Susan's Demo 9/1/17 Surgery 4wks (5/3/17LDA)

Lifelong vet found bulging disc in Dec 2016 and we did conservative care and went to Specialty Surgery Center for following and possible preventive ablation.

May 2017, immediately post ablation, Demo in terrible pain and did not have quick recovery and pain free as promised.  I took him in several times to be told he was fine.

July 28, 2017, he fell over and wouldn't use back right leg.  I took to surgeon who said it was a muscle pull.  I told him he had never been the same since the ablation but this was drastically different.  They sent us home, completely missing a ruptured disc.  I called back the next day when in more pain, Dr. was out for 2 week vacation.

I took him to a "better" vet who sent us to the Center for Veterinary Specialty & Emergency Care.  They did a $4000 MRI, I picked him up today breathing funny and smelling of urine.  MRI shows disc extrusion.  The Dr. had said surgery would have 85% chance of improvement.  Got home and saw notes said that had been reduced to 50%.  I called in and they said they have no doctors on site or on call over weekends.

I need a capable, safe, place to care for my dog in the Dallas / Ft. Worth area.

This is so frustrating. I again did not see this until now. Sadly, my pup is not my only responsibility.


Neither the surgery center that did the ablation nor the vet who has treated him for 9 years returned my calls today. 


He is awake in his crate and crying some - possibly for some attention since he is used to always being with me.  I am taking him out to pee frequently and he does walk a few steps with weight on all four legs.  He has had one tiny bowel movement in 24 hours.


Dallas has 2 vet neurologists - they are at the center that arranged for the MRI and then had no doctor to speak with me - terrible service.  And the vet surgeons are all part of the place that did the ablation and completely ignored the xray of his L6-L7 and did no more imaging, despite my requests and ignored my statements that he was in so much pain. 

I am fighting this battle alone.

I can either take him to an ER Sunday morning or show up at my vet or the surgeon's office Monday morning and just wait to be seen.  Recommendation?

Hello Susan,   I also live in the Dallas area although I'm out of state at the moment.  I'm very surprised to hear the Veterinary Specialty Center in Lewisville doesn't have a surgeon on call.  I've met with Dr. Ducote.  She is suppose to be a very good surgeon and as you can see, she has a state of the art clinic.   At this point, I would try once more to get to see her or the other neuro there or at the very least get some pain relief for Demo.  Maybe you would have to leave him there.  Then make sure you get to see Dr. Ducote or the other neuro right away in the morning.  With him having other issues she would be my first choice.   Good luck, I wish I was there and could try to help more.  

Linda
Founder, Dodgerslist

What are the credentials of the vet who adjusted the pain meds (DVM, ACVIM specialist)?

Did you ask in the very, very particalar way.... does my dog have any health issue? Not all vets appreciate the damage both stress and Prednisone can do to the GI tract!

Which kind of specialist did the LDA, a neuro (ACVIM) or an ortho (ACVS)? If getting to see this surgeon is the quickest way to get pain relief, then do it. Hope though to hear the increase in Gabapentin and Tramaodol will do the trick.

What is the dose in mL that you now give, we can computer the exact dose in mgs.

Do know there is room to move move up in dose with the Tramadol this vet is not using. And methocarbamol may be the better to control nerve contraction pain.  Nerve root signature pain can be hard to control, so have no patience with pain at all. Other options for pain control could be the addition of yet a third drug called amanatindine. Read up it ahead of tine so you know why you would be advovating for  it: marvistavet.com/amantadine.pml

Susan, first thing is that lower pain is not good enough. All pain is to be FULLY in control dose to dose of pain meds AND when he need to move such as at potty time and to reposition himself in his recovery suite.

If you can help us out, we can better make comment. What is the dose of Gabapentin?  How many mL of gabapentin are you giving 3x/day.

So if you are seeing signs ANY pain, your job would be to strongly advocate for the more aggressive of pain meds approaches.  Root signature pain can be more painful!!
~~ For a 16 pound dog you would expect Tramadol to be prescribed by a vet for 50 mgs 3xday
~~ for typical muscles spasm pain, most vets use methocarbamol. So if you are seeing pain, advocate for trying a different pain reliever.


The reason for a surgery:

~~ is that with repeated attempts to go off of the anti-inflammatory drug Prednisone, the pain will not resolve
~~ As you can see surgery for Demo is not an emergency to be done right away asap.  So I would most definately try for the least invasive treatment (conservative). It can take more than a one time 3-day course of pred. In fact it often will take several tries, several course of prednisone totally 7-30 days. Taper days do nothing to work on painful swelling. It is the safe approach to give a course try a  test-for-pain Prednisone taper to see if another course is needed.  After trying several course the pain just will not resolve, then  surgery is a consideration.
~~ to do that test for pain, requires you to hava the ability to quickly and accurately asses for pain. How can you do that when pain meds are on board?  So pain meds are stopped on the start of a pred taper. If you currently see pain, then of course there is no need to do a test for pain. There is, instead, a GREAT need to get a vet to prescribe another course of pred.
~~ What is going on with pred, the test for pain is to start today 8/14? Did you discuss getting another course of pred since you are still very likely reporting pain (laying still as in reluctant to move, maybe heavy breathing due to pain is a possiblity. Does he ever sit up acting his normal perky interested in life around him self?

pain - shivering, trembling, yelping when picked up or moved, reluctant to move much in crate such as shift positions or slow to move, tight tense tummy, can't find a comfortable position, Arched back. Holding leg flamingo style not wanting to bear weight, head held high or nose to the ground. Not their normal perky selves.

When a neck disc, full-body shakes are uncommon or less vigorous than normal. Dogs look up with just their eyes and do not move their head and neck briskly. They hold up their paws flamingo like because it is too painful to bear weight.

 ~~ another time for surgery is when there is severe damage to the spinal cord, when the last neuro function of the ability to sense a painful stimulus (deep pain sensation -DPS) is lost.  Demo is not there, that is why is is not an emergency case.  Demo is suffering with pain only, root signature pain.

As damage to the spinal cord increases, there is a predictable stepwise deterioration of functions.
1. Pain caused by the tearing disc & inflammation in the spinal cord or nerve root: avoids bearing weight on leg

Neuro damage diminishment progression:
2. wobbly walking, legs crossing 
3. Nails/toes scuffing floor
4. Paws knuckle
5. Weak/little leg movement, can't move up into a stand
6. Legs do not work at all (paralysis, dog is down)
7. Bladder control is lost
8. Tail wagging with joy is lost
9. Deep pain sensation, the last neuro function, a critical indicator for nerves to be able to self heal after surgery or with conservative treatment.
Surgery can still be successful in the window of 12-24 hours after loss of deep pain sensation. Even after that window of time, there can still be a good outcome. 

Susan, thanks for the correction to the med list. Pred did not start on 8/11 but on 8/12 and the taper starts on 8/15.

Not putting weight on a leg is a sign of pain. Not his perky self is pain. Not moving much, only staring at you is pain.  Why should Demo have to suffer with pain til a Wed 8/16 appt? Call on the phone to get him help with whatever, whichever vet will help.
~~  Perhaps a change to methocarbamol 3x/day instead of Diazepam
~~ using tramadol at an aggressive typical  for a  16 lbs dog at 50mgs every 8 hours.
~~ Have a vet extend pred (another course of pred) to help Demo until  you meet with Dr. D on Wed. 8/16  Taper days do not work on swelling and may thus increase his pain.

I have re-read all your posts and best I can tell is this is the chain of events in succinct easier to grasp form:

16.09 lbs
LDA 5/3 reports never had pain relief post procedure
7/28 fell, Dx "pulled muscle"- not strict rest, ever since extreme pain, not bearing left back leg weight.
MRI 8/11, more pain since. Dr. Rich's findings: more risk of surgical hemorrhage , 50% chance for pain improvement.
Prednisone as of 8/12: 5mgs 2x/day for 3 days, then 8/15 test-for-pain prednisone taper
Tramadol 37.5mgs 3x/day
Diazepam 2.5 mgs 3x/day
Gabapentin 50mgs/mL: 100mgs (2.mL) 3x/day

My comments:
--Pain meds have never been at the aggressive dose since the 8/11 MRI clarifying disc --> root signature problem
--100% STRICT rest 24/7 had not been fully instituted due to 7/28 mis-diagnosis for a pulled muscle
--The unnamed "she" neuro gave conservative treatment as another option, but conservative had not really been tried with an aggressive pain medication approach but there is now 100% STRICT rest including very few footsteps at potty time.
--The stomach is not yet being protected by Pepcid AC (famotidine)
-- You have an appt with Dr. Ducote, Neurology (ACVIM) on 8/17 a.m. where the two of you can fully discuss things and come to the best conclusion for Demo: a surgery or to try conservative (only in the case that pain can be fully controlled by pain meds) while pred continues to work on swelling,  the body sees what it can do to re-absorbe or shrink back the escaped disc material pressing on the back leg nerve root coming off the spinal cord going out to the back leg.

I'm so sorry that you're running into such obstacles in getting aggressive pain meds on board so that Demo can get complete relief from his pain and start to heal. Did they at least tell you not to start the taper of the Prednisone today? With obvious signs of pain so recently, there should not be a taper of the Prednisone yet. There is still swelling pressing on the nerves of the spine and still the need for the anti-inflammatory dosage of the Prednisone.

Do you think that the urinating in his crate was due to not wanting to move at potty time enough to do his business because of his pain? When you carried him out to pee this morning, was he able to sniff and release urine on his own?

Usually when a dog can still walk, a vet will try the least invasive treatment first - conservative care. Surgery is an invasive treatment with trauma to the body and includes surgical-associated risks. The spine is very fragile and the surgery is a major one. But the crate rest during conservative care does need to be very strict. The less movement of the spine, the better. Too much movement and the damaged disc can tear more or rupture, causing more pain and possibly more nerve damage. Carried in and out for potty with very few steps at potty time only. Also pain needs to be brought completely under control during conservative care as pain does hinder healing. If those two goals can be met, Demo is still a good candidate for conservative care.

The only window of time for surgery is when there is loss of deep pain sensation. Demo is no where near that at this time. After a dog is paralyzed, the existence of deep pain sensation is an indicator that surgery could STILL be successful. That window of time is 12-24 hours from losing deep pain sensation (DPS). Even after that window of time, surgery is often successful. So at this point, there is no emergency for surgery. However, there is an emergency to get his pain under control.

As for your reservation about conservative care, surgery on this present damaged disc will not ensure that another disc will not rupture or tear in the future. From reading back through the posts, it doesn't appear as though Demo has ever had a full 8 weeks of very strict crate rest for this damaged disc so the damaged disc has not been allowed to fully heal and form scar tissue. You described the first crate rest as "kind of" due to lack of detailed instructions from the vet and that Demo still had times when he moved less/had pain after the "kind of" crate rest.

Here are some pages that would be good reading for you as to speak to the vets.
www.dodgerslist.com/literature/healingsurgery.htm
www.dodgerslist.com/literature/surgery.htm

There is no right or wrong decision regarding surgery versus conservative care. We'll support you in any decision that is made. Prayers for you and the vets as decisions are made and healing prayers for Demo.

Susan, very pleased to hear Demo is in a good spot with pain relief and keeping meds the same til  your  11:30 am appt with Dr. Ducote tomorrow.

You are dealing with root signature pain. That means the piece of disc is not up against the spinal cord being squished against the encasing boney vertebrae canal. Instead the escaped disc piece is down more where the nerve starts to exit the cord going down to a limb. That nerve root is getting pressured and thus the pain. So Demo is not likely to be on any path to loosing deep pain sensation where its loss marks a time to consider surgery.

Why you would consider surgery is that his pain will not be controlled when an aggressive pain med approach has been used. Conservative treatment can't go forward if there can't be full relief from pain while the steroid is working on solving all swelling.

Why you would consider surgery, is for the reason mentioned that when scar tissue lessions develop on the nerve root or any part of the spinal cord, it makes it harder to fully remove. Sometimes we hear reports that a surgeon tried to get all of the scar tissue on the cord but felt the last bit was too dangerous to do. So then it is a waiting game, post op to see then if the pain is gone or not. Sometimes it is and sometimes a dog may end up with the help of long term modern miracle meds to live a happy pain free life.

Why you would not consider a surgery is what Dr. Rich, neurololgy (ACVIM) reported:
Why based on Dr. Rich's findings, you would go forward with a surgery. It may be Dr. Ducote's reputation and her presentation that she feels her skillfulness at this kind of delicate surgery puts you in a good zone of comfort.

All 27 discs can have the potential to age enough to tear.  Could be the same disc, could be a new disc.  Can happen after conservative treatment, can happen after  a surgery.

So, Susan, there is no one right approach. It HAS to be that you and a surgeon discussing all your concerns. You then are able to come to a decision that makes you believe you are making the best decision based on all the information  you have at this time.  We can't make that decision for you.... it is a vet and you thing to do.  We are here to support you with conservative or with a surgery.

Susan, with any invasive procedure, there is risk.  Even a less invasive LDA had an unexpected risk/outcome for Demo. The important thing is you are confident of the surgeon's skills you hire for an operation. The important things is you have asked lots of questions to gain a feeling that a surgery would be a benefit to Demo.

Dr. Isaacs answered alot of questions we've had about surgery: "Surgery needs to be a decision an owner enters into recognizing the risk, but also recognizes the benefit. This way if something unforeseen occurs an owner can be comforted and at peace with the fact that surgery was the right decision and they did all they could for their dog." You will find it worthwhile to read the rest of his answers about surgery: www.dodgerslist.com/literature/surgery.htm

Susan,

So frustrating for you and Demo that your appointment has been delayed after a long wait.  I understand jury duty but they should substitute another Neuro and stop throwing up stop signs in front of you and Demo! I would be beyond frustrated..   

Glad they at least phoned in prescriptions to get you by in the meantime, other than the Gabapentin. It seems strange that all the pharmacies are out of it.  Have you checked nearby towns pharmacies?  Thanks for keeping us posted. 

What are Dr. Ra's credentials--- a DVM,  an ortho (ACVS)?   Which LDA facilty?

A vet tech (nurse) is not qualified to tell you no anti-inflammatory level prednisone dose. she should have said Dr. XX, DVM, ACVIM or whatever credentials said this..... The vet tech would have had to speak to a DVM about prescrbing meds.  And you would want to speak to that DVM to know why.

If you intend surgery to be a possible outcome with an 8/16 Ducote appt, then because pred can disrupt blood clotting, that could be the reason why they want to continue with the taper.

If you are wanting to try conservative treatment, then prednisone would help to get the inflammation down.

IF the current pain meds are holding pain fully at bay, then good, they are right.  If not,  you need to see a vet who will help Demo.  If it takes Dr. Ra or any other doctor to get the meds right, you need to see that vet.  Best is a vet who  has seen Demo for this issue and  maybe a transport would not be necessary.  You can scroll back to my Aug 12, 2017 at 10:41am  post for things you can advocate for better pain relief 

Dr. Ducote's clinic upped Demo's ▲valium and reduced ▼prednisone to see if he would be calmer in his crate and he is sleeping better and seems more like himself.

Demo has always been pretty high maintenance so hard to tell if he is in pain, wants attention, is hungry, is thirsty or needs to potty.  I've been setting him down about 10 steps from food / back door / me to see where he heads and follow that.  PLEASE SPEAK UP IF THIS IS TOO MUCH WALKING AND SUGGEST OTHER IDEAS.  He is walking and putting weight on all 4 legs.  He has also gained weight as I am a very good mother until 2 a.m. and then I would feed him a steak to get him to be quiet.  He is peeing every 2 hours so I'm sleep deprived AND my doctor says I should not be lifting him so much.  The cat is unwilling to help either of us.  :-)

Can I do 8 weeks of strict crate and allow this small amount of supervised walking or will crate rest work ONLY if he does not move at all?

I am going to take him to Dr. Ra in morning but NOT let him take him in the back to examine him and I may not let him even touch him as Demo always comes home sore after being handled.  I am going simply to see what he recommends.  I don't think he will help on pain management because he has consistently told me Demo was NOT IN PAIN unless he was howling or refusing to eat.

I believe Dr. Ra ignored, aggravated, caused or, in the least, was negligent regarding treating Demo's bulge that became a rupture.  I can't think of a way to say it that would serve Demo's best interests though and I doubt he is willing to refund any of the thousands I paid him.  He refused to help Demo's pain back on July 28th because he was going on vacation.  He was back in the office Tuesday and would not see Demo until Friday and when I asked for him to simply call me, I have received no response.  I am really astonished at what we have been through.