|
|
Post by brysoncorgi on Dec 16, 2013 22:48:29 GMT -7
Hello, my name is Ivy and I've been lurking around here since our 9 year-old corgi, Bryson, was diagnosed with IVDD on Nov 14. Reading everything here has been so helpful, but I've come to a point where I feel like we're at a cross road and need help navigating… So here's Bryson's story: he's a Pembroke Welsh Corgi, and we got him when he retired as a champion show dog at the ripe old age of 3. He's been happy and seemingly healthy, super mellow and enjoys long walks, and all was well until the summer he was 5, when he was diagnosed with Addison's Disease (adrenal insufficiency), when he almost died during his first crisis. Long story short, after lots of adjustments (with our excellent regular vet), we found the right mix of meds for him, i.e. predinisolone 1.5 mg daily (he's 35 lb, this is a physiologic supplemental dose), plus Percorten, which he's doing well on. Around Nov 10: we've noticed that he was a bit reluctant to go on stairs, we couldn't attribute it to any specific injury, but we just came back from a road trip to LA, and thought maybe he was just tired. Nov 14: the reluctance got a bit worse, so we took him to his regular vet, who did an exam (including his back) and couldn't find any obvious pain/ neurologic signs, and thought it may be mild front leg arthritis. We got some Traumeel and Dog Gone Pain, and took it easy... Nov 15: He had some initial improvement, but the following day he was in so much pain he cannot be touched on his sides, and more reluctant to get up to walk (he could walk normally once he gets into position, and no wobbling at this point). Also never lost bowel/ urinary functions. Too him back to vet, and they did an x-ray and saw narrowing disc space between T11-12. That's when they diagnosed him with possible IVDD. P redisolone dose was increased to 3mg twice daily with a tapering schedule, plus Tramadol x 2 wk, and Pepcid 1/2 tab daily, and referred to a board-certified neurologist for further eval
Nov 16: saw neurologist, pain was slightly better, some reluctance walking but gait was normal, no other neurologic deficit at the time. He concurred with a mild IVDD diagnosis, and instructed to up pred to 4.5 mg twice daily, then taper over next week and crate rest. Discussed MRI but decided to wait since he was not doing too bad
Nov 18-19: disaster strikes… our neighbor who didn't realize how bad he was hurt tried to be helpful and took him out on a nice, long walk…. yikes. Also pred tapered to 3 mg am/ 1.5 mg pm. The next day he could not get up, hind legs were never completely paralyzed but very wobbly at this point. The neurologist was actually in England demonstrating spinal surgery so we contacted our regular vet. Saw him and upped his pred back to 4.5 mg twice daily, with very slow tapering over the next 4 weeks. We also put him in STRICT crate rest this time.
Since then, he's received laser therapy (3x/wk the first week, then 2x/wk, then once/wk), and acupuncture twice (he got worse both times after acupuncture so we've held off of it). He was observed by the vet on these visits, and he's shown gradual improvement, with some set back when his pred dose was tapered, and combined with his Addison's, we've decided to be very conservative in tapering, and now he's still on Pred 3mg in am/ 2 mg in pm. He was able to get off Tramadol with no more pain.
His appetite and bm has been normal, but he's lost 5 lb (from 35-30 lb) in 3 weeks, lots of muscle atrophy (and sounds like it's more significant than others on pred?)
He's now about 4 weeks out from his diagnosis, and we saw his neurologist today for a follow up. He confirmed that his symptoms have worsened and he's showing some gait disturbance (wobbly walk, occasional falling to butts) and knuckling. He suggests an MRI and possible surgery. We scheduled the MRI for tomorrow with surgery possibly the day after, since I'm have some time off these next couple of weeks, thought if he needs surgery it may be good to do it soon so I can take care of him.
But now coming home I'm having second thoughts... given that he's never completely lost use of his hind legs, is not in pain now, has intact bowel/ urinary control, and is slowly (very slowly…) improving… even if there's something fixable on his MRI tomorrow, is that the best choice for him? What questions should I ask the neurologist to help weigh the pros and cons? And like many others here, I also don't want to delay surgery if it's needed, as the surgeon told us the chances of recovery is better when surgery is done in the acute vs chronic phase.
We have a 4 year old daughter but we always call Bryson our "first born". We want to do the best for him and really need some help so we can make the right decision...
By the way, Bryson has his own blog 
www.thesenakams.typepad.comThanks in advance! Ivy San Francisco Bay Area |
|
PaulaM
Moderator. 
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,571
|
Post by PaulaM on Dec 17, 2013 8:41:00 GMT -7
Ivy, welcome to Dodgerlist we are glad you are here. Wonderful that you have been reading and implementing what you have learned. Very unfortunate about the neighbor walking Bryson and that true conservative treatment was never implemented upon diagnosis. What could have very possibly happened on that long walk is that the disc's early healing weak scar tissue developed another tear pushing more on the spinal cord. Nerves cells do not like being pressed on, it causes them to die…loss of nerve functions. The coinciding taper of pred could also have removed the anti-inflammatory properties of prednisone thus increasing swelling. Again the nerves do not like having pressure on them. So since no MRI has been taken and we really do not know which happened, it is best to mark true conservative treatment as starting from Nov 18. It takes 8 weeks for the disc to heal and that only happens with limited movement the recovery suite affords. The meds serve other healing purposes. It would be good to understand both treatments so you can make the best decision on whether to continue with conservative treatment vs. when to consider surgery. www.dodgerslist.com/literature/healingsurgery.htmBryson could be a good candidate to recovery with conservative treatment since he still has relatively mild symptoms and you are committed now since 11/18 to 100% STRICT crate rest 24/7, carried out to potty and then just a very, very few footsteps to get the job done. 100% STRICT crate rest 24/7 only out to potty for a full 8 weeks …. No laps, no couch, no sleeping in bed with you, no meandering around during potty times. No baths, no chiro (aka VOM). In other words do everything you can to limit the vertebrae in the back from moving and putting pressure on the bad disc. The purpose of crate rest is to act as a cast of sorts to let the disc heal… only limited movement of STRICT crate rest allows that to happen…there are no meds to heal a disc. Immediate neuro improvement (knuckling, wobbly walking) may or may not come during the 8 weeks of crate rest… as nerves may take more than 8 weeks to self heal. Here's the way prednisone works during conservative treatment. 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 back at the anti-inflammatory level, pain meds and Pepcid AC to protect the GI tract are needed. If there is no pain on the taper then Pred goes down to the needed low level to treat Bryson's Addison's. Then no more pain meds at all are needed. If you have been doing 100% STRICT rest and there have been several attempts to taper pred but the pain keeps reappearing, then surgery should be a consideration as it would seem a piece of disc is lodged into the spinal cord and needs to be physically removed. Surgery seeks to relieve pressure off the spinal cord. Surgery does not heal nerves just as conservative treatment does not heal nerves…the body has the potential to regenerate nerves..self-heal with time. Dr. Isaacs (neurology) has answered questions we all are interested in about surgery here: www.dodgerslist.com/literature/surgery.htmI, too, would be inclined to continue with the non-invasive conservative treatment since you are reporting improvements…. with an eagle eye to observing for any worsening neuro functions. 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 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. [Making Sense of the Neuro Exam] 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. We are here to support you with either decision. |
|
|
|
Post by brysoncorgi on Dec 17, 2013 9:57:26 GMT -7
Thanks, Paula for your response and all the information. Everything I've read here is so helpful, I have read (and re-read) Dr. Isaac's surgery consideration article many times, and also watched some videos of laminectomy on IVDD dogs.
I guess our main question now is: what's the risk vs benefit of doing surgery now as opposed to waiting a few more weeks (i.e. the full 8 weeks of crate rest) then re-evaluate? Yesterday at the neurologist, it seems like surgery was the obvious choice, given that his symptoms are relatively mild and "early" so surgery success rate is good, and waiting a few weeks doesn't seem like a good idea as he pointed out by then surgery success may diminish some with time, and the beginning of the year our schedule would be crazy and I won't have as much time to take care of him post-op...
But now, reading everything here including other's experience, waiting those few more weeks doesn't seem like as bad an idea as we initially thought (how much does surgery success rate really go down from Week 4 - 8??). Also, with his Addison's Disease, even though it's relatively well controlled, he does seem to be more sensitive and takes longer to recover from even minor illnesses. I'm now afraid that the surgery may pose more risk than benefit. Maybe all he need is more time to heal on his own...
A couple of benefits that I can still see with surgery though is he can get off of the high dose steroids sooner, I'm concerned that he's already lost 5 lbs and shows pretty significant atrophy everywhere (may be related to his Addison's, and maybe he'll need slower rehab?). And this neurologist does fenestration, which at least in my mind may be a good preventative measure, so we don't have to live in constant fear it may recur...
One other point the neurologist made to steer us towards the MRI is to rule out other illnesses that may mimic IVDD. I'm not a vet (I'm a pharmacist :>), but from his symptoms it seems like IVDD is the most logical diagnosis (at least for now), is it worth $2000 to make sure we're looking at a horse and not a zebra?
Sorry for all the questions.... I'm taking Bryson to see his regular vet in about an hour for his laser therapy, and will try to ask her the same questions too. The MRI is scheduled this afternoon so I need to make up my mind soon.... any thoughts you have would be soooo appreciated!
Ivy & Bryson
|
|
PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,571
|
Post by PaulaM on Dec 17, 2013 10:32:59 GMT -7
Surgery is not something to take lightly…it is invasive, there is risk that something could go wrong. On the other hand when it is needed it is the most wonderful thing. Do not be pushed/rushed to surgery as this IS a big decision, there is no need to make a decision by this afternoon, Bryson is not an emergency… he is not in extreme pain, he has not lost bladder control, he has not lost the last neuro function (deep pain sensation). Even if he had lost DPS, he'd have a window of 12/24 hours to get a surgery. We have even seen many, many dogs who did loose DPS and surgery just was not an option walk again. Nerves can and do heal. Bryson has good potential to heal his nerves since he is only wobbly walking. Conservative treatment will allow the disc to heal and Bryson can work on self healing his nerves. Sure you can do surgery with knuckling..you will have to decide the risks of surgery removing disc material and will Bryson be able to self heal his nerves? Would Bryson do just as well with non-invasive conservative treatment to let the disc heal itself and be reabsorbed and still be able to self heal his nerves? 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 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. [Making Sense of the Neuro Exam] 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. The benefit of surgery is that PT can start days after surgery. Muscles have likely atrophied, weight loss during 100% STRICT rest that conservative demands. Muscles always come back when it is safe to resume physical activity after graduation day.
Illustratrion: www.dodgerslist.com/literature/vertebraeillustration.jpg
Fenestration is controversial among surgeons. There are 27 discs. Fenestration deals with the adjacent discs to the bad one. Bryson was born with disc disease there is always the potential for any other discs to also herniate as they prematurely age. Fenestration takes more time on the table, longer anesthesia. There are pros and cons to fenestration on a case by case decision. If you choose conservative treatment there is no need to know exactly which disc is problematic. All discs receive limited movement under conservative treatment. Surgeons however need to know which disc to plan out the surgical procedure and that is done just prior to the surgery. If Bryson where not improving under conservative treatment, then you would want to know why. MRI's can help with that diagnosis…and to see if the treatment needs to be different. X-rays can be helpful in ruling out other potential causes of spinal cord damage, including tumors occurring in the bone, fractures, discospondylitis, and discospondylosis. MRIs are of course the gold standard in advanced imaging as they show "detailed images currently available of the spine, spinal cord, nerve roots, and discs. It also permits examination in multiple planes (side-to-side, top-to-bottom, and front-to-back) so that no macroscopic lesions escape detection, and it permits the most precise surgical planning." or MRIs can detect something else that could mimic IVDD. MRI's require anesthesia. The patient’s primary defense against further disk extrusion is dependent upon adequate control over the trunk muscles … this defense is eliminated with anesthesia. vetspecialistsofrochester.com/pdf/UnderstandingIntervertebralDiscDiseaseInDogs.pdf#zoom=100
I would be inclined to see how conservative treatment continues, with an eagle eye out for any signs of neuro worsening at which time I would give consideration to surgery. Jan 13 conservative graduation day or Jan 28 post op graduation day |
|
|
|
Post by brysoncorgi on Dec 17, 2013 17:54:17 GMT -7
Thanks again for all the info and advice! We went back to his regular vet today, and after looking at the way he walks (weak but less ataxic), she concurs that it is reasonable to give him a few more weeks of medical tx before re-evaluating for surgery.
Thanks again, and hoping for an uneventful few weeks of crate rest (for Bryson and many others here!)
Ivy
|
|
Marjorie
Moderator~ 
Member since 2011. Surgery & Conservative
Posts: 5,724 
|
Post by Marjorie on Dec 17, 2013 18:12:40 GMT -7
I'm very glad to hear that, Ivy. Please keep us updated on his progress.
All the best to you both.
|
|
