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CASE REPORT
Total vertebrectomy for stabilisation of chronic spinal lumbar luxation in a paraplegic dog without nociception P. V. Tertuliano Marinho, C. C. Zani, F. De Biasi and M. V. Bahr Arias Department of Veterinary Clinics, Veterinary Hospital, Londrina State University (UEL - Universidade Estadual de Londrina), CEP 86057-570 Londrina, PR, Brazil
An adult male crossbred dog was referred with a history of a road traffic accident that took place 1 month earlier. Neurological examination revealed paraplegia with absent nociception in the pelvic limbs. On epaxial palpation, significant curvature of the anatomical axis of the spine between the third and fourth lumbar vertebrae was observed, with the presence of a bone end almost piercing the dog’s skin. Survey radiographs of the lumbar spine revealed severe dislocation between L3 and L4 vertebrae. During surgery, the spinal cord was not visible between the dislocated segments. Because of difficulties in reducing the lumbar luxation during surgery, vertebrectomy and vertebral shortening were performed. After alignment between vertebrae L3 and L5, eight cortical orthopaedic screws and bone cement were used for fixation. After 30 days, the dog started to use a wheelchair and was considered by its owner to have a good quality of life with no evidence of pain. To the authors’ knowledge, this is the first case of severe luxation treated by total vertebrectomy and spine shortening in a dog. This surgery can be considered as an option in the management of severe spine luxation when the spinal cord is physically transected.
Journal of Small Animal Practice (2014) 55, 538–541 DOI: 10.1111/jsap.12246 Accepted: 9 May 2014; Published online: 24 June 2014
INTRODUCTION Vertebral fractures and dislocations are one of the major causes of neurological damage in dogs and generally arise from spinal trauma (Jeffery 2010). In many cases it is possible to reduce vertebral misalignment to relieve spinal cord compression and improve neurological condition (Wheeler & Sharp 2005), but when there is significant vertebral dislocation with transection of the spinal cord, there is no hope for functional recovery (Wheeler & Sharp 2005). Despite the poor prognosis for return to voluntary ambulation, some owners elect not to euthanase their dogs and surgical stabilisation is necessary. Unstable vertebral fractures are painful and providing relief is also a goal of stabilisation (Wheeler & Sharp 2005). Vertebral resection with spine shortening has been primarily reported in humans for the treatment of demanding cases of nontraumatic disorders as congenital disorders (Obeid et al. 2011). It was first described for the treatment of scoliosis, and since then, this technique has been used in humans in the management of congenital, tumoural, infectious, deformity, degenerative and traumatic 538
disorders (Obeid et al. 2011). In veterinary medicine, Chauvet et al. (1999) described the performance of the vertebrectomy technique for the treatment of a dog with fibrosarcoma in the fifth lumbar vertebra. This technique involved dorsal laminectomy and total resection of the vertebral body with implantation of a cortical bone graft and subsequent stabilisation with bone plates (Chauvet et al. 1999). To the authors’ knowledge, there are no reports on the performance of total vertebrectomy and vertebral shortening for the treatment of vertebral fracture-dislocation in veterinary medicine. Therefore, the aim of this case report was to describe the use of the total vertebrectomy technique for the treatment of a severe fracture-dislocation of the thoracolumbar spine in a crossbred dog.
CASE HISTORY An adult male crossbred dog (8 kg) was presented with a history of a road traffic accident that took place 1 month earlier, which resulted in paraplegia. The dog’s owner was concerned about an increase in volume and redness over the spine. The dog was
Journal of Small Animal Practice
•
Vol 55
•
October 2014
•
© 2014 British Small Animal Veterinary Association
Total vertebrectomy for stabilisation of chronic spinal lumbar luxation
underweight and had some wounds in the lumbar region, but the general clinical examination revealed no other abnormalities. Neurological examination demonstrated paraplegia, absence of proprioception and hyporeflexia in the pelvic limbs, preserved perineal reflex, urinary retention, and absence of nociception in the pelvic limbs and tail. Neurological assessment of the thoracic limbs was normal. The cutaneous trunci reflex was decreased up to the fifth lumbar vertebra. On epaxial palpation, spinal hyperaesthesia was observed. There was significant curvature of the anatomical axis of the spine at the level of the third and fourth lumbar vertebrae (L3 and L4) with the presence of a bone end almost piercing the patient’s skin, which showed signs of inflammation (Fig 1). With these findings, the lesion was localised neuroanatomically between the fourth lumbar and the third sacral spinal cord segment. Complete blood count (CBC) and serum biochemistry revealed no significant abnormalities, whereas survey radiographs of the lumbar spine revealed dislocation and a substantial curvature of the anatomical axis between L3 and L4 (Figs 2 and 3). The dog’s owner was informed that the prognosis for recovery of locomotor function was poor. As euthanasia was not considered an option, surgery was recommended in order to avoid skin
FIG 3. Ventrodorsal radiographic image showing luxation between L3 and L4 vertebrae with axis deviation
ulceration and deep wound infection that could occur because of the deformity caused by the bone edge. The surgery would also provide vertebral spinal alignment and thus comfort to the dog allowing the use of a wheelchair. During the surgical procedure, significant spinal displacement was observed between the vertebrae L3 and L4 (Fig 4), with the presence of fibrous tissue around the dislocation site. The spinal cord was not visible between the dislocated segments. Even after the fibrous tissue was removed, manual reduction of the thoracolumbar fracture dislocation was unsuccessful. Vertebrectomy of the L4 vertebra was therefore performed. Full extension of the L4 vertebra was subperiosteally dissected so that the fibrous tissue could be removed in its entirety. Articular facets were disarticulated between L4 and L5 using a number 11 scalpel blade. After synovial disarticulation, the connecting area between these vertebrae was sectioned using a scalpel and a rongeur. Following the vertebrectomy, fracture reduction was easily obtained. After alignment between vertebrae L3 and L5, eight 2·7 mm × 26 mm cortical orthopaedic screws
FIG 1. Significant curvature of the anatomical axis of the spine between the third and fourth lumbar vertebrae (L3 and L4), with the presence of a bone end almost piercing the dog’s skin
FIG 2. Lateral radiographic image showing luxation and significant curvature of the anatomical axis between L3 and L4 vertebrae Journal of Small Animal Practice
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Vol 55 • October 2014
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FIG 4. Surgical approach to the thoracolumbar spine. Significant spinal displacement was observed between the vertebrae L3 and L4
© 2014 British Small Animal Veterinary Association
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P. V. Tertuliano Marinho et al.
and bone cement were used for fixation. Radiographic examination, performed in the postoperative period confirmed a perfect reduction between the vertebrae (Figs 5 and 6).
FIG 7. Dog 4 years after surgery FIG 5. Postoperative lateral radiograph showing reduction between the third and fifth lumbar vertebrae following vertebrectomy and stabilisation with eight screws and bone cement
The dog exhibited favourable healing of the surgical wound, without epaxial pain. After 30 days, the dog began to use a wheelchair. The quality of life improved considerably, and 4 years after surgery, the dog is in good overall clinical condition and still using a wheelchair. Vesical massage is performed three times a day, combined with diaper use to ensure that urine scald is avoided (Fig 7).
DISCUSSION
FIG 6. Postoperative ventrodorsal radiograph of the dog
540
Fractures and dislocations of the thoracic and lumbar spine can present as back pain alone or neurological deficits, that can range from mild ataxia to paraplegia, accompanied or not by urinary dysfunction and loss of deep pain perception (Jeffery 2010), as observed in the dog in this case report. According to Bali et al. (2009), severe axis deviation is frequently associated with a worse outcome in dogs and leads to euthanasia at a later point. In the case presented here, the owner was aware that the surgery was recommended to improve the dog’s general condition, not the spinal cord function, because one concern was the development of pressure ulcers over the dislocated vertebra. Pressure ulcers can occur over bony prominences mainly when there is local ischaemia and sensory loss (Swain et al. 1996). The dog presented with a large vertebral column axis deviation and signs of inflammation over the bony prominence, which could represent the beginning of ulceration. Skin problems and infections are an important concern in kyphosis cases reported in humans (Kose et al. 2012). Reduction of misalignment would allow the dog to use a cart with more comfort, reducing the risk of further skin damage. When there is acute or chronic dislocation of the spine in humans, with complete transection of the spinal cord, the goals of surgical treatment are to reduce the fracture and the spinal misalignment, enable rigid stabilisation of the spine and its secondary Journal of Small Animal Practice
•
Vol 55
•
October 2014
•
© 2014 British Small Animal Veterinary Association
Total vertebrectomy for stabilisation of chronic spinal lumbar luxation
fusion, allowing early mobilisation of the patient, so reducing the problems of prolonged recumbency (Alobaid et al. 2006). Reyes-Sanchez et al. (2002) described partial vertebrectomy and vertebral shortening for the treatment of burst-type vertebral fractures in humans, which consisted of resection of proximal two thirds of the vertebra, allowing shortening of the vertebral segment with a high fusion rate. According to Obeid et al. (2011), the total vertebrectomy technique and shortening of the spine may be considered as a treatment option in fracture-dislocations of the thoracic spine when the spinal cord is physically sectioned, allowing non-traumatic reduction, solid fixation and rapid fusion of the spine. No reports of this technique were found for the treatment of severe vertebral luxations in veterinary medicine. Obeid et al. (2011) advocated vertebrectomy in three human patients presented with acute thoracic spine fracture-luxation and paraplegia at admission, in a fragmentary fashion, involving removal of all fragments to obtain good bone reduction and contact between the end plates. Direct contact between two healthy end plates allows excellent arthrodesis (Obeid et al. 2011) and solid and strong fixation with screws and bone cement provides immediate stability, eliminating pain (Jeffery 2010) and allowing the use of a wheelchair, as in this case. Total vertebrectomy and shortening of the spine was therefore a viable option in the treatment of this chronic and severe dislocation of the thoracolumbar spine in the presence of a sectioned spinal cord, and should be considered in similar cases,
Journal of Small Animal Practice
•
Vol 55 • October 2014
•
as it permitted non-traumatic reduction, solid fixation and rapid fusion of the spine. Conflict of interest None of the authors of this article has a financial or personal relationship with other people or organisation that could inappropriately influence or bias the content of the paper. References Alobaid, A., Arlet, V., Ouellet, J. & Reindl, R. (2006) Technical notes on reduction of thoracic spine fracture dislocation. Canadian Journal of Surgery 49, 131-134 Bali, M. S., Lang, J., Jaggy, A., et al. (2009) Comparative study of vertebral fractures and luxations in dogs and cats. Veterinary and Comparative Orthopaedics and Traumatology 22, 47-53 Chauvet, A. E., Hogge, G. S., Sandin, J. A. & Lipsitz, D. (1999) Vertebrectomy, bone allograft fusion, and antitumor vaccination for the treatment of vertebral fibrosarcoma in a dog. Veterinary Surgery 28, 480-488 Jeffery, N. D. (2010) Vertebral fracture and luxation in small animals. Veterinary Clinics of North America. Small Animal Practice 40, 809-828 Kose, K. C., Inanmaz, M. E., Uslu, M., Bal, E. & Caliskan, I. (2012) Kyphectomy for congenital kyphosis due to meningomyelocele: a case treated with a modified approach to skin healing. International Wound Journal 9, 311-315 Obeid, I., Guerin, P., Gille, O., et al. (2011) Total vertebrectomy and spine shortening in the management of acute thoracic spine fracture dislocation: technical note and report of 3 cases. Journal of Spinal Disorders & Technique 24, 340-345 Reyes-Sanchez, A., Rosales, L. M., Miramontes, V. P. & Garin, D. E. (2002) Treatment of thoracolumbar burst fractures by vertebral shortening. European Spine Journal 11, 8-12 Swain, S. F., Hanson, R. R. & Coates, J. R. C. (1996) Pressure wounds in animals. Compendium on Continuing Education for the Practicing Veterinarian 18, 203-218 Wheeler, S. J. & Sharp, N. J. H. (2005) Trauma. In: Small Animal Spinal Disorders: Diagnosis and Surgery. 2nd edn. Eds S. J. Wheeler and .N. J. H. Sharp. Elsevier Mosby, Philadelphia, PA, USA. pp 281-318
© 2014 British Small Animal Veterinary Association
541
CASE REPORT
Total vertebrectomy for stabilisation of chronic spinal lumbar luxation in a paraplegic dog without nociception P. V. Tertuliano Marinho, C. C. Zani, F. De Biasi and M. V. Bahr Arias Department of Veterinary Clinics, Veterinary Hospital, Londrina State University (UEL - Universidade Estadual de Londrina), CEP 86057-570 Londrina, PR, Brazil
An adult male crossbred dog was referred with a history of a road traffic accident that took place 1 month earlier. Neurological examination revealed paraplegia with absent nociception in the pelvic limbs. On epaxial palpation, significant curvature of the anatomical axis of the spine between the third and fourth lumbar vertebrae was observed, with the presence of a bone end almost piercing the dog’s skin. Survey radiographs of the lumbar spine revealed severe dislocation between L3 and L4 vertebrae. During surgery, the spinal cord was not visible between the dislocated segments. Because of difficulties in reducing the lumbar luxation during surgery, vertebrectomy and vertebral shortening were performed. After alignment between vertebrae L3 and L5, eight cortical orthopaedic screws and bone cement were used for fixation. After 30 days, the dog started to use a wheelchair and was considered by its owner to have a good quality of life with no evidence of pain. To the authors’ knowledge, this is the first case of severe luxation treated by total vertebrectomy and spine shortening in a dog. This surgery can be considered as an option in the management of severe spine luxation when the spinal cord is physically transected.
Journal of Small Animal Practice (2014) 55, 538–541 DOI: 10.1111/jsap.12246 Accepted: 9 May 2014; Published online: 24 June 2014
INTRODUCTION Vertebral fractures and dislocations are one of the major causes of neurological damage in dogs and generally arise from spinal trauma (Jeffery 2010). In many cases it is possible to reduce vertebral misalignment to relieve spinal cord compression and improve neurological condition (Wheeler & Sharp 2005), but when there is significant vertebral dislocation with transection of the spinal cord, there is no hope for functional recovery (Wheeler & Sharp 2005). Despite the poor prognosis for return to voluntary ambulation, some owners elect not to euthanase their dogs and surgical stabilisation is necessary. Unstable vertebral fractures are painful and providing relief is also a goal of stabilisation (Wheeler & Sharp 2005). Vertebral resection with spine shortening has been primarily reported in humans for the treatment of demanding cases of nontraumatic disorders as congenital disorders (Obeid et al. 2011). It was first described for the treatment of scoliosis, and since then, this technique has been used in humans in the management of congenital, tumoural, infectious, deformity, degenerative and traumatic 538
disorders (Obeid et al. 2011). In veterinary medicine, Chauvet et al. (1999) described the performance of the vertebrectomy technique for the treatment of a dog with fibrosarcoma in the fifth lumbar vertebra. This technique involved dorsal laminectomy and total resection of the vertebral body with implantation of a cortical bone graft and subsequent stabilisation with bone plates (Chauvet et al. 1999). To the authors’ knowledge, there are no reports on the performance of total vertebrectomy and vertebral shortening for the treatment of vertebral fracture-dislocation in veterinary medicine. Therefore, the aim of this case report was to describe the use of the total vertebrectomy technique for the treatment of a severe fracture-dislocation of the thoracolumbar spine in a crossbred dog.
CASE HISTORY An adult male crossbred dog (8 kg) was presented with a history of a road traffic accident that took place 1 month earlier, which resulted in paraplegia. The dog’s owner was concerned about an increase in volume and redness over the spine. The dog was
Journal of Small Animal Practice
•
Vol 55
•
October 2014
•
© 2014 British Small Animal Veterinary Association
Total vertebrectomy for stabilisation of chronic spinal lumbar luxation
underweight and had some wounds in the lumbar region, but the general clinical examination revealed no other abnormalities. Neurological examination demonstrated paraplegia, absence of proprioception and hyporeflexia in the pelvic limbs, preserved perineal reflex, urinary retention, and absence of nociception in the pelvic limbs and tail. Neurological assessment of the thoracic limbs was normal. The cutaneous trunci reflex was decreased up to the fifth lumbar vertebra. On epaxial palpation, spinal hyperaesthesia was observed. There was significant curvature of the anatomical axis of the spine at the level of the third and fourth lumbar vertebrae (L3 and L4) with the presence of a bone end almost piercing the patient’s skin, which showed signs of inflammation (Fig 1). With these findings, the lesion was localised neuroanatomically between the fourth lumbar and the third sacral spinal cord segment. Complete blood count (CBC) and serum biochemistry revealed no significant abnormalities, whereas survey radiographs of the lumbar spine revealed dislocation and a substantial curvature of the anatomical axis between L3 and L4 (Figs 2 and 3). The dog’s owner was informed that the prognosis for recovery of locomotor function was poor. As euthanasia was not considered an option, surgery was recommended in order to avoid skin
FIG 3. Ventrodorsal radiographic image showing luxation between L3 and L4 vertebrae with axis deviation
ulceration and deep wound infection that could occur because of the deformity caused by the bone edge. The surgery would also provide vertebral spinal alignment and thus comfort to the dog allowing the use of a wheelchair. During the surgical procedure, significant spinal displacement was observed between the vertebrae L3 and L4 (Fig 4), with the presence of fibrous tissue around the dislocation site. The spinal cord was not visible between the dislocated segments. Even after the fibrous tissue was removed, manual reduction of the thoracolumbar fracture dislocation was unsuccessful. Vertebrectomy of the L4 vertebra was therefore performed. Full extension of the L4 vertebra was subperiosteally dissected so that the fibrous tissue could be removed in its entirety. Articular facets were disarticulated between L4 and L5 using a number 11 scalpel blade. After synovial disarticulation, the connecting area between these vertebrae was sectioned using a scalpel and a rongeur. Following the vertebrectomy, fracture reduction was easily obtained. After alignment between vertebrae L3 and L5, eight 2·7 mm × 26 mm cortical orthopaedic screws
FIG 1. Significant curvature of the anatomical axis of the spine between the third and fourth lumbar vertebrae (L3 and L4), with the presence of a bone end almost piercing the dog’s skin
FIG 2. Lateral radiographic image showing luxation and significant curvature of the anatomical axis between L3 and L4 vertebrae Journal of Small Animal Practice
•
Vol 55 • October 2014
•
FIG 4. Surgical approach to the thoracolumbar spine. Significant spinal displacement was observed between the vertebrae L3 and L4
© 2014 British Small Animal Veterinary Association
539
P. V. Tertuliano Marinho et al.
and bone cement were used for fixation. Radiographic examination, performed in the postoperative period confirmed a perfect reduction between the vertebrae (Figs 5 and 6).
FIG 7. Dog 4 years after surgery FIG 5. Postoperative lateral radiograph showing reduction between the third and fifth lumbar vertebrae following vertebrectomy and stabilisation with eight screws and bone cement
The dog exhibited favourable healing of the surgical wound, without epaxial pain. After 30 days, the dog began to use a wheelchair. The quality of life improved considerably, and 4 years after surgery, the dog is in good overall clinical condition and still using a wheelchair. Vesical massage is performed three times a day, combined with diaper use to ensure that urine scald is avoided (Fig 7).
DISCUSSION
FIG 6. Postoperative ventrodorsal radiograph of the dog
540
Fractures and dislocations of the thoracic and lumbar spine can present as back pain alone or neurological deficits, that can range from mild ataxia to paraplegia, accompanied or not by urinary dysfunction and loss of deep pain perception (Jeffery 2010), as observed in the dog in this case report. According to Bali et al. (2009), severe axis deviation is frequently associated with a worse outcome in dogs and leads to euthanasia at a later point. In the case presented here, the owner was aware that the surgery was recommended to improve the dog’s general condition, not the spinal cord function, because one concern was the development of pressure ulcers over the dislocated vertebra. Pressure ulcers can occur over bony prominences mainly when there is local ischaemia and sensory loss (Swain et al. 1996). The dog presented with a large vertebral column axis deviation and signs of inflammation over the bony prominence, which could represent the beginning of ulceration. Skin problems and infections are an important concern in kyphosis cases reported in humans (Kose et al. 2012). Reduction of misalignment would allow the dog to use a cart with more comfort, reducing the risk of further skin damage. When there is acute or chronic dislocation of the spine in humans, with complete transection of the spinal cord, the goals of surgical treatment are to reduce the fracture and the spinal misalignment, enable rigid stabilisation of the spine and its secondary Journal of Small Animal Practice
•
Vol 55
•
October 2014
•
© 2014 British Small Animal Veterinary Association
Total vertebrectomy for stabilisation of chronic spinal lumbar luxation
fusion, allowing early mobilisation of the patient, so reducing the problems of prolonged recumbency (Alobaid et al. 2006). Reyes-Sanchez et al. (2002) described partial vertebrectomy and vertebral shortening for the treatment of burst-type vertebral fractures in humans, which consisted of resection of proximal two thirds of the vertebra, allowing shortening of the vertebral segment with a high fusion rate. According to Obeid et al. (2011), the total vertebrectomy technique and shortening of the spine may be considered as a treatment option in fracture-dislocations of the thoracic spine when the spinal cord is physically sectioned, allowing non-traumatic reduction, solid fixation and rapid fusion of the spine. No reports of this technique were found for the treatment of severe vertebral luxations in veterinary medicine. Obeid et al. (2011) advocated vertebrectomy in three human patients presented with acute thoracic spine fracture-luxation and paraplegia at admission, in a fragmentary fashion, involving removal of all fragments to obtain good bone reduction and contact between the end plates. Direct contact between two healthy end plates allows excellent arthrodesis (Obeid et al. 2011) and solid and strong fixation with screws and bone cement provides immediate stability, eliminating pain (Jeffery 2010) and allowing the use of a wheelchair, as in this case. Total vertebrectomy and shortening of the spine was therefore a viable option in the treatment of this chronic and severe dislocation of the thoracolumbar spine in the presence of a sectioned spinal cord, and should be considered in similar cases,
Journal of Small Animal Practice
•
Vol 55 • October 2014
•
as it permitted non-traumatic reduction, solid fixation and rapid fusion of the spine. Conflict of interest None of the authors of this article has a financial or personal relationship with other people or organisation that could inappropriately influence or bias the content of the paper. References Alobaid, A., Arlet, V., Ouellet, J. & Reindl, R. (2006) Technical notes on reduction of thoracic spine fracture dislocation. Canadian Journal of Surgery 49, 131-134 Bali, M. S., Lang, J., Jaggy, A., et al. (2009) Comparative study of vertebral fractures and luxations in dogs and cats. Veterinary and Comparative Orthopaedics and Traumatology 22, 47-53 Chauvet, A. E., Hogge, G. S., Sandin, J. A. & Lipsitz, D. (1999) Vertebrectomy, bone allograft fusion, and antitumor vaccination for the treatment of vertebral fibrosarcoma in a dog. Veterinary Surgery 28, 480-488 Jeffery, N. D. (2010) Vertebral fracture and luxation in small animals. Veterinary Clinics of North America. Small Animal Practice 40, 809-828 Kose, K. C., Inanmaz, M. E., Uslu, M., Bal, E. & Caliskan, I. (2012) Kyphectomy for congenital kyphosis due to meningomyelocele: a case treated with a modified approach to skin healing. International Wound Journal 9, 311-315 Obeid, I., Guerin, P., Gille, O., et al. (2011) Total vertebrectomy and spine shortening in the management of acute thoracic spine fracture dislocation: technical note and report of 3 cases. Journal of Spinal Disorders & Technique 24, 340-345 Reyes-Sanchez, A., Rosales, L. M., Miramontes, V. P. & Garin, D. E. (2002) Treatment of thoracolumbar burst fractures by vertebral shortening. European Spine Journal 11, 8-12 Swain, S. F., Hanson, R. R. & Coates, J. R. C. (1996) Pressure wounds in animals. Compendium on Continuing Education for the Practicing Veterinarian 18, 203-218 Wheeler, S. J. & Sharp, N. J. H. (2005) Trauma. In: Small Animal Spinal Disorders: Diagnosis and Surgery. 2nd edn. Eds S. J. Wheeler and .N. J. H. Sharp. Elsevier Mosby, Philadelphia, PA, USA. pp 281-318
© 2014 British Small Animal Veterinary Association
541
