Meet Daisy, a 4 month-old female mix breed that was found on the streets of Miami, unable to walk. On examination by Animal Services, she was unable to use her back legs, had crepitus (crunchiness) when the back was touched, was painful and had multiple puncture wounds on her lower back. Here is her examination at Southeast Veterinary Neurology.
The neurological examination aims to tell us IF the problem is a neurological one, WHERE in the neurological system it is, and HOW BAD the problem is.
The neurological examination evaluates mentation, gait, postural reactions, spinal reflexes, cranial nerves and pain perception.
Daisy is alert and responsive, looking around and interacting with her surroundings.Daisy’s thoracic limbs are normal. However, she is unable to ambulate in the pelvic limbs without support. There is fair movement in the right pelvic limb and minimal to no movement in the left. Although not technically part of gait analysis, notice how her tail seems to hang limp. Daisy has absent postural reactions in her pelvic limbs, but normal postural reactions in the thoracic limbs. Daisy is unable to pull her limb toward her body when stimulated and does not have a knee jerk when the patellar tendon is tapped. She has absent to diminished spinal reflexes. But notice that when her toes are pinched harder, she squirms and looks back at her toes, showing conscious recognition that a noxious stimulus is being applied to her digits. When her tail is pinched, she eventually feels the painful stimulus, but a more vigorous stimulus is necessary than in her toes.
The difference between these two acts and what they mean are paramount for the veterinarian to understand. “Pulling back of the limb” and “turning and looking or crying” are very different.
Her perineal reflex and perineal sensation are normal. Her cutaneous trunci (panniculus) reflex is normal.
She is painful when her lumbar spine is palpated and crepitus is present.
To summarize, Daisy is normal from the waist up, is unable to walk without support, has fair movement in the right pelvic limb and little in the left, has absent spinal reflexes in the pelvic limbs and a limp tail. This is “non-ambulatory lower motor neuron paraparesis with intact nociception”. In eight words, the neurologist knows exactly what the patient looks like.
Her lesion localization is the L4-S3 spinal cord, nerve roots, nerves and/or muscles. On physical examination, there was crepitus in the lumbar spine and a bite wound overlying this area. Here are Daisy’s radiographs.
Daisy has a fracture of the caudal L5 vertebral body with ventral subluxation of L6 relative to L5. The L6 vertebral body is lower than L5 as are the cranial articular facets of L6 relative to the caudal facets of L5. Note that her growth plates are open and that the fracture involves the growth plate (Salter-Harris).
Surgical stabilization was recommended, however instead of internal fixation with screws and plates or bone cement, an EXTERNAL SKELETAL FIXATOR was place for a few reasons. External skeletal fixators can be removed when the fracture is healed. This is beneficial for Daisy since she is still growing and any sort of internal fixation would like cause her vertebrae to be abnormally shortened. Furthermore, since her surgical site is likely ‘contaminated’ due to the bite wound abscess near the spine, it is advantageous to not leave surgical implants that may act as a nidus of infection. External fixators can be placed without an open approach to the spine, allowing surgery to be ‘minimally invasive’. Finally, external skeletal fixators allow a certain degree of ‘adjustment’ after surgery if alignment isn’t quite perfect.
Here are some photographs of Daisy’s surgery.
The following video shows Daisy at 2 weeks post surgery, 5 weeks post surgery and 8 weeks post surgery. In the first (green bandage over external fixator), she is now ambulatory however the left pelvic limb knuckles frequently and is short-strided. The tail still hangs, but there is more tone and she wags it slightly. In the second part (fixator removed), she is strongly ambulatory. In the third part, she has been adopted by a wonderful family and has plenty of yard to be a puppy in!
A big thank you to Jacquelyn and Dino for giving Daisy a second chance and to Daisy for being such a great patient. Please call the board-certified veterinary neurologists at Southeast Veterinary Neurology if you have any questions about Daisy’s case, external skeletal fixators, spinal trauma or any other neurological disease. Our number is (305) 274-2777. We are always available.