Neurologic Border Collie

[lehughes]

Hi Laurie,

Hope you’re doing well. Sorry to bother you again with my difficult cases

I have a very weird IVDD case and I was hoping you may be able to guide me with some questions…

Here is the case…
Apollo is a 7 year old M/N Border Collie. On 11/27/2020 He went down on the hind limbs after a year of intermittent limping (no therapy, only rest and meds were prescribed). He was taken to the specialty hospital the same day. On physical examination, he had no
motor or deep pain sensation in his hindlimbs, with withdrawals absent in both hindlimbs, and sciatic and patellar reflexes absent in the left hindlimb. He had pain on palpation of the thoracolumbar region of the spine, adequate to decreased anal tone, and normal forelimbs and cranial nerves. (per ER report)

He had an MRI done. Here are the conclusions:
There is left-sided extruded disc material, hemorrhage, or a combination of the two causing severe extradural spinal
cord compression from the midbody of L2 through to the midbody of L4. A hemorrhage sensitive image series is not
included to help differentiate between the two. There are numerous other degenerative discs but the remainder are
unlikely to be contributing to clinical signs. The hyperintensity of the cord is likely secondary to edema with
myelomalacia a less likely consideration if supported clinically.

11/27/2020 - L2-3, L3-4 Hemilaminectomy (left)

11/30/2020 - discharged - neurologic status static, without signs of decline or improvement

12/30/2020 - initial evaluation with me for home rehab - specialist had suggested rehab at their facility, but client lives too far away and they don’t have another rehab facility nearby.

Upon assessment…
- No motor - bilateral hind limbs
- No deep pain sensation
- No withdrawal
- Fecal incontinent
- Requires bladder expression
- Absent DTRs bilaterally
- Unable to sustain sit even when positioned
- Unable to sustain sternal even when positioned
- No hind limb tone

Fast forward to 2/1/2020
- Everything from the above list remains static except he now has some hip flexor activity, mostly reflexive
- Able to hold a sit when hind limbs placed
- Able to hold sternal when hind limbs placed
- Hip flexor tone increased, pretty much unable to extend both hips at all… barely get to neutral. And when I try to do an “active” stretch over the peanut, I get a audible and palpable pop over the R hip. Clients are exceptionally compliant with exercises which include hip extension PROM / psoas stretches
- We’ve been using proprioception wraps from day 1, no response even when left on most of the day
- We should be getting wheels from Jenny Moe this week


Here’s the confusion and questions…
1. I’ve tried NMES in pretty much all possible settings, at max intensity, and placing pads at several different sites and I get NO RESPONSE… not even a little twitch. The only place I get a twitch and evident reaction from Apollo that he feels the current is at the lower lumbar paraspinals. Below the iliac crest… NOTHING… this seems very odd to me. I find this very odd. What are your thoughts?
2. I was reading your blog on lasering the s*** out of an IVDD patient, something like 20J /cm2…. would you recommend I try something like that with this little guy? So far, I’ve done 3J/cm2 (superpulsed probe / Respond 2400VS) along the entire spine on both sides of the spine
3. Do you have any ideas, perhaps on FourLeg, for exercises I can do with this dog outside and in the cart? I’m running out of ideas… So far we’ve done:
1. side to sternal
2. weight shifts in supported sitting
3. weight shifts in sternal
4. Standing over peanut - I provide joint compressions and stabilize the hind limb, human brother lures to walk forward for a hip extension stretch, also lures to step onto 1 foam block (Apollo will not allow us to touch his front paws), also weight shifts backwards as I provide downward pressure through the hocks
5. Pelvic tilts with manual feedback through pelvis & hind paws
6. Modified sternal side crunches (he refuses to go fully on his side)

Thank you SO much for any feedback you may be able to give me regarding this case. I really appreciate it!

E.

[lehughes]

Okay... so it seems that this dog has suffered a progressive lesion (myelomalacia)... and at this point, you're not getting anything volitional back. You have a combination of upper motor and lower motor signs... so the cauda equina has been affected as well... which fits with the bladder findings as well as the lack of reflexes and the lack of response to the e-stim. While neuro is always a crapy shoot, it is very unlikely (read 'pretty much impossible') that this will get better.

So, I would then re-evaluate your goals.
1. bed mobility (as you describe above)
2. ability to hold an upright posture (in sternal or sitting)
3. prevent or minimize further loss of hip extension (here, you have unopposed tone of iliopsoas... you're only going to get so far.) Standing over the peanut is great. But it sounds like there is a bit of a subluxation already... ugh. Hopefully you can keep neutral.

4. Cart.
5. Teach bowel and bladder maintenance
5. Bowel and bladder MANAGEMENT (not maintenance)
6. Teach mental stimulation
7. Discuss things to watch for (bladder infection, pressure sores...)
8. Address the compensations (T/S pain, forelimb overuse (lats), etc)

This dog will not walk again - so the owners need to understand how to manage the dog they have.

Back to laser... It won't fix this. This isn't coming back.
Proprioceptive Wraps... there's no sensation... and it's not coming back either.
Direct them to Sarah MacKeigan's FB group for support from peers as well.
https://www.facebook.com/groups/1467331210138935

That's about it! You've done everything you could have. With the multiple segment involvement, the poor dog didn't really have a chance.

Laurie

[lehughes]

Thank you so much for your feedback

I’ve already directed them to Sarah’s group as well as a canine enrichment group with lots of ideas.

The clients are exceptionally diligent about bladder and bowel management. I suspected a UTI about a week ago, within 2 days they were at the vet getting that checked out and on meds to take care of the UTI

That prognosis is exactly what I was picturing but I was holding onto hope for the sake of the family They’ve adapted pretty well but at the same time, they’re pretty heartbroken over this. Apollo is super active and driven to “work”. We are anxiously waiting for the wheels to arrive to give him some freedom

In terms of the exercises or length of therapy... any other suggestions? How long would you see a patient like this once you’ve put them in their wheels?

E.

[lehughes]

As for the patient, your job after the wheels will be check ups for maintenance or identification of issues that need to be focused on... because most of it will come down to them managing their dog. We've had cases like this that come for hydrotherapy (Pool mostly) as an exercise / change of body use, and sometimes massage for the front end overuse. It really is very owner specific as to what they want to do and what benefits they see. You could say monthly, every second month, or quarterly. I'd say that one of the first two is best for maintenance.

L