AVC Class of 2013 Faculty Advisor

Robert Gracia Dr. Art Ortenberger

Degenerative lumbosacral stenosis in a dog: medical management using acupuncture, non-steroidal anti-inflammatories, and steroid epidural injection.

Abstract: A fourteen-year-old male castrated Border Collie (BC) mix was presented to the Atlantic Veterinary College for evaluation of hind-limb lameness, pain, and spontaneous vocalization. Orthopedic exam and radiography identified evidence of degenerative lumbosacral stenosis (DLSS). Over the following weeks a multimodal approach to medical management was initiated. Included were non-steroidal anti-inflammatories, acupuncture, and steroidal epidural injection; throughout the course of treatment, the patient demonstrated marked improvement, returning to almost full functionality.

It was noted that a fourteen year old Border Collie mix was losing hind limb function and collapsing during attempts at climbing stairs. Later overexertion while exercising on a walking trail led to progressive dysfunction of both hind-limbs. Episodes of shifting non-weight bearing hind-limb lameness occurred later that day resolving to bilateral weight bearing lameness a week later. The dog was given tramadol at 5mg/kg body weight by the owner, which did little to alleviate the pain seen. Seven days after onset, the dog was restless at night, not able to sleep for more than an hour before spontaneously vocalizing. The dog was brought to the Atlantic Veterinary College to identify the cause of the hind-limb dysfunction, vocalization, and pain.

At the time of presentation, the dog was bright, alert, responsive, and very anxious. He was slightly under conditioned (body condition score = 2.75/5, body weight = 21.5 kg) and had generalized muscle atrophy. His mucous membranes were pink and moist, and a grade IV/VI systolic heart murmur was auscultated. His resting heart rate was 100 beats per minute, and a resting respiratory rate could not be determined due to panting. His pulse was strong and synchronous. There was moderate enlargement of his left popliteal lymph node.

Upon orthopedic examination it was noted that he had a stiff hind-limb gait, and there was evidence of a mild to moderate left hind-limb weight bearing lameness. Circumduction of both hind-limbs was evident during walking and running. He had no signs of ataxia and a wide based hind-limb stance. He had normal range of motion on all joints. He had normal to increased patella reflexes bilaterally, and decreased sciatic reflexes bilaterally. He had decreased tail tone and a low tail carriage. He had a normal rectal exam, but decreased anal tone was noted. Pain was elicited on lumbosacral palpation.

Lateral and ventro-dorsal projections of the lumbar spine, including the lumbosacral junction, were performed. There was moderate narrowing of the intervertebral disk space of L3-L4. A moderate amount of spondylosis deformans was noted near the thoracolumbar junction.

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The results of the complete blood count, serum biochemical profile, urinalysis, and lymph node fine needle aspirates were within normal limits.

Further diagnostic testing to confirm degenerative lumbosacral stenosis (DLSS) was discussed with the owner, and it was opted to try a more conservative medical management approach. The dog was placed on meloxicam 1.5 mg/ml (Metacam, Boehringer Ingelheim, Ontario, Canada) at a dose of 0.1 mg/kg BW orally once daily for pain and inflammation for one week, and two weeks of restricted activity. After the first week, the dog displayed moderate signs of improvement.

During the second week he began acupuncture therapy for lumbosacral pain. Specific acupuncture points pertaining to the dog’s affliction were used to provide analgesia and relief from anxiety. Acupuncture was repeated weekly for three sessions and then every other month. Acupuncture points were added and removed from the original protocol, but basically remained similar throughout treatment. On the initial treatments electro-stimulation over bilateral acupuncture points was done in order to provide a longer lasting effect. The acupuncture points consisted of: Stomach (ST) 36 (Hou-san-li) reduces stifle pain and hind-limb weakness. It is located on the craniolateral aspect of the pelvic limb, 0.5 cun lateral to the cranial aspect of the tibial crest, in the belly of the cranial tibialis muscle (1). Spleen (SP) 6 (San-yin-jiao) reduces pelvic limb paresis and is located on the medial side of the pelvic limb 3 cun proximal to the tip of the medial malleolus in a small depression on the caudal border of the tibia (1). Bladder (BL) 40 (Wei-zhong) reduces pain associated with thoracolumbar disc disease, coxofemoral joint pain, and pelvic limb paresis. This point is located in the center of the popliteal crease (1). BL-54 (Ba-shan or Zhi-bian) reduces coxofemoral joint pain, osteoarthritis, pelvic limb paresis, lameness, muscle atrophy, and perianal disorders. This point is located at the coxofemoral joint at the level of the sacrococcygeal hiatus, just dorsal to the greater trochanter of the femur, around the coxofemoral joint (1). Gallbladder (GB) 29 (Ju-liao) reduces pain associated with osteoarthritis of the coxofemoral joint, pelvic limb paresis, and gluteal muscle pain. This point is located at the coxofemoral joint, in a depression just cranial to the greater trochanter of the femur (1). GB-30 (Huan-tiao) reduces pain associated with osteoarthritis of the coxofemoral joint, pelvic limb paresis or paralysis, and gluteal muscle pain. It is located in a depression midway between the greater trochanter of the femur and the tuber ischii (1). GB-34 (Yang-ling-quan) provides general pain relief, and strengthens tendons and ligaments. This point is located on the lateral side of the pelvic limb at the stifle, in a small depression cranial and distal to the head of the fibula (1). Governing vessel (GV) 20 (Bai-hui) provides sedation for acupuncture therapy. It is located on the dorsal midline on a line drawn from the tips of the ears level with the ear canals (1).

Later, the following acupuncture points were added to better address anxiety issues caused by lumbosacral pain. The acupuncture points were as follows: ST-45 (Li-dui) ameliorates behavioral problems and is located on the lateral side of the third digit of the pelvic limb at the nail bed (1). Heart (HT) 7 (Shen-men) reduces anxiety and restlessness and is located on the lateral transverse crease of the carpal joint and approached via the large depression lateral to the

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tendon of the flexor carpi ulnaris muscle although the point is medial to this tendon (1). BL-10 (Tian-zhu) reduces cervical and shoulder pain, as well as pain associated with intervertebral disc disease, it is located on the dorsolateral aspect of the cervical spine, in a depression just caudal to the wings of the atlas (at the junction of C1-C2), 1.5 cun from the dorsal midline (1). BL-15 (Xin-shu) improves cognitive function and is located on the dorsolateral aspect of the spine, 1.5 cun lateral to the caudal border of the dorsal spinous process of T5 (1).

Seven weeks after the initial presentation, the dog was markedly improved in pain control and functionality. He had been receiving consecutive acupuncture treatments which allowed for the discontinuation of his meloxicam. He was examined and pain was still elicited on palpation of his lumbosacral region. His sciatic reflexes seemed mildly improved, and his tail tone was moderately improved with normal tail carriage. A new treatment option was discussed with the owner which was the infiltration of the epidural space with a long acting steroid. The following day the dog was sedated and then placed under general anesthesia and a 21 gauge 7 cm spinal needle was placed in the L7-S1 space by the anesthesia personnel. The epidural space was infiltrated with methylprednisolone acetate 40 mg/ml (Depo-Medrol, Pfizer Canada Inc, Quebec, Canada) at a dose of 1 mg/ kg BW. The dog recovered uneventfully and was discharged later that day.

Two weeks after the epidural injection the dog returned for reevaluation and examination. The dog had returned to near full functionality with a marked increase to activity. Pain was no longer elicited on lumbosacral palpation, or during exercise. The owner was advised to continue to monitor and schedule another epidural injection of steroid if felt needed.

Degenerative lumbosacral stenosis is caused by degeneration of the lumbosacral disc resulting in a Hansen Type II disc protrusion. There is also a variable degree of subluxation, instability, soft tissue proliferation, and spondylosis deformans that may contribute to compressive radiculopathy of the cauda equina. This eventually leads to nerve root compression or ischemia which then leads to neurological signs (5). The causes for degeneration of the L7-S1 disc are malformation of lumbosacral vertebrae or the sacroiliac joint, biomechanical factors, age, and osteochondrosis. Eventually a loss of stability leads to subluxation and then to a narrowing of the vertebral canal and osteophyte formation (6), (7). DLSS involves varying degrees of anatomical pathology, such as hypertrophy and ventral folding of the interarcuate ligament, osteoarthritis and subsequent joint capsule proliferation of the articular facets of L7-S1 articulation, and occasionally osteochondrosis of the cranial sacral or caudal L7 end plate may be seen (2). The nerves most often affected by DLSS are the sciatic, pudendal, pelvic, sacral, and caudal; leading to the neurological signs seen on presentation such as hind-limb paresis and paralysis, decreased sciatic reflexes, decreased tail tone and anal tone, and incontinence (7). DLSS is mostly confined to middle aged to older, medium and large breed dogs. It is probably overrepresented in German Shepherds. Other breeds affected commonly include Great Danes, Airedale terriers, Irish setters, English springer spaniels, Boxers, Labrador retrievers, and Golden retrievers (2). DLSS is more common in working dogs that undergo rigorous activity. Males are

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twice as likely to have DLSS over females. Common findings for DLSS are pain in the caudal lumbar region and pelvic limb weakness that is manifested as a reluctance to jump, climb and rise (3). The severity of DLSS manifests itself in neurological deficits. These may be proprioceptive deficit, decreased hock flexion with a reduced Achilles tendon reflex, urinary or faecal incontinence, and root signature signs such as stamping, lifting of a hind-limb and lower back flea biting behavior (3).

Treatment options for DLSS can be divided into two categories; medical management or surgical treatment. Medical therapy consists of exercise restriction for a minimum of 4 to 6 weeks. Administration of anti-inflammatories can be used to control pain and inflammation throughout the restricted exercise period. For mild cases with little neurological signs, non-steroidal anti-inflammatories can be used (2). For moderate cases with more pronounced neurological signs, corticosteroids can be administered at anti-inflammatory doses (2). Epidural infiltration with a long lasting corticosteroid can also be undertaken for more moderate to marked severity cases. The results from one study demonstrated that 79% of the animals were considered to have improved, and 53% were totally cured. These results were comparable with percentage outcomes for surgical treatment (3). Acupuncture can be used as an adjunct therapy to help relieve pain along with the other medical management treatments previously discussed. Reduction of anxiety during the restricted activity period is a main benefit of acupuncture therapy. Surgical treatment is a consideration for animals that have a progressive decline in function or persistent pain in spite of medical therapy (2). Surgical techniques for DLSS include dorsal laminectomy, +/- discectomy, and +/- lumbosacral stabilization (2).

Resources

1. Xie and Preast. Xie’s Veterinary Acupuncture. Blackwell Publishing Ltd. 20072. Kent, Marc. Degenerative lumbosacral stenosis in dogs. DVM 360

http://veterinarymedicine.dvm360.com/vetmed/article/articleDetail.jsp?id=169902 July 1, 2005.

3. Daems, Beosier and Janssens. Lumbosacral degenerative stenosis in the dog-the results of epidural infiltration with methylprednisolone acetate: a retrospective study. Vet Comp Orthop Traumatol 2009; 22:486-491.

4. Lindley and Cummings. Essentials of Western Veterinary Acupuncture. Blackwell Publishing Ltd. 2006

5. Fossum, Theresa. Small Animal Surgery. Mosby Year Book Inc. 19976. Sharp and Wheeler. Small Animal Spinal Disorders Diagnosis and Surgery 2 nd

edition. Elsevier Limited 20057. Slatter, Douglass. Textbook of Small Animal Surgery Volume 2. Saunders Co.

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