SURGERY
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absolute cage rest is to tell them that for two weeks , the dogs have to be in “ prison .” No exceptions . That means in the kennel at all times and carried outside for bathroom breaks . They don ’ t get time to sniff around . If they don ’ t pee , they go back in the house and you can try again later . The reason two weeks is required is that if there is a tear in the annulus , then two weeks are required to heal that tear and prevent additional nuclear material from being extruded or , in layman ’ s terms , “ squished out .”
After the first two week two additional weeks of restricted activity are required with specific guidelines regarding physical rehabilitation for a total of four weeks of rest . If you give the client specific instructions , she says , then they are more likely to follow your instructions and continue the cage rest while they are doing the specific exercises . You can start with threeto five-minute walks on a leash and specific physical rehabilitation exercises such as a sit-to-stand , standing and weight-shifting exercises , and passive range of motion .
If the patient presents with moderate pain it is recommended to give an injectable opioid and a non-steroidal anti-inflammatory medication in the hospital . Butorphanolis not enough , she says — use oxymorphone , hydromorphone , methadone or morphine .
Pain may be managed orally with tramadol ( 5 to 8 mg / kg ) and an anti-inflammatory . Acetaminophen with codeine can be accurately dosed in large breeds but should be compounded for small breeds . Codeine may also be helpful .
With grade 2 disease you can add in gabapentin or methocarbamol ( Robaxin ®), but Dr Pancotto thinks methocarbamol only helps dogs with visible muscle spasms . Gabapentin can be useful long term in dogs that you think may be predisposed to chronic pain .
If the patient is severely painful hospitalisation is recommended with the administration of intermittent opioid injections ( every four to six hours ) or a poly-pharmacy constant-rate infusion ( CRI ) such as morphine / lidocaine / ketamine with loading doses . If the client is unable to elect hospitalisation because of financial constraints but you feel like this patient would really benefit from injectable pain medication , you can also suggest that the client bring the pet back for injections or apply a fentanyl patch ( Durogesic ®).
The first recheck should be within 48 hours to ensure that the patient is responding to the regimen . If the patient is the same , then you can add in additional medication , acupuncture and heat and ice packing , or consider referral . If the patient is worse than on initial presentation , then the odds of success by continuing what you are doing are not good . If the patient is improved , continue as previously directed . These patients are medicated for a full two weeks and then medications are tapered one by one .
The second recheck should be at the two-week mark , before the client re-institutes controlled physical activity , and the final recheck should be scheduled around eight weeks .
Small steps to get your patients back in the game : Dr . Pancotto recommends starting physical rehabilitation , including leash walks and massage , after the two weeks of strict rest and then more active physical rehabilitation after four weeks , with a gradual return to full function by eight weeks . In general , avoid all high-impact activities during recovery and counsel your clients to invest in ramps for the couch and the bed .
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Don ’ t be afraid to clarify the client ’ s actual financial restrictions before you make recommendations . A client that has restricted budget is going to be in a very different position than a client that has sufficient funds . While a client may not be able to afford neurosurgery , a higher budget gives you a lot more flexibility to practice higher standards of care .
Grade 3 Treatment for grade 3 is the same in regards to cage rest and pain control , but now you will need to counsel the owners to monitor their pets ’ bladder function . Bladder management impacts quality of life and is usually the leading cause of euthanasia in these patients .
If there are signs of overflow incontinence , then prazosin or phenoxybenzamine should be prescribed to relax the urethral sphincter and aid in bladder expression . It is recommended to give the medication 30 minutes before expressing the bladder . If the abdominal wall is very tense , you can prescribe diazepam or methocarbamol to reduce abdominal wall tone as needed . It is not advised to prescribing bethanechol in dogs with upper motor neuron signs ( tight urethral sphincter ) because of the risk of bladder rupture .
Hospitalisation is recommended for grade 3 dogs , if only to closely monitor them for signs of deterioration in bladder or neurologic function that may go undetected by the owner . Furthermore , manual bladder expression is cheap , but painful . If you have a grade 3 dog that is painful and needs bladder expression hospitalisation with intermittent or indwelling urinary catheterization is best to avoid exacerbating pain during manual bladder expression .
If clients cannot afford to hospitalise , even if the dog is urinating on its own , teach them how to express the bladder and to monitor whether the dog is emptying vet360
Issue 04 | AUGUST 2017 | 24