Neck pain?

Re: Neck pain?

Malcolm Ness — Tue, 01 Mar 2011 17:26:46 GMT

A bit off thread but Arlo said I could!!

Some of you may be interested in our CPD "Roadshow" which this year is a one-day seminar on SA neurology for practitioners. We are putting this on at three venues, Wetherby, Yorkshire (24/3/11); Penrith, Cumbria (12/5/11) and Dumfries (15/9/11). A full day of CPD for £75=00 and with your lunch and some free drinks thrown in!

Details are in the CPD calender.

Re: Neck pain?

Kate Richardson — Mon, 28 Feb 2011 11:11:46 GMT

Tramadol for extra pain relief (cheap) and diazepam for muscle relaxation?

Re: Neck pain?

jd2008 — Tue, 22 Feb 2011 09:32:18 GMT

In terms of additional analgesia gabapentin often works well. If you're thinking along the lines of IVDD adding methocarbamol may help.

Jane

Re: Neck pain?

Alex Gough — Mon, 21 Feb 2011 16:06:50 GMT

Thanks Malcolm - that sounds fair. Totally agree that you need to start with a comprehensive neuro appraisal - presumably like me you see cases that are sent for work up/surgery of one part of the neuro system when the neuro exam reveals the problem is elsewhere. I think MRI itself is a benign modality, but anaesthesia and manipulation certainly have the potential to worsen spinal injuries. And I have certainly seen some lengthy myelograms done where I know it would have been quicker to MRI. But I think the complication rate might partly depend on whose hands are performing the myelogram of course, so you probably see far fewer complications than many. And don't worry, you won't catch me doing neurosurgery, it's been a fair few years since I even spayed a cat!

Alex

Re: Neck pain?

Malcolm Ness — Mon, 21 Feb 2011 15:57:28 GMT

While not a benign procedure, this complication rate of myelography appears to be rather overstated - the example you give, like several others, include a large proportion of technical errors (eg injecting contrast into an inflammed csf; pithing!!; etc).

Myelography allows lateralisation of the lesion and a C spine myelog study can be completed with half a dozen or fewer films in 10 minutes or less and at a cost which is likely to be a fraction (25% or less) of the cost of MRI. Whats more, the pictures are clear, non-pixcellated and the findings correlate very very closely with what you need to know for case management.

There is accumulating evidence to show that much of the "additional" information provided by MRI is either misleading or adds little to prognosis or clinical management.

[quote user="alex gough"]carries a slightly higher risk than MRI [/quote]

MRI has been assumed to be risk free so the comparison cannot be made. There are a couple of papers (Kirberger from SA and I think Lamb from London) indicating a poorer outcome for spinal surgical cases undergoing MRI - presumably a time under anaesthesia effect. If the additional cost of MRI were added in, the modality would not come out looking good!

As a long time user of MRI I am very well aware of its POTENTIAL benefits but as a clinician and practitioner I am equally well aware of its limitations. Far too many patients are being subjected to MRI in place of a competent neuro appraisal and I fear that yet more are subject to surgery to treat lesions that look spectacular on a scan but are of little clinical significance.

Too many practitioners have been misled into thinking that MRI is the starting point for any neuro case and as a result, many patients are denied any kind of competent neuro diagnosis because "the owner can't afford referral and MRI" . Worse still, some are subjected to inappropriate or badly executed surgery by someone with MRI but no training and little expertise in neurology or neurosurgery.

Re: Neck pain?

Alex Gough — Mon, 21 Feb 2011 15:30:31 GMT

[quote user="Malcolm Ness"]

2. Further investigation (CSF analysis, plain radiography and myelography - MRI is not appropriate - it is expensive and very unlikely to tell you anything useful that won't be revealed by "lesser" imaging and a sensible clinical appraisal)

[/quote]

Malcolm, I'm not a spinal surgeon, do you find that knowing the lateralisation of the lesion is useful when doing cervical surgery, eg ventral slot, or doesnt it matter? I agree that myelography and CSF may well give you the answer, but of course myelography carries a slightly higher risk than MRI (from Hopkins, ACVIM Proceedings 2003: complications of myelopgraphy:

" Seizures

Cardio-respiratory abnormalities: Apnea, Tachypnea, Bradycardia, Tachycardia

Exacerbation of presenting neurological signs (e.g., CSM, DM, AA subluxation and meningitis

Precipitation of additional neurological signs (pithing, central canalograms)

Death"

and you will miss some spinal cord tumours on myelography. Also - is the cost of a myelogram very much less than MRI? It may well be in some centres, but I know in other centres the cost of an anaesthetic, myelogram and a series of radiographs isn't that different from the cost of MRI.

Alex

Re: Neck pain?

Aurelijus vet — Mon, 21 Feb 2011 11:10:12 GMT

I had in mind Meloxicam or Carprofen.

Re: Neck pain?

Malcolm Ness — Mon, 21 Feb 2011 10:05:42 GMT

Common things occur commonly.

This is a breed at risk of intervertebral disc disease (IVDD), at an age when such an occurence is very likely showing clinical signs entirely consistent with IVDD so that would be my provisional diagnosis.

Options are:

1. Wait and see - confine the dog and use NSAIDs to control pain and advise serial clinical and neurological exams to make sure that nothing changes except for the better. Most IVDD cases showing pain and no neuro signs will resolve completely within three weeks.

Following diagnosis, if IVDD is confirmed the treatment options are conservatism (see 1 above) or surgery. Surgical options are ventral fenestration of all 5 C discs and this is appropriate if there is minimal or no spinal compression. Otherwise ventral slot decompression - not a minor surgical undertaking but relatively safe and effective providing your surgeon knows what they are doing.

With the case as you describe it, I would go for conservatism and only move on to further investigation with a view to surgery if neuro signs appeared or if the pain gets out of hand.

Re: Neck pain?

Nicola Cole — Sun, 20 Feb 2011 19:57:10 GMT

[quote user="Aurelijus Laurinavicius"]

Methylprednisolone acetate (Depo-Medrone) Pfizer 1-2 mg/kg once a week

Pain control. Meloxicam (Metacam) and Rimadyl (Carprofen)

[/quote]

Sorry, can I check whether you mean that this dog is on steroids and two types of nsaids at the same time?!!

Re: Neck pain?

Aurelijus vet — Sun, 20 Feb 2011 19:42:02 GMT

Methylprednisolone acetate (Depo-Medrone) Pfizer 1-2 mg/kg once a week

Pain control. Meloxicam (Metacam) and Rimadyl (Carprofen)

Re: Neck pain?

Martin Jones — Sun, 20 Feb 2011 18:12:42 GMT

Wouldn't completely rule out an eosionophilic meningitis - whilst I'd certainly go with Mark's suggestion of xrays, and not only for odontoid peg problems, any chance of a CSF tap whilst you're there? Not a classic presentation, by any means, but the lack of pain and a progressive neurological condition might fit.

What dose of steroids are you on?

Re: Neck pain?

Mark Hedberg — Sun, 20 Feb 2011 18:04:48 GMT

Could be an odontoid fracture. Take a lateral xray of the neck, one with the neck extended. Take a second lateral xray of the neck, with the neck flexed downwards. Look at the space between the C2 and C1 vertebra. If the space is bigger on the flexed xray than the extended xray, the C2 vertebra is fractured. Steroids don't help - you want to put a cervical collar to keep the neck from moving. This will need to be on for six weeks.