Acute Spinal Cord Myelopathy

Acute Non-compressive Nucleus Pulposus Extrusion (ANNPE) and Fibrocartilaginous

Embolism (FCE)

Mary Stallings, DVM Neurology Intern BVNS - Richmond November 5, 2017

Overview

• Definitions/Terminology

• Signalment/History

• Diagnostics

• Prognosis

• Treatment

Definitions/Terminology

• Myelopathy: spinal cord dysfunction

• Types of Disk disease

Hansen Type I

Hansen Type II

Acute Non-compressive Nucleus Pulposus Extrusion (ANNPE)

• Other acute spinal cord myelopathy

Fibrocartilaginous embolism (FCE)

Acute non-compressive nucleus pulposus extrusion

• AKA: ANNPE, Type III Disk (misnomer), High velocity low volume extrusion, Missile disk, splatter disk (some overlap with Type I), liquid disk

• Rupture of the intervertebral disk capsule under pressure (traumatic) with explosive extrusion of the nucleus pulposus

Normal Normal

Type I Disk Disease

Type II Disk Disease

ANNPE

FCE

Acute non-progressive myelopathies

ANNPE: The spinal cord is contused by hydrated disk material due to increased discal pressure

- often after exercise or trauma

FCE: Embolization of the spinal vasculature with fibrocartilagenous material (histologically similar to disk material) resulting in ischemic insult to the spinal cord

- often associated with exercise or trauma

History/Signalment

• Large breed dogs predisposed

• Acute/peracute pain

Resolves within 24h for FCE

ANNPE may have some residual pain

• Non-progressive after 24h

• Often lateralizing (one side worse than other)

• Continence?

Exam

• Mentation: normal

• Ambulation: paresis to plegia, ataxia

• Cranial Nerves: normal

• Spinal reflexes: (stretch reflexes and withdrawal) normal to decreased to absent

• Proprioception: (placing, hopping) decreased to absent

• Cutaneous trunci: note cut off, if any

• Vertebral column hyperesthesia: variable to absent

• Nociception (superficial/deep pain perception)

You localized the lesion, What next?

• Referral to neurologist.

• Is spinal imaging recommended?

MRI can be both diagnostic and prognostic!

MRI

• Ddx to rule out: Type I Disk disease, diskospondylitis, neoplasia, syringomyelia, etc.

• Helps to distinguish between FCE vs ANNPE

Alters treatment recommendations (rest)

Prognosis can vary even if signs are similar

• Severity of spinal cord signs can alter prognosis

MRI: ANNPE

Mari, 2017

MRI: FCE

Mari 2017

Negative prognostic indicators

• Absence of nociception

• LMN signs

• Symmetry

• Severity of signs at presentation

• Ease of nursing care/rehab

• Lack of improvement

• Extent of MRI lesion

Significantly more likely to have unsuccessful outcome if:

• Lesion length > 2 vertebral bodies (LL:VL)

• % cross-sectional area of the lesion >66% (PCSAL)

(De Risio 2007)

L2

Significantly more likely to have unsuccessful outcome if:

• Lesion length > 2 vertebral bodies (LL:VL)

• % cross-sectional area of the lesion >66% (PCSAL)

(De Risio 2007)

L2

Fecal Incontinence - Recent studies

• Overall risk (Fenn 2016)

40% with FCE

7.7% ANNPE

• With T3-L3 lesions

32% ANNPE (De Risio 2009)

0% FCE (De Risio 2008)

• 5x more likely with presumptive ANNPE(23%) than FCE(7%) (Mari 2017)

• Goals

Reduce secondary spinal cord injury

Nursing care

Physical rehabilitation

Treatment

http://rehabvets.org/TreatmentsUsed.lasso

http://www.ballstonspavet.com/coupons-underwater-treadmill-exercises/

Treatment Manage urination

• ANNPE

Crate rest at least 2w, slow return to normal activity +/- pain meds

After initial crate rest consider physical rehab

• FCE

Physical rehabilitation

No Chiropractics!!!! https://www.adoptapet.com/blog/how-to-crate-train-your-puppy-or-dog/#.Wfmi9jtrzIU

• Dogs with ANNPE significantly lower chance of successful outcome (unassisted ambulation and urinary/fecal continence) (Mari 2017)

73% ANNPE

90% FCE

• Recovery rates 58% to 90%

Recovery

http://rehabvets.org/TreatmentsUsed.lasso

QUESTIONS?

References L. Cauzinille, J.N. Kornegay Fibrocartilaginous embolism of the spinal cord in dogs: review of 36 histologically confirmed cases and retrospective study of 26 suspected cases. J Vet Intern Med, 10 (1996), pp. 241–245 L. Cauzinille Fibrocartilaginous embolism in dogs. Vet Clin North Am Small Anim Pract, 30 (2000), pp. 155–167 De Risio, Luisa, and Simon R. Platt. "Fibrocartilaginous embolic myelopathy in small animals." Veterinary Clinics of North America: Small Animal Practice 40.5 (2010): 859-869. L. De Risio, V. Adams, R. Dennis, et al.Magnetic resonance imaging findings and clinical associations in 52 dogs with suspected ischemic myelopathy. J Vet Intern Med, 21 (2008), pp. 1290–1298 G. Gandini, S. Cizinauskas, J. Lang, et al.Fibrocartilaginous embolism in 75 dogs: clinical findings and factors influencing the recovery rate. J Small Anim Pract, 44 (2003), pp. 76–80 Nakamoto, Yuya, et al. "Fibrocartilaginous embolism of the spinal cord diagnosed by characteristic clinical findings and magnetic resonance imaging in 26 dogs." Journal of Veterinary Medical Science 71.2 (2009): 171-176. Webb, Aubrey A., Sybil Ngan, and J. David Fowler. "Spinal cord injury I: A synopsis of the basic science." Canadian Veterinary Journal 51.5 (2010): 485. Webb, Aubrey A., Sybil Ngan, and David Fowler. "Spinal cord injury II: Prognostic indicators, standards of care, and clinical trials." Canadian Veterinary Journal 51.6 (2010): 598. De Risio, Luisa, et al. "Association of clinical and magnetic resonance imaging findings with outcome in dogs with presumptive acute noncompressive nucleus pulposus extrusion: 42 cases (2000–2007)." Journal of the American Veterinary Medical Association 234.4 (2009): 495-504. De Risio, Luisa. "A review of fibrocartilaginous embolic myelopathy and different types of peracute non-compressive intervertebral disk extrusions in dogs and cats." Frontiers in Veterinary Science 2 (2015). Specchi, Swan, et al. "Assessment of interobserver agreement and use of selected magnetic resonance imaging variables for differentiation of acute noncompressive nucleus pulposus extrusion and ischemic myelopathy in dogs." Journal of the American Veterinary Medical Association 248.9 (2016): 1013-1021. Inter- and intraobserver agreement for diagnosing presumptive ischemic myelopathy and acute noncompressive nucleus pulposus extrusion in dogs using magnetic resonance imaging Fenn, Joe, et al. "Comparison of clinical signs and outcomes between dogs with presumptive ischemic myelopathy and dogs with acute noncompressive nucleus pulposus extrusion." Journal of the American Veterinary Medical Association 249.7 (2016): 767-775. Mari, Lorenzo, et al. "Outcome comparison in dogs with a presumptive diagnosis of thoracolumbar fibrocartilaginous embolic myelopathy and acute non-compressive nucleus pulposus extrusion." Veterinary Record (2017).