I was fortunate to moderate this year’s ACVIM Neurology panel discussion at National Harbor in Washington, DC on the topic of surgical options for disk associated cervical spondylomyelopathy (DACSM) in dogs, generically known as Wobbler’s disease. Each year a controversial topic is chosen for presentation at the neurology specialty day portion of the conference. The purpose is to provide a forum to stimulate open discussion on a topic between American and European diplomates, trainees and students.

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Investigations in 161 dogs with an intervertebral disc disease. After that, we performed a cranial (n = 31), caudal (n = 125) or both (n = 5) types of myelography at the same time, and surgery - ventral slot decompression (SLOT) (n = 18) or hemilaminectomy (n = 143). During the post.

• Recurrence of paraparesis or tetraparesis occurs in up to one-third of dogs after either ventral slot or metal implant and bone cement fixation, mainly with distraction-stabilization techniques.1 It usually occurs between six months and four years after the original surgery, with a mean recurrence of around two years.16,37 A meta-analyis of.
• Back Surgery – Hemilaminectomy/Ventral Slot. Hemilaminectomy is a surgical procedure that we perform on a regular basis for canine patients at our hospital. It is useful for correcting slipped or herniated discs in the spine. If your dog is having difficulty walking or has pain or lameness, a compressed spine might be the culprit.

Our panel this year included three experts in the field of neurosurgical approaches to DASCM: Dr. Filippo Adamo from East Bay Veterinary Specialists, Dr. Robert Bergman from Carolina Veterinary Specialists, and Dr. William Thomas from the University of Tennessee. Each one presented a specific case example with different surgical approaches as a springboard to the discussion.

As part of the presentation, the following questions were posed to help focus our discussion. As you would expect, there were divergent opinions but also commonalities.

Here is a summary of some of the questions that we addressed on disk associated cervical spondylomyelopathy (DACSM) in dogs:

• Clinical signs:

  • Is there a standardized clinical assessment and scoring system being used?
    A standardized neurological assessment and scoring system is currently not being used in the literature. However, a functional scoring system has been validated for use by Olby et al (Am J Vet Res. 2001 Oct;62(10):1624-8) that would be helpful to compare results between studies.
  • Is there breed specific pathophysiology resulting in differences in onset and progression of signs?
    Breed specific pathophysiology is likely present in the giant breed dogs (eg Great Danes), where rapid bone growth early in the first year of life has been associated with cervical stenosis due to articular facet hypertrophy. Controversy exists on whether this is a hereditary problem or enhanced by high protein diets fed to young dogs, or both.
  • What are best objective parameters to correlate to clinical signs and prognosis?
    The best objective parameters to correlate clinical signs with prognosis appear to be age of onset, severity of signs, rapidity of progression, and initial response to treatment. Mature dogs with slower progression of signs and that are ambulatory prior to surgery are deemed to have the better prognosis with surgery.

• Diagnosis

  • What is the best diagnostic method?
    MRI scanning is the recommended diagnostic test of choice. Both static (neutral position) and dynamic (distracted) sagittal and axial views of the cervical spine are recommended.

• Treatment

  • What are the parameters for decision on medical versus surgical approach?
    The question of when to recommend surgery versus medical management is quite controversial. A wide range of clinical response to medical management ranging from 38 to 81% has been reported. (Table 1). However, dogs that do not respond within the first month of treatment had a guarded prognosis for improvement, and euthanasia was most likely to occur within the first year of treatment in 85% of dogs in one study.
    The panel was in general agreement that if neurologic deficits were present associated with lesion on MRI scans, then surgery is their treatment recommendation over medical management.
  • Why do some dogs tolerate spinal decompression better than others?
    Decompressive cervical surgery, either ventral slot or dorsal laminectomy, does not address the instability aspect of this disease process. An excellent case example was presented that demonstrated resolution of disk -associated spinal compression but with progression of spinal cord damage, as noted by serial MRI scans.
  • When is decompression recommended?
    In general, a decompressive surgery is recommended when a static compressive lesion of the cervical spine is present that does not improve with simulated distraction, extradural disk rupture is present, or stenosis is present from facet and/or bone lesions.
  • When is stabilization is recommended?
    In general, cervical stabilization is recommended when a dynamic compressive lesion is observed on MRI scanning demonstrating improvement with simulated distraction and/or presence of moderate intramedullary T2W hyperintensity (associated with gliosis).
  • What is the preferred method of stabilization?
    Several methods of cervical stabilization are currently being used in veterinary medicine. No evidence currently exists that one method is superior in regards to outcome. Decision making is dictated by surgical preference and experience, cost of the procedure, patient size, and single or multiple sites to be surgically addressed.
    A newer technique of cervical disk arthroplasty (artificial disk replacement) was presented by Dr. Adamo that appears promising, as this procedure is less invasive, allows for quicker post-operative recovery, and multiple affected sites can be surgically addressed at one surgery.

• Prognosis

  • How can we best advise owners on short and longer-term prognosis?
    A review of the published literature of 235 cases treated with surgical intervention had a surprising close range of 70-72% listed as a successful outcome. However, there was a relative large degree of variability in the criteria of success, duration of observation, and when the paper was published (1 to 30 years).

In general, the panel agreed that there is a strong probability that surgery will improve the clinical outcome in dogs affected by DACSM provided that they are treated in the early stage of the disease with ambulatory function preserved.

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Table 1. Summary of clinical outcome with medical management in dogs with DASCM.

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Table 2. Summary of clinical outcome with surgical management in dogs with DASCM from literature review.

Complications are broadly defined as outcomes that differ from the norm and can be described as general, specific and technical. Common general complications following spinal surgery are gastrointestinal complications and urinary tract infections. Specific complications of spinal surgery include: haematomas, surgical site infections, nerve root injury, dural tears and progressive myelomalacia. Technical complications are generally secondary to implant placement, dislocation of the implant or instrument-related.

In a large prospective study on morbidity and mortality of major adult spinal surgery (Street et al., 2012), 87 percent of patients had at least one documented complication:

• Prolonged hospitalisation: 39 percent
• Post-operative complications: 73.5 percent
• Surgical complications: 10.5 percent
• Death: 1.5 percent

Gastrointestinal effects

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In a study by Dowdle and colleagues (Dowdle et al., 2003), endoscopy was used to determine the prevalence of subclinical gastroduodenal ulceration in 30 Dachshunds undergoing decompressive surgery for acute intervertebral disc prolapse. An overall prevalence of 76 percent was calculated. Ulcerogenic medication administered prior to admission did not appear to influence the prevalence.

Urinary tract infection

Urinary tract infection (UTI) is a common complication in dogs with acute intervertebral disc extrusion (IVDE). The prevalence for development of UTI in 25 dogs treated surgically has been evaluated. In one study (Olby et al., 2010), presence of UTI over the three-month period was correlated to potential risk factors. Ten dogs (38 percent) developed 12 UTIs over the three-month period, with the majority occurring between the first and sixth week. Sixty percent of the UTIs were occult; haematuria in the absence of pyuria or UTI was a common finding in the perioperative period. Sex, breed and ambulatory status influenced the risk of developing a UTI. Females, Dachshunds and paraplegic dogs were at higher risk.

Surgical site infection

The surgical site infection (SSI) rate in dogs undergoing hemilaminectomies or laminectomies for thoracolumbar disc herniation or lumbosacral disease, without use of perioperative antibiotics, has been retrospectively evaluated during a two-year period (Dyall and Schmökel, 2018). All incisional complications within 30 days were recorded and divided into superficial, deep (Figure 1) or organ/ space infections. This research study included 154 consecutive hemilaminectomy and laminectomy procedures. One superficial wound infection was recorded and treated with antimicrobials. Overall, the SSI rate was 0.6 percent, while the expected SSI rate in clean operative wounds in dogs and cats is 2.0 to 4.8 percent. The SSI rate in human spinal surgery is 0.7 to 4.3 percent.

Myelomalacia

Progressive myelomalacia (PMM; Figures 2 and 3) is a catastrophic disease associated with acute IVDE. The onset and progression of clinical signs of PMM has been examined retrospectively in 51 dogs, 18 with histopathologically confirmed PMM and 33 presumptively diagnosed based on clinical signs (Olby et al., 2017). Five dogs had two sites of disc extrusion, giving 56 extrusions in total. Data on nature and progression of signs were extracted. Twenty-four of 51 dogs were Dachshunds. T12–T13 was the most common site of disc extrusion (12 of 56), and 18 mid-to-caudal lumbar discs (between L3 and L6) were affected.

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Onset of PMM signs ranged from present at first evaluation (17/51) to
five days after presentation, with 25 of 51 cases developing signs
within 48 hours. Progression of signs from onset of PMM to euthanasia or
death, excluding seven cases euthanised at presentation, ranged from 1
to 13 days, with 23 being euthanised within three days. Nonspecific
systemic signs were documented in 30 of 51 dogs.

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The majority of dogs developing myelomalacia do so within two days of presentation, with euthanasia commonly occurring within another three days. The onset can be delayed up to five days after presentation, with progression to euthanasia taking as long as two weeks. Mid-tocaudal lumbar discs might be associated with an increased risk of PMM.

Neurological deterioration

Early post-operative neurological deterioration is a wellknown complication following dorsal cervical laminectomies and hemilaminectomies in dogs. Medical records of 100 dogs that had undergone a cervical dorsal laminectomy or hemilaminectomy were assessed retrospectively in one study to evaluate potential risk factors (Taylor-Brown et al., 2015). Multiple variables were evaluated and the outcome measures were neurological status immediately following surgery and duration of hospitalisation.

Diagnoses included osseous associated cervical spondylomyelopathy (OACSM), and acute intervertebral disc extrusion in 72 percent of the dogs. Overall, 54 percent were neurologically worse 48 hours post-operatively. Statistical analysis identified four factors significantly related to early post-operative neurological outcome. Diagnoses of OACSM or meningioma were considered the strongest variables to predict early deterioration, followed by higher neurological grade before surgery and longer surgery time.

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This information can aid in the management of expectations of clinical colleagues and owners with dogs undergoing spinal surgical procedures. The use of prophylactic anti-ulcer medication in spinal surgery patients is suggested. Dogs with thoracolumbar IVDE should be routinely monitored for UTI with urine culture regardless of urinalysis results. The low incidence of SSI suggested reconsideration of routine perioperative antibiotic prophylaxis in dogs undergoing laminectomy procedures.