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Initial presentation: Chunky presented with a sudden onset of paraparesis. Chunky had been sleeping earlier in the day, and when his owner went to move him, he cried out. Later, when he awoke, he was reluctant to go down steps and was not able to use his rear limbs very well. He was subsequently taken to be evaluated by his primary care veterinarian.
Primary care evaluation: Neurological exam and radiographs.
Findings: Paraparesis with minimal voluntary motor function in the left rear limb. Suspected narrowed disc spaces at T-L junction. Based on a high suspicion of an acute IVDH, the primary care veterinarian recommended referral for evaluation by a surgeon.
Condition upon arrival at The COVE: Overweight, paraparetic (severe ataxia: able to stand briefly with assistance but collapsed upon attempting to initiate voluntary motor with rear limbs), rear limb reflexes normal to increased bilaterally, rear limb withdrawal reflex weak bilaterally, superficial sensation depressed left rear, deep sensation intact bilaterally, perineal reflex intact, panniculus reflex present at L2-3, moderate pain response upon palpation of thoracolumbar spine; urinary bladder small.
Initial diagnostics: CBC, Chemistry, U/A, survey spinal radiographs.
Findings:
Lab work - hyperalbuminemia (4.0 g/dl), hyperamylasemia (1714 U/L), hyperlipasemia (5279 U/L), trace proteinuria.
Radiographs: Survey of T-L spine - narrowing and wedging of the IVD spaces at T12-13 and T13-L1. Mild mineralization of the IVD space at L1-2.
Treatment plan: Plasmalyte IV at 20 ml/hr, Fentanyl CRI at 10 ml/hr, neurological status monitoring q 4 hrs., urinary bladder monitoring q 6 hrs., surgical consult in AM unless neurological status deteriorates rapidly necessitating immediate evaluation.
Surgical consult: Chunky was examined by Dr. Stallings the following morning. His neurological status was found to be unchanged. The owners were given the options of 1) myelogram and surgery at the COVE if indicated (referral to a neurologist for further evaluation and advanced imaging was also discussed), or 2) continued conservative/medical therapy. The owners elected to proceed with option 1.
Advanced diagnostics: Myelogram.
Myelogram: Good contrast material filling of the subarachnoid space with loss of visualization of the ventral and dorsal aspects of the contrast column at T13-L1. These findings are most consistent with a ventral extradural compressive lesion at T13-L1, most likely secondary to acute IVDH. The myelogram did not indicate any lateralization of the compressive lesion.
Surgery: Based on the results of the myelogram, Chunky was taken immediately to the OR for decompressive surgery. Bilateral hemilaminectomy was done at T13-L1 in order to remove all the disc material and completely decompress the spinal cord.
Immediate post-op care: In addition to daily PCV/TS and vital signs monitoring (initially q hr. and then q 6 hrs., Chunky was placed on seizure watch for the first three hours postoperatively. His bladder was manually expressed immediately postoperatively, and he was then scheduled to be checked and expressed every eight hours thereafter if necessary. Plasmalyte (17 ml/hr IV) was continued. The Fentanyl CRI (pre-op and intra-op) was replaced with a Fentanyl/Dexdomitor CRI (10 ml/hr). Cefazolin (220 mg IV pre-op) was continued for one more injection along with Famotidine (9 mg IV SID). Acepromazine and Mirtazipine were added to Chunky's treatment protocol on the first postoperative day.
Postoperative course: Chunky remained hospitalized for three days postoperatively, during which he appeared to be much more comfortable than preoperatively and began voiding some urine without having to be manually expressed. His appetite returned by the second postoperative day. He was subsequently discharged on Cephalexin (250 mg PO q 12 hrs. x 2 more days), Tramadol (37 mg PO q 8-12 hrs. prn), Acepromazine (5 mg PO q 8-12 hrs. prn), and Alprazolam (0.5 mg PO q 8-12 hrs. prn). The owners were instructed to palpate Chunky's bladder three times a day and after urination and to manually express the bladder if it felt full or if there was residual urine following spontaneous urination. Physical therapy was recommended to begin following suture removal at two weeks. Weight loss was recommended as a medium to long term objective. Activity modification was recommended for life.
Follow up: Chunky continued to do well and progressively regain his rear limb neurological function over the next several weeks. At his six-week recheck at the COVE, and after four weeks of physical therapy, Chunky was comfortable, fully ambulatory, and exhibiting only very mild residual neurological deficits associated primarily with the right rear limb. His owners were thrilled with his progress and feel as if he has nearly fully recovered.
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In a nutshell:
Chunky's case illustrates how primary care veterinarians, emergency veterinarians, and specialists can all work together to provide outstanding patient care and facilitate the most favorable clinical outcome possible. Dr. Wathen did a great job of assessing Chunky's status and making a timely referral to a 24-hour emergency hospital. The emergency doctors and staff at The COVE did an outstanding job of assessing Chunky's neurological and overall health status, initiating a treatment plan and communicating with a board-certified surgeon about a consult. The surgeon was able to make a timely assessment and communicate directly with the owners regarding the available diagnostic/treatment options. Once the owners had made an informed decision, the surgical team was mobilized. Chunky's problem was definitively diagnosed and operative intervention initiated immediately. Post-operative management was carried out primarily by the emergency doctors and staff. Following suture removal, the certified veterinary physical therapist began working with Chunky and helped him to regain his rear limb neurological function and lose weight as safely and rapidly as possible. Now if that's not teamwork, I don't know what is!
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