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Indicators
for surgery
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Dr. Isaacs' rescued
mini Dachshund, Ginger. |
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Are
there certain IVDD or other conditions of
the spine that make a dog not a surgical candidate?
There is a balance between the risk associated
with surgery versus the benefit gained if
all goes well. With any surgery there is the
potential risk that the patient may be permanently
worse after the procedure. The risk is greater
with intervertebral disk disease that is severe,
at multiple sites, and chronic compared with
mild, singe site, acute. Myelomalacia
is situation where the benefit of surgery
is highly questionable and a dog is not a
good surgical candidate.
With
what symptoms is a dog not ready to be considered
as a surgical candidate? The decision
to pursue surgery depends on multiple variables.
Any dog can be managed medically. However,
typically the decision to treat medically
versus surgically is dependent upon the risk:benefit
ratio. If the same outcome can be obtained
medically versus surgically then it is wise
to treat medically. On the other hand, if
there is a better outcome associated with
surgery versus medical management, surgery
warrants consideration. Again, this does not
mean that medical management can not be pursued,
it just may not be ideal. In general, situations
where surgery warrants strong consideration
include dogs that have lost motor function
(plegic) and have questionable to no deep
pain sensation.
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If following strict conservative treatment, what
are the indicators for considering surgery?
Dogs that do not have deep pain sensation or deteriorate
to the point where they lose deep pain sensation
ideally benefit immediately from surgery versus
medical management. Also, if the clinical signs
deteriorate in spite of strict medical management
or there is no improvement after 2-4 weeks, surgery
warrants consideration.
Are there any indicators that would require
emergency IVDD surgery (e.g. Schiff-Sherrington
symptoms)? Schiff-Scherrington syndrome
(poor/flaccid muscle tone to pelvic limbs and increased
extensor tone to thoracic limbs) is indicative of
an acute spinal cord injury. However, deep pain
sensation can remain intact with dogs with Schiff-Scherrington
syndrome. Therefore, dogs that do not have deep
pain sensation or deteriorate to the point where
they lose deep pain sensation ideally benefit immediately
from surgery versus medical management.
If surgery is not a financial option for
the owner, what treatment options should the owner
follow?
Steroid
blasting vs. anti-inflammatory dose vs. NSAID?
Currently there is a multi-center study
investigating the potential benefit of “steroid
blasting.” There have not been any clinical
studies demonstrating a statistically significant
clinical benefit from “steroid blasting”.
Some veterinarians will use anti-inflammatory
doses of steroids, but this too has not been
documented in the scientific literature to be
of benefit. The use of NSAID’s is also
of questionable benefit.
How long is too long
to be on a Corticosteroid to get swelling and
pain down? It really
depends on the dose. At the higher end of the
dose there is a risk of developing GI tract
side effects. Also, the use of steroids in dogs
receiving or having recently received NSAID’s
increases the risk for GI tract side effects.
How long to try rest
and meds?
Typically, after 2-4 weeks the chance
of seeing benefit from medical management starts
to decline. However, as long as the dog can
be managed appropriately (pain management and
urinary bladder) it is worth seeing where things
are at in 2 months.
Corticosteroids
vs. NSAIDs? Personally, I will use anti-inflammatory
doses of steroids in cases where surgery is
warranted but not financially feasible. The
dose and course of steroids vary depending on
the response. Some dogs respond well and I am
able to taper completely off of the steroids.
The goal is to find the lowest effective dose
required to help with the neurological status.
Also, just as important as steroids, if not
more, is strict activity restriction! |
Why is euthanasia not an option for disc disease?
Euthanasia is a difficult topic
to discuss. Ultimately, the decision comes down
to quality of life. Most people would agree that
euthanasia is something to consider when a companion
animal has a poor quality of life. The difficulty
arises because different people have different perceptions
of when a poor quality of life is reached. For dogs
with intervertebral disk disease there is the initial
perception that if a dog can not walk or voluntarily
urinate it has a poor quality of life. However,
for an owner of a small breed dog, if armed with
the knowledge of how to care for their dog there
is the potential for an excellent quality of life.
Euthanasia should never be considered before all
other avenues have been pursued.
Why
is euthanasia necessary with Myelomalacia?
Two situations where euthanasia is strongly
advised are intractable pain that is not responsive
to any type of treatment and ascending myelomalacia
(if the myelomalacia ascends respiratory function
is compromised). Euthanasia (although a hard
decision) is in the best interest of the dog.
Do you believe that
a dog’s propensity to develop or not
develop myelomalacia is impacted on whether
dog undergoes surgery? There is
a good chance that surgery helps decrease
the likelihood of myelomalacia. However, dogs
that have surgery may still go on to develop
myelomalacia. I have appreciated a greater
number of dogs presenting with myelomalacia
with a history of aspirin therapy. Therefore,
it is important to not use aspirin for the
treatment of pain in dogs predisposed to having
intervertebral disk disease. |
How
critical is it to choose between a general DVM vet
that does surgery vs. a board certified veterinarian?
Board
certification is a sign that certain training requirements
have been met. There is a greater degree of consistency
with a board-certified veterinarian versus general
DVM’s in training and expertise.
Neuro
vs. ortho? The two categories
of board-certified specialists that typically
perform neurosurgical procedures are either
board-certified neurologists (Diplomate ACVIM
(Neurology)) or board-certified surgeons (Diplomate
ACVS). Board-certification is achieved though
a three year residency training program that
was preceded by a one year rotating internship
after graduation from a veterinary college.
There is a degree of variability to every
residency training program for both neurologists
and surgeons. Therefore, it all depends on
the training program as to the comfort level
the specialist has performing neurosurgical
procedures. In general, the more neurosurgical
procedures a specialist performs the greater
the competency. Typically, neurologists that
perform neurosurgical procedures have a case
load of only neurosurgical procedures.
University veterinary
hospital vs. private board certified hospital?
There are board-certified specialists at both
universities and private practices. Typically,
it is good to get the opinion of your general
veterinarian about the differences in service
offered by the two in your area. |
Is
there a good expectation that nerve root signature
pain could resolve with conservative treatment?
Pain due to nerve root compression can
respond to medical treatment. However, if the degree
of compression is severe enough and there is not
a response to medical management surgery may warrant
consideration.
In
a non-technical manner what generally does the surgery
seek to correct regarding the herniated disc, the
spinal cord and possibly adjacent discs? The
primary goal of surgery is to decompress the spinal
cord (removal of herniated disk material within
the spinal canal compressing the spinal cord). Not
all of the disk material is removed with surgery
- only the disk material within the spinal canal
that is compressing the spinal cord is removed.
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Are you a proponent
of fenestration – pros and cons?
Fenestration is the removal of disk material
from the intervertebral disk space (where
it normally is and should be). Not all the
disk material is removed with fenestration.
The concept of fenestration is to remove disk
material that may herniate at a future date.
In the veterinary literature it is not straightforward
if fenestration is beneficial. I do not fenestrate
in all cases, but do feel there is benefit
in certain situations. |
When an owner first visits his dog post op, what
might he expect to see? An area around
the incision is shaved to help prevent infection
of the surgery site. In the center of the shaved
area will be the incision. Typically, the incision
will have skin staples or suture visible to help
hold the skin together while it is healing. Immediately
after surgery and for a couple days pain medications
(narcotics) are used to help keep the dog comfortable.
The narcotics can cause the dog to be sedate, have
a suppressed appetite, and slow down defecation.
The dog may also have an intravenous (IV) catheter
to help with the administration of drugs and make
sure the dog gets enough fluids to keep hydrated.
Sometimes, the dog’s neurological status deteriorates
temporarily due to the irritation associated with
the surgical procedure. This is not anything to
be overly concerned about until 2-4 weeks post-operatively.
If the dog is not able to voluntarily urinate there
may be an indwelling urinary catheter to help keep
the urinary bladder decompressed.
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Are owner visits recommended,
beneficial? The goal of performing
the surgery is to allow the spinal cord to heal.
If a dog gets too active immediately after surgery
there is the potential for the spinal cord to
get re-injured. Therefore, even though is it
difficult for an owner not to visit, due to
the chance of undoing all the benefit gained
from surgery I will typically not recommend
visits for at least the first couple days. I
never prohibit an owner from visiting, I just
advise of the potential risk if the dog gets
too excited and let the owner decide. In some
situations I will ask an owner to visit if the
dog is not interested in eating after weaning
off of the narcotics. |
What
caveats are there to surgery: anesthesia risks,
surgical risks, guarantee of outcome? Unfortunately,
there is no guarantee with any surgery. Therefore,
I will recommend surgery only if the risk associated
with surgery is less than the risk of continuing
with medical management. There is always a small
risk the dog may not make it through anesthesia/surgery,
is permanently worse, or never improves. Because
of this, an owner should never be told they have
to do surgery. It is important to not be rushed
into making the decision and have the opportunity
to ask as many questions as needed. Surgery needs
to be a decision an owner enters into recognizing
the risk, but also recognizes the benefit. This
way if something unforeseen occurs an owner can
be comforted and at peace with the fact that surgery
was the right decision and they did all they could
for their dog.
Medications
Indicators
for Surgery
| Medications | Crate
Rest & PT | Discharge
Day
What have you found to generally be effective
medications/combinations for pain management?
Every patient is unique. Some dogs respond well
to drugs that other dogs do not respond well to.
Is Diazepam considered an effective muscle
relaxant? In some dogs diazepam
alone is enough. However, in other cases
additional medications may be required.
Is there a danger
with combining Methocarbamol and Tramadol
as we have seen some vets not wanting to
prescribe them together while others frequently
do? I
do not typically use the two together due
to a greater chance for too much sedation.
However, if appropriate doses are utilized
then concurrent therapy is not contraindicated.
Is there a danger
in combining Tramadol and Gabapentin?
No, this combination is one that I utilize
more than Methocarbamol/Tramadol.
How
long should it take to see pain getting
under control after medicated?
Medically managing pain associated with
intervertebral disk disease is dependent
on the amount of disk material that herniated
and the location of the herniated disk material.
Therefore, it is difficult to have a standard
answer.
At what point
should the surgeon be advised pain is not
under control to see if pain meds can be
tweaked for dose, frequency or mix of drugs?
At any point, if an owner is
concerned that their dog is painful they
should notify their veterinarian.
Does pain hinder
the healing process? Yes, adequate
pain management is important to the healing
process.
What
is the current thinking about pain being
used as a means of keeping the dog from
moving too much? It is not appropriate
to withhold pain medication to keep a dog
inactive.
At what point
when a disc problem appears is it prudent
to begin use of stomach medications such
as Pepcid AC or Sucralfate?
GI tract protectants (Pepcid, Sucralfate,
Omeprazole, etc.) should be used concurrently
whenever steroids are prescribed. Also,
aspirin and other non-steroidal anti-inflammatories
should not be used in conjunction with steroids.
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Crate
Rest and PT Indicators
for Surgery
| Medications | Crate
Rest & PT | Discharge
Day
How long does it take the surgical procedures
on bone to knit back together? In general,
bone can take up to 3-4 months to heal.
How long does
it take surgery on muscle tissues to mend?
The soft tissue dissection associated
with surgery typically takes 4-6 weeks
to mend.
How
long can it take for nerves to regenerate?
Nerve
regeneration depends upon the degree of
injury to the nerves. If the injury is
severe enough the damage may be irreversible.
On the other hand, if the injury is not
too severe the nerves may not be permanently
injured. Typically, at 6 months most of
the healing has plateaued, but some cases
take up to several years.
If post op there
is lack of deep pain sensation, what is
the longest period of time you have known
dogs having return of neuro functions?
I have seen dogs take up to 5-6 months
to regain deep pain sensation and know
of other cases that have taken longer.
Do you and other
specialists follow up a year after or
longer to accumulate data?
I typically do not follow up at the 1
year time frame (primarily out of convenience
to the owner). However, it would be nice
to have more consistent follow-up. |
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What effect might surgical swelling have
on neuro functions? Post-operatively
a dog can be temporarily worse. This is due to
the inflammation and irritation associated with
surgery.
Typically how
long does it take the trauma of surgical
swelling to subside? In general,
2-4 weeks we will see the temporary inflammation
and irritation resolve.
What is the typical
order that neuro functions return?
A dog gets better in
the exact opposite order that it developed
problems. The ideal recovery will progress
from no deep pain sensation, to regaining
sensation, to slight motor function, to
enough motor function to ambulate.
Why can’t
a time line be given for each to happen?
Unfortunately, no spinal cord
injury is exactly alike. Therefore, even
though the initial clinical signs may be
similar to another dog that had a disk rupture
the healing process may take a different
course. |
During the post-op healing process why
is crate rest prescribed and for how long?
Crate rest is important post-operatively to help
prevent damage to the surgical site. If a dog
gets too active bleeding can occur that leads
to a hematoma (blood clot) compressing the spinal
cord. Also, it takes 2-4 weeks for the rent/hole
in the intervertebral disk to heal and seal over.
So, if a dog gets too active post-operatively
additional disk material can rupture and we are
right back or worse than we were to to begin with.
Therefore, it is very important to keep your dog
strictly confined for 2 weeks and then after rechecking
with the surgeon at 2 weeks devising a plan to
slowly reintroduce activity. Lifelong, there needs
to be a lifestyle change to minimize activities
that can put the dog at risk at a later date in
life.
How does the physical
activity of PT fit in with the concept of
providing crate rest? Physical
therapy (PT) is performed in a controlled
setting. Therefore, the activity is not
high impact and does not run the risk of
causing harm.
When can PT usually
be started? Some mild, low impact
PT can start the day after surgery. Every
dog’s temperament is different and
the PT has to be tailored to the individual
and the degree of neurological deficits.
Why is PT ok,
but not allowed for a dog to scoot around
the house, sit on the couch or be harness
and leash free at potty times?
PT is performed in a controlled setting.
If not supervised, there is the risk of
activity causing too much stress on the
surgical site and causing harm.
What are some
examples of post-op PT that an owner can
do at home for the paralyzed dog or a dog
that is walking?The types of
activities depend on the degree of neurological
function. For dogs that are paraplegic (no
motor function at all) passive range of
motion and toe stimulation activities work
well. If the dog is non-ambulatory paraparetic
(motor function present, but not able to
walk) standing with support and hydrotherapy
can be added. If ambulatory paraparetic
(wobbly, but able to walk) additional activities
like sit to stand and cavaletti rails can
be utilized. |
There
are several options for a recovery suite.
An
ex-pen with panels accordianed to fit
the mattress provides a comfortable recovery
suite during post-op required rest. |
How
to stay calm and know there is still hope even
if the dog is not up and running in 5 days as
promised. Post-operatively,
I will advise owners that I do not get concerned
or discouraged until 2-4 weeks post-operatively.
The status at 2-4 weeks sets the tone for the
dog’s recovery. At 2-4 weeks post-operatively
I hope to have seen some (but not complete) improvement.
Sometimes the degree of improvement is dramatic
and others is only very mild. Regardless, as long
as some improvement has occurred I am not concerned/discouraged.
Before 2-4 weeks there has not been enough time
for the spinal cord to heal and we have not allowed
enough time to pass to see the benefit of surgery.
Even if no improvement is noted by 4 weeks it
is not hopeless, it is just not as likely. I also
advise that at 2-4 weeks we are not seeing the
end result of the healing process - this typically
does not occur for 6-12 months and in some cases
even longer.
At what point
post-op is it time to consider whether money
is better spent on additional PT or to invest
in a wheelchair? f there has
not been any improvement 4 weeks after surgery
I would consider getting a wheelchair. It is
important to recognize that the wheelchair itself
can be modified to help with physical therapy
and is not synonymous with giving up hope. When
ordering a wheelchair there is typically a 2-3
week delay. With this in mind, if ordered 4
weeks post-operatively it will arrive 6-7 weeks
post-operatively.
Discharge
Day Indicators
for Surgery
| Medications | Crate
Rest & PT | Discharge
Day
Generally how
many days post-op is usual for dog to stay in
the hospital for monitoring before released
home?
A typical range is from 2-5 days.
What is being monitored
at the hospital? Neurological
status, comfort level, urinary bladder status,
surgical incision, and maintaining adequate
hydration and nutrition.
What are the determining
factors for a dog to be able to be released
from the hospital to go home?
This all depends on the neurological status,
pain management, and urinary bladder function,
in conjunction with the owner’s comfort
level with providing at-home care. I will
let an owner know when I am comfortable
discharging the dog, but also let them know
that this does not mean the dog has to go
home if they do not feel comfortable providing
at-home care. |
When it is advisable for the dog to go home with
a catheter? With adequate
medication and good client education most cases
do not need to go home with an indwelling urinary
catheter and the owners can manually express the
urinary bladder. Occasionally, a dog is extremely
difficult to express and the risk is outweighed
by the benefit. It is extremely important to keep
the urinary bladder decompressed to prevent permanent
damage and dysfunction. Therefore, if the urinary
bladder can not be manually expressed an indwelling
urinary catheter may be an option your veterinarian
chooses. Another option if unable to manually
express the urinary bladder is intermittent catheterizations.
This takes an owner that is willing, able, and
has been educated properly on the technique used
to perform the catheterizations.
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What
are the pros and cons? With
an indwelling urinary catheter there is
a greater risk of developing a urinary
tract infection the longer the catheter
remains in place. Also, if not monitored
and cared for properly the catheter can
become occluded/kinked and cause even
greater problems.
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How often does
the dog’s bladder need to be manually
expressed and why is it important to do
so? Ideally, the urinary bladder
should be expressed every 6 hours (within
reason). An owner does not need to wake
up in the middle of the night to express
the bladder. Expression before bed and
when waking up is sufficient.
If left distended,the urinary bladder
will not be able to function properly
even after the spinal cord injury heals.
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Expressing
is a skill many owners have learned to
help their paralyzed friend. It takes
only a couple of minutes to express
for
urine and poop. |
How will steroids
affect the frequency of expressing?
Steroids cause increased water loss through
the kidneys. Therefore, a dog on steroids
will have an increased volume of urine
compared to a dog not on steroids and
thus require more frequent expression.
Is it “normal”
for dogs to experience post op discomfort
during expressing? After surgery
(even with pain medications) a dog can
be sore when trying to express. Some dogs
are more difficult to express than others
and require more manual pressure. This
increases the chance of causing discomfort.
It is acceptable to have a dog act somewhat
irritated with manual urinary bladder
expression, but the dog should not be
placed in a situation that causes undue
stress, excessive movement, and pain.
If an owner is concerned about this they
should contact their veterinarian.
What symptoms
indicate a UTI? Discolored,
foul smelling, blood tinged urine and
urinating small amounts frequently (if
able to voluntarily urinate) are signs
suspicious for a UTI.
Why is it important
to get this treated by the vet immediately?
A urinary tract infection
can lead to more serious infections and
problems if left untreated. |
If the dog is coughing, gagging, or hoarse
from tracheitis due to the endotracheal tube,
what treatment can soothe these symptoms?
If you notice these symptoms it would be worth
having a veterinarian examine the dog. Sometimes
this can be the initial signs associated with
aspiration pneumonia and it is best to identify
as soon as possible.
How long is too long to wait for a bowel
movement at home?It all depends on the
amount of food the dog is eating. Typically, if
the dog has not defecated within two days of getting
home and is eating well it would be worth adding
a teaspoon of plain canned pumpkin per day to
the food (for a Dachshund sized dog). It is also
important to make sure the dog is adequately hydrated.
Adding equal amounts of water as kibble will help
with maintaining hydration. If 3 days go by, or
the dog is acting uncomfortable sooner it would
be warranted to visit the veterinarian for an
enema.
With stitches, when it is OK to use a
harness? It is OK as long as the harness
is not rubbing heavily on them and the incision
looks healthy.
When can bathing or water therapy be started?
After the staples/suture is removed by your veterinarian
or earlier if the veterinarian OK’s.
What are the indicators that healing is
not taking place as it should with the incision?
Redness, swelling, hot and painful to the touch,
and any discharge. It is not unusual for a seroma
to form in some cases. A seroma is not an infection,
it is an accumulation of serum under the skin.
Most of the time with restricted activity and
warm compresses the seroma will resolve in a week
or two. If any swelling is noted at the incision
it is always warranted to have a veterinarian
examine.
Generally what kind of follow-up communications
do hospitals do during early post-op release days?
Typically, they will call to check in a couple
of days after discharge and then in 2 weeks for
staple/suture removal.
Does
the vet call or the vet tech?
This is variable depending on the clinic.
Is the owner
supposed to call in with updates?
If any concerns or questions arise it is
important for the owner to call. Otherwise
it is dependent on the clinic. |
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