Acute Paraplegia: When to ship for surgery, treat medically or consider euthanasia
It happens to all of us (perhaps to me, more than you). Monday morning, 9 am, we are presented with a dachshund (Shih Tzu, Corgi...pick your top chondrodystrophic breed) after the dog became acutely non-ambulatory over night.
You perform a neurologic examination (self high-five!) and determine that the dog has a T3-L3 myelopathy with spinal pain at the TL junction.
What do you do next?
To be clear, a T3-L3 myelopathy does NOT equal a type I disc herniation. It means the dog may have a type I disc herniation or it could have a fibrocartilaginous embolic myelopathy (FCEM), acute non-compressive nucleus pulposus extrusion (ANNPE) or in rare cases meningomyelitis. (Yes, even dachshunds can get meningomyelitis!)
If we play the odds, that chondrodystrophic dog likely has a disc herniation. What, if any, prognostic indicators can you provide to the client?
Thankfully, an article out of Frontiers in Veterinary Science entitled "Prognostic Factors in Canine Acute Intervertebral Disc Disease" was published in November 2020 for just this purpose! (1) Here are some key points from the article. (The entire article is available as an open access article if you wish to read it in it's entirety. I highly recommend doing so if you are in the habit of seeing paraplegic dogs.)
Prognostic Indicator Key Points:
Recovery following medical management (only) for dogs with paraplegia (loss of all voluntary motor) and loss of deep pain perception (DPP) is about 22.4%.
Recovery following medical management (only) for dogs with paraplegia and intact DPP is 56%.
Recovery following surgical management for dogs with paraplegia and loss of DPP is about 61%.
25% recovered at 2 weeks
42% recovered by 4-6 weeks
53% recovered by 12 weeks
Recovery following surgical management for dogs with paraplegia and intact DPP is about 93%.
*** Did you catch that?? DPP is a prognostic indicator! Dogs without DPP do worse long-term compared to dogs with intact DPP. They are also have a 10x higher likelihood of developing progressive myelomalacia which is a fatal secondary outcome from acute spinal cord injury.
What exactly does "recovery" mean? It means walking without support but it DOESN'T mean walking normally or complete continence. Dogs may (and often do) have fecal or urinary incontinence consistently or occasionally following severe spinal cord injury.
Other Key Points:
Spinal shock can be more commonly associated with long-term fecal incontinence but does not seem to affect the ability to recover ambulation.
Age, breed and weight are not associated with prognosis...mostly. Some studies have found heavier dogs have a worse prognosis, other's haven't. My take - bigger dogs are harder to care for but that doesn't mean they cannot recover.
Reduced pelvic limb reflexes due to a L4-S3 lesion (not associated with spinal shock) has a higher likelihood of incontinence long-term.
When do you send a dog for surgery?
1) if the dog is non-ambulatory or paraplegic and the clients have a desire and financial ability to pursue surgery. Surgery with imaging costs $2000-5000 USD, depending on the specialty referral center.
2) Rapidly progressive signs (E.g.: dog was walking at 8 am, and is paraplegic at 10 am, with loss of deep pain by noon) and clients wish to pursue surgical intervention if indicated after imaging.
My plea...
Please don't send clients several hours to a specialist for surgery only to discover that the cost is prohibitively expensive. It is heart breaking for everyone and unnecessarily stressful for the dog. Call me and I'll happily talk with you about consult/medical management choices or sadly advocate humane euthanasia for the dog, if it is the best option.
Stay Safe, Keep Keeping On and Have A Good Week!
(1) Olby Natasha J., da Costa Ronaldo C., Levine Jon M., Stein Veronika M. Prognostic Factors in Canine Acute Intervertebral Disc Disease; Frontiers in Veterinary Science. 2020:7 p 913.