Vol. 21, No.
11 November 1999
CE Refereed Peer Review
FOCAL POINT
★ The choice of medical or surgical
management of thoracolumbar
disk extrusion should be
determined on an individual
case basis; however, nonambula-
tory patients warrant diagnostic
myelography and decompressive
surgery.
KEY FACTS
■ Dogs with mild signs of
neurologic dysfunction can
be considered candidates for
medical management consisting
of 3 to 4 weeks of strict
confinement.
■ Methylprednisolone is indicated
in patients that have had severe
signs of neurologic dysfunction
for less than 8 hours.
■ A hemilaminectomy can
be performed over several
intervertebral disk spaces if
necessary, allowing access to
the spinal cord without adversely
affecting vertebral stability.
■ Durotomy is performed to
investigate spinal cord integrity
in dogs with loss of deep pain
sensation.
20TH ANNIVERSARY
Acute Thoracolumbar
Disk Extrusion in
Dogs—Part II*
The Pet Practice, Hamilton, New Zealand
Richard M. Jerram, BVSc, MRCVS
Texas A&M University
Curtis W. Dewey, DVM, MS
ABSTRACT: The management of dogs with thoracolumbar disk extrusion has been the subject
of numerous clinical reports in the veterinary literature, yet controversy still exists regarding
selection of cases for surgical or medical management, the use of corticosteroids in spinal
cord trauma, and the effectiveness of disk fenestration. High-dose methylprednisolone is be-
lieved to be beneficial because of its inhibition of oxygen free-radical lipid peroxidation in the
spinal cord. Hemilaminectomy, dorsal laminectomy, and pediculectomy are described as sur-
gical methods for spinal cord decompression and removal of extruded disk material.
T
he most common cause of neurologic dysfunction that is localized to the
thoracolumbar spinal cord is intervertebral disk (IVD) extrusion.1–3 Dogs
may present with clinical signs ranging from spinal hyperesthesia alone
to acute paralysis in the pelvic limbs without conscious pain perception (noci-
ception).1–5 The degree of neurologic dysfunction is related to the force of the
impact of extruded disk material, volume of disk material extruded, and length
of time the disk material has been present in the vertebral canal.1–3
Although management of thoracolumbar disk extrusion in dogs has been fre-
quently discussed in the veterinary literature, controversy still surrounds the se-
lection of cases for surgical or medical management, use of corticosteroids in
spinal cord trauma, and effectiveness of disk fenestration. In general, each pa-
tient should be treated on an individual basis with consideration given to the
neurologic examination findings, overall health of the animal, surgical experi-
ence of the attending clinician, and expectations and resources of the owner.
Part I of this two-part presentation addressed the anatomy, pathophysiology,
clinical signs, and diagnosis of acute thoracolumbar disk extrusion as well as
prognosis and the decision-making process for treatment. Part II covers both
medical and surgical management of this disease and provides a brief review of
*Part I of this two-part presentation appeared in the October 1999 (Vol. 21, No. 10) is-
sue of Compendium.
Small Animal/Exotics 20TH ANNIVERSARY
alternative treatment meth-
ods. A short discussion of
the postoperative manage-
ment of surgical patients is
also included.
MEDICAL MANAGEMENT
It is generally accepted that
nonsurgical management of
thoracolumbar disk extru-
sion in selected patients will
result in neurologic recovery. Figure 1—Strict cage confinement for 3 to 4 weeks is the most ous exercise as running, jump-
Dogs with grades 1 and 2 important component in medical management of thoraco- ing, and climbing stairs. Dogs
(using the grading system lumbar disk disease.
described in Part I of this ar-
ticle) clinical signs based on thorough neurologic exami-
nation may be considered candidates for medical man-
agement.1–5 Other indications for medical management
are dogs with loss of deep pain sensation for more than
48 hours, owners who decline surgery for their dogs,
and dogs with systemic illness that greatly increases
anesthetic risk.2,4,5
Confinement Therapy
The term conservative management has been used to
describe medical therapy for thoracolumbar disk extru-
sion in dogs, but it fails to define the intensive nature
of care such therapy requires. Owners generally provide
this care, and the term conservative may be misinter-
preted as meaning less attention is required in caring
for the animal. We prefer the term confinement therapy
when discussing medical management options because
it better describes the fundamental aspect of nonsurgi-
cal treatment of thoracolumbar disk extrusion.
The key factor in confinement therapy is strict immo-
bilization of animals in a cage or crate for at least 3
weeks1–5 (Figure 1). This period of inactivity enables res-
olution of spinal cord and IVD inflammation, some re-
sorption of any extruded disk material, and fibrosis of
the ruptured annulus fibrosus.1,3 Leash walking is per-
mitted for urination and defecation. Nonambulatory
animals require intensive recumbency management. In
dogs that have lost the ability to urinate voluntarily,
bladder expression should be performed three to four
times daily.6 Urinary catheterization (intermittent or in-
dwelling) may be necessary, particularly in dogs with a
6
hypertonic urethral sphincter. Pharmacologic agents
can improve bladder and urethral function.6 Soft, dry,
padded bedding material (e.g., foam, air, or water mat-
tresses and blankets) should be provided to prevent
7
urine scalding and decubital ulcers. Physical therapy,
including gentle massage combined with passive and ac-
tive exercise therapy, can also be helpful in maintaining
RECUMBENCY MANAGEMENT ■ PHYSICAL THERAPY ■ DEXAMETHASONE
Compendium November 1999
muscle strength and range of
motion in joints.6 The use of
carts and other walking aids
should be restricted to dogs
with prolonged or perma-
nent paralysis.7
Following the initial 3-
week confinement period,
dogs should be gradually
returned to normal activity
while avoiding such strenu-
with grade 1 and 2 clinical
signs that have repeated
episodes of severe spinal hyperesthesia despite medical
management or have worsening neurologic deficits should
be considered for surgical treatment.2–5
Pharmacologic Therapy
It is our clinical impression that drug therapy is
overused in the medical treatment of thoracolumbar
disk extrusion. Corticosteroids have been used exten-
sively in treating the spinal cord trauma associated with
IVD extrusion.1–5 Proposed mechanisms of action in-
clude reduction of edema, inhibition of inflammatory
response, and improvement of spinal cord blood flow.
However, the overall effectiveness of corticosteroids re-
mains unclear. 8 There is controversy regarding the
dosage and clinical efficacy of these drugs. The use of
corticosteroids, particularly dexamethasone, has been
associated with severe and occasionally fatal gastroin-
testinal (GI) complications in dogs with IVD extru-
sion.8–10 In one study, neurologic recovery was no dif-
ferent in cats with experimental spinal cord injury
treated with dexamethasone than in those treated with
a placebo.11 The value of dexamethasone in treating
acute spinal cord injury can be questioned based on the
potential for serious side effects (GI hemorrhage, pan-
creatitis, colonic ulceration and perforation) and its un-
determined efficacy.
Methylprednisolone is widely used in human and
veterinary patients to treat spinal injuries.8,12,13 High-
dose methylprednisolone is believed to be beneficial be-
cause of its inhibition of oxygen free-radical lipid per-
oxidation in the spinal cord.8,12 One clinical trial in
humans showed an improvement in neurologic func-
tion in patients given methylprednisolone (30 mg/kg as
an initial intravenous [IV] bolus, followed by 5.4 mg/
kg/hr IV for 23 hours) within 8 hours after injury.14,15
However, patients who were similarly treated more
than 8 hours after injury actually showed decreased re-
covery of motor function compared with those treated
Compendium November 1999 20TH ANNIVERSARY Small Animal/Exotics

TABLE I
Drugs Commonly Used for Treating Thoracolumbar Disk Extrusiona
Drug Dosage Clinical Effects Potential Side Effects
Methylprednisolone 30 mg/kg slow IV within 8 hr Inhibition of oxygen free- GI bleeding
of injury or preoperatively and radical lipid peroxidation
then 15 mg/kg IV 2 and 6 hr
later

Prednisone 0.5 mg/kg PO BID for 3–5 days Analgesic, antiinflammatory Overactivity, GI bleeding

Carprofen 2.2 mg/kg PO BID for 3–5 days Analgesic, antiinflammatory Overactivity, hepatopathy (?)

Etodolac 10–15 mg/kg PO SID for 3–5 days Analgesic, antiinflammatory Overactivity

Aspirin 10 mg/kg PO BID for 3–5 days Analgesic, antiinflammatory Overactivity, platelet
dysfunction, GI bleeding
aAtTexas A&M University Small Animal Clinic.
BID = twice daily; GI = gastrointestinal; IV = intravenously; PO = orally; SID = once daily.

with a placebo.14,15 Higher doses of methylprednisolone
(60 mg/kg) promoted lipid peroxidation, and lower
doses (15 mg/kg) failed to inhibit lipid peroxidation.12
The efficacy of methylprednisolone in veterinary pa-
tients has not been evaluated clinically. In a study of ex-
perimentally induced acute spinal cord trauma in cats,
methylprednisolone produced more rapid neurologic
recovery than did all other drugs tested.16 Another,
more recent study failed to demonstrate any significant
neurologic improvement with the administration of
methylprednisolone or a 21-aminosteroid product.17
This latter study, however, concluded that the method
used to experimentally induce spinal cord trauma
might not have produced trauma adequate to evaluate
the drugs administered.17
Serious side effects of methylprednisolone are rare,
especially if other corticosteroids or NSAIDs have not
been used previously or concurrently. 12 One study
showed that 90% of dogs treated with methylpred-
nisolone and surgery had evidence of occult GI bleed-
ing postoperatively.18 Most dogs in this study had re-
ceived prior treatment with corticosteroids or NSAIDs,
and bleeding was rarely severe enough to warrant medi-
cal attention.18 In addition, there was no prophylactic
benefit from the use of cimetidine, sucralfate, and
misoprostol.18
Current recommendations at the Texas A&M Uni-
versity Veterinary Teaching Hospital are to administer
30 mg/kg of methylprednisolone by slow IV injection
within 8 hours of spinal cord trauma (Table I). This
initial dose is followed 2 and 6 hours later with another
IV dose at 15 mg/kg. Because iatrogenic spinal cord
trauma may occur during surgical decompressive proce-
dures, the same guidelines are used in patients sched-
uled for surgery provided that other corticosteroids or
NSAIDs have not been given prior to presentation.
Calcium-channel antagonists, prednisone sodium suc-
cinate, 21-aminosteroids, narcotic antagonists, dimethyl
sulfoxide, and NSAIDs may be beneficial in the treat-
ment of spinal cord trauma; however, none of these
drugs have been evaluated clinically in animals, and po-
tential side effects have not been fully addressed.8,12 Al-
though mannitol, an osmotic diuretic, is efficacious in
treating brain edema, it can potentially impede neuro-
logic recovery in the spinal cord as a result of increased
hemorrhage in the gray matter.8 At this time, the use of
these drugs cannot be recommended.
The use of antiinflammatory drugs with confinement
therapy should be limited to the treatment of severe
spinal hyperesthesia. In such cases, oral prednisone or
NSAIDs may be used for 3 to 5 days (Table I). The
concurrent use of corticosteroids and NSAIDs is con-
traindicated in the treatment of dogs with thoracolum-
bar disk extrusion because of the propensity for the de-
velopment of severe and occasionally fatal GI bleeding
and perforation.7–10 In dogs with grade 1 and 2 clinical
signs, antiinflammatory drugs can cause overactivity,
resulting in poor owner compliance with confinement
recommendations.1–5 Recurrent clinical signs or wors-
ening neurologic deficits that may require surgical in-
tervention are common sequelae of antiinflammatory
drug overuse in dogs with grade 1 and 2 clinical signs.
SURGICAL TREATMENT
The grading system described in Part I can be useful in
deciding whether surgery is indicated in animals with

METHYLPREDNISOLONE ■ SIDE EFFECTS ■ ANTIINFLAMMATORY DRUGS

Small Animal/Exotics 20TH ANNIVERSARY Compendium November 1999

thoracolumbar disk extru- the opposite side of the spi-

sion. At the Texas A&M Uni- nal cord. In these cases, the
versity Veterinary Teaching primary hemilaminectomy
Hospital, all dogs categorized may provide sufficient spi-
in grades 3, 4, or 5 (i.e., dogs nal cord decompression or
unable to walk unassisted) an additional hemilaminec-
are regarded as candidates for tomy can be performed on
surgery. Surgery may also be the contralateral side.2,3,20
considered for dogs exhibit- In a study comparing hemi-
ing recurrent or persistent laminectomy and dorsal lam-
signs of spinal hyperesthesia inectomy in dogs, dogs that
or ataxia (grades 1 and 2). As had undergone hemilamin-
an exception, dogs with loss ectomy had significantly im-
of deep pain sensation (grade proved neurologic recovery
5) for longer than 48 hours Figure 2—Diagrammatic representation of three adjacent ver- at discharge and less deterio-
may not benefit from sur- tebrae showing the location and extent of a typical left hemi- ration of neurologic signs
gery.2,4,5 These dogs have a laminectomy. (From Dewey CW, Hoffman AG, Coates JR, postoperatively.22 Neurologic
poor prognosis for functional Ducoté J: A Practical Guide to Canine and Feline Neurology. recovery at 2 to 12 weeks
neurologic recovery, and College Station, TX, Texas A&M University Press, 1999 [in postsurgically was not signif-
durotomy should be consid- press]. Reproduced with permission.) icantly different between the
ered as a diagnostic proce- two techniques.22 Overall re-
dure to evaluate the spinal cord for evidence of myelo- covery rates following hemilaminectomy in dogs with
malacia.2 various preoperative neurologic status range from 83%
Much confusion and controversy surround the ideal to 90%.22–25 Hemilaminectomy is the spinal cord decom-
surgical procedure for treating thoracolumbar disk ex- pressive procedure most frequently performed at Texas
trusion in dogs. No specific reports in the veterinary lit- A&M University, and our clinical impression is that ex-
erature compare techniques in terms of preoperative cellent neurologic recovery occurs in more than 90% of
neurologic status, postoperative recovery, and recur- patients.
rence. Hemilaminectomy, dorsal laminectomy, and Accurate localization of a lateralized extruded disk
pediculectomy are described as surgical methods for can be difficult. Clinical findings demonstrating neuro-
spinal cord decompression and removal of extruded logic signs that are worse on one side can indicate later-
disk material.1–3,19–21 These techniques can be accom- alization of disk material; however, a recent study
plished using only bone rongeurs. However, using a found that this was the least reliable factor for deter-
pneumatic drill and bone burs allows more rapid and mining the side on which hemilaminectomy should
precise bone removal. Although it does not decompress be performed.26 The same study reported that myelog-
the spinal cord, IVD fenestration via lateral, dorsolater- raphy was better at identifying lateralized disk material,
al, or ventral approaches has also been described for although radiologists disagreed about the side of disk
treatment of thoracolumbar disk extrusion.1–4,19–21 extrusion in more than 40% of cases.26 However, ven-
tral localization of disk material was disregarded, and
Hemilaminectomy only 3 of the 50 dogs studied required bilateral hemi-
Because most disk extrusions result in a ventral or laminectomy for removal of disk material. 26 Other
ventrolateral compressive mass, hemilaminectomy is studies report accurate localization of lateral disk extru-
our preferred surgical technique for spinal cord decom- sion in 60% to 100% of cases, with very few animals
pression and removal of disk material. This technique requiring bilateral procedures.27,28 In patients with un-
can be performed over four or five IVD spaces if neces- determined lateralization, most right-handed surgeons
sary and allows access to the ventral and lateral aspects elect to perform a left-sided hemilaminectomy for ease
of the spinal cord without adversely affecting vertebral of surgical approach and instrument handling.26
stability (Figure 2). Extruded disk material can be re- A standard dorsal approach to the selected side of the
moved through the bony window that is created, there- vertebral column is made centered on the affected IVD
by decompressing the spinal cord. Durotomy, if indi- space. Visualizing the cranioventrally projected transverse
cated, can also be performed using the same surgical process of the first lumbar vertebra (L-1) and the lateral
approach. In ventrolaterally extruded disks, the bulk of transverse process and rib head of the thirteenth thoracic
the disk material occasionally cannot be removed from vertebra (T-13) makes identification of the correct disk

DUROTOMY ■ RECOVERY RATES ■ LOCALIZING LATERAL DISK EXTRUSION

Compendium November 1999 Small Animal/Exotics
COMPENDIUM
ON CONTINUING EDUCATION
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Figure 4—A completed hemilaminectomy showing the ex-
truded disk material ventral to the spinal cord. The disk ma-
terial is removed using the nerve-root retractor shown.
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space possible. Initially, the articular processes over the SHIP TO:
disk space are removed using a bone rongeur. The lami- NAME
nar bone is then removed to the level of the floor of the
vertebral canal. This can be performed using rongeurs; COMPANY OR PRACTICE

however, we prefer a pneumatic drill because it allows for ADDRESS

a safer and more accurate delineation of the hemilami-
nectomy site (Figure 3). Hemorrhage is controlled with CITY STATE ZIP

bipolar cautery and bone wax. After the inner cortical BILL TO:
layer of bone is gently removed with the drill, a small NAME
nerve-root retractor or dental scaler is used to open the
periosteum and expose the spinal cord. Extruded disk COMPANY OR PRACTICE

material is often readily seen and is removed using small ADDRESS

forceps or a nerve-root retractor (Figure 4). The hemi-
laminectomy site may need to be extended cranially or CITY STATE ZIP

caudally to remove all visible disk material and adequately Detach and Mail to: Reprints Department
decompress the spinal cord; the presence of normal epidu- Veterinary Learning Systems
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A durotomy is performed to examine spinal cord in-

PNEUMATIC DRILL ■ NERVE-ROOT RETRACTOR

Small Animal/Exotics 20TH ANNIVERSARY
tegrity in dogs that have lost
deep pain sensation.2,3 The
dura is elevated with small
forceps or a hooked hypo-
dermic needle and then in-
cised with a No. 11 or 12
scalpel blade along the length
of the hemilaminectomy site
(Figure 5). Oozing of a “paste-
like” substance from the duro-
tomy site indicates that mye-
lomalacia is present and the
prognosis for neurologic re-
covery is poor to grave de- Figure 5—A durotomy is performed over the length of the form pediculectomy because
pending on the extent of hemilaminectomy site using a scalpel blade to evaluate the in- the removal of the articular
myelomalacia.19 tegrity of the spinal cord in a dog with no deep pain sensation. facet as performed in hemi-
Placement of a free fat graft
over the hemilaminectomy
site before closure of the surgical wound has been advo-
cated to prevent perineural fibrosis and dural adhe-
sion.2,19,20 These complications of the healing process may
cause spinal cord compression and nerve-root attenuation
and complicate surgical reexploration.29 Clinical signs
(e.g., deteriorating neurologic function) attributed to the
healing of dorsal laminectomy sites are reported but are
rare when a hemilaminectomy is performed.29 In a study
comparing free and pedicle fat grafts in normal dogs,
both caused significant spinal cord compression and neu-
rologic deficits in more than half of the dogs treated.29 In
addition, there was no clinical advantage to using a pedi-
cle fat graft.29 We currently do not place a fat graft follow-
ing hemilaminectomy. To avoid wound complications
(the most common postoperative problem in dogs under-
going spinal surgery30), the thoracolumbar fascia and sub-
cutaneous tissues are closed thoroughly to eliminate dead
space.
Pediculectomy
Pediculectomy is the removal of the lateral bony wall
of the spinal canal between the vertebral body and the
31
articular processes. The terms lateral spinal decompres-
sive technique and minihemilaminectomy have also been
used to describe this surgical procedure.32–36 This tech-
nique is reportedly less destabilizing to and minimizes
manipulation of the spinal cord compared with hemi-
laminectomy but still provides spinal cord decompres-
sion and allows removal of extruded disk material.31–33,36
The surgical approach is made either from a lateral or a
modified dorsolateral approach.31–36 Bone is removed in
the region of the pedicle and accessory process ventral to
the articular facet of the affected disk space. A chalazion
spoon or amalgam spatula is used to remove disk materi-
al from the ventral aspect of the spinal cord.
DUROTOMY ■ FAT GRAFTS ■ LAMINECTOMY MEMBRANE
Compendium November 1999
Several reports of pedicu-
lectomy indicate that suc-
cessful return of neurologic
function in nonambulatory
dogs ranges from 75% to
100%.31,32,34–36 Other report-
ed advantages of pediculec-
tomy include decreased sur-
gical time (compared with
hemilaminectomy), avoid-
ance of the spinal nerve, and
minimal hemorrhage. 31,35
We currently do not per-
laminectomy has not been
clinically shown to destabi-
lize the spinal column and greater spinal cord decom-
pression is provided by hemilaminectomy.
Dorsal Laminectomy
Dorsal laminectomy (removal of the dorsal and dor-
solateral aspects of the vertebral arch) was the original
technique described for surgical treatment of thora-
columbar disk extrusion in dogs.37,38 The technique has
been modified in several reports by retaining portions
of the articular processes and the outer bone of the dor-
solateral lamina to eliminate such postoperative com-
plications as spinal cord compression due to constric-
tive fibrosis.39,40 Excellent spinal cord decompression,
removal of laterally displaced extruded disk material,
and durotomy can be performed using the modified
dorsal laminectomy. The technique does not provide
access to the ventral aspect of the spinal cord, however,
and removal of ventrally extruded disk material requires
manipulation of the spinal cord.2,22,24 Although a more
invasive surgical approach is required and a pneumatic
bone drill is mandatory, excellent decompression of the
spinal cord is achieved.2,24
Development of a laminectomy membrane causing
spinal cord compression following dorsal laminectomy
is described29; the placement of a fat graft has been ad-
vocated to reduce the incidence of this postoperative
complication.2,19,20 However, as previously discussed,
the placement of a fat graft may itself cause spinal cord
compression. Care must be taken to use a fat graft that
is no more than 3 mm thick and just large enough to
cover the laminectomy site.29 We tend to use dorsal
laminectomy for thoracolumbar disk extrusion only
when extensive spinal cord swelling is present and
myelography is unable to demonstrate lateralization of
the disk material. If spinal cord swelling is obvious at
Compendium November 1999 Small Animal/Exotics

the time of hemilaminectomy, the bony opening may

Share Your
be modified by removing the dorsal lamina to the level
of the opposite articular facet, thereby providing greater
Knowledge
spinal cord decompression.
We invite you to impart your clinical knowledge
Fenestration
by discussing your interesting cases, unusual
Perhaps the most controversial subject regarding
treatment of thoracolumbar disk extrusion is the use of presentations, or procedures for clinical solutions
disk fenestration. This technique has been recommend-
ed for treating dogs with disk extrusion and prophylac- for the following features:
tically to reduce the recurrence of extrusion at another E
IC CHALLENG

disk space.41–43 Fenestration can be performed via dor- DIAGNOST

rn on a Rat Po
isoning
Unexpected Tu
solateral, lateral, or ventral approaches.41–43 A rectangu- DIAGNOSTIC CHALLENGE By Marjory
Brooks, D.V.M
and Jeff Jacobs
on, D.V.M
.
., Dipl. A.C.V.
I.M.,

lar window is incised in the annulus fibrosis to enable

was exam-
d male Beagle,
r-old, neutere Con-
ugsy, a four-yea n of the rat poison
M ined within one
hour of ingestio l placement

A detailed account of a clini- trac® . Initial

of apomorphine
treatment consiste
and 30 mL of
d of subconjunctiva
oral hydrogen
peroxide to induce
, Mugsy vomited
a large

introduction of a dental tartar scraper, hypodermic nee-

this therapy
response to the rat bait.
Addi-
vomiting. In identified as
of green-b lue material d charcoa l by gas-
amount mL of activate
nt included 200 neously (SC).
tional treatme 2.5 mg/kg subcuta

cal dilemma takes readers from

and vitamin K1 supply of
tric intubation with a 10-day
ed to his owners
Mugsy was discharg

dle, or spatula. The instrument is then used to remove

hours orally.
mg every 24
vitamin K1 50

SEALING ry
NS BY LES
blood chemist
nation. All
ILLUSTRATIO

for PT determi PT at recheck

specific patient presentation

hours later limits. The
d for 48 hours within normal because cor-
values were ted finding

all of the nucleus pulposus. Fenestration has been

tion was schedule confirm , an unexpec K deficiency
A recheck examina vitamin K regimen to was 65.9 seconds al PT due to vitamin
ion of the owners report- initiating an
after complet Although his rection of abnorm 48 hours of
coagulopathy. and Mugsy within 24 to
resolution of K1 as directed should resolve K1. of
had given vitamin re to rat poison, clotting appropriate
dose of vitamin persistent prolongation
ed that they y the cause of
nity for reexposu was markedl To determine al vitamin
had no opportu time (PT) assay whether addition for more
prothrombin finding in the PT and
time in the : 9.5-12.5). This clotting time was sent

shown to narrow the disk spaces,44–46 and, histologically, through the steps leading to the
(normal pre- a sample
57 seconds that his early was needed, was drawn
prolonged at it appeared K therapy . Whole blood
ted because prevented ion analyses 3.8 percent
was unexpec ive vomiting had detailed coagulat anticoagulant (one part
product Contrac, how- citrate ged, and the
sentation with of rodenticide. directly into and centrifu
a toxic dose poison. parts blood) to a vet-
absorption of iolone, a long-acting K citrate to nine shipped on cold packs
s bromad vitamin 1 plasma was Coagulation
ever, contain at the same supernatant (Comparative
therefore resumed e laboratory University,
Treatment was erinary referenc ory, Cornell

fibrocartilage fills the void in the disk space by 16

two weeks. completion tic Laborat
dosage for another recheck, 48 hours after Section, Diagnos

ultimate diagnosis in 1000-1500

ed and d
At Mugsy’s next was still markedly prolong York). d of activate
Ithaca, New ion panel consiste
, the PT sample. A thrombin
of vitamin K1 from the previous The initial coagulattime (aPTT), PT, and g
unchanged vita-
essentially submitte d, parenteral partial thrombo
plastin
aPTT and
TCT screenin
ry profile was were (TCT). The
owners clotting time
blood chemist SC, and the
given 50 mg and recheck
48
min K1 was vitamin K1

weeks after the procedure.44 In addition, a postoperative

oral August 2000
resume
instructed to
ed
Peer Review

words. 76 Veterinary
Forum

increase in vertebral spondylosis has been associated THERAPEUTIC

with disk fenestration, indicating that vertebral column

CHALLENGE

instability may occur.45 THERAPEUTIC CHALLENGE

KAREN WILSON
Intussuscep
Several studies have evaluated disk fenestration as a While the course of therapy is of- tio
In a Yearlin n
g
method of treating thoracolumbar disk extrusion in ten clear-cut, some patients pre-
By Linnea Lentz,
D.V.M.

dogs.41–43 Lateral fenestration of disks resulted in suc- B eau, a 15-mont

when the owners
h-old colt, had been
colicky for about

sent true challenges to medical

called the referring four hours
veterinarian. The and no other
described as mild, colic was
abnormali-
and Beau was treated ties. An initial
IV injection
nixine) administe with 10 cc Banamin ® of xylazine appeared
red intravenously e (flu-

cessful neurologic recovery in 87% and 95%, respec-

(IV), 10 cc of control the pain to
approximately 1 dipyrone IV, and for only 20
⁄2 gallon of mineral minutes before
tube. Within the oil administered a second
hour, Beau was via nasogastric dose was necessary.
University of Minneso again colicky and Rectal
was referred to the palpation revealed

skills. In 1000-1500 words, these

ta. many
distended loops
of small
testine. After placemen in-

tively, of dogs in two retrospective studies.42,43 Time to

Initial Treatme t of
nt on Referra a nasogastric
Clinical signs l reflux were obtained. tube, 6-7 L of
on presentation Abdominocen-
included profuse tesis results were
sweating, numerous normal.
attempts to lie Because of the
down, and a distended severity of the
abdomen. Physical colic, the small
examination re- intestinal distention

cases describe the steps that

vealed a pulse and nasogastr ,
of 84 beats per ic reflux, we
minute,

neurologic recovery ranged from 2.6 to 12 weeks in one

decreased gastrointe mended explorato recom-
stinal motility ry laparotomy
all four quadrants in diagnose the cause to
, slightly toxic of the colt’s colic.
cous membran mu- The owners quickly
es, a capillary agreed, and pre-
time of 2.5 seconds refill operative antibiotic
(normal: 1-2),
and a normal
temperature. potassium penicillin s, including
work revealed Blood 22,000 units/kg
a packed cell IV and Gentocin
volume (gentamicin) 6.6

of these studies.43 This is, however, comparable to re- eventually lead to case resolu-
of 48 percent mg/kg IV, were
(normal: 32-48), administered before
protein of 7.2 g/dL total preparing the colt
(normal: 5.7-7.9), for surgery. During
surgery, a jejunocec
August 2000 al intussuscep-➔
Peer Reviewed
Veterinary Forum
73

covery times seen with medical management alone.3 Re- tion.

currence rates were not reported in either study.42,43 In MONTH
CASE OF THE

another study, ventral fenestration in 160 patients re- is

Canine Hemipares , D.V.M.

CASE OF THE MONTH

By Donivan Hudgins

portedly resulted in a recurrence rate of 24% in dogs

with mild neurologic signs (i.e., grades 1 and 2).41 Some case presentations are so J asmine, a four-year-
kg, spayed Golden
old, 29-
Retriev-
to the clinic
activity levels
and vaccinations
for distemper,
had been normal,
were current
hepatitis, lep-
nza, par-
er, was presented tosporosis, parainflue

It is generally agreed that fenestration does not re-

of lameness. irus, Lyme
for sudden onset vovirus, coronoav

confounding that both diagnosis

found a stray
The owner had sus- disease, and rabies.
and given Solu
goat in the backyard The patient was
goat may have ® (prednisolone)
pected that the Delta Cortef
On presenta- usly (IV) and
butted Jasmine. ry 100 mg intraveno 2.5 cc in-
was ambulato
tion, the dog amoxicillin injectable

move the extruded disk from the vertebral canal, but

uncoordi nated, The owner was
but obviously tramuscularly.
n revealed the provide cage rest
and observatio instructed to

and therapy are perplexing. Often,

deficit was in and return
primary walking over the weekend
dog’s condition
the right rear leg. ion re- Monday if the
Physical examinat .
had not improved
re of 101.6˚F, week, Jas-
vealed a temperatu The following

the procedure is thought to remove further degenera-

es, capil- to improve, and
pink mucous membran (normal:
CORBIS

mine appeared
of 1 sec she did have
lary refill time whatever problems
heart and Over the next
1-2 sec), normal seemed subtle.

a patient may return again and

sign of pain. The weeks, her prob-
lungs, and no two to three
did knuckle over, but not as pro-
right rear foot proprio- lems recurred the
indicating decreased indicat- before, and
nounced as

tive nucleus pulposus from the disk, thereby preventing

pinch that the dog
ception, but toe owner reported
were intact. to her deficits.
ed sensory nerves seemed to adjust
of the affected next few weeks,
Temperatures Then, over the
no different of coördination
foot and leg were Jasmine’s lack

again with continuously changing

other three feet
than that of the seemed to worsen.
and flexion 21, Jasmine
and legs. Extension On October

continued extrusion.2,3 Fenestration does not provide

hip joints were for examina-
of the stifle and reflex on was re-presented
on a leash
normal, but patellar tion. When followed appeared
exaggerated,
the right was in the lawn, Jasmine
upper motor ated, with
which suggested to be very uncoördin
Appetite and
neuron disease.

any decompression of the spinal cord, and whether this signs. Word count: 1000-2000. 66 Veterinary Forum
Peer Reviewed
August 2000

technique is superior to confinement therapy for dogs

with grades 1 and 2 clinical signs has not been ade-
quately established. We strongly recommend a decom-
pressive technique as the primary surgical procedure in
dogs with thoracolumbar disk extrusion. SEND YOUR ARTICLES TO:
Prophylactic fenestration of adjacent disk spaces at Editor, Veterinary Forum
the time of decompressive surgery has been recom- 275 Phillips Blvd.
mended to prevent recurrence of disk extrusion.19,20
This recommendation has been frequently questioned Trenton, NJ 08618
because fenestration itself is associated with recurrence Fax: (609) 882-6357
of clinical signs and it appears unlikely that all disk ma- E-mail: lmiller.vls@medimedia.com
terial is removed during either manual or power-assist-

NUCLEUS PULPOSUS ■ RECOVERY TIME

Small Animal/Exotics 20TH ANNIVERSARY
ed fenestration. 47 Recur-
rence of disk extrusion that
requires surgery at an adja-
cent disk space is reportedly
rare; therefore, prophylactic
fenestration is probably un-
necessary.3 Additional con-
trolled studies are necessary
to better evaluate the effect
of prophylactic and thera-
peutic disk fenestration in
the treatment of thoraco-
lumbar disk extrusion to re-
solve the confusion sur- Figure 6—The use of walking aids, such as the homemade
rounding this technique. cart shown, can help in the management of long-term re-
cumbency in dogs with thoracolumbar disk extrusion.
Postoperative
Management
Quality postoperative management is a critical deter-
minant in the successful recovery of dogs following
thoracolumbar spinal surgery. This topic has been re-
cently reviewed.6,7 In the initial perioperative period,
both preemptive and postoperative pain relief can im-
prove recovery and avoid the psychologic impact of
pain (e.g., anxiety, sleep deprivation).6 Opioids are the
drugs of choice perioperatively, and NSAIDs can be
used 48 to 72 hours after surgery if pain persists.6 Early
physical therapy (cold- and hot-packing the surgical
wound) can also provide some analgesic effects and de-
crease the amount of local inflammation.6
Bladder management begins immediately after
surgery. Regular manual bladder expression should be
performed until the patient has regained the ability to
urinate voluntarily. Intermittent or indwelling catheteri-
zation may be necessary in patients that are difficult to
express manually.6 More long-term management of uri-
nation may require the use of drugs that reduce hyper-
tonicity of the urethral sphincter (e.g., phenoxybenza-
mine, 5 to 15 mg once daily) or enhance contractility of
the detrusor muscle (e.g., bethanechol, 2.5 to 25 mg
three times daily).6 Care must be taken to monitor pa-
tients for the development of urinary tract infections.
Wound and GI complications are best averted by care-
ful attention to aseptic surgical technique and avoidance
of corticosteroids or NSAIDs associated with GI hemor-
rhage and ulceration (e.g., dexamethasone).7 Manage-
ment of long-term recumbency requires further physical
therapy (e.g., massage, passive and active exercise), com-
fortable bedding, avoidance of decubital ulcers, and the
use of walking aids (e.g., slings, carts [Figure 6]).6,7
OTHER TREATMENT OPTIONS
Chemonucleolysis (dissolution of the nucleus pulpo-
PAIN RELIEF ■ BLADDER MANAGEMENT ■ CHEMONUCLEOLYSIS
Compendium November 1999
sus by injection of a chemi-
cal compound into the
IVD) has been used success-
fully to treat disk disease in
humans.48 Collagenase and
chymopapain, the chemo-
nucleolytic agents most
commonly used, can be ad-
ministered percutaneously
by fluoroscopic guidance
or by injection during sur-
gery. 48 Two experimental
studies evaluating the use of
collagenase in dogs reported
significant disk-space nar-
rowing and histologic disso-
lution of the nucleus pulpo-
sus. 49,50 However, clinical
studies evaluating the efficacy of chemonucleolysis in
dogs with acute thoracolumbar disk extrusion are nec-
essary before this technique can be recommended.
Thermal ablation of the IVD using a holmium:yttri-
um-aluminum-garnet laser under fluoroscopic guidance
reportedly improved signs of recurrent back pain in 33
dogs.51 This technique shows merit, but the special
equipment required probably precludes it from wide-
spread use. Acupuncture has been used successfully in
treating thoracolumbar disk disease in dogs.52,53 Better re-
sults were obtained in dogs with back pain alone (grade
1) or mild paresis (grade 2), indicating that the primary
benefit of acupuncture may be its analgesic effects.52,53
Acupuncture, if available, may be considered in dogs
with grades 1 and 2 neurologic signs in combination
with the previously mentioned medical management.
SUMMARY
The choice of medical or surgical management in the
treatment of thoracolumbar disk extrusion should be
determined on an individual case basis; however, non-
ambulatory patients warrant diagnostic myelography
and decompressive surgery. Strict confinement therapy
of at least 3 weeks’ duration should be implemented in
patients that are not considered surgical candidates.
Methylprednisolone is indicated in patients that have
had neurologic signs for less than 8 hours. The choice
of surgical technique is probably best left to surgeon
preference, provided that the spinal cord is adequately
decompressed and the extruded disk material is re-
moved. Postoperative management is a critical factor in
assisting neurologic recovery of affected animals.
REFERENCES
1. Seim III HB: Conditions of the thoracolumbar spine. Semin
Compendium November 1999 20TH ANNIVERSARY
Vet Med Surg 11(4):235–253, 1996.
2. Toombs JP, Bauer MS: Intervertebral disc disease, in Slatter
D (ed): Textbook of Small Animal Surgery, ed 2. Philadelphia,
WB Saunders Co, 1993, pp 1070–1087.
3. Seim III HB: Surgery of the thoracolumbar spine, in Fossum
TW (ed): Small Animal Surgery. St. Louis, Mosby, 1997, pp
1101–1118.
4. Braund KG: Intervertebral disk disease, in Bojrab MJ (ed):
Disease Mechanisms in Small Animal Surgery, ed 2. Philadel-
phia, WB Saunders Co, 1993, pp 960–970.
5. Simpson ST: Intervertebral disc disease. Vet Clin North Am
Small Anim Pract 22(4):889–897, 1992.
6. Jerram RM, Hart RC, Schulz KS: Postoperative manage-
ment of the canine spinal surgery patient—Part I. Compend
Contin Educ Pract Vet 19(2):147–162, 1997.
7. Hart RC, Jerram RM, Schulz KS: Postoperative manage-
ment of the canine spinal surgery patient—Part II. Compend
Contin Educ Pract Vet 19(10):1133–1147, 1997.
8. Meintjes E, Hosgood G, Daniloff J: Pharmaceutic treatment
of acute spinal cord trauma. Compend Contin Educ Pract Vet
18(6):625–636, 1996.
9. Toombs JP, Collins LG, Graves GM, et al: Colonic perfora-
tion in corticosteroid treated dogs. JAVMA 188(2):145–150,
1986.
10. Bellah JR: Colonic perforation after corticosteroid and surgi-
cal treatment of intervertebral disc disease in a dog. JAVMA
183(9):1002–1003, 1983.
11. Hoerlein BF, Redding RW, Hoff EJ, et al: Evaluation of
dexamethasone, DMSO, mannitol, and solcoseryl in acute
spinal cord trauma. JAAHA 19:216–226, 1983.
12. Longshore RC, O’Brien DP: Medical care of the neurosurgi-
cal patient. Semin Vet Med Surg 11(4):208–217, 1996.
13. Kraus KH: The pathophysiology of spinal cord injury and
its clinical implications. Semin Vet Med Surg 11(4):201–207,
1996.
14. Bracken MB, Shepard MJ, Collins WF, et al: A randomized,
controlled trial of methylprednisolone or naloxone in the
treatment of acute spinal cord injury. N Engl J Med 322
(20):1405–1411, 1990.
15. Bracken MB, Shepard MJ, Collins WF, et al: Methylpred-
nisolone or naloxone treatment after acute spinal cord in-
jury: 1-year follow-up data. J Neurosurg 76(1):23–31, 1992.
16. Hoerlein BF, Redding RW, Hoff EJ, et al: Evaluation of
naloxone, crocetin, thyrotropin releasing hormone, methyl-
prednisolone, partial myelotomy, and hemilaminectomy in
the treatment of acute spinal cord trauma. JAAHA 21:
67–77, 1985.
17. Coates JR, Sorjonen DC, Simpson ST, et al: Clinicopatho-
logic effects of a 21-aminosteroid compound (U74389G)
and high-dose methylprednisolone on spinal cord function
after simulated spinal cord trauma. Vet Surg 24:128–139,
1995.
18. Hanson SM, Bostwick DR, Twedt DC, et al: Clinical evalu-
ation of cimetidine, sucralfate, and misoprostol for preven-
tion of gastrointestinal tract bleeding in dogs undergoing
spinal surgery. Am J Vet Res 58(11):1320–1323, 1997.
19. Harari J, Marks SL: Surgical treatments for intervertebral
disc disease. Vet Clin North Am Small Anim Pract 22(4):
899–915, 1992.
20. Shores A: Intervertebral disk syndrome in the dog. Part III.
Thoracolumbar disk surgery. Compend Contin Educ Pract
Vet 4(1):24–31, 1982.
21. Brown NO, Helphrey ML, Prata RG: Thoracolumbar disk
disease in the dog: A retrospective analysis of 187 cases. JAAHA
13:665–672, 1977.
???? ■ ???? ■ ???? ■ ????
Small Animal/Exotics
22. Muir P, Johnson KA, Manley PA, et al: Comparison of
hemilaminectomy and dorsal laminectomy for thoracolum-
bar intervertebral disc extrusion in dachshunds. J Small
Anim Pract 36:360–367, 1995.
23. Anderson SM, Lippincott CL, Gill PJ: Hemilaminectomy in
dogs without deep pain perception. Calif Vet 45(10):24–28,
1991.
24. Gage ED, Hoerlein BF: Hemilaminectomy and dorsal
laminectomy for relieving compressions of the spinal cord in
the dog. JAVMA 152(4):351–359, 1968.
25. Schulman A, Lippincott CL: Dorsolateral hemilaminectomy
in the treatment of thoracolumbar intervertebral disk disease
in dogs. Compend Contin Educ Pract Vet 9(3):305–310,
1987.
26. Schulz KS, Walker MA, Moon ML, et al: Correlation of
clinical, radiographic, and surgical localization of interverte-
bral disc extrusion in small-breed dogs: A prospective study
of 50 cases. Vet Surg 27:105–111, 1998.
27. Olby NJ, Dyce J, Houlton JEF: Correlation of plain radio-
graphic and lumbar myelographic findings with surgical
findings in thoracolumbar disc disease. J Small Anim Pract
35:345–350, 1994.
28. Kirberger RM, Roos CJ, Lubbe AM: The radiological diag-
nosis of thoracolumbar disc disease in the dachshund. Vet
Radiol Ultrasound 33(5):255–261, 1992.
29. Trevor PB, Martin RA, Saunders GK, et al: Healing charac-
teristics of free and pedicle fat grafts after dorsal laminecto-
my and durotomy in dogs. Vet Surg 20(5):282–290, 1991.
30. Hosgood G: Wound complications following thoracolumbar
laminectomy in the dog: A retrospective study of 264 proce-
dures. JAAHA 28:47–52, 1992.
31. Lubbe AM, Kirberger RM, Verstraete FJM: Pediculectomy
for thoracolumbar spinal decompression in the dachshund.
JAAHA 30:233–238, 1994.
32. Bitetto WV, Thacher C: A modified lateral decompressive
technique for treatment of canine intervertebral disk disease.
JAAHA 23:409–413, 1987.
33. Braund KG, Taylor TKF, Ghosh P, et al: Lateral spinal de-
compression in the dog. J Small Anim Pract 17:583–592,
1976.
34. Black AP: Lateral spinal decompression in the dog: A review
of 39 cases. J Small Anim Pract 29:581–588, 1988.
35. McCartney W: Partial pediculectomy for the treatment of
thoracolumbar disc disease. Vet Comp Orthop Trauma 10:
117–121, 1997.
36. Yovich JC, Read RA, Eger CE: Modified lateral spinal de-
compression in 61 dogs with thoracolumbar disc protrusion.
J Small Anim Pract 35:351–356, 1994.
37. Funkquist B, Schantz B: Influence of extensive laminectomy
on the shape of the spinal canal. Acta Orthop Scand 56:7–50,
1962.
38. Funkquist B: Decompressive laminectomy in thoracolumbar
disc protrusion with paraplegia in the dog. J Small Anim
Pract 11:445–451, 1970.
39. Trotter EJ, Brasmer TH, deLahunta A: Modified deep dor-
sal laminectomy in the dog. Cornell Vet 65:402–427, 1975.
40. Horne TR, Powers RD, Swaim SF: Dorsal laminectomy
techniques in the dog. JAVMA 171(8):742–749, 1977.
41. Knapp DW, Pope ER, Hewett JE, et al: A retrospective
study of thoracolumbar disk fenestration in dogs using a
ventral approach: 160 cases (1976–1986). JAAHA 26:543–
549, 1990.
42. Flo GL, Brinker WO: Lateral fenestration of thoracolumbar
discs. JAAHA 11:619–626, 1975.
Small Animal/Exotics 20TH ANNIVERSARY
43. Butterworth SJ, Denny HR: Follow-up study of 100 cases
with thoracolumbar disc protrusions treated by lateral fenes-
tration. J Small Anim Pract 32:443–447, 1991.
44. Wagner SD, Ferguson HR, Leipold H, et al: Radiographic
and histologic changes after thoracolumbar disc curettage.
Vet Surg 16(1):65–99, 1987.
45. Dallman MJ, Moon ML, Giovannitti-Jensen A: Comparison
of the width of the intervertebral disk space and radiographic
changes before and after intervertebral disk fenestration in
dogs. Am J Vet Res 52(1):140–145, 1991.
46. Shores A, Cechner PE, Cantwell HD, et al: Structural
changes in thoracolumbar disks following lateral fenestra-
tion. A study of the radiographic, histologic, and histochem-
ical changes in the chondrodystrophoid dog. Vet Surg 14
(2):117–123, 1985.
47. Holmberg DL, Palmer NC, Vanpelt D, et al: A comparison
of manual and power-assisted thoracolumbar disc fenestra-
tion in dogs. Vet Surg 19(5):323–327, 1990.
48. Fry TR, Johnson AL: Chemonucleolysis for treatment of in-
tervertebral disk disease. JAVMA 199(5):622–626, 1991.
49. Atilola MAO, Cockshutt JR, McLaughlin R, et al: Collage-
nase chemonucleolysis—A long term radiographic study in
normal dogs. Vet Radiol Ultrasound 34(5):321–324, 1993.
50. Miyabayashi T, Lord PF, Dubielzig RR, et al: Chemonucle-
olysis with collagenase. A radiographic and pathologic study.
Vet Surg 21(3):189–194, 1992.
Compendium November 1999
51. Dickey DT, Bartels KE, Henry GA, et al: Use of the holmi-
um yttrium aluminum garnet laser for percutaneous thora-
columbar intervertebral disk ablation in dogs. JAVMA 208
(8):1263–1267, 1996.
52. Still J: Analgesic effects of acupuncture in thoracolumbar
disc disease in dogs. J Small Anim Pract 30:298–301, 1980.
53. Janssens LA, De Prins EM: Treatment of thoracolumbar
disk disease in dogs by means of acupuncture: A comparison
of two techniques. JAAHA 25:169–174, 1989.
About the Authors
When this article was submitted for publication, Drs. Jer-
ram and Dewey were both affiliated with the Department
of Small Animal Medicine and Surgery, College of Veteri-
nary Medicine, Texas A&M University, College Station,
Texas. Dr. Dewey remains at Texas A&M University, but
Dr. Jerram is now affiliated with The Pet Practice, Hamil-
ton, New Zealand. Dr. Dewey is a Diplomate of the Amer-
ican College of Veterinary Surgeons and the American
College of Veterinary Internal Medicine (Neurology).