In July 2022, the ACVIM Consensus Statement on the diagnosis and management of acute canine thoracolumbar intervertebral (IVD) disc extrusion was published. This is the first of two installments about this consensus statement as a TidBit Tuesday. For this one, we will discuss the expected outcomes from medical vs. surgical management and what entails medical management. Enjoy!
The recommendations by the committee were graded as being supported by high, medium and low levels of evidence. Recommendations with high level of confidence include multiple randomized controlled trials with concordant findings. The evidence strongly supports the conclusions. Medium level of confidence includes retrospective studies with concordant findings, or small placebo-controlled trials. The evidence suggest that the findings are likely to be real. Lastly, low levels of confidence include isolated or small retrospective studies or single non-controlled trials. The evidence suggests that the findings might be real.
Medical vs. Surgical IVD extrusion management
A very helpful table was presented to help guide appropriate treatment for dogs presenting with signs consistent with TL IVD extrusion. The “%” represent the % of dogs that respond favorably to medical (M) or surgical (S) treatment.
· Pain only: M 80%, S 98.5% à lateral extrusion may lead to reduced response to medical management.
· Non-ambulatory paraparesis: M 81%, S 93% à level of recovery was less with medical management.
· Paraplegia with deep pain: M 60%, S 93% à medical recovery is prolonged and less complete.
· Paraplegia loss of deep pain: M 21%, S 61%
This is based on moderate level of evidence. The statement here is “In paraplegic deep pain negative dogs, success with medical management is largely poor with an increased frequency of progressive myelomalacia. Surgical management is recommended.” – moderate to high level evidence.
What is medical management?
“At least 4 weeks of restricted activity is recommended, putatively to promote the healing of the annulus fibrosus. This period should include confinement to a restricted area 9crate, ideally, or small room without furniture) except when performing rehabilitation exercises or outdoor toileting. There should be no off-leash walking, no jumping on or off furniture and no access to stairs during this time”. This statement was supported by low level evidence. Corticosteroids are NOT recommended (moderate level evidence). Dogs with NSAIDs had a higher quality of life score than those on corticosteroids but NO STUDIES specifically address the use (or no use) of NSAIDS. Pain management is discussed, but no recommendations were made because of the lack of studies evaluating different medication protocols. Acupuncture was noted to be good adjunctive treatment for medical management but is not a recommended substitution for surgical management. What are my typical recommendations? For an uncomplicated T3-L3 myelopathy without MRI, with a strong suspicion of IVDH, I recommend NSAIDs, muscle relaxants and most importantly, cage rest for at least 3 weeks.
I hope this was enlightening. Please reach out with questions and stay tuned for the next update on the consensus statement. I hope you have a wonderful week. I am enjoying our tiptoe into fall and hope you are too!