Neuro case study: 6 years old Staffi male entire suddenly 'off it's legs'!

In summary for this case so far, we have a sudden onset and a dog with poorly ambulatory paraparesis, normal spinal reflexes suggesting a T3-L3 lesion, a right sided panniculus cut-off near L3 suggesting a T13-L1 lesion.

You can use the VITAMIM D acronym to think about the possible differential diagnosis and I have done this for you in the attached slide. When you do this, remember that it is crucial to take into account the speed of onset and the progression. For example, a stroke will have a very acute onset. So if your dog has a slow onset (say over 3 days) a stroke is out! Etc etc for all the various categories of diseases.

Perhaps have a look at this list and see which disease you would go for! I have circled in green those that may / may not be more or less likely but every thing is possible! You can also consider what tests you would recommend.

I will finish the case tomorrow.

Thanks for joining. Best wishes. Nicolas

Hi,

So to finish the week, I am giving you the final diagnosis for this case. I realise I didn't mention that the dog was not painful on palpation of the spine or throughout, just at the beginning so this may help you to order your list of differential diagnosis.

I am going to create another post to leave the final diagnosis just so that you can go back now to the list from yesterday in light of my comment above.

So, based on the list of diseases I have given you, and the sudden onset of the signs, slight improvement initially and lack of pain on spinal palpation, I would have gone for a vascular injury (fibro-cartilaginous embolism) or disc herniation with no compression (acute non-compressive nucleus pulposus disc extrusion or hydrated / gelatinous disc extrusion). A calcified disc herniation (and compression) was also possible because sometimes these dogs are quite stoic. For all the other conditions, the very sudden onset is unusual. One would expect a meningitis or disco-spondylitis, or neoplasm to perhaps come on slightly more slowly with signs the owner may have picked up in the days to weeks before onset.

In terms of choice of tests, an MRI is the modality likely to give you the best cover for your differential diagnosis. Here you are looking for a spinal cord disease and the MRI will study the cord parenchyma well. A CT is not a bad idea but would only help to 'rule out' compressive lesions. A CT often gives you an answer as to whether the condition is surgical or not (that is not a 100% rule but close). An MRI will always be superior.

Now consider that the client can't afford the MRI. Based on the diagnosis, which I will reveal in the next post, does it matter? Could you have treated this dog 'without MRI'?

The dog had a non-compressive lesion at T13-L1 and most likely an acute non-compressive nucleus pulposus disc extrusion. We clearly see that bright hyperintensity within the spinal cord (see the red arrow). The volume of the disc at that space is also slightly less than the other discs. The discs are normally white (i.e. hyperintense on MRI T2 signal - this is the image I am giving you here, because they are hydrated; if they go black, they are dehydrated, a degenerative process).

This is a non compressive lesion and therefore surgery is not indicated. Therefore, if you had no MRI, you could have given this dog time and seen a recovery. Obviously, it is better to have a diagnosis, it allows to gain confident that you are expecting a recovery, but if the client were keen to give the dog a chance, then waiting doesn't hurt. The prognosis is good because of the presence of voluntary movement and deep pain sensation. In dogs with more severe signs (paraplegia) the prognosis is reasonably good too (most recover walking) but they may remain ataxic and some continue to display signs of urinary or feacal incontinence. With no deep pain, the prognosis is guarded to poor (~30-50% recover).

We would recommend physio / rehab early on and lead walk early on increasing over 6 weeks to promote return of function. Think of it a bit as a stroke. You would want to re-train your brain as soon as possible to compensate.

I hope this all make sense. Feel free to post questions on the forum and I hope this was a useful case that allowed you to gain a bit of confidence in neurology. Hopefully there might be more cases to come!

Have a good week-end.

Bw

Nicolas