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Ariel Kravitz Senior Seminar March 5, 2014 Basic Science Advisor: Dr. Marnie FitzMaurice Clinical Advisor: Dr. Chelsie Estey Signalment 13 wo FI CKCS Not vaccinated Previously diagnosed with Bordetella Day 2 of Amoxicillin/Clavulanic acid Unsupervised outside Good Samaritan witnessed the vehicular trauma and brought her to an ER/CC center Treated for shock and cerebral edema Kept overnight - no improvement Initial assessment Vocalizing in pain when moved → methadone Mild hypoxemia (SpO2: 21%: 92-93%) Hypotensive (96/58) (MAP 72) → fluid bolus T FAST → negative A FAST → negative Parvovirus SNAP test → negative Neurologic examination Mental Status: Bright, Alert, Responsive Attitude/Posture: Slightly hunched posture Conformation/Muscularity: Normal Gait: Non ambulatory paraparesis (with minimal motor) Cranial Nerves: Normal Proprioception: Absent in pelvic limbs Spinal Reflexes: normal thoracic limb reflexes; decreased withdrawal reflexes bilaterally in the pelvic limbs; decreased patellar reflexes on the right and absent on left; normal cutaneous trunci reflex on the right but cutoff at L3 on the left Nociception: lumbar discomfort Neurologic examination Mental Status: Bright, Alert, Responsive Attitude/Posture: Slightly hunched posture Conformation/Muscularity: Normal Gait: Non ambulatory paraparesis (with minimal motor) Cranial Nerves: Normal Proprioception: Absent in pelvic limbs Spinal Reflexes: normal thoracic limb reflexes; decreased withdrawal reflexes bilaterally in the pelvic limbs; decreased patellar reflexes on the right but absent on left; normal cutaneous trunci reflex on the right but cutoff at L3 on the left Nociception: lumbar discomfort Neurologic examination Mental Status: Bright, Alert, Responsive Attitude/Posture: Slightly hunched posture Conformation/Muscularity: Normal Gait: Non ambulatory paraparesis (with minimal motor) Cranial Nerves: Normal Proprioception: Absent in pelvic limbs Spinal Reflexes: normal thoracic limb reflexes; decreased withdrawal reflexes bilaterally in the pelvic limbs; decreased patellar reflexes on the right but absent on left; normal cutaneous trunci reflex on the right but cutoff at L3 on the left Neurolocalization: T3-L3 and L4-S3 myelopathy Nociception: lumbar discomfort Plan Full body CT Restrained on a backboard in O2 cage Supportive care in ICU Transfer to the Neurology Service in the AM Transverse soft tissue window post-contrast Coronal bone window post-contrast Transverse soft tissue window post-contrast Coronal bone window post-contrast Transverse soft tissue window post-contrast Coronal bone window post-contrast Sagittal bone window Sagittal bone window Transverse soft tissue window Transverse soft tissue window Transverse bone window through L4 Sagittal bone window throughL3-L5 Transverse bone window through L4 Transverse bone window through L3 Sagittal bone window throughL3-L5 Comminuted fracture of L4 vertebra Fissure fracture of C3 vertebra Bilateral pulmonary contusions Fractures of the right orbit Fractures of the frontal sinus with pneumocephalus and intracranial hemorrhage Hypoxemia Bordetella positive High energy blunt injury Trauma - 2nd most common cause of death Most common cause of vertebral fractures 2nd spinal fracture/luxation - ~20% Additional injuries – 40-50% PE findings more sensitive radiographs than Figure 2 from Evaluation of vehicular trauma in dogs: 239 cases (January-December 2001) Pathophysiology 1o injury Immediate result of the trauma Mechanical damage to the spinal cord → physical disruption of neuronal and glial cell membranes 2o injury Hours to days following trauma Biomechanical processes triggered by the primary injury → worsening spinal cord damage Pathophysiology 1o injury immediate result of the trauma Mechanical damage to the spinal cord → physical disruption of neuronal and glial cell membranes 2o injury Hours to days following trauma Biomechanical processes triggered by the primary injury → propagated spinal cord damage 3 compartment model Boney and soft tissue structures Dorsal Middle Ventral If 2 of the 3 compartments are affected → unstable injury Figure 12.1 from A Practical Guide to Canine and Feline Neurology Prevent ongoing primary injury and allay perpetuation to secondary injury Stabilization of a fracture is based on: The damaged structures The forces acting on them Goals Realign and stabilize the spinal column Decompress the spinal cord Surgical techniques Pins + PMMA* Locking plates * External fixators* Vertebral body plates Modified segmental fixation Tension band stabilization Spinous process plating Goals Realign and stabilize the spinal column Decompress the spinal cord Surgical techniques Pins + PMMA* Locking plates * External fixators* Vertebral body plates Modified segmental fixation Tension band stabilization Spinous process plating Dorsal laminectomy Dorsal decompression Visualize L4 vertebral fracture Cortical screw placed transarticularly through the R articular facet joint of L4 4 screws placed bicortically through L3 and L5 Screws placed through the base of L and R transverse processes of L3 Screw placed through the base of the L transverse process of L5 Screw placed through the R transverse process and pedicle of L5 PMMA with cefazolin molded around the screws Fig. 35-6 from Small Animal Surgery Transverse bone window through L5 Sagittal bone window through L2-L5 Treatment 40% O2 Plasmalyte + 1.5% dextrose Fentanyl CRI Ampicillin/Sulbactam Ceftazidime Ondansetron, Pantoprazole and Sucralfate Neurologic examination – Day 1 post-op Ambulatory paraparesis with voluntary motor function in all limbs Absent placement in the hindlimbs bilaterally Intact withdrawal, patellar and perineal reflexes Cutaneous trunci reflex cutoff at the level of L3 on the left; normal on the right Continue to improve in hospital Oxygen independent day 3 post-op Fluids tapered and switched to all oral medication TGH Medications Cefpodoxime Amoxicillin/Clavulanic acid Pregabalin Tramadol Metronidazole Exercise restriction At home rehabilitation Fair to good Comminuted fracture - L4 Vertebra Failure of perfect anatomical alignment - potential for the spinal cord to be compressed if the fragments dislodge from their current locations 60-70% chance to return to normal function Fissure fracture - C3 Vertebra Not at issue at this time Potential for neurologic deficits in the future Growing Trauma Bilateral pulmonary contusions – improving Fractures of the right orbit Not at issue at this time Unknown in future Fractures of the frontal sinus with pneumocephalus and intracranial hemorrhage Not at issue at this time Unknown in future Predisposed to seizures 4 weeks post-op Neurolocalization: Thoracolumbar spine (T3-L3) Mild hindlimb spinal ataxia Absent postural thrust on the right, delayed on the left, normal placing in all four limbs Pain elicited on head palpation, cranial cervical and thoracolumbar spine Spinal radiographs Prognosis Still fair to good Recommendation: Medications Pregabalin Tramadol Exercise restriction At home rehabilitation 10 weeks post-op Neurolocalization: Thoracolumbar spine (T3-L3) Mild hindlimb spinal ataxia Delayed hopping on the right pelvic limb, normal hopping in other limbs, normal placing in all four limbs No pain elicited on palpation Spinal radiographs Prognosis Good! Recommendation: Medications Pregabalin (tapered dose for 1 week) Tramadol Exercise restriction Initial Stay ECC exam $113.00 Full body CT $733.00 Surgery + Anesthesia $2078.26 Supportive therapy +maintenance in ICU x 9 days $4254.34 Total $7178.60 4 Week Recheck Exam + Radiographs $220.40 10 Week Recheck Exam + Radiographs $200.00 Total Cost $7599.00 Dewey, C. A Practical Guide to Canine & Feline Neurology. 2nd ed. pp 405-414. Wiley-Blackwell, 2008. Ames, Iowa. Fleming J.M. et al. Mortality in north american dogs from 1984 to 2004: an investigation into age-, size-, and breed-related causes of death. Journal of Veterinary Internal Medicine. 2011 Mar. 25(2), pp 18798. Fossum , T. Small Animal Surgery. 1st ed. pp 1118-1127. Mosby and Co., 1997. St. Louis, Missouri. Olby, N. The pathogenesis and treatment of acute spinal cord injuries in dogs. 2010 Sep. 40(5), pp791-80. Rockar, R.A et al. Development a Scoring System for the Veterinary Patient. Journal of Veterinary Emergency and Critical Care. 2007 Jul. 4 (2), pp 77-83. Streeter, E. et al. Evaluation of vehicular trauma in dogs: 239 cases (January–December 2001). JAVMA. 2009 Aug. 235 (4), pp 405-408. Tobias K, Johnston S: Veterinary Surgery: Small Animal. 1st ed. pp 487496. Elsevier/Sauders, 2012. St. Louis, Missouri. Dr. Chelsie Estey Dr. Marnie FitzMaurice Dr. Sofia Cerda-Gonzalez My family Class of 2014