Surviving Veterinary Medicine. Be smart, be bold, be creative and be your own boss. At the very least, find a practice where you can do what you do in the most positive way that gives you the space to practice medicine as you see fit. Because at SVM we set a higher standard for medicine than what you learned in school.
Today’s focus is The Untold Story on Spinal Cord Injury. And I’m Dr. Narda Robinson, Osteopathic Physician and Veterinarian. And I am the founder and CEO of CuraCore Vet.
And so, this Untold Story series is specifically designed for veterinarians or veterinary students who are going through school and, in my opinion, not learning the full story.
And we have taught thousands of veterinarians, medical acupuncture, photo medicine, all these different things. And it turns out they didn’t learn these things either. And when I go to visit other veterinary schools and teach, turns out that those students aren’t learning anything like this currently. So, that leads me to believe that there is an untold story here that I am interested in telling.
So, the first untold story, we covered, Scientific Integrative Medicine for Seizure Disorders. And so, that’s what these installments are about. And again, for some of my webinars at large, I also put them on our podcast called Surviving Veterinary Medicine, available through Stitcher and Apple and all the other ones that you typically go to for podcasts, so that you can listen to it as well.
So, I’m going to be reading a lot of the citations that I have here for the podcast purposes, so you can read along with me, because if you’re on video, then you will see that.
But anyway, so today, The Untold Story About Spinal Cord Injury. This is a lot like, in many ways, the TPLO issue. And why it aggravates me so much is that you have so many different types of approaches that are available and effective and are untold to you as students or were untold to you as veterinarians and then you never learned it, maybe, because there are investments in maintaining the status quo of surgery and various other invasive procedures.
And when you think about, how does a veterinary teaching hospital survive, they need to make a lot of income. Why would you, as the hospital director, say, “Well, you know what? You could go for a series of medical acupuncture, photobiomodulation, herbal consultation, medical massage, and rehabilitation treatments for X amount of dollars per week, or you could come in for a surgery and get, at the minimum $5000 or throw in an MRI there. And, oh, if there’s complications, you come back to us for those as well.”
Not saying it’s all about the money, but as we saw in our other Wednesday webinar on “Wait! Don’t Cut!” there is a financial investment in having more surgeries by hospital administrators; if you work for corporate, by the corporate bottom line.
There is the very well-worn rut in the road. You go into a vet teaching hospital, likely you’ll go into emergency with your dog. So, if you’re a client or a vet student or a vet, you go into emergency and they take you in and then they talk about MRI and then they talk about surgery. It’s just what you do. And for those that have kind of considered, “Is this really the right thing to do?”, there is a lot of fear involved.
So, we’re going to go into all that. But that’s what this untold story is about. And few, if any, speak about it, which remains untold therefore.
Our goal for today is actually many goals. Stop telling people that surgery is the only option. Stop telling people that their dog needs to get an MRI and then surgery.
So, frequently, the approach is, “Well, we’re going to do an MRI.” “Okay, fine. Thank you. I think that’s good. You’re the boss. You’re telling me this,” and then we might not wake them up until they’re done with surgery, because it’s just better; you just go from anesthesia, continued anesthesia into the surgery suite.
And you scare people by saying, “Oh, if we wake them up, that would be horrible. Let’s just keep them under anesthesia.” Not really telling them how bad, just all that super prolonged anesthesia is going to do and not giving them the option to say, “I need to think about this. Give me time to call my veterinary acupuncturist, my veterinary rehab people. Let’s see what the other options are.” “No, no, no, no. You go under and you stay under until you get out and then we’ll see what the outcome is then.” We don’t know for sure. I’ll talk about that.
Stop telling people that they need to use high dose steroids for a long, long, long, long time. Stop telling people (This is all about their dog) that acupuncture and laser don’t work; we hear that. People in academia don’t necessarily know the latest information. They don’t know where human medicine necessarily has gone. They don’t know the evidence and the mechanisms of action of acupuncture, massage, photobiomodulation, even cannabis, even rehab. “No, no, no, don’t do that. This is what you need to do. The research says…” Let’s look at what the research says.
Stop telling people that cage rest is absolutely needed when you can’t defend that, when you can’t show me one study that says that strict cage rest, sticking them in a box for six to eight weeks, only letting them go outside for the bathroom and then putting them back in there. They will have mental breakdown, even in the household, especially with Covid, “You’re all going to have mental breakdowns.”
Stop telling people to delay rehab, acupuncture, laser, etc. until so much damage has been done, from the strict cage rest, from the surgery or the no surgery, from the steroids, if your dog is still alive, if they’re even still walking, if whatever, if you have any resources left after you had to do another surgery and so on, but then maybe, “Okay, maybe you could do some acupuncture.” And the dog doesn’t even know how to walk anymore. It has just destroyed the joints, because there hasn’t been enough weight bearing.
So, why is it so hard to challenge surgeons? There are inbuilt reasons and just impediments for you to not, you know, why you don’t feel empowered. You feel small. You feel like, “Oh, I’m just a vet student.” or “I’m just an essential worker somewhere else.” or “I’m the house cleaner.” (or whatever) and here’s this big surgeon (or little surgeon). But it’s a surgeon and so, you feel intimidated because of that and you feel they have all the answers and they should be able to tell you, is non surgery an option? And you’re so clearly telling me I need to do surgery and really quickly that who am I to say otherwise?
You’re feeling small, you’re feeling boxed-in and you feel like you have no options, because nobody has given you options and you haven’t had the wherewithal to study and you just feel disempowered because you’re scared. So, you end up feeling utterly overwhelmed. And it’s with vets and vet students, as well as clients.
What’s the good news is that you are not alone. And so, we are here for you. We are educating people, every month and even every day, because we have people in our online courses, learning about spinal cord injury and how to address it in a multimodal, integrative fashion.
So, other good news is that not all surgeons rush to cut. And as I said, we have many graduates from our acupuncture course that are veterinary neurologists and veterinary neurosurgeons.
So, anyway, if the dog doesn’t have surgery and they tell you, “That neurological injury is going to last forever and you are responsible and it’s your fault and it’s morally reprehensible if you don’t bring that dog to surgery right now.”
Okay, well, let’s look at some evidence. Humans: Lumbar Herniated Disc: Spontaneous Regression. So, this from Korean Journal of Pain. So, previously, five patients had received physiotherapy, seven patients had been on medical therapy. How did these people do conservative treatment?
“All patients reported that they had benefit from the non-surgical treatment. They also had radiologic improvement observed simultaneously on MRI scans.”
It took a few months. But as they concluded;
“It should be kept in mind that lumbar disk hernias could regress with medical treatment and rest without surgery. And there should be an awareness that these patients could recover radiologically.”
So, if you are listening to this on a podcast, just for the citation, Korean Journal of Pain in 2017. Lumbar Herniated Disc: Spontaneous Regression.
So, that was one study. And they also go on to say that, yeah, if you had an epidural abscess, if you had cauda equina syndrome or severe and progressive neurologic deficits, after six weeks of trying conservative therapy, you might try surgery. But they are saying, of course, try conservative measures first.
Here in 2009, Journal of Chinese Medical Association; case report by Chang, et al. on the Spontaneous regression of lumbar herniated disk.
So, if it’s going to regress, then your cause of wanting to go in and remove it kind of disappears as well. That regresses as well, because you’re not still having that spinal cord impingement.
As they say,
“Intervertebral disk herniation…”
Now, they’re not just talking about back pain, but they’re talking about herniation;
“of the lumbar spine is a common disease representing with low back pain and involving nerve root radiculopathy.”
So, you are having neurologic problems as well. And now, they can watch the changes with MRI.
“Many reports have demonstrated that the herniated disk has the potential for spontaneous regression.”
Oh, no. If the disk resolves on its own, our surgeons are going to be out in the street without jobs.
“Regression coincided with the improvement of associated symptoms.”
They’re still trying to unpack what’s the mechanisms.
But here we present two cases of lumbar intervertebral disk herniation. And yeah, it’s cases, but this is because there’s a lot of people out there that get these things and they never go into the hospital and they never get surgery and then, “Oh, okay. They’re better.”
Now, then the question is, how much better would they be if we, regularly, as standard of care, instituted electro acupuncture, photobiomodulation, medical massage, certain amount of neuroprotection and anti-inflammation from cannabis and other anti-inflammatory analgesic herbs and appropriate exercise therapy.
As they say;
“In conclusion, many studies have demonstrated that herniated lumbar discs have the ability to spontaneously regress. This phenomenon may be related to dehydration…”
So, the thing; it’s just sitting out there, it’s not getting anything to juice it up. So, it’s going to dehydrate. It’s going to shrink, retract and then the inflammation that does develop can help to clean it up.
So, it makes me think a lot of TPLO and the cranial cruciate issues and like, “Let’s just surgerize this situation before it heals on its own,” versus the other way to think about it is, “Let’s do some nice nourishing treatments that will help it resolve on its own and help those reparative mechanisms work even better, so that they don’t get stuck along the way.”
Does this happen in dogs? Oh, look at that. Spontaneous regression of lumbar Hansen type 1 disk extrusion detected with MRI imaging in a dog. So, they actually saw that it happened.
“A three-year-old French bulldog evaluated because of acute signs of back pain and spastic paraparesis.”
So, here’s like a down dog, upper motor neuron injury (T3 to L3). MRI evidence of extradural spinal cord compression at the disk space of L3-4. Saw it was a disk without extradural hemorrhage.
“Dog was treated conservatively, again, with cage rest, restricted exercise, on a leash, and NSAIDs.”
So, the dog was able to get out, was kept confined. I don’t love the cage rest. I don’t see any acupuncture or anything here. And even without that, which would facilitate the resorption.
“Results of follow up examinations, five weeks later, indicated complete resolution of signs.”
Five weeks later; complete resolution of clinical signs.
“Results of repeated MRI indicated a 69 percent reduction in the volume of the herniated disk material.”
What happens if you do surgery? You are cutting into the skin, you are cutting — right? You got to get down deep. So, you’re cutting into the skin, you are working with the muscles there and moving them. You are ronguering bone and dealing with ligaments as well and causing, who knows how much, trauma.
You have destabilized that back. Maybe you love that because you’re a surgeon and you think that’s great and you should do more of those levels, just in case. But the disk could disappear on its own and then you haven’t done all that.
So, here’s the crux of it with the pathophysiology of spinal cord injury. And in the first phase of it, the physiologic changes were the primary phase and then the secondary phase, the benefits of integrative medicine and rehab or surgery are different.
And if you don’t institute some kind of supportive care, once you get past that initial thing, whether — Okay, if you’re going to do surgery, whatever; you’re going to induce more trauma. But let’s say you do surgery, there is still that secondary phase of spinal cord injury to deal with.
And so, our plan is to match the mechanisms of photobiomodulation and neuromodulation with acupuncture, et cetera, to mechanisms of spinal cord injury.
Because we are scientists at CuraCore Vet, and our community of graduates, we understand what the science-based mechanisms are of the treatments that we employ. And in that way, we can say, “Okay, what’s going on here that’s broken? How can we fix those specifically?”
So, we can identify ways in which patients with spinal cord injury can benefit. So, we know the pathophysiological mechanisms and we know the therapeutic mechanisms.
So, how big a problem is spinal cord injury? We can also look at the human implications of really perfecting our approaches with the dog, because the dogs are even responding, it seems, faster than a human might, but it’s still an uneven playing field.
And here again, when I’ve spoken to human physical medicine and rehab specialists or acupuncturists or whatever, they say — They see the cases that I present that we’ve worked on with dogs and they say, “That is fantastic. That is mind blowing. That would be enormously wonderful to have. But that seems to take a lot of effort. It seems to take repeated visits. We don’t know if insurance would cover it.”
And so, they are so constrained by the insurance system that they are in, by the hospital system that they’re in, that it’s like we, as veterinarians, can give so much more care in our freedom-of-choice way. And even a lot of times, doggie insurance will cover it, but it’s like just the problems with health insurance here, and even in Canada or wherever are then leading to limitations in what can be done for humans.
And so, it’s just such an opportunity to work with naturally occurring disease and be able to show this is how we repair the spinal cord. And it makes me think what would happen if some of these high-profile individuals with spinal cord injury like Christopher Reeves or whoever, what if they got the treatment that we’re giving to dogs, what if they got that right away?
And just how much suffering, how much suicide, how much just death is occurring because things that are readily available, explainable, accessible, otherwise; it’s like, “Just come in and we’ll work with you.” could have been tried.
So, the scope of — I mean, millions of people are living with spinal cord injury; there’s lots of new cases annually. They’re usually traumatic. So, this is the human and their rehab is, to me, really limited. It’s not fully including everything that we could. For dogs, intervertebral disc disease is the most common spinal cord disorder and it affects many breeds; mainly the dyschondroplastic types. Dachshunds are over-represented.
And so, this is where we can translate insights from the dog work to the human. And these academic centers have large caseloads of dogs and unfortunately, a lot of them get surgery. But we could, with a forward-thinking school, help to change that.
But veterinary clients are often willing to participate, especially if they’re going to get a break on the cost, the multi, multi, multi thousands of dollars. And so, they typically sign up at a rate of 90 percent or more.
And so, Levine et al. had mentioned;
“Despite decades of research using experimental models of spinal cord injury to identify candidate therapeutics, there has only been limited progress towards translating beneficial findings to the human spinal cord injury.”
That’s with the experimental model. But here, we have so many dogs and we could study them with naturally occurring disease because that’s more akin to what happens in the humans.
So, anyway, the gross and histopathologic lesions are similar between canine disk herniation and some types of human traumatic myelopathy. And then for those of you that have seen me speak about spinal cord injury before, we’ve seen this dog and just all the myriad problems and complications of spinal cord injury that accrue. There’s pain; there’s neuropathic pain, somatic pain, musculoskeletal pain, visceral pain, inflammation, cardiac and abdominal complications, paresis, paralysis, urinary and fecal incontinence. Then you get skin breakdown.
So, there’s lots of things that go into spinal cord injury and it’s so much beyond that little piece of disk that you’re going to carve up the back for and then we’ll see what happens. We’ll see if that animal walks again or not.
Because in my experience, being in an academic center, I mean, there were a lot of surgeries that just didn’t turn out well. Same with TPLO. And that information doesn’t necessarily filter down to the client, who is desperate for somebody to help, and to make a meaningful and hopefully safe and effective approach.
So, what’s the best way forward? Again surgery can cause clinically significant spinal instability, especially when you’re going to be taking out multiple spinal segments, when you’re going to be destabilizing things on multiple levels.
And so, here’s a citation about Spinal instability resulting from bilateral mini hemilaminectomy and pediculectomy in 2009. Here’s another one, 2012; Early re-herniation of disk material in 11 dogs with surgically treated thoracolumbar intervertebral disk extrusion.
Now, keep in mind, as I mentioned, in terms of being a critical consumer of the literature, when you go online shopping for free, and especially because when I’ve tackled with surgeons, when they’ve sat in my lectures at these meetings and just wait for my Q&A or they raise their hand in the middle, “Oh, how many studies do you have for acupuncture?” And we talk about that.
And it’s like, “How many cases are in your studies?” You don’t have 50, 60, 70, 80, 100, unless you’re doing like an overall retrospective. When you’re testing a procedure, you have really limited numbers of animals in your studies. And I’ll tell you what, you do not have double blind placebo-controlled surgeries, even though you have told me, dear surgeons, that you do it. And so, it’s like, “Yeah, we need to take you back to Research 101 here.”
Anyway, this is from Veterinary Surgery 2012, this early re-herniation of disk material in 11 dogs who have already had the surgery. So, their objective was;
“To report the findings and outcomes of dogs with re-herniation of nuclear or disk material within seven days of hemilaminectomy for acute thoracolumbar intervertebral disk extrusion.”
And they had the chondrodystrophic dogs, 11 of them; this was a retrospective case series.
“They had dogs with acute neurologic decline within one week of surgical decompression. They had advanced imaging in 10 dogs. 10 of 11 dogs had a second decompressive surgery to remove extruded nuclear material.”
So, we not only paid many thousands of dollars for the surgery and for the advanced imaging. And I’ll tell you what, there are a lot of dogs that don’t come out well from the MRI, especially if it’s a cervical, because they have this posture that their neck gets put in. Oftentimes, they are pretty painful after the imaging.
Anyway, So, “Oh, look. There’s another disk; right after surgery. We have to do all this again. Were you planning to pay your credit cards this month, because I think you’re going to get a new one.”
“All dogs had acute neurological deterioration two to seven days after initial hemilaminectomy.”
Bummer! Look, medical acupuncture, photobiomodulation, rational herbal therapy, medical massage, and also rational, careful rehabilitation does not give you a second disk herniation.
“Dogs that had a second surgical decompression improve neurologically within 24 hours and were peripatetic at discharge.”
“Early re-herniation at the site of previous hemilaminectomy can produce acute deterioration of neurologic function and should be investigated with diagnostic imaging. Repeat decompressive surgery can lead to functional recovery.”
Yeah, for how long? And how long does it take your bank account to recover? Are people even going to do this? And then what? You’re just going to leave them in a box for eight weeks? Are they ever going to walk again?
So, risk of recurrence:
“Even after surgery, the rate of recurrence of neurologic signs and consequent euthanasia in dogs nears 50 percent.”
So, you’ve got a little Dachshund, you’ve sent them for surgery, and, yeah, a lot of them go back and the people say, “We can’t go through that again.”
According to one paper:
“Dogs were euthanatized for financial reasons or because the owners did not wish their pet to undergo a second surgery or have the potential for further recurrences.”
And that was in JAVMA, 2004 on 265 cases. Recurrence of thoracolumbar intervertebral disk extrusion in chondrodystrophic dogs after surgical compression with or without prophylactic fenestration: 265 cases.
Here, long-term outcome (JAVMA, 2012). Long-term neurologic outcome of hemilaminectomy and disk fenestration for treatment of dogs with thoracolumbar intervertebral disk herniation: 831 cases.
So, they did a long retrospective, over seven years. They wanted:
“To determine the proportion of dogs that had herniation that successfully recovered after surgery, and look at the time to ambulation, and the frequency of urinary and fecal incontinence (because that could be a death sentence) and to document long-term complications.”
That’s a noble approach. Okay, 831 dogs.
And just reassessed over three to six months, evaluation looked at things. Okay,
“Out of the 831 dogs, 122 had unsuccessful outcomes.”
You do the math: that’s 15 percent of dogs that had surgery had unsuccessful outcomes. And then they’re saying,
“709 had successful outcomes.”
But let’s look;
“Of 620 dogs that had intact, deep pain before surgery, 97 percent were ambulatory after surgery. Despite maintaining the ability to walk, seven dogs were judged to have an unsuccessful outcome because the severity of the ataxia did not improve. Of 211 paraplegic dogs with loss of deep pain, 110 dogs became ambulatory after surgery.”
“Long term complications included incontinence, permanent neurologic deterioration and self-mutilation.”
Okay, so you might be able to get them walking again, as we do also with our integrative approaches. But;
“Dogs with paraplegia before surgery had a higher frequency of urinary and fecal incontinence compared with dogs that were ambulatory.”
So, it’s like, “Oh, well, if we can get you to walk, at least, for a little while, okay, we’ll call that good.” But what are they going to do with the permanent neurologic deterioration? It’s only permanent because maybe they didn’t have mechanisms to improve that.
And their incontinence, what did they do about it? Just say, “Oh, whatever.”
So, we obviously have a situation here. For those of you that need something to push back on surgeons when they say, “It’s proven to be the gold standard. It’s going to give you the best outcome.” This is a paper that can give you more information. I’m only showing you the abstract because we only have a little bit of time.
But we have to know that there are other options and that the whole story is not told by these papers on just the long-term debility, the financial outcomes and what else happened.
So, what does the literature say? In Vet Journal, 2017; Proportion recovery in times to ambulation for non-ambulatory dogs with TL disk disease, treated with conservative approaches.
We know that it’s a common problem and that there are issues and:
“Data presented in this review support the current recommendations for surgical management of non-ambulatory dogs with disk extrusion.”
but only because they compared cases to cases. And they say,
“Controlled clinical studies comparing outcomes are necessary to confirm these findings.”
They only looked at cases to cases. And who is it that are putting these papers together? Typically, often surgeons.
Journal of Veterinary Internal Medicine, 2018. The comparison of surgical and conservative treatment of hydrated nuclease pulposus extrusion in dogs. Remember, there is a whole potential for spontaneous regression of the disk material.
So, this was with:
“Whether compressive cervical myelopathy caused by the disk should be treated surgically or conservatively has been debated. Only one recent study contradicted this…”
But idea about surgery, because again, this is a very pro-surgery profession.
“18 of 36 dogs underwent surgery, where 18 dogs were managed conservatively; including cage rest, (unfortunately) and physiotherapy (We don’t know exactly what that consisted of).”
“The most common affected disk space was C4-5 with the neck or T13-L1 with the T-L region. Median time to regain ambulation was 6.6 days after surgery, and 5.9 days with conservative management.”
So, even shorter with conservative management.
“Only the length of a potential intramedullary lesion in the neck had an influence on the prognosis to gain ambulatory status.”
So, anyway, conclusion is;
“Conservative management of the extruded disk in the cervical as well as the TL region represents a reasonable alternative to surgery showing similar favorable outcomes.”
Note that. Have that with you when you need to educate people, when you need to be there for yourself, when you need reassurance, and ultimately, when you are dealing with clients. This is where education is important, where we have to have the knowledge, and command of the science and the mechanisms of action of our treatments against the mechanism of injury of what we’re dealing with.
And then we can show them; here’s the evidence. Humans they say do six weeks of conservative, meaning nonsurgical approaches, and then you could consider surgery. Surgery is always an option.
We have been brainwashed or cultivated to believe or whatever it is that, “Oh, no, if there’s any kind of disk there, it’s going to be a permanent lesion. We must go in there, very heroically, Start scrubbing as soon as we hear somebody’s coming, we’re going to be ready to cut right away.”
And it’s like, “You know what? That thing could disappear by itself and we have ways to improve the nervous system.” So, it’s kind of a battle.
So, can we recognize issues before they become bigger problems? Yes, and that’s where the prevention comes in. That’s where education about what to look for in the dog and cat and everybody.
But if we look, “Okay, do I look normal?” Yes. This dog looks normal, has a nice curvature of the back. What about this? “Do I look normal?” (showing this thoracolumbar kyphosis) No, not really. You are hunching up. You are showing evidence of some problems.
This little guy says, “I’m normal; aren’t I?” No, you’re not sitting normally. And we see this hair coat off here. So, for those of you listening on podcast, you should watch the video because we’re showing nice pictures now. This is not a normal way to sit. There’s something going on there. And at the lumbosacral region.
This little girl here; very kyphotic. We have hair coat changes. And your big brother there isn’t so great either. We see the muscle tension and we see a hair coat change here.
You just have to be taught how to look at these animals and you are not taught, typically, in vet school how to visually observe for changes in posture, for changes in function, and to be able to prevent things from happening; whether it’s a joint disorder, cruciate, or anything else, or the back. How can we keep them healthy? How do we keep them limber? What are the factors that go into spinal integrity and the maintenance thereof?
So, once things happen, though, the complexity of spinal cord injury; it takes hold. So, it would be great if we can see this early and if we can offset early issues with our interventions. But if it happens, we have to get over this idea that we don’t know what’s going on because there is information and that’s what we will do for the rest of this webinar, in terms of focusing–multimodal approaches.
We have that initial primary phase that happens after the injury. And then we have the secondary phase that starts pretty early on. But in the primary phase, you’ve got something mechanical that is either endogenous (like a disk) or exogenous (car hits you) and you’ve got compression, contusion, laceration, sheering, and/or traction of these neurons in the spinal cord.
This will impact the assessment of your neurologic status, in the early phase. And it has been considered a strong prognostic indicator, but it’s really the secondary injury that will define your long-term morbidity.
So, for you watching on video, this is my own development of illustration of spinal cord, where this is the spinal cord here and then we have meninges, the dura mater, arachnoid and then pia mater.
We have spinal arteries here that are important because when they get injured, then we’re going to have compromise of oxygenation and ischemia. We have segmental arteries as well. And if we go in a parasagittal section like this, everything’s just another walk in the park until we have an injury; whether it’s a disk coming in one direction or mechanical assault, hammering down on the spinal cord and causing interruption of the neurons.
So, we’ve got direct cell trauma to these neurons in the spinal cord, leading to potentially orthostatic and systemic hypotension, spinal shock, vasospasm and cell injury, leading to cell death and also ischemia and edema.
So, the hemorrhage will come in; that will be like a space occupying lesion. We’ve got orthostatic or systemic hypotension. We’ve also got vasospasm, which is not going to be good for oxygen delivery to the cord.
So, we’ve got relative ischemia coming in, just choking off the blood supply; the ability for the situation to heal and recover and get nourishment through oxygen. And we’ve got edema, which itself will be the space occupying lesion, further causing compression of neuronal pathways.
Then inflammatory cells infiltrate in the area and they have all kinds of cytokines and things that they’re releasing. There is release of ATP from the cells and potassium and that is hard on the tissue.
After that gets cleaned up, that’s where — Okay, if you’re going to do something surgically, that’s where you’re going to have an effect. But if you do something surgically, you are also participating in the secondary injury, which is a cascade of events that include vascular, cellular and biochemical aspects to it. And it’s the extent of the secondary injury that determines the greater extent of the damage, long-term morbidity and the thwarting of restorative processes. So, just think about what surgery is going to do on top of what has already happened.
Another aspect of that is the release of glutamate, which is an excitatory neurotransmitter that’s going to just contribute to wind up. We’re going to get proapoptotic signaling where the cells are, just like, “I’ve had it. Just kill me now. I’m dead.” And so, there’s going to be a die off of the neurons. We got cell necrosis and just death of certain aspects.
So, where can we start to intervene and start to think, “What are the mechanisms of healing that I can impart for this individual?” So, we’ll be getting to that.
The subacute is just after the acute phase. We’ve got development and release of free radicals, excessive nitric oxide, noradrenalin. The ATP has spilled all over the place. We’ve got reduced ATP availability, which is necessary for the maintenance and recovery of things. Invasion of immune cells, cytokine release, neurite growth-inhibitory factors and vertebral compression/spinal cord instability, potentially.
But we see these first three things; the free radicals, the excessive nitric oxide and neurotransmitters, reduced ATP availability. And we can think, “Wow, you know what? I’ve been thinking photomedicine here. I’m thinking that that’s part of the mechanism of action that I can start to reverse.” But look, this is a subacute phase.
So, if we want to prevent the demyelination of the surviving axons, the apoptosis, the initiation of the central cavitation and the beginning of the astroglial scar, why didn’t we intervene early with immediate photomedicine? So, we can offset that loss of myelination, the neurons, the cyst producing, syrinx potentially, a fibroblast infiltration where we’re getting connective tissue invading that neurologic area, producing a fibrous scar with the release of the proteoglycans from those fibroblasts.
Which brings up the question, “Should you be administering polysulfated glycosaminoglycans to your patients with spinal cord injury? Even if they have arthritis, is that the best thing to do?
And then the glial scar, the astrogliosis can set in, the microglia, the immune system cells within the nervous system, they come in, and they’re just contributing to this inability of the neurons to rejoin, if there’s going to be a big inflammatory immune reaction there.
As we move into the intermediate and chronic phase, we still have more of the same with the demyelination and et cetera, the alteration of ion channels and receptors. We have regenerative processes starting to happen with neuronal sprouting, but we also have this altered neural circuitry because the neurons have not been prompted to work. We’ve kept the dog in the cage. We’re not letting them walk. We’re not doing the restorative support of rehab in a very conscious, rational manner and then the acupuncture to send appropriate neural signaling through.
So, we end up with this glial or fibrin scar, attempting to remyelinate, but getting halted, they cannot grow, they’re restricted. And then we’ve got the altered neural circuitry and ion channels, which just makes mayhem of the information that has to go through that cord to make it improve.
So, with all that’s happening, can we get from that down dog to a happy and restored dog, without having this re-herniation and spinal cord instability? So, how do we reverse the damage and get a functional nervous system once again.
We want to improve the tissue milieu to support the recovery, cultivate new neurons and glia that can actually make it to each other and restore that functional integrity with the new cells coming into the preexisting neural tissue.
How do we do that? We have to stimulate the substrate appropriately and we have many ways to do that.
So, when is it appropriate to begin implementing integrative medicine? Right away. Start now. But if you have faculty, if you have clinicians, if you have an intern, if you have a resident, whoever it is, that says, “No, no, no, no, no. We are only going to do surgery, keep them in a box. Don’t move them. We’re going to do something else other than surgery?”
Let’s see where we might have made a difference if we took a more enlightened approach. Acute spinal cord injury, where bone loss occurs rapidly and consistently after the spinal cord injury, leading to decreased bone mineral density and higher risk of fractures.
What can be done there? Oh, photobiomodulation. Low level laser therapy accelerates bone healing in spinal cord injured rats.
“Results suggest that laser therapy accelerated the process of bone repair in rats with complete spinal cord injury.”
Complete spinal cord injury. Usually, in the dog, it’s not complete. This is complete in the rat; experimentally induced.
So, we have the acute spinal cord injury features; the hypotension, the shock, the vasospasm, the ischemia and all that. What can we do? Oh, vasospasm; we can treat that with lasers.
- The effects of transcranial (another central nervous system structure) transcranial LED therapy on cerebral blood flow in elderly women.
- Light induced vasodilation of coronary arteries and its possible clinical implications.
Vessels respond to photobiomodulation to relax, which gives you better blood flow.
- Intensive vasodilation in the sciatic pain area after dry needling.
- The effect of transcutaneous electrical nerve stimulation of sympathetic ganglion and acupuncture points on distal blood flow.
The mechanisms are clear; they are neuromodulatory.
What about orthostatic hypotension:
- Laser applications and plastic and reconstructive surgery.
“Laser therapy for plastic surgery includes pain attenuation, wound healing acceleration, enhanced remodeling and accelerated bone and tendon repair, restoration of normal neural function, normalization of abnormal hormonal function, modulation of the autoimmune system (think glial scars, think the astroglia, the gliosis), control of hyper- and hypotension and so on.”
Is this too simple? Is it too cheap; meaning inexpensive? Is too patient-empowering, client-empowering? Why aren’t these things standard of care? They need to be. New standard of care starting today.
“Electroacupuncture ameliorates the coronary occlusion related tachycardia and hypotension in acute rat: myocardial ischemia models.”
So, again, dealing with the hypotension, we want to have appropriate blood pressure so that we can get blood to where it needs to be.
“Hemodynamic stability in cervical spinal cord trauma patient with acupuncture.”
Then we have the edema; the inflammatory cell infiltrate, that happens as a consequence of the injury.
Oh, photobiomodulation. Because I’m just taking these two out of the whole gamut of things we could be talking about.
But let’s just talk about acupuncture and photomedicine.
- Effects of laser phototherapy on wound healing following cerebral ischemia by cryogenic injury. (Experimental)
“Laser phototherapy emerges as an alternative auxiliary therapy for acute ischemic stroke, traumatic brain injury, degenerative brain disease, spinal cord injury and peripheral nerve regeneration, but its effects are still controversial. We have previously found that the laser phototherapy immunomodulates the response to focal brain damage.”
So, there a lot of times they say, “Oh, there hasn’t been enough research and that’s why we’re doing it.” When you can really see, when you go back, there’s quite more research than you would have even expected.
The gist of this is they are treating edema with laser photomedicine.
- Electroacupuncture at acupoints of the governor vessel (which is dorsal midline acupuncture channel) in rats with experimental spinal cord injury.
So, relieving edema of the spinal cord with this acupuncture.
- Acupuncture mediate inhibition of inflammation facilitates significant functional recovery after spinal cord injury.
in Neurobiologic Disease, 2010.
What about the release of glutamate?
- Low level laser therapy protects primary cortical neurons against excitotoxicity, in vitro.
Glutamate, excitatory neurotransmitter and the NMDA receptors.
“Excitotoxicity describes a pathogenic process whereby the deaths of neurons releases large amounts of the excitatory neurotransmitter glutamate, which then proceeds to activate a set of glutamatergic receptors on neighboring neurons (glutamate, NMDA, and kainate), opening ion channels leading to an influx of calcium ions producing mitochondrial dysfunction and cell death.”
Remember apoptosis? So, here we have the means by which to counteract that glutamatergic neurotoxicity and take down spinal cord wind-up.
“Excitotoxicity contributes to brain damage after stroke, traumatic brain injury in neurodegenerative diseases and is also involved in spinal cord injury.”
Then they talk about their approach with;
“Laser therapy produces ATP (remember, that was a deficit), raising mitochondrial membrane potential, reducing intracellular calcium concentrations (which is important, in terms of this neurotoxicity, excitotoxicity), reducing oxidative stress. (remember, there was oxidative stress. There wasn’t enough blood flow and oxygen coming in there) and reducing nitric oxide. (Just all those changes from that ischemia and inflammation.) The action of laser in abrogating excitotoxicity may play a role in explaining its beneficial effects in diverse central nervous system pathologies.”
Should become a first-line procedure and is in my book. Whenever we have people that graduate and that’s the first thing they do. And that’s the reason for our PRIMA Program, PVM PRIMA and the Graduate PRIMA, where people are learning the diversity of techniques that they need to institute to make these meaningful differences come to life, come to the fore in the actual clinic environment.
- The regulatory effect of electroacupuncture on the expression of NMDA receptors in a spinal cord injured rat model.
So, showing how we can wind down the spinal cord with electroacupuncture. Preferentially, get it early, but if you don’t, at least get in there.
Chronic spinal cord injury: major features. We went through this in the altered neural circuitry. But photomedicine:
- Light promotes regeneration and functional recovery and alters the immune response after spinal cord injury.
That’s from Lasers and Surgery in Medicine.
“Photobiomodulation with 6% power penetration to the spinal cord depth, significantly increased axonal number and distance of regrowth. Photobiomodulation also returned aspects of function to baseline levels and significantly suppressed immune cell activation and cytokine/chemokine expression.”
Again, I just ask you, are you learning this in school? If not, why not?
“Our results demonstrate that light delivered transcutaneously (so, no need to cut into things; make them unstable) improves recovery after injury, and suggests that light will be a useful treatment for human spinal cord injury.”
Canine studies. This is one just out on April 25th, 2020 BMC Veterinary Research.
- Perilesional photobiomodulation therapy and physical rehabilitation in post-operative recovery of dogs surgically treated for thoracolumbar disk extrusion.
So, this, they’re still post-operative, unfortunately. Think what would happen if they weren’t and we can just get in there without that added trauma of surgery. We don’t know; we need studies. Is that added trauma of surgery worth it or not, when you have everything else brought to bear?
What we do see is that when people can’t afford it or they decline it, we see animals, anecdotally, but lots of them in our community that are getting up and walking again, fairly quickly, without all that added expense and trauma of the surgery. And maybe the second surgery because another disk herniated.
So, 24 dogs included in the study, treated with laser therapy and rehab. And 12 dogs (So, half and half) some receive rehab and laser, some received just rehab.
“All dogs treated with laser therapy showed improved neurologic status if deep pain on admission was maintained. The use of laser therapy in the post-operative rehabilitation dogs affected by laser and submitted to surgery for surgical decompression could help the neurologic status because there was a tendency for shorter meantime of days in the laser group versus the no laser therapy group to regain ambulation.”
Acupuncture in dogs with intervertebral disc disease. I believe it’s a study from Korea.
- Bee venom injections (which is just an Alpha-2 agonist) where it’s aqua puncture in a way to put into the acupuncture points. Looking for TL disc disease in dogs; randomized, controlled prospective trial.
Bee venom injection exerted a particularly strong effect on canines with moderate to severe intervertebral disk disease and dramatically reduced clinical rehabilitation time.”
Another study comparing decompressive surgery, electroacupuncture and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disc disease with long-standing severe neurologic deficits.
That’s from JAVMA, 2010.
“Electroacupuncture was more effective than decompressive surgery for the recovery of ambulation and the improvement in neurologic deficits in dogs with long-standing severe deficits attributable to TL disc disease.”
This was a retrospective study however, this was not a prospective study.
This is Hayashi et al.;
- Evaluation of electroacupuncture treatment for dogs with TL disc disease. JAVMA, 2007.
“Electroacupuncture combined with standard Western medical treatment, was effective and resulted in shorter time to recover ambulation and deep pain perception than did use of Western treatment alone in dogs with signs of thoracolumbar disc disease.
And so much more to cover.
So, effects of acupuncture and photobiomodulation on endogenous and implanted stem cells should be studied on peripheral nerve health, muscle tissue, bowel, bladder function, skin ulceration, chronic pain, sensory or motor dysfunction.
There’s so much more to cover, but I’m just giving you a little slice here because there’s more information out there and there’s just more integration that needs to happen.
There’s also the neuroprotection and analgesic effects of cannabis. We didn’t even touch on that and then the multiple benefits of medical massage. Not to mention what you’re doing for people’s hearts because you are offering them something else and they don’t have to be intimidated, but they can be a partner in this animal’s recovery and they don’t have to be scared and they don’t have to put the dog down, if they can’t afford it. So, they can go step by step, literally and figuratively.
So, with so much more to cover, join us for more in-depth information on the treatment of spinal cord injury in our other CuraCore online courses, we’ve touched on things, talked about acupuncture and mechanisms thereof, and of cannabis and so on, in our other webinars, some that have been transferred to podcasts. Additional reading, if you’d like:
There’s Beyond the Laboratory. This is an invited editorial I did for Photomedicine and Laser Surgery back in 2017.
- Beyond the Laboratory, Into the Clinic: What Dogs with disc disease have taught us about photobiomodulation for spinal cord injury implicating in humans.
And then here’s another reading, 2018.
- Topics and Companion in Animal Medicine. Veterinary Neurologic Rehabilitation: The Rationale for a Comprehensive Approach.
And as they say,
“Although the primary neurologic disorders researched tend to be spinal cord injury (and so on), can be (how we can apply them to) veterinary neurological disorders… There’s limited research.”
And so, they’re just talking about;
“Physical therapy has been the standard of care for patients with neurologic injury in human medicine for decades, whereas similar rehabilitation techniques have only recently been adapted and utilized in veterinary medicine.”
And talking about the common problem of spinal cord injury in dogs and all that.
“Of particular interest to clients and veterinarians are techniques and modalities used to promote functional recovery after neurologic injury, which can mean the difference between life and death for many veterinary patients.”
And when your animal goes, your life has changed forever and you still have to foot the bill. So,
“The trend in human neurologic rehabilitation, often regardless of ideology, is a multimodal approach to therapy.”
So, why are surgeons saying — I mean, I’ve had surgeons in an academic environment withhold pain medicine after surgery saying, “Well, I took the disc out. That was the problem. That was the cause of pain.”
I mean, this was such an unethical thing that should have been reported to the board. They’ll say, “Oh, well, he’s going to be moving on in a few weeks. So, we’re not going to rock the boat.”
Anyway, moving on. So, yeah,
“Evidence supports faster and improved recoveries in people after neurologic injury using a combination of rehabilitation techniques.”
And so, how are we going to work with animals? And as they say in this paper,
“Studies, both laboratory and clinical, support the use of acupuncture in the management of neurologic conditions in small animals, specifically in cases of intervertebral disc disease, other myelopathies and neuropathic pain conditions. Acupuncture’s ability to promote analgesia, stimulate trophic factors and decrease inflammation, including neuroinflammation, make it an alluring adjunct therapy after neurologic injury.”
And just talking also about laser and rehab;
“Accordingly, due to the relative lack of evidence-based studies in veterinary neurologic rehabilitation, much of the data available is human or laboratory-animal based.”
But we’re getting more dog — I just showed you some of the dog studies- clinical.
“However, evidence supports the utilization of an early comprehensive treatment protocol for optimal neurologic recovery.”
So, get your hands, even on this abstract. Read this. Take it into your practice. Be able to defend what you do as a science-based integrative medicine and rehab practitioner. Give people options. The rationale for why an integrated approach is critical.
So, words for the journey: If you are in veterinary school currently and if your faculty is not supportive of science-based integrative medicine, remember your options and resources. Zoom us in. Get me to speak there for your faculty and students; it’s what I do all the time.
Have those skeptics be there in the front row. They can give me questions in advance or ask me on the spot; I am ready for them. I’ve done this before.
Enroll in PVM PRIMA, our professional veterinary medical curriculum, which is the Pain Rehabilitation Integrative Medicine Advantage Program. It’s a vertically and horizontally integrated curriculum. It’s about 10 to 15 to 20 hours of online instruction and remote laboratory engagement per academic year. So, you can do this. But it will help you fill in the blanks, as you go, as you learn things. That’s the vertical and horizontal integration.
Consult the literature to make your case. I’ve already shown you a plethora of things and there is so much joy in online shopping for free articles. And review our Wednesday webinar recordings and podcasts.
So, get in touch. We are here for you. This is what we do. This is why we do it, because we care about animals and their appropriate care and your mental health as a caregiver, so that you can give options and you’re not euthanizing animals where they don’t have to be. You’re giving people the ability to intervene on their animal’s behalf with meaningful clinical measures.
So, we’ll see you next time. Thanks for being here and appreciate you joining us.
If you’d like to learn integrative medicine from a scientific perspective, visit us at curacore.org. Thanks for listening to another installment of Surviving Veterinary Medicine.