Dachshund spine

RE: Dachshund spine

Malcolm Ness — Tue, 03 Jan 2017 11:06:54 GMT

[quote user="David Mills"]How difficult would you say spinal surgery is and what's the learning curve/time for a competent surgeon? [/quote]

Technically, a limited hemilaminectomy or similar is no more difficult than the fractures you mention. The difficult bit, as with all surgery, is the decision making (Is this a surgical case? Is this a case that I should be operating? what operation should I be doing? what are the alternatives?etc etc). The other complicating factor is the diagnostic imaging. The overwhelming majority of spinal surgical cases in SA practice are inter-vertebral disc extrusions amenable to surgical decompression by hemilaminectomy or similar (TL spine) or ventral slot decompression (C spine). Accurate identification and localisation of the extruded disc material (especially lateralisation) is essential and while often quite simple, that is sometimes the most technically challenging part of the procedure.

MRI is neither essential, nor in fact terribly appropriate - it is costly to the extent of being cost-prohibitive in many cases and while good quality MRI provides additional information about spinal cord pathology, such information is not usually of great clinical/prognostic use relative to what can be known form competent neurological exam and 'lesser' diagnostic imaging.

CT is great - in many cases a standard CT reveals presence, location and lateralisation of extruded disc material - all you need to plan your surgery. Contrast CT (CT myelography, either cisternal or lumbar) give loads of information.

That said, I performed 500+ laminectomy or slot operations without access to CT or MRI. A good neurological examination supported by plain rads and cisternal myelography provides enough information in almost every case and remains an appropriate and cost-effective approach to these cases. Lumbar myelography is technically more difficult than cisternal. In experienced hands, about 5% of attempts at lumbar myelography will end in failure and about a further 10% of studies will be sub-optimal because of epidural leakage of the contrast that should ideally all enter the sub-arachnoid space.

There are, as far as I am aware, no published estimates on learning curves but as one who has done some spinal surgery, trained several residents in the skills and taught on spinal surgery courses, I would think that the learning curve is in the region of 20-50 cases for the "finger-tricks". The surgery should not be contemplated by anyone not competent and confident in neurological examination and the necessary diagnostic imaging. Similarly, access to dedicated and adequately trained nursing is essential.

RE: Dachshund spine

grumpyoldman — Sun, 01 Jan 2017 23:30:35 GMT

[quote user="Anthony Todd"]So the one star is because they're jealous of your skill!![/quote]

Absolutely no idea, I either like it or leave it ,so its either 5 or 0 ,which maybe worse. It could have touched a nerve or two with those who refer it or bag it. A lot of people buckle under client pressure to try and manage surgical cases medically.

RE: Dachshund spine

grumpyoldman — Sun, 01 Jan 2017 23:02:25 GMT

[quote user="David Mills"]How difficult would you say spinal surgery is and what's the learning curve/time for a competent surgeon? By the latter, I'm meaning one who is happy with complex fractures, and more advanced soft tissue procedures. What are set up costs equipment-wise?[/quote]

You need some small gelpi's a "freer", a set of bone burr's ,a new head for the high speed burr that fits on your dental equipment , so not too much £££ really . Good pics in Sharpe and Wheelers Neurology book. Or you can spend £1000 on an Orthomed course ,which is very good ,lasts 2.5 days ,was in Iowa annually but now in Glasgow as well. Good course run by Karl Krause, but it does include 101 ways to fit an SOP plate somewhere on a vertebral body ,which is not necessary most of the time.

The hardest part of the whole thing is following a dorsal spinous process into the L5-L6 gap for the Myelogram. We use CT now but for years I just used ordinary radiographs. The CT 3d recon does give a better idea of which side to cut , but mostly it follows the clinical neurology with the panniculus cut off being more definite on one side or the other. The odd tumour and arachnoid/sub arachnoid cyst can pop up and behave like a disc.

I would say its no more difficult than a TPLO, unless the problems are high thoracic ,or static dynamic contrast studies demonstrate dorsal Cervical compression.

The important thing is practice, all that needs is a quiet afternoon and a visit to the body freezer with informed consent.

RE: Dachshund spine

David Mills — Sun, 01 Jan 2017 20:54:12 GMT

[quote user="grumpyoldman"]

[quote user="Anthony Todd"]Criticise, comment or even condemn but one stars just confirms your senseless one star anonymous reply![/quote]

Not everyone is surgical and bold. There are a lot of people out there who refer, manage conservatively, or euthanise. I think its fear, lack of experience, and mostly lack of support/time in their working environment. If something is grade 3-4 but still has deep pain ,your unlikely to make things worse and with a steady hand have a 75% chance of making things better.

[/quote]

How difficult would you say spinal surgery is and what's the learning curve/time for a competent surgeon? By the latter, I'm meaning one who is happy with complex fractures, and more advanced soft tissue procedures. What are set up costs equipment-wise?

It's something we're looking at currently.

RE: Dachshund spine

rhmrcvs — Sun, 01 Jan 2017 19:50:39 GMT

Will only let me 2 star but wanted to 5 star !

RE: Dachshund spine

Anthony Todd — Sun, 01 Jan 2017 18:38:22 GMT

[quote user="grumpyoldman"]Not everyone is surgical and bold.[/quote]

So the one star is because they're jealous of your skill!!

RE: Dachshund spine

grumpyoldman — Sun, 01 Jan 2017 18:34:21 GMT

[quote user="Anthony Todd"]Criticise, comment or even condemn but one stars just confirms your senseless one star anonymous reply![/quote]

RE: Dachshund spine

Anthony Todd — Sat, 31 Dec 2016 18:20:52 GMT

[quote user="grumpyoldman"]they will often form a block vertebrae after surgery[/quote] etc Etc

Why would this measured, sensible, comprehensive reply get the cowardly one-star.

Criticise, comment or even condemn but one stars just confirms your senseless one star anonymous reply!

RE: Dachshund spine

grumpyoldman — Fri, 30 Dec 2016 20:56:02 GMT

they will often form a block vertebrae after surgery which causes instability immediately in front and behind. This usually causes repeat episodes 12-18 months later, but by then the insurance wonga is spent/depleted and they are not re insured so no one gets to do any flow up . With a bit of practice you can do an L5-L6 tap and perform a myelogram which will tell you if the problem is the same place or adjacent to the surgical site, Sometimes a laminectomy membrane forms which creates a tight fibrous band at the surgery site and adheres to the cut surface of the bone. You can dissect it away and free it up if you have patience and a steady hand , If your brave you can also perform a Durotomy and relieve the distortion that way . the best way to tell is MRI with T1 + contrast and T2 imaging to assess the permanence of any scarring in the cord itself, if they have any funding left. You can also ask to see the original imaging or imaging reports.

RE: Dachshund spine

Jenny Harris — Fri, 30 Dec 2016 19:25:40 GMT

I think it is up to the owners to decide how to proceed - it may help to tell them that for grade 2 IVDD (paresis but ambulatory) then prognosis for recovery with conservative treatment is about 85% but with approx. 35% recurrence, with surgery 95% and 10-20% recurrence. If additional analgesia required then gabapentin is good

RE: Dachshund spine

Busybee — Fri, 30 Dec 2016 19:11:09 GMT

I'll happily defer to those more experienced but these are my thoughts....

Presented with a Dachshund with acute spinal pain and proprioceptive deficits and if referral for MRI etc is an option, I'd send them off straight away. For those that require surgery, the sooner it's done, the better the expected outcome - 24 hours can make all the difference!

If spinal pain but no proprioceptive deficits, happy to treat with pain relief and recheck the following day and warn the owner if proprioceptive deficits develop referral should be strongly considered.

If referral not an option at all, rest and pain relief for 4-8 weeks seems to give a reasonable outcome as long as the owner is aware of the likelihood for persistent deficits.

Unfortunately, in your case, it is unclear if this dog has had persistent proprioceptive deficits since the previous surgery. I guess it would come down to how the owner wishes to proceed - offer referral to see if a new acute spinal trauma has occurred but if not, I'd treat as you currently are.