Managing acutely paralyzed patients with disc herniation or spinal sord injury (Proceedings)

Presenting new drugs and procedures that have been very helpful and leading to recovery (from laser, to electromagnetic resonance, to hyperbaric oxygen (chambers that do not cost and arm and a leg).

Spinal cord associated acute disc herniation and paralysis, spontaneous or secondary to trauma

Most (80%) of disc herniation that lead to acute paralysis occur at T11-L3, then L4-S3,. The Area most protected T1-T10, by the dorsal longitudinal ligament. Second most common is C2-C6 but cases have been reported at C7-T10 but rarely.

Initial care begins with history

Gotten with the phone call coming into the practice by the owner or person trying to help the acutely paralyzed dog at the scene. IF the paralysis was due to trauma instruct the responders/owner to transport on a flat solid surface if at all possible, right from where the pet is laying, keeping them in one plane in horizontal lateral recumbency. Duck tape the head and pelvic area and several other points between. Rarely breathing may stop if the herniation of disc or injury has occurred at the cervical-vertebral region. Then in these cases mouth to nose (snout) (MS ) ventilation (rescue breathing) is life saving and must be done immediately and continued en route. Some years ago I had a small poodle fall down some stairs once and stopped breathing soon after it came to rest at the bottom of the stairs. The owner was a physician and he began mouth to snout ventilations approx 8-10 times a minute and he had a neighbor drive the dog and him, continuing to perform the MS rescue breathing. The dog arrived with profound spastic paralysis but with deep-pain sensation. Following iv placement, anesthesia, hand bagging to get the radiographs and do a myelogram that should a ruptured C4-5 space and cord compression. She was placed on an anesthetic ventilator, taken to surgery and a slot and ruptured disc removal was accomplished. The remained on a ICU ventilator (old Puratian-Bennett) for 5 days and began bucking the ventilator more all the time. The dog was able to be off the ventilator shortly after that she made a complete neurologic recovery.

Initial neuro-exam

Should be done to determine. location, degree of problem and prognosis, and provide a baseline to log progress should treatment be performed. The neuro exam will involve the following:

1. gate (not done in the paralyzed patient)

2. Postural reactions (proprioceptive positioning = sensory & motor).

3. paw recognition; assesses ascending pathways (dorsal spinocerebellar tract)

4. surface receptor, periph & spinal N, brain stem, cerebellum, cerebral cortex

5. assesses descending upper motor neuron pathways (cortico and rubro [opposite side] and reticulospinal pons/medulla area [same side] tracts.

6. returning cord white matter (lateral and ventral funiculi)

7. assesses reflex pathway and muscle tone (passive manipulation of each limb = normal, hypo, hypertonia)

8. spinal reflexes: (hyporeflexia= lower motor neuron, hyper reflexia =upper)

     extensor thrust Femoral N + L4-5 segments (hyperextensor thrust = upper)

     patellar reflexes ( Femoral N + L4-5 segment (hyperpatella reflex = upper)

     biceps and triceps reflexes Radial N + C7-T2 segments

ON ADMISSION if the animal is not immobilized and history reveals possible acute intervertebral disc herniation – or acute back injury, teat all of these as if they all had just fractured and place the animal in lateral recumbency and IMMOBILIZATION CONTINUE using cardboard, tape, duct tape, similar to how it is described lately. Working with Cardboard and Tape, MANUFACTURE THE SPINE BOARD. It stabilizes the spine, Stabilizes clots, Helps decrease pain. Allows radiographs as x-ray beams to go through it.

PERFORM A HISTORY, PHYSICAL EXAM, NEUROLOGICAL EXAM AND SCORE INJURY beginning with level of consciousness. Caution is advised with cases that also have other injuries, are in shock and in cases where the acute paralysis has just occurred or is very recent (hours) as some spinal cord shock, contusion, and decreases in spinal cord blood flow due to vasospasm can provide injury scores that are going to be worse and location indications that may change over the course of the next few hours.

Localization and Severity Judged by Exam of Reflex Arcs, Superficial and Deep Pain Responses

• Upper motor neuron (neuronal segments above (cranial) (caudal) to the arc tested...

• hyper-reflexia because intranuncial (natural suppression area above lesion) is blocked e.g., patella reflex = L3-4 segment

• (+2 = normal, +3 = hyper-reflexia, +4 = clonus)

     o Hyper-patella reflex = lesion cranial to L3-4 segment

     o Deep pain response = patient responds w/ recognition

• Lower motor neuron (neuronal segments that involve the reflex arc being tested)

     o Hypo-patella reflex = lesion involving the peripheral N (Femoral) and/or the spinal segments (L3-5, L4-L5 commonly)

     o (0 = absent, +1 = hypo-reflexia)

Neurological grading in canine intervertebral disc disease (and spinal cord injury)

Grade 0: normal

• Grade 1: cervical or thoracolumbar pain, hyperaesthesia.

• Grade 2: paresis (muscle weakness), decreased proprioception,

• Grade 3: severe paresis absent proprioception, not walking

• Grade 4: paralysis (not able to stand or walk), decreased or no bladder control, conscious deep pain perception present.

• Grade 5: paralysis, urinary and fecal incontinence, no conscious deep pain perception present

Bjorn M: Cervical and Thoracolumbar Disc Disease: Diagnosis and Treatment. Proceedings World Small Animal Veterinary Assoc., 30 th Congress, Mexico City, Mexico, May11-14, 2005.

Indications for emergency surgery (within hours ideally)

• Instability based on plain films with .> 80% open canal

• Compression based on plain films with more compressions BUT deep pain sensation or thought of the presence of it. In dogs in general pain consider placement of a Dopper on the palmar arterial arch and then while listening to blood flow pinch the toes in question. A good sign of some pain perception being present is a rise in blood flow during the pinching.

• Compression based on myelogram with at least some space and no filling of contrast with the cord and some degree of sensation. No sensation is not a good prognosis at all BUT is not definitive... exploration is definitive and is recommended especially in dogs and cats with otherwise a good quality of life prognosis.

• Instability based on fluoroscopy take care! Recommend stabilization surgery if owners understand the poor prognosis if no deep pain is present – I had a remarkable Fox Terrier name Whisky that had instability at L2-L3 with some compression and no deep pain sensation that was hit by an SUV the day before but maintained on a back board over 12 hours and recovered completely but we had the fortune of the use of a low pressure hyperbaric oxygen chamber and the misfortune of him having a cardiac arrest I the hospital on his 9 days post op check up, following cord decompression and stabilization with two plates. The arrest was due to a severe diaphragmatic hernia that was not detectable despite chest radiographs and abdominal ultrasound the day of his admission nine days previously. He had been home only four days when he came in having difficulty breathing. We was successfully resuscitated with open chest CPR and the diaphragm repaired and he was discharged a few days following that episode. He received another 6 hyperbaric oxygen treatments while then in the hospital. After another repair needed for re-herniation of some intestinal contents he has remained healthy with his folks and likes chasing his family cats.

• Penetrating wound into the spinal area

• Neurologic deficits progressing

• Deep pain sensation present or "just gone"

• Continued pain following medical care

Work-up

• H & P, Neuro exam, Immobilization, 02, IV meds protocol, Labs, Radiographs plain + subtraction & obliques, ecg, us, tv, Myelography at L4-5, L5-6 5th 6th dorsal proc. CSF collect if possible. Use Omnipaqe 300mg/ml at 0.3 ml/kg slowly ~ ? test rad. Get Laterals, VD, obliques, use fluro if have.

• If block = Atlanto-Occipital (Cerebellomedullary Cistern) by Left lateral or Sternalapproach. Do not rely on pop of atlanto-occipital membrane & dura

• Helical CT, NMRI, US

Exploratory and decompressive techniques

• Hemilaminectomy - Thoracic – Lumbar; Dorsal Laminectomy (Wide)- Cervical

• Dorsal Laminectomy - T-L, Lumbar, L-S ; Ventral Decompressive Slot - Cervical

• Durotomy – Investigative, Therapeutic; Use Surgical Loops and Headlight w/ 2.5 magnification

• BIPOLAR electrocoag; Lempert Rongues; Microair & Burrs; Love-KerrisonRonguers; Diode laser

• Stabilization Techniques - Internal

     o Lubra Plate (Securose) - Thoracic – Lumbar; Bent Steinmen Pin Wired to Dorsal Spines

     o Bone Plate & Screws to Vertebral Body ; Pins in Vertebral Bodies Fused w/ PMM

     o Vertebral Bodies Fused w/ Bone Graft

• Stabilization Techniques - External

     o V tent system for relatively stable fracture ; Fiberglass and Body Bandage - head to pelvis

     o Aluminum Rods in soft bulky dressing; Limited "Cervical Collar"; Supportive Dressing

Pathophysiology of spinal cord injury

Seven mechanisms of injury: 1.anatomic related to amount of "cord & vessel* room" 2. concussion seen with rapid "shock wave" force; 3. compression amount and its persistence – progressive ; 4. hypoxia - ischemia – initial and then secondary edema; 5. Inflammation – secondary to poor DO2:VO2 cytokines; 6. Microcirculation impairment – endothel-reflow affected; Reperfusion injury – related to ROS, NO, electrolytes; 7. Electromagnetic (ion channel) changes – electron quanta

Treatment based on pathophysiology

• anatomic improve room (surgical decompression) asap

• concussion cool to decrease edema (locally, systemically)

• compression remove all pressure (disc, hematoma, dura)

• hypoxia - ischemia – hyperbaric O2 best, O2 suppl., HBOC

• Inflammation – methylpred. 30 mg/kg, dexameth. 1 mg/kg

• Microcirc. impairment – NaCl 7% 3 ml/kg, pentox 2 mg/kg

• Reperfusion injury – B-vit, mannitol 250 mg/kg, PEG 300/kg

• Electromagnetic (ion channel) changes – Photonic Therapy, Biomagnetic resonance, Acupuncture, Trace minerals, early physical therapy, analgesics, pulse signal therapy (PST)

     o Ultimate Treatment Goal: Normalize DO2 to cord -best as possible EARLY ... w/in minutes ideally

     o DO2 sc = Effective SC Cord Blood Flow X [O2]

• [O2] Oxygen Content = 1.34 x Hb x % saturation + 0.003 x PaO2 (mmHg) Need Hb, high SpO2, pO2

     o Boyles Law =pAO2 proportional to FiO2 and the ...PaO2 proportional to PAO2

• Higher the A pressure gradient = the faster diffusion

     o through alveoli- capillary; through capillary – interstitial; through interstitial – cell membrane

     o DO2cord proportional to Hb O2 Sat. O2 Sat proportional to pO2 and Q cord

     o [O2] Oxygen Content = 1.34 x Hb x % saturation + 0.003 x PaO2 (mmHg) Need Hb and high SpO2

     o Boyles Law pAO2 proportional to FiO2 ... PaO2 to PAO2

• The higher the pressure gradient the faster diffusion

     o Pcord O2 proportional to PaO2 influenced by atmospheric pressure: Pcord of 90 mm + surrounding Patmospheric – increasing PO2 is good HYPERBARIC (>760 mmHg or 1 ATA)

     o Low pressure 1.3 ATA =1080 mmHg

     o High pressure 2 ATA = 1500 mmHg .... ? Amount needed

     o As there seems to be even beneficial effects at 1.3 x 300 = 400

"Jet" Young DSH w/ head and neck injury: received jet blow by, hood "Baggy" O2

• Non-contact Supplemental Oxygen Investigations Drs. Mark Engelhard and D. Tim Crowe, Proceedings IVECCS 2004

• oxygen sensor at patient's nose mouth

• 15 LPM, 5 PLM, timed the speed of increase

• determined FiO2 MAX, speed of fall when DC'ed

• Practical Ways of Providing Supplemental O2

• Flow verses Pressure

• Important Interventions

     o Most Important

          • Prevent further anatomic injury - immobilize

          • Prevent hypoxia - maintain cord blood flow & pO2

          • (supplemental oxygen, hyperbaric oxygen, HBOC)

     o Next Important - Prevent & treat cord compression

          • Document if gross compression - myelogram

          • (Helical CT without & with contrast, MRI) -> Surgery

          • Add cooling (systemic and local)

     o Third - Prevent & treat secondary cord edema -

          • Hypertonic saline, mannitol, colloids,

          • methylprednisolone., dexamethasone, cautious fluids, etc.

• HBOTx

• Mobilizes stem/progenitor cells from bone marrow of humans into systemic circulation

• Elevations were found in number of colony-forming cells (CD34+ cells increased 8 fold)

• Stem cells are produced in both brain and spinal cord and enhance neuropoieses

• Angiogenisis has been proven to occur with low pressure (1.3 ATA, 28% O2) HBOTx..

• Has improved learning in autism and SPECs

• Physiologic Effects of HBOTx

• Canine IV disc herniation and hyperbaric oxygen therapy

• Depth of "dive"

• Holbach proved shallow dives 1.3 -1.5 A 60 min. were very effective in TBI & inflammatory spinal cord diseases (such as trauma, MS)

• Trauma and MS lesions may start w/ apoptosis of oligodendrocytes secondary to ischemic or metabolic insults, which lead to inflammation

• Micro-fat embolization in trauma and MS and associated damage to the BBB ...leading to downstream hypoxia, endothelial damage, myelin damage, and holes in neuro-cells...cell death.

• Expanded Indication for HBOC use = SCI as SCI is associated with:

     1. Lower CO (shock)

     2. Poorer local circulation

     3. Especially gray matter - has 6 X

     4. demand as white matter

     5. 3. Lower Hb (blood loss)

     6. 4. Cellular -interstitial edema

     7. ("oxygen jumping distance"

     8. increased) especially with crystalloids (LRS...also contains Ca++ ion = arteriolar constriction (less flow) + BAX proteins = more mitochondrial injury; use Mg++

• *Providing a HBOC (Oxyglobin) can also increase oxygen delivery as it

     1. Provides a Hb based molecule w/ 80% same O2 (has 13 g/dl Hg; Cl ion, not 2,3 DPG dependent)

     2. Provides a more rapid uptake of oxygen in the pulmonary capillary (facilitates oxygen "on loading")

     3. Provides a more rapid release of oxygen at the tissue level (oxygen dissociation curve shifted to the right - and facilitates oxygen "off loading")

     4. Is a "transporter" or "oxygen bridge" from RBC surface to endothelial surface) BJ Med Online

• Other SCI Medical Treatments

     o Hypothermia – IV 10C Plasmalyte (Mg ++).. 32 C

     o Polyethylene glycol – plugs holes cell membranes

     o poloxamer 188, restores impulses. 300 mg/kg

     o Hypertonic Saline -decreases edema 3-4 ml/kg

     o Mannitol - O2 radical scavenger 0.5 G/kg

     o Pentoxifylline - RBC improved deformation, 2 mg/kg

     o Nicotinic Acid other Bs as a O2 radical scavenger 10 mg/kg

     o Acetylcysteine - improved neuronal survival 140 mg/kg

     o Lidocaine – membrane stabilization 50mcg/kg/min

     o Methylprednisolone - membrane stabilization 30 mg/kg

     o Resveratol, red wine polyphenol, scavenges ROS 10 mg/kg

     o Imposed oscillating electrical field 500mcV (implanted)

• Photonic therapy, biomagnetic resonance, acupuncture, minerals

Other spinal cord injury cases

4 year old DSH - GSW 7mm pellet L2 canal

guided by wound & Rads, Durotomy pellet was in canal - through dura - removed pellet - irrigated - SIS covered- HBOTx - mannitol, MPS - external support (fiberglass) = recovered

3 year old jack russell terrier – HBT

Fx L2-L3 compression on myelogram, Hemilaminectomy – cool saline, durotomy, unstable = vertebral body & dorsal spinous plates + HBOC + MPS + hypertonic saline + HBOTx bid, x 4 days...saw improvement

• Returned w DH - resuscitative thoracotomy + diaphragm repair + HBOC + PT + HBOTx

• Recovered= walking + swimming = running!!

• Whisky White lateral and ventrodorsal radiographs postoperatively – 5 AM

• SPECT scanning pre/post 1.3 28% HBOT in 12 yo boy with autism... note increased perfusion

• SPECT scanning pre/post 1.3 28% HBOT in 12 yo boy with autism... note increased perfusion

• Helical CT preop, post op + HBOTx d 3

Summary

• Time is cord! - 3 hours - medical Tx, HBOTx; Medical Tx – hypothermia, methylpred, PEG

• Adequate ventilation & oxygenation, supplemt; Blood flow and pressure- infuse HBOC

• Surgery Tx time - within 24 -36 maximum Decompression – hemilaminectomy, durotomy

• Stabilization - internally, externally other MEDS CONSIDER Acetylcysteine, Pentoxifyllin, B complex, propolene glycol as a deterrent to excitation injury within the cord; mannitol, others

• Early physical therapy, Photonic Tx, Biomag

• QUESTIONS? Motto " Early in the morning..at the break of day...another cord to save "

• Spinal Injury Care, like Firefighting...time and oxygen are key.

References

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2. Borgens RB, Shi, R: Immediate recovery from spinal cord injury through molecular repair of nerve membranes with polyethylene glycol. FASEB J 14, 27-35, 2000.

3. Dimar JR, et al: The role of directly applied hypothermia in spinal cord injury. Spine 25 (18): 2294-2302, 2000.

4. Ha KY, Kim YH: Neuroprotective effect of moderate epidural hypothermia after spinal cord injury in rats. Spine 33(19): 2059-2065, 2008.

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6. Meij B: Cervical and thoracolumbar disc disease: diagnosis and treatment. Proceedings 30th World Congress of the World Small Animal Veterinary Association, May, 2005.

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21. Kinzel S, et al: Partial percutaneous discectomy for treatment of thoracolumbar disc protrusion: retrospective study in 331 dogs. J Small Anim Pract 46(10): 479-784, 2005.

22. Forterre F, Konar M, Spreng D, Jaggy A, Lang J: Influence of intervertebral disc fenestration at the herniation site in association with hemilaminectomy on recurrence in chondrodystrophic dogs with thoracolumbar disc disease: a prospective MRI study. Vet Surg. 37(4):399-405, 2008. (6 times more re-occurrence in those w/o fenestration)

23. Jensen VF, et al: Quantification of the association between intervertebral disk calcification and disk herniation in Dachshunds. J Am Vet Med Assoc. 233(7):1090-5, 2008. Disk calcification at 2 years of age was a significant predictor of clinical disk herniation with an odds ration of 1.42 per calcified disk., involving all the disks that were calcified not just those disks between T10 and L3. Recommend having a fenestration completed if 3 + seen.

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25. Baltzer WI, et al: Randomized, blinded, placebo-controlled clinical trial of N-acetylcysteine in dogs with spinal cord trauma from acute intervertebral disc disease. Spine 33(13):1397-1402, 2008. N-acetylcysteine is a ROS scavenger. All 70 dogs in this study had hemilaminectomy; with ½ receiving N-acetylcysteine before surgery. There was no difference in recovery despite experimental studies on induced spinal cord injury that revealed improvement.