Hi Laurie,
Saw an odd case the other day, whole RHS of the dog less well muscled and sore pretty much everywhere. Was suspicious of her back so I sent her for CT. I will attach the results. What would you do with her? Its a bit beyond my comfort level but O really wants me to see her. No modalities yet as just started on my own. Thanks!
-had to copy paste since it said pdf was invalid attachment sorry-
Thank you for your referral of Sousie Alt. Please find her recent medical notes and any client instructions
attached:
SURGERY INITIAL CONSULTATION (13/12/21)
Reason for visit: R sided weakness/lameness
History:
O reports that about one month ago dog was being minded with a dog sitter and was running around and
playing enthusiastically with other dog. Was contacted to say that sousie was limping in her RH and when
O came to collect her few days later thought she was sore/weak in her RF as well.
Gave it a week or so to see if she would improve, however when she didnt she took her to her vet for
assessment. Referring vet found Sousie to be 2/4 lame in the RH, but no obvious focus of pain and no
clear issues in the RF
Was commenced on previcox, paracetamol and has also been on gabapentin as well. Prior to this she
was not on any medications. O feels as though she is medication responsive (ie she is better when she is
on medication).
Has also been resting her over the last month but did take her for a longer walk today and after about 25
minutes she seemed to have had enough, whereas normally she would go for longer than this
Prior to this episode she has been a very active dog and will walk many kilometres with O's when they go
hiking etc and loves to exercise.
Is otherwise well and is E/D/D/U fine and there is no vomiting or diarrhoea.
Has a prior history of being neglected when she was younger and O took her in and cared for her and has
done a significant amount of rehab with her involving building up her musculature including her with her
tail which had weakness issues for some time.
Sousie did have an abscess on the side of her face which required surgery and this took about a month to
resolve properly. The underlying issue was never found, but it had just resolved before this issues started.
1 of 6
Multiple issue case
Re: Multiple issue case
Hey Kriszty,
Well, this is an odd case. Two things come to mind.
1) FCE
2) Tick borne illness
From a rehab perspective... work on function, and controlled strengthening. Add in some therapies for the spine (neck in particular) - traction, mobilization, laser, and perhaps PEMF.
From a medical perspective... maybe additional bloodwork? Maybe even a trial of antibiotics?
This is one of those cases, where as a rehab practitioner, I feel like I need to push the dog back for diagnostics, while still keeping tabs on the dog and/or treating the functional deficits.
That's off the top of my head anyways...
Well, this is an odd case. Two things come to mind.
1) FCE
2) Tick borne illness
From a rehab perspective... work on function, and controlled strengthening. Add in some therapies for the spine (neck in particular) - traction, mobilization, laser, and perhaps PEMF.
From a medical perspective... maybe additional bloodwork? Maybe even a trial of antibiotics?
This is one of those cases, where as a rehab practitioner, I feel like I need to push the dog back for diagnostics, while still keeping tabs on the dog and/or treating the functional deficits.
That's off the top of my head anyways...
LAURIE EDGE-HUGHES
Re: Multiple issue case
Aargh sorry Laurie I thought the whole thing pasted but obviously not. Here is rest incl CT
Long discussion with O about Sousie's signs. Discussed that may be either orthopedic or neurological,
and could potentially be both. Some of the signs that she describes and also clinical exam findings may
suggest a neurological cause such as IVDD in the lumbar spine, however others could be orthopedic.
Very difficult to find a clear cause in consult, however does seem to have RH muscle atrophy and also
some lumbar pain. Therefore Hx and findings could be indicative of IVDD, or could be a soft tissue or
orthopedic issue too. Probably the broadest and thorough look we could do today is to CT the spine and
HLs to look for any causes. O is also keen to do the FLs whilst we are there which is fine. Discussed MRI
VS CT, but CT gives us our broadest look and if we need to do MRI at a later date then we can do that as
required. O aware we may not find anything, and would like to proceed today.
Computed Tomography Report
Study date: Monday, December 13, 2021
Findings:
Plain CT acquisitions of the entire vertebral column, both forelimbs, pelvis and hindlimbs are available for
review in soft tissue and bone reconstruction algorithms.
Right forelimb: The shoulder is unremarkable. There is minimally displaced fragmentation of the tip of the
medial coronoid process. There is mild periosteal new bone formation on the proximal aspect of the
anconeal process. There is no elbow joint effusion. There is no evidence of elbow incongruency. There is
fragmentation of the sesamoid of the abductor policis longus. The carpus, metacarpus and phalanges are
otherwise unremarkable.
Left forelimb: The shoulder is unremarkable. There is a fissure across the tip of the medial coronoid
process. There is mild periosteal new bone formation on the proximal aspect of the anconeal process.
There is no elbow joint effusion. There is no evidence of elbow incongruency. There is mild new bone
formation on the distal aspect of the accessory carpal bone. The carpus, metacarpus and phalanges are
otherwise unremarkable.
Vertebral column: There is mild mineralised material on the ventral aspect of vertebral canal at T13-L1,
slightly worse on the right. There is mild dorsal protrusion of the L7-S1 intervertebral disc causing mild
bilateral foraminal narrowing. There is mild mineralisation on the floor of the vertebral canal at C7-T1.
There is incidental ventral spondylosis at T10-T11, L5-L6, L6-L7. The remainder of the vertebral column is
unremarkable. There is mild enlargement of the left medial iliac lymph nodes.
Pelvis and hindlimbs: There is reduced muscle mass of the right hindlimb. The pelvis and coxofemoral
joints are normal. The patellae are positioned normally. The intercondylar groove and ridges appear
normal. There is no evidence of stifle degenerative joint disease. The tibiae and fibula are normal. There
is irregular new bone formation on the distoplantar aspect of the calcaneus in both hindlimbs. The tarsi in
view are otherwise normal. There is no evidence of abnormal intra- or extra-capsular soft tissue swelling.
There are no subchondral bone defects noted. There are no osteolytic or osteoproliferative bone lesions.
The metatarsi and phalanges are unremarkable.
Conclusions:
• Bilateral medial coronoid disease (fragmentation in the right, fissuring in the left) and mild
degenerative joint disease.
• Right abductor policis longus sesamoid fragmentation.
• Left accessory carpal bone palmar enthesopathy.
640 Beeliar Drive
Success WA 6164
Tel: 9412 5700
Fax: 9412 5788
Email: referral@wavets.com.au
• T13-L1 chronic mineralised intervertebral disc protrusion/ventral extrusion, slightly worse on the right.
• L7-S1 mild intervertebral disc dorsal protrusion and foraminal narrowing compatible with lumbosacral
disease.
• Right hindlimb muscle atrophy.
• Bilateral calcaneal enthesopathy/osteophyte.
• Mild left medial iliac lymphadenomegaly likely reactive.
• No other abnormalities noted.
Dr Timothy Foo
BSc, BVMS, MANZCVS (Radiology), MVetStud, DipECVDI
Registered Specialist, Diagnostic Imaging
Client communication: Tuesday, 14 December 2021
EBM - STO (Karin) - 1915 - discussed findings of the CT. Advised findings in the forelimbs are quite mild
and I suspect incidental and I wouldn't be recommending any specific treatment from a surgical point of
view for these as I don't believe they are causing her major if any problems.
Orthopedically the HLs are sound, however she definitely does have muscle atrophy in the RH.
Major findings are @ T13-L1 with a discu extrusion lateralized to the RHS which I think certainly could
explain the signs that she saw with Sousie a month ago, and also would explain why she is getting better
over the last month as this is not a major lesion.
Also has LS disease which may be having a variable impact on her - causing some degree of pain
possibly. This lesion is likely to degenerate to a variable degree over time.
O is glad to have some answers and at this stage will continue on with her rehabilitation with her regular
vet given there is no surgery recommended at this time.
Advised rest for another 2 weeks and stop paracetamol now, but continue previcox and gabapentin for
another 2 weeks before weaning off previcox and then gabapentin after that.
SURGERY DISCHARGE NOTES (for Sousie Alt 14/12/2021)
Summary:
Sousie underwent CT scan of her spine, forelimbs and hindlimbs to investigate for a possible cause of
right hindlimb weakness/lameness along with suspected spinal discomfort.
Multiple changes were seen in her spine and her forelimbs, a number of which we would suspect are
incidental and unlikely to be causing her any clinical issues. Such incidental findings include: the changes
associated with her right abductor pollicus longus sesamoid, the left accessory carpal bone palmar
enthesiopathy and the bilateral calcaneal enthesiopathy. Sousie shows no signs that these lesions are
affecting her clinically and they would be deemed mild.
Also evident, was mild bilateral medial coronoid disease in her elbows, associated with mild degenerative
joint disease. It is hard to know whether these changes are affecting her at all, and clinically she does not
show any major discomfort with manipulation in her elbows, and also does not show significant lameness.
It is also unlikely given her clinical condition at this time, that surgical intervention with her elbows will
benefit her.
4 of 6
Long discussion with O about Sousie's signs. Discussed that may be either orthopedic or neurological,
and could potentially be both. Some of the signs that she describes and also clinical exam findings may
suggest a neurological cause such as IVDD in the lumbar spine, however others could be orthopedic.
Very difficult to find a clear cause in consult, however does seem to have RH muscle atrophy and also
some lumbar pain. Therefore Hx and findings could be indicative of IVDD, or could be a soft tissue or
orthopedic issue too. Probably the broadest and thorough look we could do today is to CT the spine and
HLs to look for any causes. O is also keen to do the FLs whilst we are there which is fine. Discussed MRI
VS CT, but CT gives us our broadest look and if we need to do MRI at a later date then we can do that as
required. O aware we may not find anything, and would like to proceed today.
Computed Tomography Report
Study date: Monday, December 13, 2021
Findings:
Plain CT acquisitions of the entire vertebral column, both forelimbs, pelvis and hindlimbs are available for
review in soft tissue and bone reconstruction algorithms.
Right forelimb: The shoulder is unremarkable. There is minimally displaced fragmentation of the tip of the
medial coronoid process. There is mild periosteal new bone formation on the proximal aspect of the
anconeal process. There is no elbow joint effusion. There is no evidence of elbow incongruency. There is
fragmentation of the sesamoid of the abductor policis longus. The carpus, metacarpus and phalanges are
otherwise unremarkable.
Left forelimb: The shoulder is unremarkable. There is a fissure across the tip of the medial coronoid
process. There is mild periosteal new bone formation on the proximal aspect of the anconeal process.
There is no elbow joint effusion. There is no evidence of elbow incongruency. There is mild new bone
formation on the distal aspect of the accessory carpal bone. The carpus, metacarpus and phalanges are
otherwise unremarkable.
Vertebral column: There is mild mineralised material on the ventral aspect of vertebral canal at T13-L1,
slightly worse on the right. There is mild dorsal protrusion of the L7-S1 intervertebral disc causing mild
bilateral foraminal narrowing. There is mild mineralisation on the floor of the vertebral canal at C7-T1.
There is incidental ventral spondylosis at T10-T11, L5-L6, L6-L7. The remainder of the vertebral column is
unremarkable. There is mild enlargement of the left medial iliac lymph nodes.
Pelvis and hindlimbs: There is reduced muscle mass of the right hindlimb. The pelvis and coxofemoral
joints are normal. The patellae are positioned normally. The intercondylar groove and ridges appear
normal. There is no evidence of stifle degenerative joint disease. The tibiae and fibula are normal. There
is irregular new bone formation on the distoplantar aspect of the calcaneus in both hindlimbs. The tarsi in
view are otherwise normal. There is no evidence of abnormal intra- or extra-capsular soft tissue swelling.
There are no subchondral bone defects noted. There are no osteolytic or osteoproliferative bone lesions.
The metatarsi and phalanges are unremarkable.
Conclusions:
• Bilateral medial coronoid disease (fragmentation in the right, fissuring in the left) and mild
degenerative joint disease.
• Right abductor policis longus sesamoid fragmentation.
• Left accessory carpal bone palmar enthesopathy.
640 Beeliar Drive
Success WA 6164
Tel: 9412 5700
Fax: 9412 5788
Email: referral@wavets.com.au
• T13-L1 chronic mineralised intervertebral disc protrusion/ventral extrusion, slightly worse on the right.
• L7-S1 mild intervertebral disc dorsal protrusion and foraminal narrowing compatible with lumbosacral
disease.
• Right hindlimb muscle atrophy.
• Bilateral calcaneal enthesopathy/osteophyte.
• Mild left medial iliac lymphadenomegaly likely reactive.
• No other abnormalities noted.
Dr Timothy Foo
BSc, BVMS, MANZCVS (Radiology), MVetStud, DipECVDI
Registered Specialist, Diagnostic Imaging
Client communication: Tuesday, 14 December 2021
EBM - STO (Karin) - 1915 - discussed findings of the CT. Advised findings in the forelimbs are quite mild
and I suspect incidental and I wouldn't be recommending any specific treatment from a surgical point of
view for these as I don't believe they are causing her major if any problems.
Orthopedically the HLs are sound, however she definitely does have muscle atrophy in the RH.
Major findings are @ T13-L1 with a discu extrusion lateralized to the RHS which I think certainly could
explain the signs that she saw with Sousie a month ago, and also would explain why she is getting better
over the last month as this is not a major lesion.
Also has LS disease which may be having a variable impact on her - causing some degree of pain
possibly. This lesion is likely to degenerate to a variable degree over time.
O is glad to have some answers and at this stage will continue on with her rehabilitation with her regular
vet given there is no surgery recommended at this time.
Advised rest for another 2 weeks and stop paracetamol now, but continue previcox and gabapentin for
another 2 weeks before weaning off previcox and then gabapentin after that.
SURGERY DISCHARGE NOTES (for Sousie Alt 14/12/2021)
Summary:
Sousie underwent CT scan of her spine, forelimbs and hindlimbs to investigate for a possible cause of
right hindlimb weakness/lameness along with suspected spinal discomfort.
Multiple changes were seen in her spine and her forelimbs, a number of which we would suspect are
incidental and unlikely to be causing her any clinical issues. Such incidental findings include: the changes
associated with her right abductor pollicus longus sesamoid, the left accessory carpal bone palmar
enthesiopathy and the bilateral calcaneal enthesiopathy. Sousie shows no signs that these lesions are
affecting her clinically and they would be deemed mild.
Also evident, was mild bilateral medial coronoid disease in her elbows, associated with mild degenerative
joint disease. It is hard to know whether these changes are affecting her at all, and clinically she does not
show any major discomfort with manipulation in her elbows, and also does not show significant lameness.
It is also unlikely given her clinical condition at this time, that surgical intervention with her elbows will
benefit her.
4 of 6
Re: Multiple issue case
Yes... the rest of the story helps fill in the blanks a bit.
While it's hard to follow, I think you need to break it down into manageable parts.
LH lameness after running about, and RF sore as well. BUT the dog was fine before that.
What of these finding makes the most sense?
I'd guess the LSDD for the hind leg, and elbow for the front leg... but the neck could be an issue.
That's based on simply betting on which problems would be the most problematic.
However... a physical exam that can confirm / localize the problem holds more weight than just a bunch of pictures. So, really, nothing matters without the physical exam. I'd go back and do the physical exam, slowly and objectively and THEN decide which of the CT findings correspond.
Sorry... it's sort of like looking at the whole of the alphabet and then asking, "What words do they spell?" Too many options. You need to knock some of the differentials off the list...
Laurie
While it's hard to follow, I think you need to break it down into manageable parts.
LH lameness after running about, and RF sore as well. BUT the dog was fine before that.
What of these finding makes the most sense?
I'd guess the LSDD for the hind leg, and elbow for the front leg... but the neck could be an issue.
That's based on simply betting on which problems would be the most problematic.
However... a physical exam that can confirm / localize the problem holds more weight than just a bunch of pictures. So, really, nothing matters without the physical exam. I'd go back and do the physical exam, slowly and objectively and THEN decide which of the CT findings correspond.
Sorry... it's sort of like looking at the whole of the alphabet and then asking, "What words do they spell?" Too many options. You need to knock some of the differentials off the list...
Laurie
LAURIE EDGE-HUGHES