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Hawksmoor News

August 2016 Case Study – William

will1Name:            William

Age:               4 Years Old

Breed:            Cavalier King Charles Spaniel

Condition:       Suspected Fibrocartilagenous Embolism or Disc Extrusion.

William has been attending the centre for Hydrotherapy Pool Treatment following an injury to his spinal region Thoracic to Lumbar region.

The Veterinary advised that this injury was likely to be a Fibrocartilagenous Embolism or a Disc Extrusion and as such Conservative Management was advised to aid William in his recovery.

Fibrocartilagenous embolism is a sudden onset spinal cord injury as a result of a sudden blockage of a vessels blood supply to an area of the spinal cord.

Fibrocartilagenous emboli are believed to be associated with intervertebral discs. Intervertebral discs (IVD) permit stability and support of the spine whilst allowing movement and distributing loads between the bones of the spine (the vertebrae). To perform this function the IVD has two components: an inner cartilagenous bag called the nucleus pulposus; and an outer multi-layered ligament that contains the nucleus, called the annulus fibrosus. The embolising material is believed to be fibrocartilage from the nucleus pulposus.

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MRI Scan indicating FCE in the thoracolumbar region of the spinal column. (From Fitzpatrick Referrals Website)

Why fibrocartilaginous emboli occur is not fully understood. We know that a spinal cord injury is the result of a sudden blockage of a vessels blood supply to an area of the spinal cord by a fragment of ‘fibrocartilage’ – a substance that seems to originate from the nucleus pulposus of the intervertebral disc. We assume that a traumatic incident (minimal trauma like heavy exercise, jumping for a frisbee, etc) causes part of the nucleus pulposus to embolize into a blood vessel. The loss of blood supply and reduced oxygen tension causes infarction (i.e. tissue death) of the spinal cord. Often other blood vessels open to facilitate collateral circulation to the spinal cord and the oedema surrounding the infarcted area resolves, explaining how dogs can recover relatively soon after the accident.

 

The clinical signs are very sudden in onset and non-progressive;

  • Pain is not a feature of fibrocartilagenous emboli although some dogs may vocalise when the problem first happens.
  • As a general rule, the clinical signs are usually asymmetrical (i.e. affecting one side) and their severity relate to the degree of spinal cord injury and subsequent dysfunction. Clinical signs may vary, ranging from paresis (i.e. weakness) to a complete paralysis (i.e.-plegia). It may affect one limb (mono -paresis/plegia), one side of the body (hemi -paresis/plegia) or pelvic limbs (para-paresis/plegia). The most severe cases may become unable to urinate.

William first attended the centre in July 2015 where he was carried in by the owner and unable to ambulate or stand/support himself on the hind limbs.

 

William was fully assessed but at this point we were unable to carry out a gait analysis due to the fact that he was unable to ambulate.

There was a withdrawal pinch / deep pain reflex present in both hind limbs and his proprioception was 2-3 seconds in both hind limbs.

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This picture demonstrates a proprioception test that is carried out to test if a canine patient is able to feel the limbs and correct a knuckling over in the limb. This is usually reduced in neurological patients.

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This picture indicates the withdrawal reflex test – this is where the patient is pinched between the toes to test if deep pain is present in the limbs – if the patient reacts by pulling the limb away then this reflex is present. This again can be reduced in neurological or orthopaedic patients.

On this initial session, William’s muscle mass measurements were taken as follows:-

 

Limb Measurement
Left Fore 17cm
Right Fore 17cm
Left Hind 21cm
Right Hind 22cm

 

Although the muscle mass was almost even in the limbs it was obvious on palpation that there was marked muscle atrophy and so reduced strength in the hind limbs.

The left hind limb also appeared weaker on examination.

After the assessment it was decided that William would be best suited to initial treatment in the Hydrotherapy Pool due to the fact that he was unable to use his hind limbs.

On the first session, William was showered, fitted with a Life Jacket and an ear wrap and lifted into the pool with the Hydrotherapist.

William was initially worried by the water so took a few minutes to start to relax within the pool environment.

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William in the pool with Becky getting used to the water before starting his session.

On the first session, William carried out 2 sets of static swims facing his owner at the side of the pool and swam very strongly through the fore limbs, however the hind limbs required some stimulation in order to encourage movement. It was noted that the hind limb flexion appeared stronger than the extension.

 

Following on from the initial session, William attended the centre twice per week and continued with Hydrotherapy Pool treatment.

After 10 sessions, William was re assessed.

 

 

 

August 2015:-

 

Limb Measurement
Left Fore 17cm
Right Fore 17cm
Left Hind 26cm
Right Hind 26cm

 

This demonstrated that William had built up the hind limb muscle mass and it was also apparent that he was able to stand better but still required support. The proprioception had also improved and he was trying to get about but unfortunately still dragging the hind limbs.

 

We decided at this point to carry on with Hydrotherapy Pool treatment and re-assess William again after 10 further sessions.

 

November 2015:-

 

Limb Measurement
Left Fore 18cm
Right Fore 18cm
Left Hind 26cm
Right Hind 28cm

 

This indicated that he had bulked up a little in the fore limbs and although the muscle mass was not even in the hind limbs he was again able to stand more by himself and able to walk around slowly with support.

After 20 sessions in the pool, William was able to walk but he was still very ataxic (wobbly) when walking so still needed support.

At this point we decided to try William in the treadmill – unfortunately he did not do as well as expected in the treadmill and after a few sessions it was decided to continue with Hydrotherapy Pool treatment.

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William swimming in the hydrotherapy pool assisted by Becky during one of his sessions.

William has been progressing well during his sessions and now carries out some circuits and static swims assisted by the hydrotherapist.

He is a very strong swimmer on the fore limbs and his hind limb usage in the pool has also improved greatly.

 

William now walks into the centre but still has an ataxic (wobbly) gait and struggles with urinary continence so does need to wear a canine nappy when he comes to the centre or is moving around at home.

 

The last measurements carried out in June 2016 were as follows:-

 

Limb Measurement
Left Fore 16cm
Right Fore 16cm
Left Hind 22cm
Right Hind 22cm

 

This indicated that although William had lost some muscle he was even through the limbs. Also he was stronger in the limbs now and he had also lost some weight.

From this point forward we have managed William within the Hydrotherapy Pool and he is doing really well. The right hind limb now also appears to be the weaker hind limb and so requires some extra stimulation during the sessions.

Overall we are pleased with Williams progress and he continues to attend the centre once per week.

William is a proper little star and he enjoys coming along for his sessions. He is particularly fond of all the ladies and works very hard for his gravy bones during his sessions.

Well done so far William, your determination has helped so much in your recovery, keep going you can get there.

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