Marcy's Lilly 9/25 conservative Terrier

Hi, welcome to Dodger'sList! My name is Sabrina - what's yours? I'm so sorry to hear of Lilly's diagnosis, but I'm so glad you've found this forum. If you haven't already seen it, be sure to check it out this page: YES, Your Dog CAN Have a Great Quality of Life! - www.dodgerslist.com/index/SDUNCANquality.htm - it gave me so much hope when my dog was first diagnosed!

With this disease self education is critical not just so you make sure the right things are being done for the best recovery but also for your own emotions. The unknown is simply a scary place. (Boy, is it ever!) Get ready to fight this disease now and in the future by knowing all things IVDD. Have you found the articles on the Dodger'sList main site yet? If not, start with "Overview: the essentials" and then read all you can as soon as possible. Here's the link www.dodgerslist.com/healingindex.htm

Could you fill us in on a few more details about Lilly's current condition?

-- So glad to hear Lilly's on crate rest - is it 100% STRICT crate rest? (24/7 only out to potty …. No laps, no couch, no sleeping in bed with you, no meandering, scooting or dragging around during potty times. No baths, no chiro (aka VOM)?) What date was 100% Strict crate rest started?

-- Is there still currently pain - shivering, shaking, crying when picked up or moved?

-- What are the exact names of meds currently given, their doses in mgs and frequencies?

-- Poops OK - normal color and firmness no dark or bright red blood?

Dodger'sList has a comprehensive "must-have" $3 DVD on IVDD for you to add to your arsenal of educational resources. Friends, family and those who will be caring for Lilly should also watch this DVD; plus don't forget to order one DVD for your vet www.dodgerslist.com/store/DVDorder.htm

With IVDD, pain should be controlled so that Lilly feels no pain dose to dose. If she's showing any signs, call your vet and ask that the pain meds be adjusted.
Pain Control: www.dodgerslist.com/literature/healingpain.htm

Is Lilly on a stomach protector like Pepcid AC? Cortisteroids (Prednisone, Prednisolone, Dexamethasone, etc.) are involved with stimulating gastric acid secretion causing GI upset to the more threatening bleeding ulcers or holes in the stomach or intestine. Phrase the question to your vet in this particular way: "is there any medical reason my dog may not take Pepcid AC?" If there is no reason, we follow vets who are proactive in protecting the stomach by giving doxies 5MG Pepcid AC (generic name is Famotidine) 30 mins prior to steroid. Pepcid AC is a generally safe over-the-counter suppressor of stomach acid production for healthy dogs. Dogs don't speak up at first signs of trouble like a person would. By the time we notice black or red blood in the stools, things can quickly go from bleeding ulcers to a life threatening perforated stomach. We ask that all members read about each med their dog is on or may take as a safety measure. This directory is in alpha order:
www.marvistavet.com/html/pharmacy_center.htm

My own dog was diagnosed with IVDD this past July, and I had to wrestle with the surgery vs. conservative treatment decision. Here is a great page comparing the two:
www.dodgerslist.com/literature/healingsurgery.htm

From what you've described, it sounds like Lilly is a good candidate for conservative treatment.
As damage to the spinal cord increases, there is a predictable stepwise deterioration of functions. When nerve healing begins, often it follows the reverse order.
1. Pain caused by the tearing disc & inflammation in the spinal cord
2. Wobbly walking, legs cross <-------- Lilly is here
3. Nails scuffing floor
4. Paws knuckle
5. Legs do not work (paralysis, dog is down)
6. Bladder control is lost
7. Tail wagging with joy is lost
8. Deep pain sensation, the last neuro function, a critical indicator for successful surgery. Surgery can still be successful in the window of 12/24 hours after loss of deep pain

In regards to the MRI - since Lilly's improving on conservative treatment, I'd discuss with the neurologist if they judge they still "need" the test or not. Diagnostic tools of an MRI, CT or myelogram not only see discs and spinal cord but also can confirm if another disease that can mimic disc disease is the problem. So if symptoms would worsen under conservative treatment, it makes sense to consult with a specialist and possibly employ one of the advanced imaging tools.

I know that there is sooooooo much information to process!!! When my Charley was first diagnosed, I had to re-read everything so many times before things started falling into place in my addled brain! Do fill us in on some more details about Lilly. We are here to support you!

))Hugs!((
- Sabrina

Marcy, one has to weigh the benefit of a dog who has pretty good neuro function and seems to be healing just fine with conservative treatment (i.e. pain is controlled, disc is healing itself due to crating, neuro signs are not diminishing) VS the risk of an invasive procedure that could make things worse as your surgeon told you. Most surgeons would not operate on a dog who has such good neuro function and the pain is in control…they would continue to monitor conservative treatment.

An MRI is not something to take lightly as it involves anesthesia which basically takes away the dogs main defense against further disc tearing because the trunk muscles will be asleep. So if LIlly is on a good path, I agree, why an MRI at all at this point.

Dr. Isaacs, ACVIM (Neurology) forthrightly answers our members questions about surgery. www.dodgerslist.com/literature/surgery.htm

How the meds work with conservative treatment. During the time on the anti-inflammatory, Pred  the pain meds do need to be adjusted so that there is no pain surfacing dose to dose of pain relief medications.  You report Lilly has no pain…very good!!

Often it takes being at the anti-inflammatory dose of prednisone (5mg 2x/day) for 1-2 weeks or even for some dogs more like a month before all the swelling is gone. When the vet guesses swelling might be gone there will be a taper. The dose is lowered to less than the anti-flammatory dose your job at home would be to assess just how well reduction of swelling is going by observing for any hint of pain. To have a clear picture on a taper, pain meds are also stopped or backed off too.

Rule of thumb is:
pain = swelling = more time on Pred needed.

If there is no pain on the taper then it goes to completion. Then no meds at all are needed. Disc healing will continue for the remainder of the 8 weeks. Nerves can continue to self heal…think in terms of months.

The surgeon may be starting the pred taper because of a possible impending surgery or he is guessing all the swelling may be gone by now.  If Lilly is in the neighborhood of a 13-20lbs dog, the pain meds she is on are very, very light and for a dog still with a lot of swelling, would not do the trick of giving comfort.  How much does Lilly weigh?

We see everyday dogs with far worse signs of loss of bladder control, loss of legs having a good outcome with conservative treatment. It will take a commitment of 8 weeks of 100% STRICT rest 24/7 only out to potty in order to let the disc heal.   I personally would opt for going with conservative until you see it is not working… so far it IS working.  Dr. Isaacs kinda sums it up best as he writes in the article I mentioned above:  Any dog can be managed medically. However, typically the decision to treat medically versus surgically is dependent upon the risk:benefit ratio. If the same outcome can be obtained medically versus surgically then it is wise to treat medically. 

We are here to support your decision with either conservative or with surgery.

Thank you all!

I am in the process of composing an email to the Neurologist in regards to my question of surgery vs conservative treatment. It is a lot to process right now, especially as I notice Lillys improvements after the Pred taper. I will update once I receive a response.

In regards to your question of weight, Lilly only weights 10 lbs. I am assuming that is why her pain med doasage is light. I also wanted to ask if her panting was a side effect or indication that she's in pain? She no longer trembles or shivers.

Hi Paula,

I hope you dont mind that I quoted some of your words and learning literature in the letter I wrote to the Neuro regarding Lilly's surgery vs conservative treatment. This is what I wrote:

Dr Bodreau,

Since Lilly's appointment on 10/17/13, I have done extensive research on IVDD. At this point I am trying to weigh the benefit of Surgery vs conservative treatment for Lilly. Since her appointment, her pain is controlled, she's walking better, her neuro functions are not diminishing, she is tolerating 'crate rest' well and all after the Prednisone taper of 1 x's daily. I am assuming that the disc is healing itself to some extent at this point but wanted your professional opinion prior to making the decision of surgery. Since she appears to be healing, I just dont want to have to take the risk of an invasive procedure that could make things worse for her, rather consider 'conservative treatment', rehabilitation and therapy.

I thought to just have the MRI done so that you could could tell me whether or not the spinal compression is enough to validate surgery but I was told that an MRI is a pre-surgery prep and if I am going put her through the anesthesia that it involves, I midas well do the surgery. I was already advised that if she does have a ruptured disc and decompressive surgery is pursued, her pain would resolve but it has already moderately subsided. Also, because of the length of time since the onset of signs (9/22/13), it is difficult to give a prognosis for Lily’s return to function and she could already be in the healing process. Since she is now walking (almost normally now) She may not regain voluntary motor skills post surgery as you mentioned the other day. It has already pretty much been confirmed that the Neuroanatomical localization is within the T3-L3 region. So why exactly would I do the MRI if I am not 100% sure about surgery at this point?

Do you have any statistics on how many patients do well with conservative therapy and what the risks of it are? If I opted to proceed with the conservative treatment route, would you continue to monitor her, show me how the meds work with conservative treatment and teach me how to care for her? (Rehabilitation referrals, etc) I am aware that conservative treatment would take a commitment on my behalf but either way, I am committed to Lilly's health and well being.

I am weighing the options and I am sure that the decision to treat medically versus surgically is dependent upon the risk/benefit ratio. I feel like if the same outcome can be obtained medically versus surgically and her quality of life would have the same outcome, then wouldn't it be wise to treat medically with rehabilitation instead, based on her remarkable progress? Please share with me your opinion based on your evaluations and the level of her deep pain sensation/motor functions/etc.during her neuro exam , if you thought think this route would be appropriate and beneficial for her.

Thank you for assisting me in the decision of whether or not surgery is warranted at this point. I trust your opinion and UC Davis Animal hospital has been very pleasant. Whatever the decision may be, I look forward to Lilly's healing process with you.
Please forward this email to Dr Knipe for her input.Thank you greatly.
Respectfully,

Marcy D.


AND THIS WAS HER RESPONSE (although she didnt answer a lot of my questions):


Hi Marcy,

I think that if Lilly is continuing to improve with her current treatment, and you are not interested in pursuing surgery for her if a compressive disc were identified on imaging, that it is a good idea to just continue with your current treatment plan of rest and a tapering prednisone dose.

We know that there is a relatively high chance of recurrence of signs for dogs that have suspect disc herniation that are treated conservatively, but there is also a chance of recurrence (at a different site, usually) in dogs that have surgical treatment on confirmed disc herniations.

If Lilly’s signs do not continue to improve, worsen again at any time, or recur after full recovery, we would recommend reconsidering possible diagnostics and surgery in the future. If she continues to do well, you may not have to worry about these issues again.

I have forwarded your e-mail to Dr. Knipe and am awaiting her response.

--
Dr. Beth B


Thoughts? Opinion or Recommendations?

I'm very Happy to announce Lilly had her first appointment with Rehabilitation/physical therapy today. She had a laser treatment and water treadmill time. She tolerated it well. I have video & wish I could post it here to show people that 'conservative treatment' is as good an option as surgery is. I was skeptical Weeks ago but for the first time today, after Lilly's consult the therapist said, ”I definatly think you made the right choice with conservative treatment. We'll have her well & taking neighborhood walks in no time!” She asked that I taper her to every other day dosages of prednisone. I'm confident that I made the right choice to skip surgery!!!

Premature rehabilitation was something I asked her therapist today. She assured me that she would start mildly but although there is no trembling, I do hear a low 'hisp' sound from her when picking her up out of her create to go potty (which was something she hadn't done for two weeks.)

She recommended the pred taper of every other day versus once a day but I haven't started that until tomorrow.
Its still 5mg prednisone once a day & tramadol 50mg twice a day.

Dr. Medina has been an Associate Editor and regular contributor to the AJTCVM since its inception. She is on the Board of Directors for the International Veterinary Academy of Pain Management and the American Association of Rehabilitation Veterinarians. She is is currently the only boarded diplomate of ACVSMR (canine) in the State of California and works closely with IVDD patients.

She knew Lilly's timeline. Perhaps giving her another 3 Weeks is best.

Everyone has an agenda. Your job is to question everything, try to figure out the agenda if they are not up front about it. For example often the agenda PTs have is to make sure there is no muscle deterioration by getting PT started soon to the exclusion of protecting an early healing disc, some surgeons feel a disc episode has an exclusive surgical solution when many have and can heal with conservative treatment. Our agenda here at Dodgerslist is clear and we are very up front about it.. we follow the vets who are successful with conservative treatment by informing their clients how important crate rest is to healing a disc.

Discs only heal with little movement…there are no meds to heal a disc…the recovery suite for 8 weeks is how to ensure a disc heals.

Muscle tone will always come back after crate rest is complete when the disc has formed good secure scar tissue and it is safe to again begin physical activity.

The spinal cord is very delicate. If a bad disc pressure the nerves too much the nerves could have the potential to be permanently damaged and never come back. It's a no brainer…protect the spinal cord at all costs by 100% STRICT crate rest 24/7 for 8 weeks.

When Lilly has no pain and is off all medications, and still on conservative treatment you should do the very, very lightest and least aggressive of passive range of motion and massage for her legs… that is the link above Pauliani pointed you to to read the info highlighted in PINK if Lilly can't move her legs herself.

Glad to hear Lilly is doing well. Dobby has had acupuncture treatments and I think they have helped.