6 year old MN Boston Terrier with possible autoimmune spinal cord ischemia mild disc lesions and shoulder hyperextension

[lehughes]

Hello again!

Okay, so the sneezing with testing that AO joints could be due to your hand position over his squashy little Boston Terrier face while assessing flexion / extension etc. I originally had thoughts about whether it could be correlated to the possible disc lesions, but I don't think so.

The increase in tone in the neck makes sense to me in that if there is inflammation from the discs pushing on nerve roots or disc degeneration that causes secondary pinching of nerve roots, you can get an increase in tone. Alternately, simply spinal cord lesions that result in upper motor neuron damage creates increases in tone. So, if the neck isn't painful, I'd go with either option #3.

The change in the bowel function / awareness is likely a progression of his autoimmune spinal cord ischemia. Same with the CP deficits and weakness.

In a case like this, or rather, a case with this diagnosis, you may see various iterations of lower motor neuron signs and upper motor neuron signs, depending on what part of the spinal cord is currently under attack... or where and how the disease progresses. Motor cord body lesions at C5-T2 can show LMN signs in a front leg and UMN signs in a rear leg. Motor cord body lesions affecting L5 - S1 will show LMN signs to a rear leg and maybe UMN signs for bowel and bladder.

It might be worthwhile to teach the owner how to be proactive about a bowel routine, and how to use a Q-tip to stimulate the rectum and get any poop that's 'sitting at the back door' to be expelled at regular times. It's not fool proof, but it might reduce the incidences of 'in-house fall-outs'!

I hope this helps!

Laurie

[JuliPotter]

Thank you so much, Laurie!
yes, that does make sense that an UMN lesion would cause increased muscle tone but what about the increased muscle mass? I feel that his muscle mass has increased in both the right quads and hamstrings (the affected hind limb) yet he continues to have CP deficits as well as the change in bowel awareness....this confuses me for I would think that with nerve damage/spinal cord lesion/inflammation, we would continue to see muscle atrophy.....
I guess I am trying to understand the disease process to help guide my treatment plan for him. I appreciate your patience will all of my questions!

Juli

[lehughes]

Well... in regards to the muscle mass. You have a couple of options:
1. Is what you are feeling / assessing REAL? Or is is just how the dog is weightbearing now, and just the fact that he is using the leg when you feel or measure, that it seems to be increased? I've had that with some cases that just weren't WB on a leg enough that to measure it, is was hugely different then when they were WB on the leg.

2. Is it a factor of being an UMNL... and there is tone in the muscle and it feels to have more bulk?

3. It's one of the damn pieces of blue sky in a puzzle that you just don't know how it fits in yet. (Neuro cases can be like that sometimes.)

Don't get hung up on it. Sometimes you just have to say 'huh' and carry on with treating what makes sense to treat!!



Laurie

[JuliPotter]

Thank you, Laurie!! this really helps!
so what I need to focus on is function! and to treat what I am seeing! not to necessarily get hung up on the pathology?
Juli

[lehughes]

Exactly!

There is a movement in physiotherapy to call that Physio diagnosis, a pathofunctional diagnosis vs a pathoanatomical diagnosis. Both are diagnoses but with a different focus.

Sometimes with your physical evaluation you can make a pathoanatomical diagnosis (i.e. medial patellar luxation, full cruciate tear...) but other times in order to make a pathoanatomical diagnosis, you need more advanced imaging. And sometimes a pathoanatomical diagnosis can't be made with full confidence. Oh well.

When it comes to rehab, what can matter more (and especially in a case such as you describe), the pathofunctional diagnosis is more appropriate & useful anyways. What is not functioning? What can you do to address the function?

So, just carry on with helping your patient to function better in this case.

Best!

Laurie

[JuliPotter]

Laurie
Thank you so much!!
Juli

[JuliPotter]

onset of new symptoms -
Good morning, Laurie
I would appreciate your insight in regards to Mason (hx of possible autoimmune spinal cord lesion in C-spine, mostly right side affected, was diagnosed a year ago)
Mason has been doing pretty well, aside from ototoxicty from topical ear medication and a toe injury, oh my....but over the last weekend, so 5 days ago, Mason started limping on his right pelvic limb and 3 days ago, he took off running and was running into the walls and furniture and at one point in the day, he appeared to be unsteady in the rear end, swaying the the side as he stood.
Mason is always BAR and never slows down.
When I saw him 3 days ago, he did not appear to be ataxic and is not lame while walking but while standing he will hold up his right pelvic limb and/or toe touch and he does seem a little unsteady while standing. Mason can be hard to "read" sometimes for he is quite stoic and is also very food motivated so will intently concentrate on the treats during the exam but with side glide of C6/7 on the right, he did become a little tense, though he did not move away and he did not do this with side glide of C6/7 on the left. He did seem slightly reactive with palpation of rib 1 on the right as well. CPs have not changed on the right, he has always been a little slower on this side, he is reactive/flinches with unilateral transverse process DV pressures of T-spine from T8-13 and this seemed worse on the left side,he flinches with ventral pressure along the angle of the rib from T8-13 as well, mostly on the left but I did not get any reaction with testing of lateral translation. he is reactive with unilateral transverse process DV pressure along the lumbar spine and he is warm to the touch (dramatic difference) along lumbar spine and at L-S. Mason does seem painful (moves away) with palpation of left dorsal SIJ ligament, seems painful with palpation of the right piriformis muscle (repeatedly sits down), the right ilium appeared to be ventrally rotated. Seemed reactive with thigh thrust technique on the right.
I performed side glide at C6/7 from left to right, individual side bend/rotation of the T-spine and L-spine, isolated flexion of L-spine. Rib rotation glide, thigh thrust technique on both the right and left and dorsal mobilization of the Right SIJ and ventral mobilization of the left SIJ.
Advised the owner to avoid any jumping, running and slick surfaces, we discussed trying booties for traction, to do traction of C-spine, chest lifts, traction of L-spine, skin pulls and massage of intercostal muscles. After talking to the owner yesterday, she reports that Mason is about the same, still toe touching on the right PL when standing but he is not worse. I am wondering, do you think these new symptoms could be related to an SIJ dysfunction? or my other rule out is nerve root entrapment, facet joint dysfunction, though I have not been able to isolate the lesion. If the symptoms were due to a disc herniation at C6/7, I would expect his symptoms to be worse!? I do appreciate your input and any suggestions you may have!

Sincerely and with much gratitude,
Juli

[lehughes]

Hey Juli,

Oh, this poor little guy! What a mish-mash of stuff going on!

So. Let me type as I think.

1. The C/S issue wouldn't cause an unweighting of a pelvic limb. No direct correlation there. Same goes for the T/S - Rib findings. (Fair game to treat them, but they don't make sense to be the root of the problem for the RH unloading at stance.

2. No lameness during gait... So this makes me think that the issue isn't joint or soft tissue 'pain' per se, but rather a different sensation in the limb. As such 'nerve' come into my list of differentials.

3. That takes us to L/S or SIJ. Which might mean that there is something causing a mild pinch, stretch, or inflammation of a lumbar or sacral NR.

4. If you can find a root problem in the L/S or SIJ, then treat it / continue to treat it. Alternately, just treat the region for NR inflammation (mobs, laser, acup, tractions, skin pulls, etc...)

Those are my thoughts off the top of my head anyways. Hopefully they help to direct your search for the lesion and/or where to target your therapies!

All the best!

Laurie

[JuliPotter]

Laurie,
Thank you so much for your input! Yes, this helps alot and helps to decrease some of my anxiety!
I saw Mason again earlier this week and he seems to be doing better; only occasional toe touching while standing, according to the owner, certainly he has not gotten worse. The o has been doing traction as part of the home exercise program. Upon exam this week, I noticed that while standing, Mason does shift his weight to the left hind limb, he has moderate muscle loss over the gluteals and hamstrings, which seems a little more significant than when I saw him a few months ago, I did see less reactivity along the T-spine and ribs, no reactivity with strumming of the piriformis muscle or the dorsal SIJ ligament as before but I do feel that the right ilium was ventrally rotated and he did show some sensitivity with gentle palpation of the Iliopsoas on the right.
I did continue to treat the T-spine,ribs, L-spine and SIJ as before and added the pelvic tilt exercise in a down position.
I am wondering, could this be an SIJ dysfunction causing NR irritation/inflammation, even though I can not appreciate pain with palpation of the piriformis, sacrotuberous ligament and dorsal SIJ ligament? as well, how can I tell if the SIJ is hypermobile versus hypomobile (I watched your video on this)?
and once a patient has improved from a SIJ dysfunction, how do you prevent this from happening again?
I have also been wondering what can cause the SIJ dysfunction? I think you mentioned trauma before, especially when doing your puppy evals. I suppose an Iliopsoas strain? hypomobility of the Lumbar spine and LS issues - IVDD, fact joint dysfunction, nerve root entrapment....does this sound reasonable? Thank you so much, Laurie!!

[lehughes]

Hey Juli,

So, from what I have found in teaching hundreds of rehab practitioners over the years is that sometimes they do not push/ strum hard enough to get a reaction from the animal. That might be the case. (??)

In regards to hypermobility. When you become sensitive enough with your testing, you compare mobility from side to side (shears and thigh thrust techniques). As well, you could always treat the non-painful side with an assumption that it might be hypomobile. In difficult cases, I will always treat both sides.

Chronic / Recurring SIJ issues are often due to lack of gluteal muscle support. So that is key in helping to return this to normal function. Do glute stim (manual as a home program & e-stim during your sessions) with 3-leg stands (sliding the unaffected rear leg off the ground).

Of course whatever caused the iliopsoas strain could have caused trauma to the SIJ.

One other thing I've found is that dogs with a lumbarized S1 or sacralized L7 might also have recurring SIJ issues.

I like that you've prescribed the pelvic tilts.

Okay... back to you!

Laurie