AFFORDABLE SPINAL SURGERY FOR PETS IN ONTARIO
Espanola Animal Hospital offers numerous spinal surgery options for our patients with advanced imaging support provided by our portable CT machine. Surgeries are offered for a variety of disorders including spinal fracture management, decompression surgery for intervertebral disc disease (“ventral slot” and dorsal hemilaminectomy), lumbo-sacral stenosis stabilization (“cauda equine syndrome”) and stabilization of cervical spondylomyelopathy (“Wobbler disease”) and atlanto-axial instability.
In order to facilitate care to our patients for these disorders, a flat-rate fee of $3500 + HST will apply to all spinal surgeries. This fee includes all standard post-operative medications and laser treatments. The cost of the CT scan is not. Referrals can be arranged by contacting the hospital by any of the usual means.
For more information regarding pricing, diagnostics, and surgical techniques, please refer to the above handout or contact us directly.
Client Handout: Intervertebral Disc Disease (IVDD) And Other Spinal Disorders
The Spine
The spine arises from the base of the skull and traverses the whole length of the body to the end of the tail. The spine serves multiple functions; it participates in locomotion, is the attachment for the pelvis and various major muscle groups and it is a bony column that protects the spinal cord from trauma. Paired nerve roots exit the spine between each vertebra and supply the entire body with the exception of certain portions of the head and neck that are supplied by specialized cranial nerves.
The spine is segmental in nature and is composed of numerous individual vertebra separated by intervertebral discs. In the dog and cat, there are 7 cervical vertebrae (neck), 13 thoracic vertebrae (chest), 7 lumbar vertebrae (lower back), 3 fused sacral vertebrae (that the pelvis attaches to), and a variable number of coccygeal vertebrae (those that make up the tail). Certain breeds of dogs, particularly Dachshunds, Boston Terriers and French Bulldogs may have more thoracic or lumbar vertebrae than normal, or may have malformations such as hemi- vertebra. The individual vertebrae in each segment are significantly different from those of another segment and may have additional functions, such as providing attachment points for ribs (thoracic vertebrae).
The bony tube formed by the alignment of adjacent vertebra, the neural tube, contains the spinal cord and associated structures such as blood vessels, fibrous connective tissue and fat. This bony canal protects the delicate spinal cord and the associated structures from damage. Anything that effectively decreases the volume of this canal (such as a tumor or extruded disc) or causes misalignment of adjacent vertebrae (such as a fracture or instability), will cause compression of these structures and the spinal cord. Signs associated with spinal cord compression range from mild neurological deficits to paralysis depending on severity.
In between the vertebrae, at the level of the discs, are holes called foramina where nerve roots exit the spine to supply the body. Unlike the spinal cord itself, compression of nerve roots causes pain. The degree of discomfort caused by nerve root compression can vary considerably and include non-weight-bearing lameness of an affected limb (a “nerve-root signature”) to very severe signs frequently associated with neck pain and can be associated with vocalization. The vocalization may be continuous or may be manifested in the form of yelping when the patient moves in a certain manner.
The Intervertebral Disc & IVDD
In between the vertebrae are intervertebral discs composed of an outer ring of dense fibrous tissue (annulus fibrosis) and an inner core of gelatinous material (nucleus pulposus). The discs perform multiple functions: they provide articulation between the vertebrae allowing for movement of the spine and they provide shock absorption and dissipation during locomotion for activities such as jumping. Tearing of the annulus or changes in the structure of the disc over time can lead to the ejection of the nucleus pulposus into the spinal canal, compressing the spinal cord and/or nerve roots resulting in clinical signs of disc disease. This is called Intervertebral Disc Disease (IVDD). Extrusion of disc material in the neck tends to mostly be accompanied by signs of pain, although neurological signs can occur and tend to be worse in the front limbs than the hind. Disc extrusions in the thoracic and lumbar regions generally tend to produce neurological signs of varying severity, however pain is frequently also associated with these cases.
Some Other Spinal Diseases Not Involving IVDD
There are many other diseases of the spine that are commonly seen that do not involve intervertebral disc disease. The following section is not intended to be a comprehensive list of all spinal disorders, but a brief description of some of the more common diseases and their treatments. Detailed descriptions of medical and surgical therapies can be found after this section.
Degenerative Myelopathy
Degenerative Myelopathy is as the name implies, a degenerative spinal disease of usually older dogs, particularly German Shepherd although many different breeds are affected. This disease is progressive and may start with very subtle signs, such as scuffing of the nails in the hind-limbs while walking. This disorder always affects the hind-limbs first and progresses to include the tail, urinary and fecal incontinence and ultimately laryngeal paralysis and death.
The only treatment known to have any impact on the disease is rehab. The typical course is approximately 18 months however with rehab patients may survive up to 3 years. Degenerative Myelopathy is a diagnosis of exclusion, although there is a recently available genetic test to see if a dog carries the gene for the disease. It is important to note that lumbo- sacral disease is frequently misdiagnosed as degenerative myelopathy and it is important to distinguish these diseases, as lumbo-sacral disease is quite treatable.
FCEM/“Spinal Stroke”
Fibrocartilaginous embolic myelopathy (FCEM or “spinal stroke”) is a common condition with an acute onset of neurological signs that are frequently severe and involve paresis or paralysis of one or more limbs. While the exact cause is unclear, it seems to involve embolism of the spinal cord with small pieces of disc material or cartilaginous material. One of the hallmarks of FCEM is that the lesions are asymmetrical (involve one side of the dog more than the other) and this disease is completely non-painful. Dogs may have a history of prior, but less severe episodes on presentation.
The only effective treatment for this disease is rehab and the sooner it is started the better the prognosis generally. The prognosis for FCEM is fair to good; many if not most dogs will fully recover but some will not. Some may recover some function but have some permanent deficits.
Wobbler’s Disease
This disease is properly called cervical vertebral instability and has specific breed predispositions involving large and giant breed dogs. Wobbler’s disease leads to stenosis or narrowing of the vertebral canal and associated compression of the spinal cord and nerve roots in the neck. Two forms are recognized: bone-associated, which affects typically young Great Danes, Weimaraner’s, and a few other breeds and disc associated affecting older dogs, particularly Dobermann Pinchers.
This disease may be treated either medically or surgically depending on the severity of signs. Like disc disease, medical management is successful in approximately 50% of cases. Surgical management may consist of decompression, stabilization by distraction and fusion of the vertebrae or a combination of both. Surgical management has a much better success rate than medical management but may not be curative and 20% of patients develop disease in the adjacent vertebrae/discs.
Lumbo-Sacral Stenosis/Instability
This is a disease or syndrome that affects the junction between the lower lumbar vertebrae and a special fused group of vertebrae called the sacrum, which attaches the pelvis to the spine. This disease may be manifested as instability and back pain in younger dogs but more typically affects older dogs and cats and involves narrowing of the spinal canal and nerve impingement. It is frequently associated with hip dysplasia but most commonly exists as a separate issue. It is variably called L-S disease, cauda equina syndrome, and lumbo-sacral stenosis or instability – all of these terms relate to the same disease. L-S disease is an extremely common and significantly under-recognized and under-diagnosed disease. As the clinical signs tend to develop in middle-aged and older pets, typically large-breed dogs 10-12 years of age, most pet owners ascribe the patient’s mobility problems to “old age”, “arthritis” or “his hips are gone”. Frequently veterinarians themselves lack knowledge of this disease and either fail to appreciate the actual nature of the problem or misdiagnose the issue as another disease. Breeds most commonly affected are German Sheppard Dogs, Labrador Retrievers and many other large breed dogs, including mixed breeds.
Cats also frequently develop L-S disease as they age.
L-S disease is in fact usually a fairly straight-forward diagnosis, is extremely rewarding to treat, and most patients respond well to treatment. This can usually be diagnosed based on a combination of standard spinal radiographs, history and physical exam findings. MRI is also very reliable in diagnosing L-S and is currently the diagnostic gold standard. Treatment may be either medical or surgical depending on the nature and severity of signs. Surgical treatment usually consists of a dorsal laminectomy to relieve the nerve compression but may include stabilization/fusion in some cases. Surgical patients tend to do very well and most clients report a noticeable improvement immediately after surgery.
Other Spinal Diseases of Interest
These include disk spondylitis (an infection of the disc), spinal tumors, and spinal fractures. These are less commonly seen and will be discussed in detail with clients during the diagnostic or pre-surgical consult as appropriate.
Management of Disc Disease and Spinal Instability
Management of these issues may involve either medical management, surgical management, or a combination of both. Which type of management is appropriate is based on a combination of clinical signs, radiographic findings, and the exact nature of the individual problem and the associated prognosis for each type of treatment. This necessarily must rely on the good clinical judgement of the veterinarian as the individual details and clinical signs vary considerably on a case-by-case basis. It is also
very common for cases to evolve over time and a case that may be managed medically initially can become surgical. Some surgical cases may still require some ancillary medical treatment in the long-term.
Medical Management
“Medical Management” basically encompasses all treatments other than surgery. For IVDD, medical treatment may mean medications, laser therapy, weight management, physical rehabilitation and chondroprotectants. All patients receive some form of medical management either as a primary treatment and post-operatively for surgical cases.
Weight, Diet and IVDD
In any patient with any spinal or disc disease, the most important factor impacting the development of disease, prognosis and treatment is the weight of the patient. Obesity is a major risk factor for the development of IVDD and other spinal diseases. Regardless of the condition, failure to recognize and address issues of diet and obesity will likely result in treatment failure, no matter how much is invested in treatment and surgery. Your veterinarian should provide specific dietary recommendations including not only a specific diet(s), strict feeding guidelines that include specific measuring instructions and complete diet counselling. Any complicating medical conditions such as hypothyroidism need to be diagnosed and treated.
Therapeutic Diets – A prescription veterinary diet formulated specifically for addressing obesity and sometimes joint disease and arthritis in our patients may be prescribed. Many older dogs with spinal problems have concurrent joint disease such as hip dysplasia and arthritis of the intra-articular facets of the vertebrae is also very common. These diets are designed not only to deal with inflammation associated with joint disease but are excellent at addressing weight issues that will have the most impact on patient outcomes. These diets have had a major impact on how we manage disease over the past few decades.
Medications
NSAID’s - All dogs presented with clinical signs initially start on NSAID’s as this is our primary means of immediately addressing pain and inflammation. Historically, steroids have been prescribed in acute cases of IVDD, however this has become extremely controversial in recent years. When a disc extrusion has occurred, the resulting inflammation is frequently as significant a cause of compression as the offending disc material. It is therefore imperative that we control this inflammation as quickly as possible. NSAIDs may be a primary means of treatment in medically managed cases or prescribed post-operatively in surgical cases. Often we will withdraw the NSAID’s if possible when other therapies have had time to take effect and the patient has responded well to treatment. A number of options are available, including some newer products that have a reduced incidence of adverse effects.
Gabapentin – this is a first-line treatment in any dog that has any significant pain component to their spinal problem. Gabapentin is a neuroleptanalgesic – it controls spinal pain, in a highly effective manner, and is also used in humans for this purpose. At analgesic doses, gabapentin has very low potential for side-effects, is very safe for long-term use, easy to administer, is highly effective and inexpensive. This makes gabapentin an excellent choice for management of patients with chronic problems.
Codeine – is an opioid medication that is highly effective in dogs for managing more severe pain. Any dog that has severe pain issues (ie vocalizing) will be prescribed codeine preoperatively to manage them pending surgery. Any dog that requires treatment of this nature is definitively surgical. In dogs, codeine does not have significant narcotic effects, but it is a controlled drug and should be handled and stored accordingly.
Chondroprotectants - Recent large-scale studies have shown that glucosamine and chondroitin have no therapeutic value unfortunately. However, since it is important that patients be on an effective long-term joint supplement, most surgeons have shifted their recommendations to a product called Flexadin, which has good evidence to support its use. UCII modulates the immune response to supress inflammation. This usually prescribed and supplied in our hospital at the initial visit. Chondroprotectants otherwise have no value in the treatment of primary spinal disease.