MCAH Blog

FORLs

Friday, January 16, 2015 | Comments (0)

January and February are dental awareness months here at Mt. Carmel Animal Hospital.  All our dental procedures are 20% off, which makes a necessary medical procedure a little more manageable financially!  While there are many reasons to perform dental procedures on our furry friends, they are especially important for our feline companions.  Cats have a particular issue called Feline Odontoclastic Resorptive Lesions (FORLs).  While we don’t know the underlying cause for these dental changes, we do know what they do to the teeth of cats: cause them to dissolve. 

The tricky thing about these types of lesions is where they occur.  Typically this dissolution occurs under the gumline at the root level.  As we cannot always see these lesions on a basic physical exam, they frequently go unnoticed during a yearly check-in.  If they are more progressed, cats can show an aversion to hard food, excessive drooling or abnormal lip smacking.  Other times cats start dropping hard food out of their mouth while chewing.  These lesions can be quite painful, which is the cause of these clinical signs.  If we are able to see evidence of FORLs above the gumline, these are typically more advanced cases.  The gumline at the affected teeth frequently is very red and inflamed.

The treatment of choice for these lesions is to remove the affected teeth.  Due to the fact that they are actively dissolving when they are found, there is little that can be done to save them.  There are cats that, over the course of their lives, have all their teeth surgically extracted due to the recurrence of such lesions.  As these are very painful for cats, after their post-surgical pain is controlled they are much more comfortable.  Even cats with no teeth are able to eat hard food once the source of their discomfort is gone!

Similar to when we go to the dentist, xrays are key to diagnosing underlying dental issues.  There is a large portion of a dental exam that occurs under the gumline, which can’t be seen by the naked eye.  As our dog and cat friends don’t say “aahhh” and open wide very well on their own, they do require general anesthesia for a full dental exam and dental xrays.  This allows a full examination, dental probing, cleaning and dental xrays to be done safely and easily.  If you are concerned that your feline friend may be suffering from dental issues, give us a call today! 

 

 

 

 

IVDD Part 2

Tuesday, January 13, 2015 | Comments (0)

When an intervertebral disk bulges and pushes on the spinal cord, it affects the relay and transmission of signals in the nervous system.  The severity of the compression of the spinal cord directly can relate to the severity of the clinical signs seen in our patients.  The grade of compression may be listed on a scale of 1-5.

A mild compression may result in only a pain sensation in a dog.  The bulging disk presses on the spinal cord, transmitting a pain signal to the brain.  Additionally, the muscles of the back around that area tend to be tense and rigid, eventually resulting in a muscle spasm.  This rigidity is a natural reaction to holding as still as possible to create as little additional pain as a patient can.  When touched, these muscles tend to start having fasiculations.  Fasiculations are a muscle twitch, a small, local, involuntary muscle contraction and relaxation which may be visible under the skin.  This is a grade 1 compression.

A moderate compression may lead to pain and a loss of “conscious proprioception.”  This is the conscious awareness of body position and where body parts are in space.  Typically, we see this in the hindlimbs when there is a mid-back spinal compression.  On physical examination, we will flip a back foot so it is resting on the top of the toes instead of on the pawpads.  A dog that has lost its conscious proprioception will not put its foot back in its appropriate position; instead, it will continue standing on its foot inappropriately.  A dog that still retains the ability will flip its foot back into its rightful place.  This is a grade 2 compression.

A more severe compression will lead to an animal having changes in its ability to appropriately use its legs.  Frequently, this is seen as a condition we call “ataxia.”  Ataxia is defined as a lack of voluntary coordination of muscle movements.  These dogs are able to move their back legs of their own free will.  However, they typically have uncoordinated movements, almost appearing to have a drunken stumble when they try to walk normally.  This is a grade 3 compression.

A very severe compression of the spinal cord will lead to a loss of voluntary movement in an animal’s legs.  This can happen in either the front or back legs, but it more frequently is seen in the hindlimbs.  An animal will abruptly be unable to stand, walk, or use its affected legs.  When its toes are pinched, an animal may retain its automatic reflexes and pull its leg away from you or whimper in pain.  It is able to do this because it is an automatic response that requires no conscious thought.    This type of paralysis indicates a grade 4 compression.

Finally, the most severe type of compression results in a loss of sensation in the affected limb.  In these animals, when its toes are pinched, it will no longer pull its leg away or whimper in pain.  It has lost the ability to feel its leg, indicating a grade 5 compression.

The clinical signs an animal is displaying typically are indicative of the degree of compression.  The gold standard diagnostic for intervertebral disk disease is an MRI.  With an MRI, we are able to see definitively which disks are affected, and the degree to which the spinal cord is compressed.  These findings may be indicative of whether or not a surgery to relieve the compression is a good option for a patient.  Other diagnostic options include a CT scan or a myelogram.  A myelogram uses X-rays and a special dye called contrast material to make pictures of the bones and the fluid-filled space between the vertebrae and spinal cord.  These more advanced diagnostic techniques are performed at a veterinary neurologist.

Zoey's ACL Injury Part 6

Monday, December 15, 2014 | Comments (0)

Physical therapy attempts to maintain muscle mass and range of motion in the affected leg while the bone is healing.  On average, bone takes approximately 8-12 weeks to heal in young, healthy dogs that are not overly active on their injured leg.  In older patients or patients who are not adequately exercise restricted, bone healing may take up to 10-12 weeks.  We traditionally take our first set of post-op radiographs at 10-12 weeks.  At this point, we are able to assess how well the bone is healing, as well as determine the remaining physical therapy plan.  Typically, these radiographs do not require sedation or an in-hospital stay (unless a patient is too excited!).  The following is Zoey's 7-week post-op xray (hers were taken on the earlier side, to show the healing process).

 

Zoey's ACL Injury Part 5

Monday, December 08, 2014 | Comments (0)

There are multiple conditions that can benefit from a mainstay physical therapy in post-TPLO patients: the underwater treadmill.  Underwater treadmills are a great option for neurologic diseases, obesity and post-orthopedic patients.  They are effective due to the fact that they provide an environment that allows full function of a limb with a reduced amount of weight-bearing.  This allows for less pain on a post-surgical joint while encouraging the patient to continue to use the affected limb.  Following an ACL injury, most dogs become non-weight bearing on the affected limb.  This causes muscle loss (atrophy) due to disuse, which is solved by the usage of the underwater treadmill.  We are able to control the water level, treadmill speed and incline, allowing the sessions to progress as strength and confidence build.

Following TPLO surgery, dogs' knees initially show a reduced range of motion.  Walking on the underwater treadmill allows for a correct but exaggerated gait pattern, improving joint flexion.  Many dogs that are unwilling to use a limb after surgery will use the limb to help maintain balance and stability in the water.  There is a perception of increased comfort on the party of the dog, and there is a resistance to forward motion in the functional limbs, which slows the gait pattern and forces use of all four legs.

Surprisingly, most animals adjust very well to their sessions in the treadmill.  Even animals who don't love water are able to start enjoying their treat-motivated exercises!

 

Zoey's ACL Injury Part 4

Friday, November 21, 2014 | Comments (0)

Following surgery for a torn ACL, physical therapy is an extremely important part of the recovery process.  Initially after surgery, for the first two weeks the dog goes through "phase one" physical therapy.  There are multiple goals for this time period, including post-operative pain management, maintaining an adequate range of motion in the joint, encouraging normal controlled usage of the leg, and managing the post-operative inflammation.

These goals are achieved through several different therapy techniques.  In the days immediately following surgery, ice packs should be applied to the leg 4-5 times a day for 10-15 minutes.  A gentle massage of the leg will help promote blood flow and decrease post-surgical swelling.  After the initial surgical pain is diminished (48-72 hours post-surgery), passive range of motion exercises are used to promote joint fluidity and to stretch the knee and hip.  About one to two weeks post-surgery, we start encouraging our patients to use their leg, with slow controlled leash walks 3 to 4 times daily for 5-10 minutes.  Therapeutic anti-inflammatory laser treatments can also decrease pain, inflammation and swelling.

 

 

 

 

 

      

 

Zoey's ACL Injury Part 3

Wednesday, November 19, 2014 | Comments (0)

After a torn ACL has been diagnosed, the next obvious step is what the treatment options are.  We will be discussing the most common surgical repair, the tibial plateau leveling osteotomy (TPLO).  The diagnostic xrays taken prior to surgery are used to measure the angle at the top of the shin bone, known as the tibial plateau angle.  The surgical goal is to reduce this angle to eliminate the abnormal "thrust" caused by the torn ligament. 

 During surgery, the joint itself is opened and the torn ligament removed.  This decreases inflammation and the pain associated by the ligament rubbing within the joint capsule.  Additionally, when the ligament ruptures, the menisci (the "pillows" within the joint) can be damaged and need removal.  After the joint itself is examined, a curved saw blade is used to make a half-moon cut into the tibial bone itself.  The cut bone piece is then rotated to the pre-calculated angle to create the appropriate "tibial plateau."  A stainless steel plate is then placed on the tibia to hold the bone together as it heals over the following 6-8 weeks.   

The most important thing to remember with the TPLO procedure is that the plate placed on the tibia during surgery is to hold the bone in place as it heals in its new position.  It is not meant to fully bear the weight of the dog; this is why appropriate rest and exercise restriction is a critical part of the healing process.  It takes a full six to eight weeks (at least) for the bone to fully heal.  After the bone has fully healed, the plate is no longer necessary.  However, unless there is an infection or a complication, dogs typically have the plate for the remainder of their lives.  As the plate causes them no pain or discomfort (and they don't need to pass through TSA as much as we do!), we don't do another surgery to remove it unless it is medically warranted.  Once the healing process is complete, dogs return to a normal quality of life.

 

 

 

Zoey's ACL Injury Part 2

Monday, October 27, 2014 | Comments (0)

While clinical history and physical exam findings are helpful in allowing us to suspect a ruptured ACL, further diagnostics are needed to confirm the ligament is torn.  Typically, this involves sedation and xrays of the knee.  These animals usually need sedation because the knee is so painful it is difficult for us to manipulate, as they tense their muscles to resist movement of the joint.  A combination of a sedative and a pain medication is used to allow the animal (and subsequently muscles!) to relax to allow a full manipulation and examination…as well as making them perfectly still for xrays! 

A standard abnormal finding of a ruptured cruciate ligament is the demonstration of an abnormal knee motion called a drawer sign. It is not possible for a normal knee to show this sign.  When we attempt to find a cranial drawer sign, we stabilize the position of the femur with one hand and manipulate the tibia with the other hand. If the tibia moves forward, the cruciate ligament is ruptured.

If the rupture is older, there is swelling on side of the knee joint that faces the other leg. This is called a “medial buttress” and is indicative of arthritic changes in the joint.

After manipulation to find cranial drawer, xrays are taken of the knee as well as the hips.  Hip xrays are helpful to determine if there is any preexisting arthritis or congenital abnormalities that could influence surgery.  Xrays of the knee allow a surgeon to calculate the angle of the knee necessary for surgical repair.

 

 

 

 

 

Zoey's ACL Injury Part 1

Friday, October 24, 2014 | Comments (0)

Zoey, my four and a half year old Pembroke Welsh corgi, was out running in the yard a week ago.  As a member of the herding breed, she has an overabundance of energy that she needs to burn off regularly; this is usually accomplished by running full-tilt in circles in my backyard.  After her latest sprinting episode, she came inside and refused to bear weight on her right hindlimb.  I could tell by palpating her leg that her knee (stifle) was the main source of her pain, and her muscles were so tense she would not let me manipulate it.  As is the case with most veterinarians, the knowledge that we have is dangerous with our own animals, and I immediately jumped to the worst case scenario of a torn ACL, not something simple like a muscle strain.  I withheld breakfast from her Monday morning, and brought her in to have Dr. McGee examine her knee.  She showed no improvement overnight, and the next day he confirmed what I thought, that she had ruptured her ACL.  And so our story begins…

A ruptured cruciate ligament is the most common knee injury of dogs.  The typical presentation of the injury is an active healthy dog that suddenly becomes completely non-weight bearing on a hindlimb and is very painful.  Mild improvement will be seen if left untreated after the first one to two weeks, but the animal will never bear 100% of normal weight and arthritis will begin to form relatively quickly.

The knee is a fairly complicated joint. It consists of the femur, the tibia, the kneecap (patella), and the bean-like fabellae. Pieces of cartilage called the medial and lateral menisci serve the function of a cushion in the join, fitting between the femur and tibia. An variety of ligaments holds everything together, allowing the knee to bend the way it is supposed to and also to keep it from bending a way it shouldn’t.

There are two cruciate ligaments that cross inside the knee joint: the anterior cruciate and the posterior cruciate. Their names are derived from the side of the knee (front or back) where their lower attachment is made. The anterior cruciate ligament prevents the tibia from slipping forward from under the femur.

Over the following weeks, I will post a series of blogs following Zoey through her diagnosis, repair, and rehabilitation for her knee injury.  This is a very common injury we see here at Mt. Carmel, and it is also something that tends to be an overwhelming diagnosis.  Feel free to follow along as we track her progress over the next month!

~Dr. Mara Schultz

 

 

 

 

 

 

Intervertebral Disk Disease (IVDD)

Wednesday, October 15, 2014 | Comments (0)

The spine of our pets is made of numerous small bones called vertebrae.  These are the bones that contain and protect the fragile spinal cord. The vertebrae form multiple joints that allow for the flexibility of the back. These joints are called intervertebral disks.

The disks serve as cushions between the vertebral bodies. They consist of a fibrous outer shell (the annulus fibrosus) and a jelly-like interior (the nucleus pulposus). Ligaments run below and above the disks. These ligaments are called the dorsal (above) and ventral (below) longitudinal ligaments.

Intervertebral disk disease is a process that can cause the disk to press painfully against the spinal cord itself.

 

There are two types of intervertebral disk disease: Hansen Type I Disk Disease and Hansen Type II Disk Disease. In Type I, the jelly center of the disc becomes hardened. A normal movement by the patient can cause the rock-like disk material to shoot out and press on the spinal column.

Type II Disk Disease is a slower degenerative process. In this scenario, the outer shell (annulus fibrosus) collapses and protrudes upward creating a more chronic problem with pain and spinal cord compression.

Dogs that develop either of these conditions typically present with a hunched posture, shaking, pain when touched, and an unwillingness to move.  With more severe cases, dogs can become paralyzed in affected limbs.

The treatment protocol for this disease process depends on the severity and duration of the disease process.  This may be something where we as general practitioners recommend a transfer to a specialist to evaluate for surgery, in particular a veterinary neurologist. 

Typically we are able to localize the area of spinal pain on physical examination.  Any of the disks in the spinal column can degenerate, from the neck to the pelvis.  Intervertebral disks cannot be seen directly on an xray; they can only be visualized on more advanced imaging, such as an MRI.  It is important to take an xray in these cases to rule out other diseases that can cause the same symptoms, such as a spinal infection or vertebral cancer.

After isolating the area of discomfort, the doctors at Mt. Carmel Animal Hospital place these pets on a program of strict rest and restriction.  They are not allowed to run, jump or play for approximately four weeks, to allow the spinal inflammation to decrease and scar tissue to form over the affected disk area.  In the meantime, we place them on various pain medications, muscle relaxers, and anti-inflammatories to keep them comfortable and allow the body to heal.  Additionally, anti-inflammatory laser treatment can provide relief to sore muscles and promote blood flow to the affected area of the spinal cord.

 

Trudy's Weight Loss and Rehabilitation Journey

Wednesday, June 11, 2014 | Comments (0)

Meet Trudy, she is one of the McGee family pets. She is a 6 year old French Bulldog. She shares her house with Roo (12 yr old Pit Bull Terrier), 3 cats (Pitter, Boo, and Holmes), 3 boys (ages 10, 6 ,1.5) and her loving parents. She was adopted by my wife, Dr. Jenny Longbottom, when she was about 5 months old. She was born with a hiatal hernia which resulted in severe aspiration pneumonia and esophageal ulceration. Surgery was done to repair her hernia and place a feeding tube directly in to her stomach. She was tube fed for over a month while her ulcers healed and her pneumonia resolved. She completely recovered and has been doing great for the past few years.

Trudy also has another congenital issue that is very common in her breed. She has a orthopedic condition known as medially luxating patellas.

Her patellas or kneecaps slide from the front center of her knees to the inside of her knees occasionally. This creates inflammation and arthritic change in her knees which can cause her intermittent pain. This is a link for more detailed explanation of luxating patellas. http://www.veterinarypartner.com/Content.plx?A=2448

Trudy has gained some weight over the past year due to extra snacking from my 1 1/2 year old. He loves to feed her and it has become a game for them both. Our busy schedules and this long winter have not allowed us to get the exercise Trudy needs to stay fit.

We use a numeric score to judge an animal's fitness called a Body Condition Score (BCS). This is a scale from 1 to 9, with 5 being ideal, 1 being emaciated, and 9 being obese. Trudy has a BCS score of 7/9 which means she is overweight. That extra weight puts added stress on her joints and back. The added weight also causes her patella to luxate more frequently causing her pain.

Weight loss and exercise to strengthen the quadriceps leg muscles will greatly improve her condition. The underwater treadmill at Mount Carmel Animal Hospital will help her with those two goals.

Please follow Trudy and cheer her on over the next couple of months as she reaches her weight loss goals and hopefully improves her patellar condition.

If we can help your dog with weight loss or an orthopedic condition please give me or our rehabilitation technicians a call.