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Common Spinal Common Spinal Disorders Disorders

PPéter Csébi DVMéter Csébi DVMVeterinary UniversityVeterinary University

Surgical Department Surgical Department

HungaryHungary

Spinal disorder?Spinal disorder?

TransversTransversalal myelopathymyelopathy::

Alteration caudal to the lesion:Alteration caudal to the lesion:

►► Postural deficitsPostural deficits

►►AtaxiaAtaxia

►► ParesisParesis

►►Abnormal spinal reflexes (HypoAbnormal spinal reflexes (Hypo--, , hyperreflexiahyperreflexia))

►►MicturationMicturation abnormalities (UMN and LMN bladder)abnormalities (UMN and LMN bladder)

►► (Pain)(Pain)

(See the detailed explanation in pathophysiology lecture!)

Severity Severity –– GradingGrading11--5 5 scalescale

►►GradeGrade 11:: only only hyperaesthesiahyperaesthesia

►►GradeGrade 22:: mildmild paraparesisparaparesis andand ataxiaataxia

►►GradeGrade 3:3: severesevere paraparesisparaparesis andand ataxiaataxia

►►GradeGrade 4:4: nonnon--ambulatory ambulatory paraparesisparaparesis with with intact deep pain perceptionintact deep pain perception

►►GradeGrade 5:5: paraplegiparaplegia without deep pain a without deep pain perceptionperception

This scoring is used in most of the neurological textboooks.

Severity Severity –– GradingGradingModifiedModified Frankel Frankel ScoreScore (MFS)(MFS)

►►0: 0: nonnon--ambulatoryambulatory parapara//tetraplegiatetraplegia, , lacklack of of superficialsuperficial and and deepdeep nociceptionnociception

►►1: 1: nonnon--ambulatoryambulatory parapara//tetraplegiatetraplegia, , lacklack of of superficialsuperficial butbut retainedretained deepdeep nociceptionnociception

►►2: 2: nonnon--ambulatoryambulatory parapara//tetraplegiatetraplegia, , retainedretained superficialsuperficial and and deepdeep nociceptionnociception

►►3: 3: nonnon--ambulatoryambulatory parapara//tetraparesistetraparesis

►►4: 4: ambulatoryambulatory parapara//tetraparesistetraparesis ((ataxiaataxia))

►►5: 5: segmentalsegmental hyperaesthesiahyperaesthesiaThis is the preferred scoring in some surgery literature.

Diagnostic work up in suspected Diagnostic work up in suspected spinal diseasesspinal diseases

►► SignalmentSignalment►► HistoryHistory►► Neurologic examinationNeurologic examination

�� LocalizationLocalization�� AssesmentAssesment of severity of severity -- gradinggrading

►► Ancillary testsAncillary tests�� Blood workBlood work, , urineurine analysisanalysis�� RadiographyRadiography�� Advanced imaging: MRI, CTAdvanced imaging: MRI, CT�� CSF analysisCSF analysis

►► Differential diagnosis, diagnosisDifferential diagnosis, diagnosis►► PrognosisPrognosis►► Therapeutic planTherapeutic plan

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Localisation„Anatomical diagnosis”

C1-C5

craniocervical

C6-T2

caudocervical

T3-L3

thoracolumbal

L4-S

lumbosacral

Gait

Postural reactions

Reflexes

Fore limb: UMNRear limb: UMN

Fore limb: LMNRear limb: UMN

Fore limb: normalRear limb: UMN

Fore limb: LMNRear limb: LMN

Differential diagnosis – VITAMIN D

►►V = V = vascularvascular

►► I I = = immunimmunmediatedmediated, , inflinflammatoryammatory//infinfectiousectious

►►T = T = traumtrauma, a, toxitoxicc

►►A = A = anomanomalyaly (malformation)(malformation)

►►M = M = metabolimetabolicc

►► II = idiopathic= idiopathic

►►N = N = neoplasmneoplasm, , nutritionalnutritional

►►D = D = degeneratdegenerativ, developmentaliv, developmental

VascularVascular FCEFCEMM, , EEpiduralpidural bleedingbleeding

Inflammatory/infectious Inflammatory/infectious DiscospondylitisDiscospondylitis, , MeningitisMeningitis, , MeningomyelitisMeningomyelitis, Empyema, Osteomyelitis, Empyema, Osteomyelitis, GME, GME

TraumaTrauma FFracturracturee, , LLuxatiouxationn, , TTraumraumaticatic disc herniadisc herniationtion, , TTraumraumatic atic AA--L lux.L lux.

ToxicToxic NNoo

AnomAnomalyaly AA--L luxatioL luxationn, , ChiariChiari--likelike malformatiomalformationn and and SSyringomyeliayringomyelia, , HemivertebraHemivertebraee, , Arachnoid Arachnoid cystcyst, Spina bifida, Dysraphismus, Multiple , Spina bifida, Dysraphismus, Multiple cartilaginous exostosescartilaginous exostoses

MetaboliMetabolicc NNoo

IdiopathicIdiopathic DisseminDisseminatedated idiopathic idiopathic skeletalskeletal hyperostosishyperostosis

NeoplasNeoplasiaia PrimPrimary or ary or sesecocondndaryary tumortumorss

DegeneratDegenerativeive Intervertebral disc diseaseIntervertebral disc disease, , DegeneratDegeneratiivveemyelopathmyelopathyy, , DegeneratDegeneratiivvee lumbosacrallumbosacralstenosisstenosis, Osteoarthritis, , Osteoarthritis, EExtradural synovial cystxtradural synovial cyst, , Spondylosis deformans, Spinal stenosis, etc.Spondylosis deformans, Spinal stenosis, etc.

DevelopmentalDevelopmental or or DegenerativeDegenerative

Cervical spondylomyelopathCervical spondylomyelopathyy

AncillaryAncillarydiagnosdiagnosticstics

CSF analysis CSF analysis (total protein, cell count, (total protein, cell count,

cytology, PCR etc.)cytology, PCR etc.)

Meningitis, Meningitis,

meningomyelitis!meningomyelitis!

Occipital puncture can be seen.

ImagingImaging

►►TraumTrauma?a? –– CT, (RTG)CT, (RTG)

►►Compression?Compression? –– MRI, (myelographMRI, (myelographyy, CT, CT, CT, CT--myelo)myelo)

►►Developmental abnormality? Developmental abnormality? –– RTG, CT, CTRTG, CT, CT--myelo, MRImyelo, MRI

►►Vascular? Vascular? –– MRIMRI

The position of the lesion relative to the The position of the lesion relative to the spinal cordspinal cord

►► ExtraduralExtradural: : Disc herniationDisc herniationTraumaTraumaNeoplasiaNeoplasiaDiscospondylitisDiscospondylitis

►► Intradural, Intradural,

extramedullaryextramedullary:: Neoplasia, CystNeoplasia, Cyst

►► Intramedullary:Intramedullary: NeoplasiaNeoplasiaInflammatoryInflammatoryIschaemicIschaemicHaematomaHaematoma

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DDegenerategenerativeivediseasesdiseases

Intervertebral disc diseaseIntervertebral disc disease, , DegeneratDegeneratiivveemyelopathmyelopathyy, , DegeneratDegeneratiivvee lumbosacrallumbosacralstenosisstenosis, Osteoarthritis, , Osteoarthritis, EExtradural synovial cystxtradural synovial cyst, ,

Spondylosis deformans, Spinal Spondylosis deformans, Spinal stenosisstenosis

Intervertebral Disc DiseaseIntervertebral Disc Disease

The Intervertebral DiscThe Intervertebral Disc

Annulus fibrosusAnnulus fibrosus�� Concentric rings of Concentric rings of

fibrocartilagenous lamellaefibrocartilagenous lamellae

Nucleus pulposusNucleus pulposus�� 80 80 –– 88% water bound by 88% water bound by

proteoglycansproteoglycans

�� Type II collagenType II collagen

�� Chondrocytes, fibrocytes and Chondrocytes, fibrocytes and notochordal cellsnotochordal cells

Cartilagenous endplates of Cartilagenous endplates of the vertebraethe vertebrae�� Thin layer of hyaline cartilage Thin layer of hyaline cartilage

Disc DegenerationDisc Degeneration

►►ChondrodystrophoidChondrodystrophoid breedsbreeds�� ChondroidChondroid metaplasiametaplasia of the nucleusof the nucleus

–– Hansen Hansen typetype--II

►►NonchondrodystrophoidNonchondrodystrophoid breedsbreeds�� Fibroid Fibroid metaplasiametaplasia –– Hansen Hansen typetype--IIII

Hansen TypeHansen Type--I. disc herniation (extrusion)I. disc herniation (extrusion)

►►Described in Described in chondrodystrophoid chondrodystrophoid dogsdogs

►► Peak incidence: 3 Peak incidence: 3 –– 6 y6 y

►► 75% TL herniations 75% TL herniations between T11between T11/12 and /12 and L1/2L1/2

TypeType--II. disk herniationsII. disk herniations

►►Often multipleOften multiple

►►Occur at points of greatest Occur at points of greatest mobilitymobility

►►Dehydration and fibrosis of Dehydration and fibrosis of the nucleus results in the nucleus results in transference of load to the transference of load to the annulusannulus

►►Annulus bulges and Annulus bulges and fragmentsfragments

►►Generally large breedsGenerally large breeds

►►>8 y>8 y

„„Other Acute Disc HerniationsOther Acute Disc Herniations””

►►Low volume, high velocity; missile; Low volume, high velocity; missile; „„type 3type 3””�� Can be traumaticCan be traumatic

►►Large breed acute annular disc herniationsLarge breed acute annular disc herniations

►►Acute herniation of dehydrated, fibrotic Acute herniation of dehydrated, fibrotic nucleus: old dachshund, large breedsnucleus: old dachshund, large breeds�� Undergone chondroid metaplasia but not Undergone chondroid metaplasia but not

degeneration and calcificationdegeneration and calcification

►►Acute herniation of hydrated nucleusAcute herniation of hydrated nucleus�� Most common in the cervical spine Most common in the cervical spine

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Breed predispositionBreed predisposition The DachshundThe Dachshund

►► Occurrence of 19% across Occurrence of 19% across dachshunds, some families dachshunds, some families as high as 75% (Ball et al., as high as 75% (Ball et al., 1982)1982)

►► Complex trait, Complex trait, environmental factors environmental factors importantimportant

ImagingImaging

Survey radiography:Survey radiography:

►►Disk diseaseDisk disease

MyelographyMyelography::Disk extrusionDisk extrusion

(Occipital puncture)(Occipital puncture)

(Lumbal puncture)(Lumbal puncture)

Myelography:Myelography:DisDisk protusionk protusion

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CT: discus hernia Myelo-CT:discus hernia

Simon Platt: Small Animal Spinal MRIHansen I discus hernia MR image of dehydrated & protruded MR image of dehydrated & protruded

disk in multiple regiondisk in multiple region

TherapyTherapy

►►ConservativeConservative::--CageCage restrest forfor atat leastleast 2 2 weeksweeks afterafter clinicalclinicalsignssigns havehave resolvedresolved!!--MedicationMedication:: NSAIDsNSAIDs oror steroidssteroids, , tramadoltramadol, , gabapentingabapentin, gastric protection, gastric protection

►►SurgicalSurgical::decompressiondecompression, , fenestrationfenestration--SevereSevere neurologicneurologic signssigns--FailureFailure of of nonsurgicalnonsurgical therapytherapy

►►+ Physiotherapy+ Physiotherapy

Decision making in therapyDecision making in therapy

►►Acute or chronic?Acute or chronic?

►►Severity?Severity?

►►Grading!Grading!

�� Grade Grade 55: surgical: surgical

�� Grade Grade 44: surgical, may be conservative: surgical, may be conservative

�� Grade Grade 2, 32, 3: surgical or conservative: surgical or conservative

�� Grade Grade 55: conservative: conservative

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Succes of cSucces of conservative vs. onservative vs. ssurgical urgical treatmenttreatment

Grade Grade 1, 1, 2, 3, 2, 3, 82%82%--88%88% 1100%00%

Grade Grade 44 43%43%--51%51% 8800--100%100%

Grade Grade 55 00--7%7% 00--75%*75%*

*It mainly depends on the time of the surgical decompression!

Chance of relapse in case of Chance of relapse in case of conservative managementconservative management

►►ThoracolumbalThoracolumbal: 3: 300.9%.9%

►►CervicalCervical: 33%: 33%

Levin et al. Evaluation of the Success of Medical Management for Presumptive Thoracolumbar Intervertebral Disk Herniation in Dogs.

Veterinary Surgery. 2007

Levin et al. Evaluation of the Success of Medical Management for Presumptive Cervical Intervertebral Disk Herniation in Dogs.

Veterinary Surgery. 2007

When should be performed the When should be performed the surgical decompression?surgical decompression?

►►As soon as possible!As soon as possible!

►►Prevent secondary damage caused by the Prevent secondary damage caused by the prolonged compression and loss of prolonged compression and loss of circulationcirculation

►►What if there is no more deep pain What if there is no more deep pain sensation?sensation?

�� Does it make sense to do surgery in 12Does it make sense to do surgery in 12--2424--48 48 hours or even later?hours or even later?

►► LoughinLoughin (VCOT 2005)(VCOT 2005)�� In In 12 12 hh→→ 6600% % recoveredrecovered

�� More then More then 48 48 hh →→ 6.7%6.7%

►► Laitinien Laitinien (Acta Vet Scan, 2005)(Acta Vet Scan, 2005)

�� In 24 h 41.3% recovered in avarage In 24 h 41.3% recovered in avarage 12.5 12.5 monthmonth

�� More then More then 24 24 h no recovery!h no recovery!

�� In cases when deep pain sensation recovered in 2 weeks the In cases when deep pain sensation recovered in 2 weeks the recovery rate was recovery rate was 66.7%, 66.7%, when only later the rate waswhen only later the rate was 110%0%

►► Olby Olby (JAVMA 2003)(JAVMA 2003)

�� 58% recovered if treated in 48 h58% recovered if treated in 48 h

�� 78% 78% regained deep pain sensation in the first 2 weeksregained deep pain sensation in the first 2 weeks

�� 19% 19% in the second two weeksin the second two weeks

�� 3%3% laterlater

�� 41% 41% was incontinent laterwas incontinent later

�� Progressive hemorrhagic myelomalacia occurs in up to 11% of dogs Progressive hemorrhagic myelomalacia occurs in up to 11% of dogs that have lost nociception!that have lost nociception!

What is the prognosis in general?What is the prognosis in general?

►►Intact deep pain s.Intact deep pain s.: : favourablefavourable

►►No deep pain s.No deep pain s.: : gravegrave –– poorpoor

►►If deep pain s. regains in 2 weeksIf deep pain s. regains in 2 weeks: : favourablefavourable

Current surgical treatment of Current surgical treatment of IVDDIVDD

Aim is to decompress the spinal cordAim is to decompress the spinal cord

►►HemilamiHemilaminnectomectomyy

►► PediculectomyPediculectomy

►► ForamenotomyForamenotomy

►► Lateral corpectomyLateral corpectomy

►► FenestrationFenestration

►► LaminectomLaminectomyy

►►Ventral slot (cervical)Ventral slot (cervical)

►►Dorsal laminectomy (cervical)Dorsal laminectomy (cervical)

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Which surgical approach?Which surgical approach?Hemilaminectomy

Which surgical approach?Which surgical approach?

►►HemilaminectomyHemilaminectomy+ Great access laterally + Great access laterally

and ventrallyand ventrally

+ Minimal laminectomy + Minimal laminectomy membrane problemsmembrane problems

-- Access to contralateral Access to contralateral side limitedside limited

-- Access ventrally is Access ventrally is limited if disc is firm, limited if disc is firm, adherentadherent

-- Can cause instability if Can cause instability if performed bilaterallyperformed bilaterally

►►MiniMini--Hemilaminectomy (Pediculectomy, Hemilaminectomy (Pediculectomy, Foramenotomy)Foramenotomy)�� Preserves articular facetsPreserves articular facets

�� Dorsal limit Dorsal limit –– dorsal aspect of accessory processdorsal aspect of accessory process

�� Can be performed bilaterallyCan be performed bilaterally

�� Less access to the vertebral canal and therefore Less access to the vertebral canal and therefore the disc materialthe disc material

�� Can cause instabilityCan cause instability

►► Possible complications:Possible complications:�� Severe bleedingSevere bleeding

�� Respiratory failureRespiratory failure

►►Ventral slotVentral slot�� Cervical disc diseaseCervical disc disease

�� Wobbler syndromeWobbler syndrome

Ventral slotVentral slot Other surgical approachesOther surgical approaches

►► LS spine LS spine –– dorsal or dorsal or sometimes a sometimes a dorsodorso--lateral approachlateral approach

►►Cervical spine Cervical spine –– dorsal dorsal or hemior hemi

►►TL spine: lateral TL spine: lateral corpectomycorpectomy in case of in case of chronic disc protrusionchronic disc protrusion

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Other surgical approachesOther surgical approaches

►► FenestrationFenestrationFenestrate calcified disks, Fenestrate calcified disks, fenestrate higher risk disks fenestrate higher risk disks T11T11/12/12 -- L2/3L2/3

+ Decreased recurrence of the + Decreased recurrence of the diseasedisease

-- Longer surgical procedureLonger surgical procedure

-- Can cause instabilityCan cause instability

-- Extensive muscle dissectionExtensive muscle dissection

What can go wrong?What can go wrong?

►► Cut the wrong siteCut the wrong site

►► RecurrenceRecurrence

►► Iatrogenic damage of the spinal cordIatrogenic damage of the spinal cord

►► Failure to remove disk materialFailure to remove disk material

►► HemorrhageHemorrhage

►► ArrhytmiasArrhytmias

►► Damage to local soft tissueDamage to local soft tissue

►► InstabilityInstability

►► Laminectomy membraneLaminectomy membrane

►► SeromaSeroma

►► InfectionInfection

Treatment doesn`t end with surgery!Treatment doesn`t end with surgery!Treatment doesn`t end with Treatment doesn`t end with

surgery!surgery!►►Management of painManagement of pain

►►Management of Management of incisionincision

►► Prevention of decubital Prevention of decubital ulcersulcers

►►Rehabilitation Rehabilitation exercises, exercises, hydrotherapyhydrotherapy

►►Bladder care Bladder care (evacuation 3 times (evacuation 3 times daily!)daily!)

►►Mental stimulationMental stimulation

Take home messagesTake home messages►► Most commonly the Th11Most commonly the Th11--L2 sites are involved in TL2 sites are involved in T--L disk L disk

extrusion extrusion

►► It is extremely important that deep pain be properly It is extremely important that deep pain be properly assessed. The withdrawal reflex does not verify the assessed. The withdrawal reflex does not verify the presence of deep pain. The animal should vocalize or presence of deep pain. The animal should vocalize or otherwise indicate that pain was feltotherwise indicate that pain was felt..

►► Control of adequate bladder function is very importantControl of adequate bladder function is very important

►► The most common mistake made in managing animals The most common mistake made in managing animals with disk extrusions is administration of corticosteroids with disk extrusions is administration of corticosteroids and analgesics without appropriate concurrent and analgesics without appropriate concurrent confinement. Strict cage rest is mandatory in these confinement. Strict cage rest is mandatory in these patientspatients..

►► It is generally accepted that patients with paresis should It is generally accepted that patients with paresis should be treated by early decompressionbe treated by early decompression..

►► Patients without deep pain s. should be operated on Patients without deep pain s. should be operated on within 24 (within 24 (–– 48) hours of disk extrusion48) hours of disk extrusion..

►► It is not sufficient to remove lamina, facets and It is not sufficient to remove lamina, facets and pediculespedicules alone without the compressive disk materialalone without the compressive disk material..

►► The role of prophylactic fenestration remains unclear.The role of prophylactic fenestration remains unclear.

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DDegenerategenerativeivediseasesdiseases

Intervertebral disc diseaseIntervertebral disc disease, , DegeneratDegeneratiivveemyelopathmyelopathyy, ,

DegeneratDegeneratiivvee lumbosacrallumbosacral stenosisstenosis, , Osteoarthritis, Osteoarthritis, EExtradural synovial cystxtradural synovial cyst, , Spondylosis deformans, Spinal stenosisSpondylosis deformans, Spinal stenosis

Degenerative lumbosacral stenosisDegenerative lumbosacral stenosis(Cauda Equina Compression)(Cauda Equina Compression)

Cauda Equina CompressioCauda Equina Compression = compression of the n = compression of the terminal nerve filamentsterminal nerve filaments

The most common The most common causes of LS stenosiscauses of LS stenosis

►► Hansen TypeHansen Type--II. disc II. disc protrusionprotrusion

►► Lumbosacral instabilityLumbosacral instability►► NeoplasiaNeoplasia►► FractureFracture►► Discospondylitis Discospondylitis ►► Spondylosis deformans Spondylosis deformans

compressing L7 nerve rootcompressing L7 nerve root►► OCD of the sacrumOCD of the sacrum

Clinical signsClinical signs(LMN signs + pain)(LMN signs + pain)

►► LLumboumbo--sacralsacral painpain!!►►Difficult to stand up or jump Difficult to stand up or jump ►►Dragging the toes on the groundDragging the toes on the ground►►Hind limb paresisHind limb paresis►►Muscle atrophy except m. quadricepsMuscle atrophy except m. quadriceps►► Low carriage of the tailLow carriage of the tail►► FecalFecal and urinary incontinenceand urinary incontinence►►Decreased anal reflexDecreased anal reflex►►Hyperaesthesia, Hyperaesthesia, prurituspruritus, , automutilationautomutilation is is

possiblepossible

Ancillary testsAncillary tests

►►RadiographyRadiography

►►MyelographyMyelography

►►EpidurographyEpidurography

►►DiscographyDiscography

►►CTCT

►►MRIMRI

►►ElectrophysiologyElectrophysiology

LS stenosis can be seen

MyelographyMyelographyDisk protusion Disk protusion -- CECCEC

C.E.C. epidurogrC.E.C. epidurographyaphy

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CTCT

Sacrum OCD és CEC

MRI

TherapyTherapy

►►Conservative Conservative �� In mild casesIn mild cases

((onlyonly painpain))

�� Exercise restrictionExercise restriction(4(4--6 w)6 w)

�� NSAIDs, corticosteroidsNSAIDs, corticosteroids

�� PhysiotherapyPhysiotherapy

►►Surgical Surgical �� In case of gait In case of gait

abnormalitiesabnormalities

�� In case of failure of In case of failure of the cons. treatmentthe cons. treatment

�� Dorsal Dorsal laminectomylaminectomy►►(+(+foramenotomyforamenotomy))

►►(+(+stabilisationstabilisation))

L7L7--S1 dorsal laminectomS1 dorsal laminectomyy L7L7--S1 dorsal laminectomS1 dorsal laminectomyy

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DDeevelopmental or velopmental or degenerative diseasedegenerative disease

Caudocervical Caudocervical spondylomyelopathyspondylomyelopathy

Cervical spondylomyelopathyCervical spondylomyelopathy(Wobbler-syndrome)

►► Cervical vertebral malformation or malarticulation results in Cervical vertebral malformation or malarticulation results in compression of the cervical spinal cord segmentscompression of the cervical spinal cord segments

►► Most common in middle aged Dobermans (3Most common in middle aged Dobermans (3--9 y) and 9 y) and young Great Danes (2)young Great Danes (2)

►► C5C5--6 and C66 and C6--7 is the most common7 is the most common

►► Chronic, slowly progradiating diseaseChronic, slowly progradiating disease

The most common causes of WobblerThe most common causes of Wobbler--syndromesyndrome

►►Narrowing of the Narrowing of the vertebralvertebral canal because of canal because of osseus malformation osseus malformation (Great Danes)(Great Danes)

►►Hypertrophy of the Hypertrophy of the lig. lig. flavum and joint capsulesflavum and joint capsules

►►Annulus hypertrophy and Annulus hypertrophy and dorsal longitudinal dorsal longitudinal ligament pathologyligament pathology

Clinical signsClinical signschronic compression of the cervical spinal cordchronic compression of the cervical spinal cord

►► Stiff neckStiff neck

►► AtaxiAtaxiaa

►► ParesisParesis

►► „Two engine dog”„Two engine dog”

►► LMN signs on the front LMN signs on the front limbslimbs

►► UMN signs on the hind UMN signs on the hind limbslimbs

►► First signs on the hind First signs on the hind limbslimbs

Wobbler therapyWobbler therapy

►►Conservative Conservative �� In mild casesIn mild cases

�� Exercise restrictionExercise restriction

�� NSAIDs, NSAIDs, corticosteroidscorticosteroids

�� PhysiotherapyPhysiotherapy

►►Surgical Surgical �� High potential for morbidity High potential for morbidity

and postop. complications!and postop. complications!

�� In case of gait abnormalitiesIn case of gait abnormalities

�� In case of failure of the cons. In case of failure of the cons. treatmenttreatment►►Dorsal laminectomyDorsal laminectomy

►►Ventral slotVentral slot

►►Ventral slot + stabilisationVentral slot + stabilisation

Continuous dorsal lContinuous dorsal laminectomaminectomyy

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DDegenerategenerativeivediseasesdiseases

Intervertebral disc diseaseIntervertebral disc disease, , DegeneratDegeneratiivveemyelopathmyelopathyy, ,

DegeneratDegeneratiivvee lumbosacrallumbosacral stenosisstenosis, , Osteoarthritis, Osteoarthritis, EExtradural synovial cystxtradural synovial cyst, , Spondylosis deformans, Spinal stenosisSpondylosis deformans, Spinal stenosis

Degenerative myelopathyDegenerative myelopathy

►► Slowly progressive axonal degeneration and Slowly progressive axonal degeneration and demyelindemyelinisisationation

►► Older German shepherdOlder German shepherd (>8 y)(>8 y) and mixes, boxer and mixes, boxer etc., rarely in catsetc., rarely in cats

►► Hind limb ataxia and paresis, Hind limb ataxia and paresis, nonpainfulnonpainful!!►► Imaging: spinal cord atrophyImaging: spinal cord atrophy►► Genetic test is availableGenetic test is available►► No curative treatment, poor prognosisNo curative treatment, poor prognosis►► PhysiotherapyPhysiotherapy

►► Direct trauma to the spinal cord results primary Direct trauma to the spinal cord results primary and secondary injuries and secondary injuries (See in closed (See in closed mechanical injuries lecture!)mechanical injuries lecture!)

►► Emergency initial examination and stabilizationEmergency initial examination and stabilization

�� Immobilize the spine to prevent further Immobilize the spine to prevent further damage!damage!

►► Detailed nDetailed neuroleurologicalogical examinationexamination

►► Radiography, CTRadiography, CT

►► Surgical or conservative treatmentSurgical or conservative treatment

Fracture, luxationFracture, luxation

TraumaTrauma FFracturracturee, , LLuxatiouxationn, , TTraumraumaticatic disc disc herniaherniationtion, , TTraumraumatic atic AA--L lux.L lux.

►►DecompressionDecompression�� LaminectomyLaminectomy

�� Durotomy (in case of Durotomy (in case of severe swelling)severe swelling)

►►Stabilization:Stabilization:�� Pins, screws and Pins, screws and

polymethylmethacrylatepolymethylmethacrylate

�� Vertebral body plates Vertebral body plates

C5 fracture

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Post op.

►►Tumors can affect the vertebrae, Tumors can affect the vertebrae, meningesmeninges and and spinal cordspinal cord

►►NeoplasiaNeoplasia can be classified as can be classified as extraduralextradural, , intraduralintradural--extramedullaryextramedullary, or , or intramedullaryintramedullary�� ExtraduralExtradural tutummors can be primary or secondary.ors can be primary or secondary.

►►Primary vertebral tumors: Primary vertebral tumors: fibrosarcomafibrosarcoma, , osteosarcomaosteosarcoma, , chondrosarcomachondrosarcoma, , hemangiosarcomahemangiosarcoma, myeloma, myeloma

►►Secondary vertebral tumors: mammary, prostatic, thyroid Secondary vertebral tumors: mammary, prostatic, thyroid carcinomas, malignant melanoma, metastatic carcinomas, malignant melanoma, metastatic osteosarcomaosteosarcoma

►►Epidural tumors: lymphoma, metastatic tumorsEpidural tumors: lymphoma, metastatic tumors

�� IntraduralIntradural--extramedullaryextramedullary: : meningmeningiiomaoma, peripheral , peripheral nerve nerve sheatsheat tumor, lymphoma, tumor, lymphoma, nephroblastomanephroblastoma

�� IntramedullaryIntramedullary: : astrocytomaastrocytoma, , oligodendrogliomaoligodendroglioma, , ependymomaependymoma, , metastametastatictic

NeoplasNeoplasiaia PrimPrimary or ary or sesecocondndaryary tumortumorss

Clinical signsClinical signs

►►Pain!Pain!

►►TransversTransversalal myelopathymyelopathy

►►Any breed, most common in older large Any breed, most common in older large breed dogsbreed dogs

►►Cats: lymphoma, Cats: lymphoma, meningiomameningioma, , osteosarcomaosteosarcoma!!

Vertebral tumors:Vertebral tumors:

Osteolyis Osteolyis –– osteoproliferatioosteoproliferation on radiographsn on radiographs

►► Ventral part of the vertebral body or Ventral part of the vertebral body or proc. spinosus proc. spinosus

Vertebral tumors:Vertebral tumors:

Osteolyis Osteolyis –– osteoproliferatioosteoproliferation on radiographsn on radiographs

►► Ventral part of the vertebral body or Ventral part of the vertebral body or proc. spinosus proc. spinosus

Osteosarcoma of the sacrumOsteosarcoma of the sacrum

ImagingImagingExtraduralExtradural??IntraduralIntradural--exramedullaryexramedullary??IntramedullaryIntramedullary??

Intramedullar tumorIntramedullar tumor

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LymphomaLymphomaLocated intraduralLocated intradural--extramedullaryextramedullary

FibrosarcomaFibrosarcoma

Multiplex Multiplex myelomamyelomaTreatmentTreatment

►►LongLong--term prognosis is poorterm prognosis is poor

►►Medical therapy consists:Medical therapy consists:�� Prednisone palliativelyPrednisone palliatively

�� Chemotherapy (lymphoma, solitary Chemotherapy (lymphoma, solitary plasmacytoma)plasmacytoma)

�� Radiation therapyRadiation therapy

►►Surgical therapySurgical therapy�� Decompression + surgical resection or Decompression + surgical resection or

debulkingdebulking

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Inflammatory/Inflammatory/infectious infectious

DiscospondylitisDiscospondylitis, , MeningitisMeningitis, , MeningomyelitisMeningomyelitis, Empyema, , Empyema,

OsteomyelitisOsteomyelitis, GME, GME

DiscospondylitisDiscospondylitis

►► Septic infection of the disc and adjacent vertebraeSeptic infection of the disc and adjacent vertebrae

►► Common: Staph. intermedius, Streptococcus, E. coli, Common: Staph. intermedius, Streptococcus, E. coli, Actinomyces, Aspergilllus, Brucella canis!, PasteurellaActinomyces, Aspergilllus, Brucella canis!, Pasteurella

►► Mainly in middleMainly in middle--aged large breed dogsaged large breed dogs

►► Single or multiple sitesSingle or multiple sites

►► Clinical signs reflect the location, pain is the most common!Clinical signs reflect the location, pain is the most common!

►► Other infection or systemic disease can be in the Other infection or systemic disease can be in the background!background!

►► Therapy: long term antibiotic treatment (6Therapy: long term antibiotic treatment (6--8 weeks), 8 weeks), NSAIDNSAID’s’s

►► Septic infection of the disc and adjacent vertebraeSeptic infection of the disc and adjacent vertebrae

►► Common: Staph. intermedius, Streptococcus, E. coli, Common: Staph. intermedius, Streptococcus, E. coli, Actinomyces, Aspergilllus, Brucella canis!, PasteurellaActinomyces, Aspergilllus, Brucella canis!, Pasteurella

►► Mainly in middleMainly in middle--aged large breed dogsaged large breed dogs

►► Single or multiple sitesSingle or multiple sites

►► Clinical signs reflect the location, pain is the most common!Clinical signs reflect the location, pain is the most common!

►► Other infection or systemic disease can be in the Other infection or systemic disease can be in the background!background!

►► Therapy: long term antibiotic treatment (6Therapy: long term antibiotic treatment (6--8 weeks), 8 weeks), NSAIDNSAID’s’s

XX--rayray:: osteolysis osteolysis surrounded by sclerosis on the vertebral surrounded by sclerosis on the vertebral endplatesendplatesCave:Cave: radiographic signs only after the first 2 weeksradiographic signs only after the first 2 weeks

OsteomyelitisOsteomyelitis MeningitisMeningitis

►►Most common form is the immuneMost common form is the immune--mediated mediated ((„„beaglebeagle--painpain””, , „„steroid responsive meningitissteroid responsive meningitis””))

�� Typically in young (7Typically in young (7--18 month) dogs18 month) dogs

�� Most common in beagle, bernese, boxer, vizslaMost common in beagle, bernese, boxer, vizsla

�� Severe neck pain and feverSevere neck pain and fever

�� CSF cytology is the definitive diagnostic testCSF cytology is the definitive diagnostic test

�� Treatment is longTreatment is long--term (min. 6 month) term (min. 6 month) immunosuppression with tapering dosage of immunosuppression with tapering dosage of prednisolonprednisolon

�� Prednisolon can be combined with other Prednisolon can be combined with other immunsuppresants (azathioprin, cyclosporin)immunsuppresants (azathioprin, cyclosporin)

Infectious meningomyelitisInfectious meningomyelitis

►►Viral, bacterial, protozoal or fungal Viral, bacterial, protozoal or fungal

�� Cats: FIP, FeLVCats: FIP, FeLV, toxoplasmosis etc., toxoplasmosis etc.

�� Dogs: distemper, toxoplasmosis, neosporosis, Dogs: distemper, toxoplasmosis, neosporosis, cryptococcosis etc. cryptococcosis etc.

►►Multifocal neurological signs, can iclude Multifocal neurological signs, can iclude paresis and ataxiaparesis and ataxia

►►Often systemic signs tooOften systemic signs too

►►CSF test is the basis of the diagnosticsCSF test is the basis of the diagnostics

►►Vascular compromise of the spinal cord that often Vascular compromise of the spinal cord that often progresses to local infarctionprogresses to local infarction

►► Fibrocartilaginous embolic myelopathy (FCEM) or Fibrocartilaginous embolic myelopathy (FCEM) or spinal cord infarct or ischemic myelopathyspinal cord infarct or ischemic myelopathy

►► Peracute onset, nonprogressive, nonpainful, often Peracute onset, nonprogressive, nonpainful, often asymmetricalasymmetrical

►►Transverse myelopathy (ataxia, paresis)Transverse myelopathy (ataxia, paresis)►►Most common in large breed dogs, miniature Most common in large breed dogs, miniature

schnauzers and catsschnauzers and cats►► Imaging: MRI is definitiveImaging: MRI is definitive►►Treatment: physiotherapyTreatment: physiotherapy

VascularVascular FCEFCE, , EEpiduralpidural bleedingbleeding

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FCEM on MRI

AtlantoAtlanto--axial luxationaxial luxation►► Instability or malformation of the atlantoaxial joint Instability or malformation of the atlantoaxial joint

allows excessive flexion of the cervical 1allows excessive flexion of the cervical 1--2 joint2 joint

►► Subsequent ventral cord compression occurs from the Subsequent ventral cord compression occurs from the cranial aspect of the body of the axiscranial aspect of the body of the axis

►► Most common in young toy breedsMost common in young toy breeds

►► Neck pain, ataxia, tetraparesisNeck pain, ataxia, tetraparesis

►► XX--ray, CT, MRI is definitiveray, CT, MRI is definitive

►► TreatmentTreatment�� Conservative: neck splinting for 8Conservative: neck splinting for 8--10 weeks (long term 10 weeks (long term

efficacy:?)efficacy:?)

�� Surgical: Fusion of the C1Surgical: Fusion of the C1--C2C2

AnomAnomalyaly

AA--L luxatioL luxationn, , ChiariChiari--likelikemalformatiomalformationnand Sand Syringomyeliayringomyelia, , HemivertebraHemivertebra, ,

Arachnoid cystArachnoid cyst, Spina bifida, Dysraphismus, , Spina bifida, Dysraphismus, Multiple cartilaginous exostosesMultiple cartilaginous exostoses

ChiariChiari--like malformation and like malformation and syringomyeliasyringomyelia and and

hydromyeliahydromyelia

►► HydromyeliaHydromyelia is a fluid dilatation of the central canalis a fluid dilatation of the central canal

►► SyringomyeliaSyringomyelia is a fluid dilatation in the spinal cord that is a fluid dilatation in the spinal cord that may communicate with the central canalmay communicate with the central canal

►► Any condition that causes obstruction of normal CSF flow Any condition that causes obstruction of normal CSF flow along the spinal cord can cause italong the spinal cord can cause it

►► Most common in cervical regionMost common in cervical region

►► Cervical Cervical syringohydromyeliasyringohydromyelia occurs as a component of occurs as a component of congenital anomalies associated with caudal occipital congenital anomalies associated with caudal occipital malformation syndrome (malformation syndrome (ChiariChiari), which is most common in ), which is most common in Cavalier King Charles spanielCavalier King Charles spaniel

►► Neck pain, Neck pain, persistantpersistant scratching, ataxia, paresisscratching, ataxia, paresis

MRI is MRI is definitivedefinitive►►TreatmentTreatment ((inin casecase of of clinicalclinical signssigns))

�� PrednisolonPrednisolon 0,5 mg/kg/SID0,5 mg/kg/SID

�� GabapentinGabapentin 55--10 mg/kg/TID10 mg/kg/TID

�� PregabalinPregabalin 33--4 mg/kg/TID4 mg/kg/TID

�� OmeprazolOmeprazol 0,5 mg/kg/SID0,5 mg/kg/SID

�� NSAID (NSAID (MeloxicamMeloxicam, , CarprofenCarprofen, , CoxibCoxib))

�� OtherOther painkillerspainkillers (pl. (pl. FentanylFentanyl patch)patch)

�� FurosemidFurosemid

�� SurgicalSurgical decompressiondecompression++titaniumtitanium mashmash??

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HemivertebraeHemivertebrae►►Wedge shaped malformation, with the apex Wedge shaped malformation, with the apex

dorsally, ventrally, or medially across the midline dorsally, ventrally, or medially across the midline which often results in angulation of the v. columnwhich often results in angulation of the v. column

►►Spinal cord compression can occurSpinal cord compression can occur

►►Most common: bulldog, pug, yorkie, boston Most common: bulldog, pug, yorkie, boston terrier, german shorthair pointerterrier, german shorthair pointer

►►Clinical signs: slowly progressive ataxia, paresis, Clinical signs: slowly progressive ataxia, paresis, (pain)(pain)

►► Imaging: XImaging: X--ray, Myelography, CT, MRIray, Myelography, CT, MRI►►TreatmentTreatment

�� Conservative: physiotherapy, NSAIDs, steroids?Conservative: physiotherapy, NSAIDs, steroids?

�� Surgical for progressive clinical signs: stabilisation + Surgical for progressive clinical signs: stabilisation + decompressiondecompression

(Massimo Baroni felvételei)

Arachnoid cystArachnoid cyst

►►CSF filled diverticuli of the arachnoid membraneCSF filled diverticuli of the arachnoid membrane

►►Most common in young adult rottweilers, cervicallyMost common in young adult rottweilers, cervically

►►Chronic progressiveChronic progressive

►►Clinical signs: ataxia, paresis, (pain), incontinenceClinical signs: ataxia, paresis, (pain), incontinence

►► Imaging: Myelography, MRIImaging: Myelography, MRI

►►Treatment: Treatment: �� Conservative in mild cases: NSAIDs, steroidsConservative in mild cases: NSAIDs, steroids

�� In severe cases surgical decompression, partial excision In severe cases surgical decompression, partial excision and marsupalisation of the dura is recommendedand marsupalisation of the dura is recommended

Subarachnoideal cyst

Thank you for your attention!Thank you for your attention!

Literature

•BSAVA Manual of Canine and Feline Neurology•Handbook of Veterinary Neurology•Small Animal Spinal Disorders•Veterinary Neuroanatomy and Clinical Neurology•Small Animal Surgery