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Post by Dawn & Arnie on Oct 27, 2019 8:03:36 GMT -7
Hello. Answers to the introductory questions:
1. Yes there still pain when he tries to go out for bathroom trips and is uncomfortable being carried. Primary symptom is right front leg pain only relieved by lying on his belly with head on floor. Seems comfortable the rest of the time. Is able to sleep.
2. He weights 15 lbs. Currently on meloxicam - 6 kg dose once daily, Tramadol 50 mg every 8 hrs, gabapentin 50 mg every 8 hrs, methocarbamol 125 mg four times per day. Not on Pepcid AC. Will pick purchase today.
[Moderator's Note. Please do not edit 15 lbs 10/10 Cervical diagnosis: meds Rx'd? disc relapsed Oct 24 -neck pain Meloxicam as of 10/25: 6kg dose 1x/day for ? days, then a test stop to reveal any: _pain / _neuro tramadol 50 mgs 3x/day gabapentin 50 mgs 3x/day methocarmabal 125mgs 4x/day not on Pepcid AC ]
3. Eating and drinking fine
4. Miniature Dachshund, Arnold is his name, My name is Dawn.
5. Got a likely diagnosis of cervical ivdd. Had mild episode of left front leg pain August 10, 2019. At that time X-rays were taken and sent for radiology consult. Thoracic limbs were normal and no orthopedic abnormalities were noted. His diagnosis at that time was mild soft tissue injury of the front leg. (There was some narrowing of the disk space at C5-C6 which may have been associated with nerve root compression manifesting as lameness noted on the radiology report). His symptoms resolved by the following day.
This most recent episode occurred the evening of October 24. Sudden onset of pain right front leg, very painful, lying down flat with head flat on ground. Took to emerg vet morning October 25 and was given a likely diagnosis of cerival IVDD based on previous history. Plan was to treat conservative unless neuro deficits appear or pain cannot be controlled.
He is currently on crate rest and being carried out to bathroom. He is having difficulty managing these trips outside because that is what elicits his pain.
Should I have expected some amount of improvement by now or is it still too soon? I am trying to decide at what point to seek a referral to neurologist vs going to his regular vet for additional pain meds.
Thanks
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PaulaM
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Post by PaulaM on Oct 27, 2019 9:12:57 GMT -7
Dawn sorry to hear of a relapse since the 8/10/19 episode surfaced. Since you last posted back in Feb 2017 are you still in Canada? What happened with that disc episode-- did he continue to heal with conservative or did he have a surgery? Did you do 100% STRICT crate rest 24/7 only out for a very, very few footsteps at potty time on 8/10 so that the disc could heal?? Was he Rx'd meds on 8/10? Just trying to figure out why the increase of pain on Oct 24. In one hour IF the pain meds were correct, then there would be no pain dose to dose of the 3 pain meds and no pain when having to move such as at potty time. Can you call your vet if he's open Sundays, or get him to ER today to get the meds adjusted. Never have any patience with pain at all...pain deters the healing process. --- gabapentin may be able to increased in mgs every 8 hrs. --- a fentanyl patch can be added to help get the pain back in control. The effective life of the patch is about 3 days in dogs -- Amantadine: When meds are properly used at the aggressive dose and 3x/day but pain is still not fully controlled, then bring to the discussion with your vet the addition of amantadine for further control of that tough pain. Pain is a complicated issue. Often it will take 3 pain med for full control. Each pain med works on a different type of pain. Amantadine is something we are seeing neuros Rx as part of the pain med cocktail as it allows other analgesics to function more effectively . The Mar Vista vets explain the mysteries of amantadine www.marvistavet.com/amantadine.pml Basically when stressed as our dogs are with a disc episode they may be more susceptible to physical pain. Muscle spasms hurt worse, everything hurts more. Amantadine alone is not an effective analgesic but when combined with the other IVDD pain relievers (methocarbamol for muscle spasms, gabapentin for nerve pain and tramadol as the general analgesic), it adds an extra dimension of pain relief. At this time veterinary experience with Amantadine is rather limited but it seems to be emerging as helpful addition to pain relief regimens for our IVDD dogs. As always be fully knowledgeable about each med by reading the link provided above. Is a surgery a consideration for your family? Read up ahead of time about conservative vs. a surgery. when to get a consult about surgery, and more. This is must-do reading for you: www.dodgerslist.com/literature/healingsurgery.htm
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PaulaM
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Post by PaulaM on Oct 27, 2019 9:32:17 GMT -7
The Meloxicam Rx'd on 10/25 is to be taken for how many days? Another thought on getting that pain in control. Meloxicam belongs to the lower power class of anti-inflammatory drugs. Switching to the most powerful class (the steroid) class may well help to get that painful swelling move in the direction faster. CONCERN with any switch between classes of anti-inflammatory drugs is DOUBLE STOMACH protection because pain is deemed an emergency where the normal 5-7 days of washout is not used. Instead double protection not only of the Pepcid AC but the addition of sucralfate is impletmented with the switch to the steroid pills (prednisone). Dr. Wong, DVM, Neurology (ACVIM) in a Oct 25, 2019 live Q&A explained: “I would say for the majority of IVDD dogs, prednisone to me works better. When I say steroids I specifically mean prednisone at anti-inflammatory doses meaning .5mg/kg twice a day for 3-7 days, then decrease to once a day for a few days , then every other day for a few days. Source: " Dr. Wong Answers Your Questions about IVDD " Advance to 1:34:21 to view. Learn how anti-inflammatory drugs (Non-steroid NSAIDs and steroids) are used during a disc episode, more good info to have under your belt as you advocate for Arnold: www.dodgerslist.com/literature/healingsweling.htmPlease bookmark Arnold's thread. We are anxious to get feedback from you on what changes to his meds the vet has made to get Arnold out of the great torture he is in. Thank you...here is Arnold's thread to bookmark: dodgerslist.boards.net/thread/7158/dawns-arnold-rlpse-conservative-canadaBookmark a thread to receive an email alert when someone has replied 1. Go to your Profile> Profile Edit > Notifications: checkmark BOOKMARKS + "instant" email 2. Next, go to the CONSERVATIVE Board: checkmark your dog's thread, then use the ACTIONS button to select "bookmark"
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Post by Dawn & Arnie on Oct 27, 2019 9:59:04 GMT -7
Thank you for your quick reply. Yes I am still in Canada. His previous presentations have always been very vague compared to this one. I have had difficulty even obtaining a diagnosis of IVDD. In 2017, his pain was difficult to localize and I really had to advocate for treatment with the typical ivdd pain meds and anti-inflammatory. I did institute 100% strict cage rest for 6 weeks and he did very well. No surgery or even recheck appointmentwas required. His pain was resolved within only one or two treatments but I continued the meds for 1 week anyway just to be safe. The episode in August of this year was equally vague and frustrating. The emerg vet did not find obvious neck pain beyond the left front leg lameness. The same meds were instituted at that time as he is currently on now. His lameness was completely gone within 24 hours. The comment by the radiologist was that a neuro consult was warranted given the clinical signs if neck pain was present on physical exam (it wasn't).
I discussed the possibility of neck pain with Arnold's regular vet and he was of the opinion that since his symptoms resolved so quickly and there was no obvious neck pain, that it was unlikely to be a disk. He really felt that it was a soft tissue injury to the front leg. There was no strict rest period because I wanted to believe him, though my gut told me otherwise. In hindsight, I believe without a doubt that the August episode was cervical ivdd, even though it's the other front leg affected this time. This is the only episode that the pain has persisted for more than a day so that's why I don't really know what to expect in terms of response to treatment.
I would pursue a neuro consult and even surgery if it was recommended. My nearest emerg. clinic is one hour away. I am trying to decide what to do today. Arnold is comfortable when he is resting in kennel, it is only when I take him out that he is painful. I'm stuck on whether to pay another emergency fee to get fentanyl patch today, or wait until morning to see regular vet and at the same time discuss when and if to get a neuro consult.
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PaulaM
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Post by PaulaM on Oct 27, 2019 14:00:13 GMT -7
Dawn, with a disc episode there are 4 phases of healing. When the pain healing phase has been resovled, that does not mean the disc healing phase is complete. This page has a really great timeline to help you visualize what heals when, what promotes healing (each phase is different) Here is the link: www.dodgerslist.com/literature/healingpage.htm
Here are the extra things you can do at home to help with a neck disc: www.dodgerslist.com/literature/cervical.htm
It sounds very, very much like a nerve root signature pain. That certainly WOULD BE pain caused by a neck disc but the animal perceives the pain is in the limb and does not want to bear weight on it!! The pain is actually where the nerve root exits off of the spinal cord going out to the front limb. A piece of disc material is pushing on that nerve root going to the limb. Quite painful!
The Veterinary Specialists of Rochester: In some dogs, the internal degeneration of the disc itself might stimulate sensory nerves and be perceived as a painful stimulus. This is called “discogenic” pain. However, when dogs with neck pain are carefully evaluated, fewer than 5% are found to have discogenic pain as the cause. The other 95% or more are found to have pain due to the actual displacement of disc material from the space between the vertebral bodies into the space above, called the vertebral canal. The vertebral canal is the tunnel which contains the spinal cord and the nerve roots which leave the spinal cord and extend out to connect to the body. Thus, when the disc is displaced it can put pressure on the nerve roots. This is exactly analogous to the problem people suffer with “pinched nerves”. The reason some dogs will hold their arm or leg up is that, as the nerve root which supplies the limb is “pinched”, the brain is fooled into thinking it’s the end of the nerve that is being irritated; the animal probably perceives this as a tingling, numbness or “pins and needles” sensation in its digits.
This Bagley article is written for veterinarians. Excellent information, if you have patience for the technical vocabulary. Good to share with a vet as a basis of discussion for what might be going on with Arnold.
Click to enlarge image Spinal Cord is in yellow. Disc material is pressuring not the spinal cord but the nerve root exiting and leading to the front limb. © Copyright 2015 The Spinal Research Foundation. All rights reserved.
Dr. Isaacs, DVM, Neurology (ACVIM) explains more about nerve root signature pain at the Dodgerlist Neuro Corner: www.dodgerslist.com/neurocorner2/rootsignature.htmhttp://www.dodgerslist.com/neurocorner2/rootsignature.htmSo in order to continue with conservative treatment for a suspicioned neck disc episode: -- The pain needs to be controlled. In light of that, I would go to ER to get meds adjusted today. If with addition of amantidine and maybe a fentanly patch, possibly switching to steroid(prednisone), the pain simply will not fully be masked, then you have your answer. You need a consult with a specialist: ortho (ACVS) or neuro (ACVIM) on Monday morning to give you a good diagnosis of whether root signature pain or something else that may require a different treatment.
SIGNS OF PAIN: ◻︎ shivering-trembling ◻︎ yelping when picked up or moved ◻︎ slow to move ◻︎ tight tense tummy ◻︎ arched back, ears pinned back ◻︎ restless, can't find a comfortable position ◻︎ slow or √reluctant to move much in crate such as shift positions ◻︎ not their normal perky selves + NECK Disc pain: ◻︎ looks up with just eyes and does not move head and neck easily. ◻︎ not eating due to painful chewing or in too much overall pain ◻︎ √holds front or back leg flamingo style not wanting to bear weight ◻︎ head held high or √nose to the ground. QUESTIONS:-- For how many days is the Oct 25 Meoxicam for?
Dawn, would you keep us posted on Arnold. Hope that pain can be controlled so he may heal in comfort.
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Post by Dawn & Arnie on Oct 28, 2019 16:32:22 GMT -7
Just a quick update on Arnold. We were not very successful getting any additional pain meds. I called the emergency clinic yesterday (Sunday) before heading down and they said they wanted to speak with the vet before I came. He called me back and it ended up being the same one I saw on 10/25. He advised that Arnie was pretty much maxed out on everything that he had in his arsenal and that he would give the meloxicam a little more time to work. He seemed to think that because his appetite was still so good that it was a good sign. He also added that I could consider repeating the x-rays from August to see if there was any change. I felt this would be a waste of my money since it probable would not tell us anything. I was not very encouraged by the conversation and did not end up going down to see him. I finished setting up Arnold's recovery suite instead.
This morning I took him to his own vet as soon as they opened. His bathroom trip this morning went quite well. He was able to manage a bowel movement and a pee in the same session without needing to lie down for pain relief. He walked quite well with his limp barely noticeable. The vet did not get too far in her exam as Arnold can be quite difficult to examine. He usually needs to be muzzled. He did become uncomfortable from all of the movement but she was unable do a very thorough exam of his neck/back.
I asked about additional pain meds, specifically Amantadine. She said she had very limited experience with it. She discussed the possibility of other meds such as codeine or buprenorphine. She also said I could increase the ▲Gabapentin to as much as 100mg (Arnold was currently on 50mg every 8 hrs). I requested a neuro consult and she requested a bit of time to look into the various pain med options. I was able to get a consult with a board certified neurologist on Wednesday October 30 at 1 pm. In the meantime, the vet called back to say she had done some checking and that quite a lot of neurologists were in fact using Amantadine but she was having difficulty sourcing it. In the end, I ended up only increasing the Gabapentin. I gave him 75 mg at 2 pm this afternoon.
Yes, Pepcid AC 5 mg twice daily with his meals as of yesterday evening.
[Moderator's Note. Please do not edit 15 lbs 10/10 Cervical diagnosis: meds Rx'd? disc relapsed Oct 24 -neck pain Meloxicam as of 10/25: 6kg dose 1x/day for ? days, then a test stop to reveal any: _pain / _neuro tramadol 50 mgs 3x/day gabapentin ▲75 mgs 3x/day methocarmabal 125mgs 4x/day Pepcid AC 5mgws 2x/day]
He was with me all day in his kennel just resting while I attended to my job. When we got home this evening he had a pee and again seemed to be walking much better, with no sign of pain. If there is any pain this evening I will increase the Gabapentin to 100mg. Maybe the anti-inflammatory has begun to work better and the increased gabapentin dose will be the only adjustment required.
My next consideration is what to do with him tomorrow. I commute an hour to get to my job and then it consists of more travel and site visits. In the past, anytime Arnold has had health issues, the flexibility of my job has allowed me to just bring him along. He has always loved riding around in his kennel with his little heated bed, as snug as a bug. He came with me today but I am wondering if this is just too much vibration and not restful enough, even though he is confined to his crate. I try to drive as smoothly as possible. I have no one to help me with him and with the med dosing at every 8 hrs, it will be difficult to leave him at home and still stick to the dosing schedule.
Any thoughts on the car travel?
Also, to answer the question about duration of Meloxicam script. There is no duration on the label. It just says 6 kg dose once daily with food.
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PaulaM
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Post by PaulaM on Oct 28, 2019 17:22:01 GMT -7
Meloxicam is not a pain reliever. I'm glad you got an Rx for increase in gabapentin..sounds like it is doing the job! Kudos to you! Good job in knowing xrays do not prove a disc episode and are not used to see what changes there are since the last disc episode. Meloxicam may take 7-30 days to resolve all painful swelling! Most Rx's are for a 5 or 7 day course or maybe even a 14 day course. It is all guess work and you should know the guess. At the stop of meloxicam, then is the test to find out if all pain is really gone. No one wants a dog on any anti-inflammatory one bit longer than necessary.
If Arnold will behave in the car and remain settled down, taking him with you may be an option. Pad out the wire kennel with a rolled up blanket so that when you corner or come to a stop his body will not be shifting.
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Post by Dawn & Arnie on Oct 28, 2019 17:46:50 GMT -7
Yes, Pepcid AC 5 mg twice daily with his meals as of yesterday evening.
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Marjorie
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Post by Marjorie on Oct 29, 2019 6:40:02 GMT -7
Great to hear that Pepcid AC is now on board, Dawn. It should be given 30 minutes before the Meloxicam and then every 12 hours thereafter, if possible. The Meloxicam should be given with a meal.
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Post by Dawn & Arnie on Oct 29, 2019 14:57:23 GMT -7
Thanks Marjorie, yes he gets his meloxicam with his dinner at 6:00 tonight so will give Pepcid now.
Arnold had a good day today so far. Has had two trips out to the bathroom and both were pain free.
Tomorrow is the neuro consult and they told me to hold off on all his meds tomorrow so that they could properly assess his neuro status. This worries me, but I guess they know what they're doing and will treat any pain at the end of the consult. I'm also wondering how much in terms of diagnostics will actually happen tomorrow.
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Marjorie
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Post by Marjorie on Oct 29, 2019 16:10:48 GMT -7
Yes, you should hold off on giving meds for at least 8 hours before the exam so they can make a good assessment of pain. An IVDD episode is usually diagnosed based on breed, history and symptoms. Arnold is still a good candidate for conservative care so an MRI or CT scan would not be needed. MRIs and CT scans are only done just prior to surgery so the surgeon knows where to operate. With conservative care, there's no need to know exactly which disc is damaged as all discs are treated the same.
However, if Arnold's pain is now completely under control (no sign of pain at all? no limping at all?), then the meds are now correct and no further adjustment to meds is needed. So I don't believe a neuro consult would be necessary at this time unless there is still some doubt as to the diagnosis. Transport involves risk of too much movement of the spine and vet visits should be kept to only the very necessary. It sounds as though Arnold is now doing very well on the meds.
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Post by Dawn & Arnie on Oct 30, 2019 15:22:15 GMT -7
So I kept my neuro consult appointment today just for my own peace of mind. Arnold would have been travelling with me today anyway to stick to his med schedule. The neurologist was able to do quite a thorough exam of Arnold. In fact, Arnold has never been more friendly at any exam appointment. There was not a single growl and no muzzle was required. He even wagged his tail and gave a friendly greeting to the neurologist, though it was probably because he was getting lots of treats.
I don't believe he found anything very remarkable on the exam other than the mild occasional right front lameness after walking to the exam room. Given Arnold's history and response to meds, his recommendation was to continue with the conservative treatment and begin weaning off some of the meds. He recommended continuing with the Meloxicam 6 kg dose once daily for one more week maximum. He suggested weaning off ▼Tramadol and ▼Robax but suggested keeping Arnold on ▼Gabapentin 50 mg twice daily indefinitely. He suggested that if these past episodes have in fact been disc episodes affecting possibly more than one disc, then there would likely be some degree of chronic discomfort. He said that Gabapentin is such a safe, well tolerated medication that it would likely benefit Arnold to just stay on it. He recommended MRI should conservative treatment fail.
So, no definite answers without MRI but I am happy to have a well documented plan in place. Arnold continues to do very well and will continue with his 100% strict cage rest. Weaning his meds down to twice daily should also allow me to leave him at home instead of having him drive around with me all day.
[Moderator's Note. Please do not edit 15 lbs 10/10 Cervical diagnosis: meds Rx'd? disc relapsed Oct 24 -neck pain Meloxicam as of 10/25: 6kg dose 1x/day for 13 days, Nov 7th a test stop to reveal any: _pain / _neuro tramadol 50 mgs ▼2x/day gabapentin ▼50 mgs ▼2x/day methocarbamol 125mgs ▼2x/day Pepcid AC 5mgs 2x/day]
Will update his progress or report any troubles. Thanks very much for the support and information.
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PaulaM
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Post by PaulaM on Oct 30, 2019 15:55:05 GMT -7
Dawn just so we have clarity on the med list --Tramadol is now 50mg 2x/day -- gabapentin is now 50 mgs 2x/day -- methocarbamol is now 125mgs 2x/day? -- Meloxicam will be stopped on Nov 6th as test for pain or any neuro dimishment? -- Pepcid AC 5mbs 2x/day still?
I see by the photo that Arnold is a senior...what is his age?
Nice for Arnold to feel comfortable in being examined today!!!
Did you ask if this was root signature pain? What did the neuro think?
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Post by Dawn & Arnie on Oct 31, 2019 7:44:48 GMT -7
Hi Paula, Yes that list of medications is accurate as of this morning. If he is still comfortable prior to this evening's dose time, I will further decrease the ▼Tramadol to 25mg twice daily for a day or two before discontinuing completely. I want to have enough left over to keep on hand just in case. Will keep the Pepcid AC 5mg going 2x daily with the Metacam once daily until Nov 6. The ▼Robax I will reduce to 125mg once daily in the evening for it's sedating effect as this is when Arnold is most frustrated with his confinement. He is 10 yrs old.
[Moderator's Note. Please do not edit 15 lbs 10 y.o. 10/10 Cervical diagnosis: meds Rx'd? disc relapsed Oct 24 -neck pain Meloxicam as of 10/25: 6kg dose 1x/day for 13 days, Nov 7th a test stop to reveal any: _pain / _neuro tramadol ▼25 mgs 2x/day if no pain 10/31 evening, then stop 10/3ish gabapentin 50 mgs 2x/day methocarbamol 125mgs ▼1x/day for sedating effect Pepcid AC 5mgs 2x/day]
I did ask specifically about nerve root signature pain and he thought it very well could be. His only reservation in making that diagnosis was the lack of obvious neck pain upon palpation and range of motion. I described Arnold's posture when he was at his worst, which was to lie sternal and rest his head flat on the ground. I also showed him the video that I had taken when the event first occurred. I asked if it was possible to have nerve root signature without neck pain? He said yes it is technically possible but more often than not, they are concurrent. I will be interested to see his report.
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PaulaM
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Member since 2007: surgery, conservative . Montana, USA
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Post by PaulaM on Oct 31, 2019 8:02:47 GMT -7
Dawn, good job in interacting with the specialist with your questions about nerve root signature pain. We continue to learn things via what you learn and report...thank you. If you continue to find it is a good working relationship with with this neuro specialst during conservative treatment, would you consider sharing in our Directory? Members sometimes are not able to find a local DVM vet who knows IVDD and need to quickly find one to get meds right...your comment can be very useful to get quick help for the dog. Would you consider helping another trying to find an IVDD knowledgeable vet by adding to our directory: dodgerslist.boards.net/board/10/guidelines-posting vet recommendations: Name of Vet Name of Clinic Street Address City: State or country: Type of vet (general/board certified surgeon, acupuncture, etc.) Comments about conservative treatment care:
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