Non-Surgical Options For IVDD? Keeping Hope, And Dogs, Alive


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All too often, those whose dogs have disk disease are offered only two options: costly MRI followed by surgery, or euthanasia.

Thirty years ago, surgical intervention was recommended “when there is no response to conservative management, when the animal becomes progressively worse, when the condition recurs, and when the animal is more severely disabled.”1 Where has conservative management gone in so many cases, and why are some specialists reluctant to inform clients of the diverse multimodal interventions available for spinal cord-injured dogs?

With or without surgery, a dog can experience multiple intervertebral disk disease episodes during her life. As Brisson et al noted, “All intervertebral disks in dogs are susceptible to degeneration; therefore, a dog can have several episodes of disk extrusion.”2  They continued, “Dachshunds were found to be approximately 10 times more likely to have recurrence than other breeds…”

In this retrospective look at the recurrence of thoracolumbar (TL) intervertebral disk extrusion in chondrodystrophic dogs after surgical decompression  +/- fenestration, the authors discovered that:

“The rate of euthanasia in dogs that developed recurrence of neurologic signs after decompressive surgery but did not return to the OVC [Ontario Veterinary College] for evaluation was 44.4 percent. Dogs that were euthanatized had various degrees of neurologic deficits and signs of pain. Dogs were euthanatized for financial reasons or because the owners did not wish their pet to undergo a second surgery or have the potential for recurrences in the future.”

So, even if a clinician convinces clients of the superior recovery rate of surgery for the first disk extrusion (approaching or surpassing 90 percent recovery for TL IVDD), shouldn’t effective, integrative options be discussed the next time around, other than offering only euthanasia as an “alternative”? Physicians don’t recommend euthanasia for their human patients who cannot afford an MRI and surgery. Why would we recommend this to a client, especially when options clearly exist?

Especially when surgery and imaging are unaffordable or unattractive and steroids are contraindicated or considered too risky,3-4 our profession owes clients information that conservative options exist.

It no longer requires a leap of faith or affinity for the supernatural to “believe in” acupuncture. Evidence supporting acupuncture for neurologic injury is rapidly accumulating.

Other Options

Laser therapy, too, is building a solid scientific foundation for its value in neurologic recovery. The latest facet of nonsurgical management on the horizon for spinal cord injury (SCI) incorporates stem cell therapy. 

Both LT and acupuncture have beneficial influences on stem cell activities. All of these deserve mention when presenting options to canine caregivers whose dog is “down,” especially if the value of surgery for that patient is uncertain.

Other novel therapies include polyethylene glycol to aid axonal fusion within the spinal cord, matrix metalloproteinase blockade to reduce enzymatic destruction of the cord, and olfactory ensheathing cells transplanted onto the cord.5

Whatever decision they make, clients usually want treatments to give their pets comfort and contentment. In a 2008 study at Texas A&M University, owners of dogs with SCI were asked to state five areas of life or activities that they considered as most influential on their dog’s quality of life (QOL).6 Responses fell into five domains: mobility, play or mental stimulation, health, companionship or “other.”

The authors noted, “Although most health-care professionals have been trained to focus on the physical aspects associated with quality of life, findings of the present study suggested that dog owners often placed a greater emphasis on companionship and other nonphysical parameters.”

The bonding that takes place between clinician, client and patient through a course of non-surgical or post-surgical SCI treatment with acupuncture, lase, and massage promote the human-animal bond and elevate QOL for the patient.

Furthermore, it fosters an active role for the caregiver in the dog’s recovery process.

Simple in-home exercises such as assisted standing, proprioceptive training and core strengthening transform feelings of helplessness into hopefulness as strides are made and monitored. Painful backs and necks are assessed and treated when dogs receive regular physical medicine treatments.

Clients are ready, willing and able to learn soft tissue techniques to maintain improvements and incorporate them into their daily routines with their dogs.

Acupuncture

Evidence demonstrates benefit of acupuncture for dogs with SCI, in both acute and chronic scenarios.7 Researchers from Sao Paulo State University’s School of Veterinary Medicine and Animal Science compared the effectiveness of decompressive surgery, low-frequency (at 2 and 15 Hz) electroacupuncture (EA), and the combination for thoracolumbar IVDD in dogs with severe neurologic deficit longer than 48 hours’ duration.8

They found EA alone or in combination with surgery to be more effective than surgery alone in improving neurologic outcomes.

A 2009 review pointed to the accelerated improvements made possible on multiple measures with acupuncture. One study showed a “much larger effect of electroacupuncture on ultimate neurologic recovery from acute SCI than any pharmacologic intervention to date.”9 Another report found that EA produced doubly fast recovery of proprioception and even quicker return of motor control when combined with corticosteroid treatment.10

EA combined with conventional approaches for IVDD shortened the time needed to recover deep pain perception and ambulation compared to standard of care alone in dogs with TL IVDD, based on a study published in JAVMA in 2007.11

Acupuncture stimulates neuronal regeneration, possibly through stem cell mobilization and differentiation;12-13-14 it also reduces apoptotic cell death after SCI.15 Although some practitioners maintain that steroids negate the benefits of acupuncture, a 2003 study from Korea demonstrated the opposite; i.e., that the combination produced synergistic effects for pain relief, inflammation control and edema resolution.16

Laser Therapy (LT)

LT also aids in pain control, neuronal regeneration and tissue healing. LT modulates neural traffic in nociceptive axons and facilitates expression and release of endogenous opioids in inflamed tissue. 17-18

Research in dogs with IVDD suggests that LT improves neurologic function.19 Dogs with experimental TL spinal cord transection and sciatic nerve autograft insertion who received LT were walking after two to three months; those without LT remained paralyzed. Histologic analysis of spinal cords in the LT group exhibited new axons and blood vessels migrating into the graft and only limited scar tissue; these changes were not found in controls.20

Research on Naturally Occurring Disease and Integrative Therapies

From a research perspective, the ethical and translational benefits of inviting domestic client-owned dogs and their caregivers to participate in clinical research on conservative integrative treatments for SCI would be plenty.

Studying naturally occurring IVDD could eliminate the need to drop weights on cords to model contusion.21 Scientific investigations would require scoring systems such as the Texas Spinal Cord Injury Score that provides the ability to detect and follow subtler changes than the commonly employed Frankel scale.22 However, neither includes assessment of back pain and muscle tension. Ideally, these measures should be added, as they may impede progress and rehabilitation for SCI patients.

Treatment of pain and tension along the spine have largely fallen under the radar in studies monitoring the benefits of surgery, as has the impact of autonomic dysfunction and voiding disorders on QOL. Medical acupuncture and related techniques have much to offer patients in each of these categories. And finally, exploring the mechanisms through which they help dogs recover from naturally occurring SCI from IVDD could supply translational humans.

Dr. Robinson, DVM, DO, Dipl. ABMA, FAAMA, oversees complementary veterinary education at Colorado State University.

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FOOTNOTES

1. Brown NO.  Thoracolumbar disk disease in the dog:  a retrospective analysis of 187 cases. Journal of the American Animal Hospital Association.  1977;13(6):665-672.
2. Brisson BA, Moffatt SL, Swayne SL, et al.  Recurrence of thoracolumbar intervertebral disk extrusion in chondrodystrophic dogs after surgical decompression with or without prophylactic fenestration:  265 cases (1995-1999).  J Am Vet Med Assoc.  2004;224:1808-1814.
3. Anor S.  Management of acute spinal cord injuries.  Small animal and exotics. Proceedings of the North American Veterinary Conference, Orlando, Florida, USA, 17-21 January, 2009; Gainesville: The North American Veterinary Conference, 2009, 796-798.
4. Boag AK, Otto CM, and Drobatz KJ.  Complications of methylprednisolone sodium succinate therapy in Dachshunds with surgically treated intervertebral disc disease.  J Vet Emerg Crit Care.  2001;11(2):105-110.
5. Levine JM.  Novel treatments for spinal cord injury.  Small animal and exotics. Proceedings of the North American Veterinary Conference, Orlando, Florida, USA, 16-20 January 2010; Gainesville: The North American Veterinary Conference, 2010, 872-873.
6. Budke CM, Levine JM, Kerwin SC, et al.  Evaluation of a questionnaire for obtaining owner-perceived, weighted quality-of-life assessments for dogs with spinal cord injuries.  J Am Vet Med Assoc.  2008;233:925-930.
7. Dorsher PT and McIntosh PM.  Acupuncture’s effects in treating the sequelae of acute and chronic spinal cord injuries:  a review of the allopathic and Traditional Chinese Medicine literature.  eCAM.  2009;doi:10.1093/ecam/netp010. 
8. >Joaquim JGF, Luna SPL, Brondani JT, et al.  Comparison of decompressive surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long-standing severe neurologic deficits.  J Am Vet Med Assoc.  2010;236:1225-1229.
9. Wong AM, Leong CP, Su TY et al.  Clinical trial of acupuncture for patients with spinal cord injuries.  Am J Phys Med Rehabil.  2003;82:21-27.  Cited in: Dorsher PT and McIntosh PM.  Acupuncture’s effects in treating the sequelae of acute and chronic spinal cord injuries:  a review of the allopathic and Traditional Chinese Medicine literature.  eCAM.  2009;doi:10.1093/ecam/netp010. 
10. Yang JW, Jeong SM, Seo KM, et al.  Effects of corticosteroid an delectroacupuncture on experimental spinal cord injury in dogs.  J Vet Sci.  2003;4:97-101.  Cited in:  Dorsher PT and McIntosh PM.  Acupuncture’s effects in treating the sequelae of acute and chronic spinal cord injuries:  a review of the allopathic and Traditional Chinese Medicine literature.  eCAM.  2009;doi:10.1093/ecam/netp010. 
11. Hayashi AM, Matera JM, et al.  Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs.  J Am Vet Med Assoc.  2007;231:913-918.
12. Moldenhauer S, Burgauner M, Hellweg R, et al.  Mobilization of CD133(+)CD34(-) cells in healthy individuals following whole-body acupuncture for spinal cord injuries.  J Neurosci Res.  2009 Dec 22 [Epub ahead of print].
13. Yan Q, Ruan JW, Ding Y, et al.  Electro-acupuncture promotes differentiation of mesenchymal stem cells, regeneration of nerve fibers and partial recovery after spinal cord injury.  Exp Toxicol Pathol. [Epub ahead of print].
14. Sun Z, Li X, Su Z, et al.  Electroacupuncture-enhanced differentiation of bone marrow stromal cells in to neuronal cells.  J Sports Rehabil.  2009;18(3):398-406.
15. Choi DC, Lee JY, Moon YJ, et al.  Acupuncture-mediated inhibition of inflammation facilitates significant functional recovery after spinal cord injury.  Neurobiology of Disease.  2010; 39:272-282.
16. >Yang J-W, Jeong S-M, Seo K-M, et al.  Effects of corticosteroid and electroacupuncture on experimental spinal cord injury in dogs.  J Vet Sci.  2003;4(1):97-101.
17. Hagiwara S, Iwasaka H, Okuda K, et al.  CaAlAs (830 nm) low-level laser enhances peripheral endogenous opioid analgesia in rats.  Lasers in Surgery and Medicine.  2007;39:797-802.
18. Chow RT, David MA, and Armati PJ.  830 nm laser irradiation induces varicosity formation, reduces mitochondrial membrane potential and blocks fast axonal flow in small and medium diameter rat dorsal root ganglion neurons:  implications for the analgesic effects of 830 nm laser.  Journal of the Peripheral Nervous System.  2007;12:28-39.
19. Chyczewski M.  Laser biostimulation in neurological diseases of dogs.  Annales Universitatis Mariae Curie-Skodowska.  Sectio DD. Medicina Veterinaria.  2005;60:55-58.
20. Rochkind S. The role of laser phototherapy in nerve tissue regeneration and repair:  research development with perspective for clinical application.  In:  Proceedings of the World Association of Laser Therapy.  Sao Paulo, Brazil.  2004.  Pp. 94-95.  Cited in Millis DL, Francis D, and Adamson C.  Emerging modalities in veterinary rehabilitation.  Vet Clin Small Anim.  2005;35:1335-1355.
21. Jeffrey ND, Smith PM, Lakatos A, et al.  Review.  Clinical canine spinal cord injury provides an opportunity to examine the issues in translating laboratory techniques into practical therapy.  Spinal Cord.  2006;44:584-593.
22. Levine GJ, Levine JM, Budke CM et al.  Description and repeatability of a newly developed spinal cord injury scale for dogs.  Preventive Veterinary Medicine.  2009;89:121-127.

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