BL28 were manually stimulated for compensatory muscle strain from abnormal ambulation and neck pain. Outer bladder line points were used if the iliocostalis was tight. This was variable each treatment based upon myofascial exam. BL 15 and PC6 were used to address the intermittent SVT. PC6 was also selected for the nausea post Cytarabine treatment. The kidney tiara (GV4, BL23, and BL 52) was manually stimulated for neuromodulation of kidney function. LI11 was manually stimulated for immune modulation and anti-inflammatory effects. Manual stimulation of needles circling the ulcer was used for wound healing.

The patient was treated biweekly until her relapse of neck pain. At that point, treatment was increased to three times weekly and continued for 3.5 months. Following the neurology recheck, treatment decreased to once weekly and were continued as needed in June. The patient had approximately 41 treatments from January until June (continuing as needed at this point).

Outcomes, Discussions, and References: The patient’s quality of life would have declined without the use of acupuncture and other physical medicine modalities (massage, heat for muscle spasm, exercise). The patient’s cervical active ROM improved and she had better affect immediately following acupuncture, but the other positive outcomes are difficult to assess because of all of the other treatments used (Prednisone, Cytarabine, Amantidine, Fish oils, Baytril and suture seal for wound care, kidney sparing diet and Benazapril). The patient gained muscle mass despite treatment with steroids for 4 months. Her conscious proprioception scores, by a neurologist, improved. In January, the neurologist scored her left hind CP at 1-1.5 and in May she was 1.5-1.75. Her right hind limb was scored as a 0.5-1 and was 1.25 in May. Poppy’s BUN and Creatinine decreased to normal following intervention. Most importantly, Poppy has returned to her normal activities of daily living and activities she loves like hiking. Because of the improvement and durable remission from neck pain, neoplasia is unlikely and the main differential is idiopathic hypertrophic cervical spinal pachymeningitis. There were no adverse effects related to acupuncture, but the patient developed a decubitus ulcer and kidney dysfunction with immunosuppressive treatment.

Poppy was a great learning case! The case included aspects of treatment for pain, neurologic dysfunction, and internal medicine problems. I was able to treat many points because Poppy was very tolerant (and enjoyed) the needles, so I believe I was able to fine tune needling technique (I have been mentored by Dr. Wright) because of her. Most importantly, Poppy’s case reminded me that I had other treatment options that would provide comfort without the heavy use of sedating opiods. As Poppy’s family member (and veterinarian) I have been extremely thankful for the knowledge that I have obtained from this course.

To my knowledge, there isn’t a case study describing acupuncture for the treatment of idiopathic hypertrophic cervical spinal pachymeningitis because the condition is very rare. A study describing the benefits of acupuncture for inflammatory CNS conditions could benefit many patients, especially those that suffer from frequent debilitating relapses of pain.

References:

Li P et al. Mechanism of the inhibitory effect of electroacupuncture on experimental arrhythmias. J Acupunct Meridian Stud. 2013; 6(2):69-81

Paterno JC et al. Electroacupuncture and moxibustion decrease renal sympathetic activity and retard progression of renal disease in rats. Kidney Blood Press Res. 2012;35(5):355-364

Yang JW et al. Effects of corticosteroid and electroacupuncture on experimental spinal cord injury in dogs. J Vet Sci. 2003;4:97-101.