Ryan's Woody 2016 surgery6wks- Canada

Ryan, welcome to Dodgerslist. We are glad you've joined us all. There is no right or wrong with deciding for surgery or wanting to give true conservative treatment a chance. The things the surgeon has mentioned are ideas to take into account in your decision making. These two pages will be very important in gaining a full understanding and deciding which is the best option for your family.
--- Dr. Isaacs ACVIM (neuro) answers the questions our group wanted to know more about surgery: www.dodgerslist.com/literature/surgery.htm
--- This page goes over surgery vs what would be expected with conservative treatment, how to monitor for neuro diminishment  www.dodgerslist.com/literature/healingsurgery.htm

For right now we would be best able to help if you can fill us in a bit more:

☐ Let us know you are now on the same page about crate rest.  The hallmark component of conservative treatment is the crate rest part. With little blood supply discs are much slower to form good scar tissue than it takes a blood rich broken bone to heal. That 6 weeks of a cast for a broken arm to heal is similar to the recovery suite being a kind of cast for the disc. 100% STRICT crate rest 24/7 for 8 weeks provides limited movement to allow good strong scar tissue to form.
STRICT means: 
- no laps                    - no couches
- no baths                  - no sleeping with you
- no chiro therapy      - no meandering at potty times.

Carry to and from the recovery suite to the potty place and then allow a very few limited footsteps. Using a sling (long winter scarf, ace bandage, belt) will save your back and help to keep a wobbly dog's back aligned and butt from tipping over.  A harness and 6 foot leash is to control speed and keep footsteps to minimum as you stand in one spot. 
An ex-pen in the grass is an excellent alternative to minimizing footsteps with the physical and visual to indicate there will be no sniff festing going on!

Super tried and true tips for setting up the recovery suite in far right column- look for the pink box on this page: www.dodgerslist.com/literature.htm

☐ Is there still currently pain beyond the neuropathic pain of licking biting lower body such as: - ◻︎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 ◻︎restless, can't find a comfortable position. ◻︎arched back, ears pinned back ◻︎head held high or nose to the ground.  ◻︎ holding the back leg flamingo style not wanting to bear weight ◻︎not their normal perky selves . 

☐ How much does your Woody weigh?  Please list the meds Wood is currently on. The dose in mgs and how often each is given.  For how many days is/was the anti-inflammatory Rx'd for?
   Metacam as of date?:  ?mgs  ?x/day for x days?
   gabapentin  ?mgs  ?x/day
   Pepcid AC (famotidine)

It is prudent to use an acid suppressor (Pepcid AC) with any use of an anti-inflammatory which causes extra stomach acids.

☐ Eating and drinking OK? Poops OK - normal firmness & color -no dark or bright red blood?

NOTE: During conservative treatment, anytime out of the recovery suite is a dangerous time for the healing disc. Movement of the back can increase a disc tear and escape of disc material into the spinal cord . For an animal with very mild neuro deficits, the risk of transporting to therapy has to be carefully weighed against what benefit is to be gained.

The date 7/7 in the subject line reflects the date you are starting true conservative treatment until a surgery decision is made..... the crate rest is the single most important part. There are no meds to heal a disc just the 100% STRICT crate rest 24/7 only out to potty for a full 8 weeks.

Ryan, as you may have already read, the expectation with conservative treatment is that the body will be able to reabsorb enough so that the disc or disc material is not pressing on the cord. There are situations where that does not happen and a surgery may be the option to physically remove the offending disc material.

Licking per se is not damaging. Dogs will lick themselves many times as a comfort thing, a calming thing or as a grooming thing. However, you will want to be observant for obsessive licking escalating to breaking the skin, biting or deadly chewing off body parts in an attempt with neuropathic pain to alleviate quite burning painful sensations. Gabapentin is the drug that helps to tame this kind of nerve pain and he is on an aggressive dose of it.

Have prepared a towel you can fold lengthwise to wrap around the neck and secure with duct tape to prevent him from reaching his lower body as you get to the vet for an e-collar and see what other meds can help with neuropathic pain.

Do let us know specifically that Woody is in no pain. "not that much pain" "relatively comfortable for the most part" would too much pain. Often it takes three kinds of pain meds to address each source of typical pain with a disc episode. Tramadol as the general pain reliever, methocarbamol for muscle spasm pain and gabapentin for nerve pain. So.  as you can see, IF you are seeing pain there is much in a vet's medicine bag to provide complete comfort from pain. What are the specific observation of pain you see and when do they occur.... nearing next dose of meds, when moving such as at potty time or repositioning in his crate?

A pain med chart can be quite useful to make notes and see patterns with meds as a basis to discuss/advocate with your vet.
D/l and print from here: www.dodgerslist.com/literature/crateRRP/medchart.pdf
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Ryan, the time to reduce pain meds is when the test for pain stop of metacam begins. As no one wants to be using Metcam or any antiinflammatory past the benefit of all painful swelling resolved, many vets will try a 7 or a 14 days course. Then call for a test for pain stop of Metacam and the pain masking pain med.  If there is no pain, then no meds at all are needed.  If pain would surface then it is known another course of anti-inflammatory, pain meds and stomach protection is warranted.  The full scoop on how anti-inflammatories are used with a disc episode is well worth reading or re-reading:  www.dodgerslist.com/literature/healingsweling.htm

Please let us know what the bottle says about how long a course of metacam has been prescribed...7, 14 days or ?

Do let us know what your surgeon or your vet says about how long wound healling/lesion development on the cord might take.... how long before a piece of escaped disc material might be kinda grown into/stuck to the cord?

On the Forum we have observed too many issues even death because the stomach was not protected with the relatively safe for a health dog over the counter Pepcid AC (famotidine). So now we do stress to follow those vets who appreciate the need for GI tract protection. North Carolina U. recognizes the high incidence of GI irritation in dogs with disc problems. The reasons are that pain and body changes are stresses. Just as humans can experience ulcers when under stress. NCU and 11+ hospitals working with NCU prescribe a GI protectant. Dogs presented to NCU with IVDD often develop GI upset whether they are given anti-inflammaotry meds or not.
www.cvm.ncsu.edu/vhc/tc/clinical_services/neuro/acute_disc.html

Fenestration to my knowledge and personal experience with my own dog does not cause the bony vetebrae to fuse together.  My dog walked quite normally with a fenestration on either side of a bad disc.  His back was not stiff. The entire disc is not removed only the inside material that has maybe hardened in order to prevent vertebral pressure from causing a tear to the exterior of the disc which is no longer very elastic and cushiony.  What did the surgeon say when you asked about that dog, could it have been other diseases such as developing arthritis, a bone infection disease, etc.

Please let us know what the bottle says about how long a course of metacam has been prescribed...7, 14 days or ?

We did the 8 weeks of crate rest and our boy healed nicely! It's called strict crate rest though and they mean it! He was completely paralyzed couldn't even pee on his own 😪 Really listen to this boards advice! They're experts on IVDD and many vets are not... Good luck!!!!

Thanks guys.

Woody has been on crate rest since Thursday officially. He seems pretty good overall - no pain at all, except for what I assume is just a mild discomfort when he licks his back-left paw. (Doesnt seem painful).

However, last night, for seemingly no reason (although he was chewing a bone which we had given him to occupy him), he all of a sudden was very uncomfortable. He wasn't whining or anything, but coudln't sit still. He would lie down, then twitch or kick his legs, then get up and reposition. Over and over. And he was sort of convulsing as if to throw up, but didn't.

It was about time for his pain meds anyway though so we gave those to him and went to bed - although I kept an eye on him. He settled and today he seems fine again.

I know we're early in crate rest, but is it normal to see a little up and down in terms of how things progress?

Ryan, would you be able to tell us what the stumbling block is to getting stomach protection on board? Pepcid AC (famotidine) 5mgs 2x/day?

I introduced Woody a couple weeks ago. He's been on crate/room rest now for 2 weeks and seems to be doing much better - no pain at all from what we can see, happy, pep in his step, wants to play, etc. We took him to our regular vet a couple days ago (rehabilitation specialist) who did a physical examination of his back (he literally goes through each vertebrate checking for pain reaction). There was virtually no pain, compared to few weeks ago where he was very sensitive. So that was good, and based on what he saw, he recommended we go with conservative treatment. However, right after that visit our vet hopped on the phone with the neurosurgeon who did Woody's MRI couple weeks ago to compare their findings.. and now our regular vet - based on that phone call, has said that actually, surgery would probably be our safest option... So now I'm am just totally lost in what to do, and I'm having a hard time coming to a logical decision..

So, here's fully story up to current day:

History of Back Episodes:

1st episode: September 2014. He just seemed a little painful/uncomfortable. For probably a month following the episode, he was on 100mg of gabapentin and 0.5kg of metacam (for 2 weeks). We also did a few laser therapy treatments. He seemed to recover pretty well and quickly from that.

2nd episode: March 2015. Pretty much same as above.

3rd episode: happened in January 2016 while running through the snow. He was in pain/uncomfortable, but not "screaming" in pain and no neuro deficit at all from what we could tell. For almost 2 months from this time we took it a lot easier with him - a lot of rest, slow, flat walks, no jumping, etc. He was on 100mg of Gabapentin every 8 hours for this time, as well as 0.5kg of metacam for probably 2 weeks when it first happened. We also did laser therapy and acupuncture for the first 2-3 weeks. He seemed to recover fairly well, but ever since this episode up to today, he now licks his back-left paw every night, and occasionally even nibbles the spot between his thigh and back.

4th episode: happened mid-June 2016 after spending a week with his brother (wrestling) and chasing squirrels. This one seemed to cause him the most pain, and his back-left leg was clearly painful, stiff, and stuck out to the side. For the first couple weeks we employed same treatment program as above - except this time upped his Gabapentin dose to 200mg every 8 hours, but he was borderline getting worse - or at least not getting better. That's when I thought it was time to go get MRI to see exactly what is happening. At the same time as the MRI two weeks ago, we read more on Dodgerslist and decided to put him on stricter crate rest, which brings us to current date. (Before this time, we had never employed FULL crate rest. Yes, we always prevented him jumping and leaving him unattended, but would still take him on short leashed walks).

Latest MRI photos (low res): imgur.com/a/ITY5Q

- Spinal cord compression between L2 & L3

- Mild lateral herniation around L5
- Neurosurgeon also seemed to think Woody might have mild deficit in back-RIGHT leg because of the compression up and to the right of the spinal cord. However, our regular vet has since re-tested this and there is very minimal difference in the reaction time to flip the paw back over for the back-right paw.

Neurosurgeon recommendation:
The neurosurgeon who analyzed the MRIs seemed to think this is a chronic issue that will keep recurring, and said he is probably licking his back-left paw because of a tingling sensation caused by the pinched nerve root from L2 / L3, and that this tingling will likely never go away.

Knowing our lifestyle with Woody (lots of travels, meeting people, etc), he recommended a type of surgery that involves coming in from the side (as opposed to cutting in from the top), drilling two holes in the vertebrate, and then using a (stick?) to enter through the first hole and push disc material out the second hole - to relieve spinal compression. He recommended this procedure as it is less invasive, allows for quicker recovery time, and would also be less visible afterwords.

Our regular vet (rehabilitation specialist):
Following the MRI, we went to see our regular vet who specializes in rehabilitation. He observed that Woody was walking absolutely fine, no arch in his back, no pain. He recommended to continue with conservative treatment; room rest, gabapentin/metacam, laser therapy, and acupuncture.

However, following the consultation he spoke to the neurosurgeon over the phone. It seems our regular vet was under the impression that the L2/L3 herniation was a recent, acute lesion, whereas what he had been treating before (and the causing of the licking/tingling) was likely caused by a minor lateral herniation at L5ish. BUT by the neurosurgeon's point of view (and ultimately influencing our regular vet's opinion), it seems it is more likely that it has been this L2/L3 herniation all along causing issues, and is a chronic disc, and is likely the one causing the tingling/licking as well. So, our regular vet called us back and said ultimately, he thinks it would be safer in the long run to do the surgery suggested, since; it's a chronic disc, is pushing on the spinal cord, and the surgery is minimally invasive enough that rehabilitation and recovery would not be that bad...

Today:
It's been two weeks since the MRI and recommendation from the neurosurgeon, and about 2 days since our regular vet gave his recommendation. After two weeks on crate/room rest he seems to be doing better. He is showing no discomfort (except for occasional licking of back-left paw) and has a pep in his step. However, he is still on pain meds, so it's hard to say. We are doing very short, slow 5-minute walks just to keep the muscles around the spinal cord strong.

The predicament:
We realize it is probably a chronic issue, and there's a good chance it will come back in the future. How bad, or when, I don't know. We also worry that if he were ever to have another serious episode while away on travels in a foreign country, it could be a very dangerous situation if he needed emergency surgery. So, surgery is appealing in that it could solve this issue (for that disc) once and for all. But for some reason it still feels like we may be jumping the gun, as generally the rule of thumb from what I've read is that "surgery should be a last resort", and it seems we're considering surgery more of a "preventive" measure than a "reactive" measure. So.. is that still a good reason for surgery??

We're just having a hard time comprehending that we're going to put a walking, happy, (seemingly) pain-free dog into back surgery, with some scary risks, like potentially making it worse than it is. But on the other hand, if we wait and wait, it will likely come back - and how bad will it be the next time?

Side note:

I don't want to stir the pot so to speak, but I just want to throw another opinion out there on crate rest. Our vet specializes in rehabilitation and in his opinion, feels the "strict" crate rest is a traditional approach, but in fact, musculoskeletal considerations are very important for back recovery. Muscles will deteriorate very quickly with little to no movement, and it's those muscles keep the spinal cord and discs in place. Especially after 2 months of crate rest, there is much more stress on teh spine to support itself with all that muscle degeneration. And for 1 day of no muscle use, it takes 3 days to recuperate it to the same state. So 2 months does a lot of damage. He says the reason most people employ "crate rest" is because the alternative is free-for-all. But if you can allow the dog to walk around in a very controlled environement, including very short, slow walks (no jumping, running, playing - or anything that causes the back to bend quickly) then this is much better for keep the muscles strong around spine. He says even in poeple nowadays who experience disc herniations, physical therapy starts virtually immediately. Just wanted to put that out there. Even the neurosurgeon we spoke to agreed with that. 

Ryan, the crate is to keep them from over doing, going on walks is overdoing... it is causing vertebral pressure to that weak disc trying to heal.  There is no proof that all the spinal cord swelling has been resolved until all meds have been stopped and there is no pain.  When there have been several repeated attempts to stop meds and yet the pain will not resolve, that would be time to consider surgery to avoid a life time of having to use pain meds to enjoy life. If the pain has not resolved in 28 days of metacam it may well be time for a consideration of a surgery. Disc healing is a whole different matter.... there are no meds to help a disc form scar tissue...that takes limited movement and time of 8 weeks.  So until there would be a surgery, let that disc heal, protect the spinal cord!
12.5 pound
gabapentin 200mg 3x/day
metacam (1.5mg/ml )as of 6/23: 5kg dose 1x/day for 14 days
                               as of 7/7: 5kg dose 1x/day for 14 days 

Was Metacam extended?  Is gabapentin the only med on board now?

Disc disease demands owner understanding the the disease. Muscle tissue will always come back when it is safe to again have the back, the vertebrae moving.  There are potty breaks every 4-6 hours where the few footsteps will keep muscle circulation up and joints flexible. If there is too much movement before the disc has healed in 8 weeks there is a good chance for that still weak and early healing disc to do great damage to the spinal cord. Would the spinal cord become too severerly damage it will not ever come back. Woody would then have been sentenced to life-time paralysis. My instincts follow along with vets who do understand IVDD that the priority is to preserve the spinal cord by waiting til all 8 weeks of 100% STRICT crate rest have been completed before beginning a slow introduction back to physical activity.  Not all vets know IVDD, that is why it is so important to do your own reading so you are prepared to politely say "no thank you" to harmful advice.

Disc surgery, btw, IS NOT a minimally invasive procedure!
The vertebral bone is drill/cut into, muscle tissue is cut and the surgeon will be working on the spinal cord itself in removing escaped disc material...that is no small thing, no minimally invasive procedure at all! Things can go wrong. That all being said when you have a qualified, well trained surgeon and the surgery is needed it is a wonderful thing and the risk of surgery is reduced.

When there are repeated disc problem at the same disc (a chronic situation) that could well mean the time to consider if surgery is an option for your family. Ryan, there is no right or wrong answer here about when or if a surgery.  The decision is to be made by you weighing all the factors so that as Dr. Isaacs, ACVIM (neurology) says:  " It is important to not be rushed into making the decision and have the opportunity to ask as many questions as needed. 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.  There is a balance between the risk associated with surgery versus the benefit gained if all goes well. With any surgery there is the potential risk that the patient may be permanently worse after the procedure. The risk is greater with intervertebral disk disease that is severe, at multiple sites, and chronic compared with mild, single site, acute."  The rest of Dr. Isaac's information is here:  www.dodgerslist.com/literature/surgery.htm  Also recommended reading on surgery here:  www.dodgerslist.com/literature/healingsurgery.htm

Surgery immediately removes the offensive disc material and stops the pressure on the spinal cord. Immediate neuro improvement may or may not come during the 6 weeks of post-op rest… as nerves may take more than 6 weeks to heal… in fact there is no time limit for nerves to heal. There may be temporary neuro setbacks caused by the swelling the surgical procedure itself causes. Surgical swelling likely will subside in two weeks so that the true direction of nerve healing can better be seen. Dr. Isaacs, DVM, ACVIM (Neurology) addresses Dodgerslist members' questions on surgery:
www.dodgerslist.com/literature/surgery.htm

It is great that Woody is walking well.   The knuckling is a caused by the nerve damage and should improve over time. 

I am going to ask a few questions to help us understand Woody's post surgery situation better.
▷ Is the surgeon a general practice DVM or a specialist (ACVIM neurology or ACVS ortho)?

▷ What medications are currently being used. Please include dosage and frequency?
▷ Is Woody showing any signs of pain at this point?
▷ Is Woody eating and drinking OK? Poops OK - normal firmness & color -no dark or bright red blood?
▷ How long did the surgeon recommend for crate rest?

Water therapy is excellent for a post surgery dog.  My Frankie walked on an underwater treadmill after his crate rest was over following his surgery.  I don't think he would have recovered nearly as fast without it.  

Here is a video of what it looks like:


We have some information about supplements for the IVDD dog here:
www.dodgerslist.com/literature/Supplements.htm

Ryan, if you had a chance to read our supplement article, Romy pointed you to, you'll see there is no research evidence to prove if the GAG type supplements do anything to keep a disc maintained and from prematurely aging. If money is no object you can try them as they likely would not do any harm....do read the supplement article for the full story:

Consider that Woody is like a stroke victim in having to relearn coordination of muscles with the nerve messages sent to his paws and legs. I really sounds like Woody is on a very good path of nerve repair. Nerves are slow to heal and something we need to accept that it just takes time. Maybe thinking in terms of months rather than days/weeks.
The very best therapy will be the underwater treadmill, as it really expedites the ability to re-learn how to walk and place paws properly plus strengthing his muscles: www.dodgerslist.com/literature/Supplements.htm

If the dark spot in the poop was black, tarry digested blood, then it is the GI tract that has been damaged by the Metacam and the reason your vet asked that it be stopped.

Pepcid AC works to suppress the extra acids that Metcam and ordinary stress can cause. By discussing with the vet if sucralfate can be added, that med will place a gel coat over any of the damaged areas of the stomach linings (ulcers) that were bleeding and under the gel coat provide the right environment for better healing. Read so you know why you are advocating for sucralfate and the timing it will need with food, with Pepcid AC:
marvistavet.com/sucralfate.pml

Ryan, sounds like maybe just the Pepcid AC with food and no more metacam will be work. Hopefully no post op pain will surface.. if it does you would just alert your vet and likely just pain meds would be adjusted for a bit longer.

Ryan, we follow the vets who use the higher end of the range for Pepcid AC. Dogs are creatures of routine, when their "usual" changes, they can get stressed just as people do and produce more stomach acid. And. of course, all anti-inflammatory drugs can cause an increase in stomach acids.  So for a 12 lbs dog 5mgs of Pepcid AC 2x/day is the usual.