Possible TMJ with cervical disc disease

[JuliPotter]

I would appreciate your thoughts on Sassy! What concerns me the most is that I am not sure of the cause of the muscle atrophy over her skull and the fact that she yelps with the slightest touch of her head behind her right ear.
Sassy is a 13 year old (DOB 3/26/2005) Jack Russel Terrier owned by Stephanie Frye. In January of this year, the owner touched Sassy’s head behind her right ear and Sassy cried out. (Radiographs from her initial veterinary visit are attached) Initially, Sassy was treated with tramadol, gabapentin and laser therapy and the owner did not notice any improvement. Since then, the owner has noticed that Sassy is not as social and she tends to withdraw from the family. Sassy does twitch her ears all the time. As well, the owner has noticed that Sassy won’t open her mouth all the way and she eats slower than normal. Sassy no longer barks normally.
Sassy has seen by the orthopedic surgeon at VVS in Charlottesville as well as the neurologist at BVNS at Dogwood in Richmond. On February 19th, the day of the visit to the neurologist, Sassy did develop a head tilt; the head tilt disappeared 2 days later. An MRI was performed and there were no significant findings. The neurologist dispensed valium but the owner has noticed only slight improvement. Sassy was recently taking antibiotics for a possible tooth root abscess but there has been no improvement. The diagnosis is still open.
Recent blood work was done on 1/26/2018 – CBC- HCT – 44%, Chemistry – TP – 5.7, Albumin – 2.8,
AST – 96, Corrected Ca – 9.7, Na – 148, K- 5.2, Na/K – 28, HWT – negative, a Urine sample was not submitted.
Today, March 26, Sassy is Bright, Alert and Responsive; she is a very sweet girl and readily takes treats! The owner reports that Sassy’s current weight is 14# and her current diet is Life’s Abundance.
Sassy has mild kyphosis, her back legs are longer than her front legs, there is a very slight head tilt to the right and the palpebral fissure of the right eye is slightly smaller. When Sassy is relaxed, not distracted, her left ear twitches frequently. There is moderate muscle loss over her head (Temporalis, Masseter, Frontalis). She avoids an oral exam and I was not able to evaluate lateral deviations of her maxilla; she appears painful with lateral pulls and rostral glides of the mandible. The angle of the jaw feels thickened, worse on the right, and is painful with palpation.
The space between the Occiput and the Atlas appears to be smaller on the left side and she resists flexion of the AO joint. She is reactive with palpation of C2, C6, C7 on both the right and left sides. The epaxials of the C-spine feel atrophied and tense. The first rib on the right feels more cranial and she moves away with palpation; the pectorals are tense. There is muscle atrophy of the right triceps, decreased extension of the right shoulder and decreased flexion of the right carpus.
Thoracic spine - Sassy flinches with lateral pressure of the spinous process of T8 – T13/L1 and she flinches with palpation at the rib angle of ribs 8-13.
There is muscle loss in the right pelvic limb, quadriceps and hamstrings, the quadriceps are tense and the hamstrings are low tone. The right patella is more mobile and she resists palpation of the left patellar tendon.

Performed –
Side glide of C6 – C7 from the left to the right (grade 2)
Gentle traction of the C-spine
Right & Left - Rostral glide of TMJ (grade 2)
Rib springing of ribs 1-13 on the right side
Gentle traction of the lumbar spine

Thank you!
Juli

[JuliPotter]

I forgot to mention that Sassy did have an MRI on 2/19 when she went to the neurologist and there were no significant findings.
I apologize that the radiographs are upside down!
Thank you!
Juli

[drwall]

Juli,

Interesting case in which I think it is quite evident we can probably not explain your very detailed findings with one simple cause.

Regarding the atrophy of the muscle of mastication and pain my considerations would be;
- TMJ - oblique radiographs of the skull can be use to better visualize the joint and/or CT scan
- Masitcatory muscle myositis - 2M antibody testing and/or muscle biopsy - Comparative Neuromuscular Laboratory - University of California, San Diego [http://vetneuromuscular.ucsd.edu]
- Trigeminal Neuralgia/Tumor - MRI

Pelvic limb muscle atrophy likely due to decrease weight bearing. Always rule out CCLD.

[lehughes]

I would agree.. quite an interesting case.
In a scenario such as this. I'd see how the dog did with your treatments (did the mobilizing help... if yes, then you're on the right track.) But if not, or just a short lived improvement, then it might be one of those cases that traditional medicine can't answer.

I've had a handful of these in the last 3 years, where the vet 'system' (multiple vets) couldn't come up with an answer. Nor could I. So I made a suggestion to see a holistic / Chinese Medicine vet for a totally 'outside the box' look at the dog. (And for us, we have THE guru, Dr. Steve Marsden, just 3 hours away in Edmonton). On all of these occasions, Dr. Marsden did find 'something' (TCM) and whatever herbs etc he put the dogs on, did the trick.

I've always keep my 'holistic vet' recommendation in the back of my mind for cases such as these.

Laurie

[JuliPotter]

Dear Dr Wall and Laurie,
Thank you so much for your responses.
I am concerned that there may be several underlying problems .....Sassy's most recent bloodwork, as reported by her rDVM, showed a mild decrease of albumin, a slight increase in CPK and a mild increase in liver enzymes. UA is still pending. Blood work done in January, did not reveal an elevated CPK or globulin as one might expect with an acute onset of masticatory myositis but several other vets (including one who does acupuncture) have suggested to the owner that this is the problem and have recommended testing. I agree that testing for 2M antibodies is a good idea; I just don't want to overlook other possible problems. I do believe that Sassy has neck pain and pain at the TMJ though this could possibly be secondary problems....actually, she is reactive with palpation along her T-spine and Lumbar spine as well! My concerns - Sassy is eating with no vomiting or diarrhea, so why is she losing weight? What is causing the decrease in albumin. With this patient, I wish I could be more involved in the medicine workup. Maybe we will have some more answers next week. Thanks for listening!