Allow me to rock the boat for a moment! In this blog, I want to discuss conservative management of disc lesions. Discs can resorb. They can heal on their own. With our therapy tools and techniques, we can help the process. Let’s dive into the topic a bit further!
I found a paper that sparked this blog!
Sharma AK, Gandhoke CS, Syal SK. Spontaneous regression of herniated cervical disc: A case report and literature review. Surg Neurol Int. 2021 Apr 8;12:141.
The researchers searched the literature and found 75 cases of herniated cervical discs which spontaneously regressed; to this, they added their own case.
What they noted:
“Patients averaged 40.95 years of age. Discs were paracentral or foraminal in 84% of the cases, with most occurring at the C5-C6 (51%) and C6-C7 (36%) levels. Symptoms included neck pain/radiculopathy (91%) or myelopathy (9%). The average interval between initial presentation and spontaneous regression of herniated discs on MRI was 9.15 months. Interestingly, on MRI, extruded/sequestrated discs were more likely to undergo spontaneous regression versus protruding discs.”
The paper goes further to discuss the three proposed mechanisms for spontaneous cervical disc resorption:
1) The first involves dehydration and shrinkage of the herniated nucleus pulposus.
2) For the second, there is a retraction of the protruded disc.
3) In the third, there are enzymatic degradation and phagocytosis of the extruded/sequestrated disc material due to an inflammatory reaction/neovascularization. Notably, in the third hypothesis, when the disc penetrates the annulus fibrosus and the posterior longitudinal ligament, they are exposed to the systemic circulation in the epidural space where they are recognized as a foreign body, leading to an inflammatory response, and subsequent disc resorption (e.g., the intervertebral disc produces chemokines such as monocyte chemotactic protein 1 (MCP-1) and interleukin 8 (IL-8) that act as chemoattractants for macrophages and capillaries).
So, why not in the canine disc? Well, firstly, let me tell you that I have rehabbed dogs with disc lesions. Some that have had neurologic compromise as well. That being said, I don’t want to talk someone out of surgery if they have a paralyzed dog and they want to do surgery. If the owner wants to do surgery and can afford surgery in that case, I am going to advise that they proceed with that course of action. However, if the owner cannot or does not want to do surgery AND / OR the dog is merely paretic… or just has back pain or neck pain, then I believe strongly that a course of well thought out and structured rehab be trialed before considering a surgical option!
What does that look like?
Slap palm to forehead if you think the treatment strategy involved the underwater treadmill!!! It doesn’t! The UWTM can help to retrain function… but it doesn’t address the root of the problem, so please don’t start there!
You goals in conservative disc management? They’re simple.
1) Increase blood flow.
2) Pain management.
3) Advice to protect the disc environment.
So… Laser, PEMF, Acupuncture, Traction, Mobilizations, Active ROM exercises, perhaps TENS, prescribed medications, and lifestyle advice (i.e. no play, no jumping off furniture, caution on stairs or no stairs, etc. – perhaps dog-specific advice).
Especially if a dog is ambulatory, I feel strongly that conservative therapies should be tried first. I have seen from first-hand experience that a dog that ‘walks in’ for spinal surgery, does not always ‘walk out’. Surgery is always an option should clinical signs fail to improve or if they worsen.
With more and more canine rehab practitioners out there, I sure wish we could produce some studies to back this up! (Things I dream about late at night!)
On that note, have an impactful week out there!