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Spinal cord injuries can have a devastating impact on a patient’s life. For the canine patient, spinal cord injuries are surprisingly common, accounting for approximately 2% of all cases that are presented to the veterinarian*. The most common forms of injuries arise from acute disc herniation, spinal trauma, fibrocartilaginous embolic myelopathy and chronic diseases including degenerative myelopathy and spinal stenosis. While the initial injury to the spine is a major concern, it’s the secondary effects of that trauma that have long lasting effects including impaired blood flow which can lead to “stroke-like” events.
Spinal tissue has poor regenerative properties, which can provide a challenge to the attending veterinarian when choosing a treatment program for their patient. Depending on the severity of the injury, some patients can make a significant recovery with a comprehensive rehabilitation program. Some patients, however, may remain unresponsive to physical rehabilitation and require further intervention. Below is an overview to a case study originally reported in Veterinary Practice News (February 2016) by David R. Mason, B. Vet. Med, DACVS, DECVS, of Las Vegas Veterinary Specialty Center. This case study focuses on a young, 5-year-old Labrador Retriever named Duncan with Fibrocartilaginous Embolic Myelopathy (FCE).
FCE is a condition in which a fragment of disc material is somehow forced into the spinal vasculature. This migration of disc material causes a “stroke-like” event, cutting off blood flow to the surrounding spinal tissue. This event can cause partial or complete paralysis to the patient. FCE is most commonly reported in large and giant breeds, but is also prevalent in sheep dogs and miniature schnauzers. The most common treatment protocol for patients with FCE is based around aggressive supportive care and physical therapy.
Duncan’s owners reported that he was in the back yard when he vocalized and then was found unable to move his back limbs. After undergoing a thorough evaluation at Las Vegas Veterinary Specialty Center (LVVSC), it was determined that Duncan was suffering from FCE. Subsequently, Duncan was enrolled in a 16-month rehabilitation program, but his condition did not improve and he remained non-ambulatory in his back limbs. Knowing that additional treatment options were limited for Duncan, Dr. Mason elected to treat Duncan with a combination of Platelet Rich Plasma (PRP) and Bone Marrow Aspirate Concentrate (BMAC). Duncan was treated with an epidural injection of PRP/BMAC solution which was produced using the Companion Regenerative Therapies System. After injection, Duncan recovered from anesthesia without incident and returned to his dedicated rehabilitation program.
By day 14, Duncan’s owners reported an increase in energy and after continuing his rehabilitation, Duncan is now able to take several steps without the assistance of a sling or cart. Although Duncan’s condition may not return fully to pre-injury form, this case provides a positive outlook to treating spinal conditions with regenerative medicine.
To read more about Duncan’s story, click here.
* https://cvm.ncsu.edu/research/labs/clinical-sciences/canine-spinal-cord-injury/
For any practice utilizing laser therapy, it is crucial that a treatment design be formulated according to the types of patients that are treated, as well as taking into account the number of technicians trained to perform these treatments. Starting with a basic organization of setting out to do these treatments on a daily basis, the practice needs to start by having a core message to the clients when laser therapy is discussed.
Oftentimes, it is a veterinary technician who will be the laser safety officer of the practice and will take ownership of providing the benefit of this modality to the patients. From this person, others can be cross trained so that there is a system of redundancy and personnel availability at any given time when the practice is open.
Some practices are so invested in laser therapy that they will have a “designated daily operator” who will have scheduled outpatient appointments. In order for any practice to be efficient and reliable in having multiple operators deliver specific treatments for each patient, a laser treatment form must be documented in the patient’s daily record, this will ensure that all operators are on the same page when treating a specific patient.
Depending on the type of practice and the number of technicians trained to perform laser therapy treatments, it is not unusual for a practice to need several laser units. Some practices have a laser unit available for scheduled outpatient treatments, as well as another reserved for surgical or dental procedures, as well as being used to treat the hospitalized patients.
The attending veterinarian who has ordered laser therapy also needs to set specific goals for each patient, and to include a timeframe for either an intermittent course of treatments or establish a starting philosophy to treatment phases (induction, transition, and maintenance phases). This way, the client will also have reasonable expectations in how the patient should respond.
It is important to remember that “the plan” is only “the plan”. This may very well need to be adjusted as per the patient’s response to laser therapy. The conscientious laser operator will be sure to keep the attending veterinarian informed of the patient’s progress, as well as being prepared to deal with potential setbacks. The latter can occur early in the treatment phase as the patient starts to heal, they will get a false sense of security and may be prone to overdoing it with home activity, etc.
In order for a practice to be efficient in their use of this modality, multiple team members need to be adequately trained, a basic framework of scheduled appointments be set out, open communication between laser operators and attending veterinarians be maintained, and a hierarchy of oversight be established.
Intra-Articular (IA) injections are common place in human and equine medicine, whether being used for diagnostic or therapeutic procedures. In particular, IA injections have been a vital component of the successful treatment of osteoarthritis (OA). While similar benefits can be achieved for dogs with OA, the use of IA injections in the small animal practice is less common.
Why is this? Historically, IA injections weren’t a common procedure for OA treatment due to a lack of products available for small animal species and there was an educational void surrounding the use of those products. Additionally, there is a decreased comfort level in performing IA injections in smaller animals since the joint spaces are much smaller than that of the large hooved patients and the procedure is not as common place.
In today’s blog, we will discuss the uses of intra-articular Injections, products that are commonly used for IA treatments and educational opportunities that can equip the small animal practitioner with the skills necessary to perform these procedures.
Intra-articular injections can be used in a multi-modal approach for treating osteoarthritis or can be used for a variety of other indications including:
- Patients with residual post-operative intra-articular symptoms (effusion, discomfort, lameness)
- Supplementation/ alternative treatment to oral meds
- Post-surgical lavage
- Arthrocentesis for differentiating OA from inflammatory joint diseases
- Joint blocking for lameness workups
Which products are commonly used in IA injections?
- Regenerative Medicine Products
As discussed in our previous posts, regenerative medicine, which includes Platelet Rich Plasma (PRP) and Stem Cell therapies, utilizes the body’s own cells to heal and regenerate tissue. With minimal side-effects and treatment benefits lasting upwards of 9-12 months, regenerative medicine treatments are ideal for patients with mild to moderate osteoarthritis.
- Hyaluronic Acid (HA)
Hyaluronic Acid is a naturally occurring polysaccharide in the extracellular matrix of the body. HA has been synthetically manufactured for the treatment of OA in dogs, horses and humans. When injected, HA binds to receptors on the chondrocytes which induces cellular proliferation and extracellular matrix production. Typical treatment schedules require a series of loading phase (weekly administration) injections and re-administration every 3-6 months. Efficacy of HA injections varies depending on the molecular weight of the HA and can adversely affect tissue if injected outside of the joint capsule.
- Corticosteroids
Commonly used in human medicine, intra-articular injections of corticosteroids are recommended in several guidelines for the treatment of patients with OA but remain controversial. Corticosteroids prevent the formation of prostaglandins and are a powerful modulator of inflammatory pathways. However, it is not recommended for long term use (no more than 4 administrations/ year total) and can have negative side effects to the cartilage in the joint.
Now that we know what intra-articular injections can be used for and what can be administered using them, we’re ready to inject, right? For some that may be the next step. But for most of us, IA injections can seem daunting, especially if we’ve never done one before (or perhaps haven’t done them since the equine rotation back in vet school). The good news is that now there is a wealth of educational resources available to gain proficiency at IA injections, including the Companion Regenerative University events. Companion Regenerative University is a one-day live seminar where attendees learn the background to regenerative medicine and get the hands-on practice of performing intra-articular injections. To learn more about this course or to see when and where upcoming courses are taking place, click here.
Stay tuned for our next post where we will take a closer look at a case study involving a patient with a Fibrocartilaginous Embolism who got his step back thanks to regenerative medicine.
