Acupuncture for Neurological Disorders

1
Acupuncture for Neurological Disorders

• It matters not whether medicine is new or old, it
  only matters that it is applied for the benefit
  of the patient.

2
Neurologic Assessment

• Is it a neurologic disease?
• Seizures
• Intention tremor
• CN deficits
• Head tilt
• Nystagmus
• CP deficits
• Dysmetria
• Paralysis

3
Minimum Database

• CBC
• Chemistry
• Bile acids
• Cholinesterase
• Urinalysis
• Chest and abdominal radiographs

• Abdominal ultrasound
• Heartworm test
• Fecal

4
Ancillary Neurologic Tests

• Radiographs
• Skull spinal films
• Myelography
• CT scan
• MRI
• Muscle Analysis
• Enzymes
• 2M antibody
• Anti-ACH receptor antibody
• Biopsy

• Electrodiagnostics
• EEG
• EMG
• BAER
• CSF tap analysis
• Cells protein
• Pressure
• Cholinesterase
• Titers

5
When all else fails
Look at the patient!!!
6
Seizures in Small Animals

• It is estimated that the overall incidence of
  seizure disorders in dogs and cats is around 1
• In pure breed dogs, this incidence may increase
  to 15-20, due to the presence of inherited,
  primary epilepsy in those breeds

7
Lesion Localization in Seizures

• Cerebral Cortex
• Diencephalon
• Thalamus
• Hypothalamus
• Mesencephalon

8
Seizure Diagnoses
9
Seizure Diagnosis

• Minimum Database
• Abnormal in Reactive Epilepsy
• CSF tap analysis
• Abnormal in Active Secondary Epilepsy

• CT or MRI Scan
• Abnormal in Active Secondary Epilepsy
• EEG
• Abnormal in Secondary Epilepsy

• All test are normal in Primary Epilepsy

10
Asymmetrical Seizures
11
Licking Seizure
12
Fly-Biting Seizure
13
Seizures and Signalment

• Primary Epilepsy- purebred dogs 1-3 years of age
• Secondary Epilepsy- any age but especially under
  6 months and over 3 years

14
Seizure Treatment

• Acupuncture alone
• Acupuncture in conjunction with drugs
• Traditional Chinese herbs
• Western herbal medicine
• Valerian Root
• Kava Kava
• Oats
• Hops
• Passionflower
• Western drugs

15
Phenobarbital

• Cheap and effective
• Dose 2-4 mg/kg for a serum level 20-40 mcg/ml
• Takes 3-5 days to reach steady state
• Safe but can effect the liver in a few cases
• Controls 80 of seizures

16
KBr (Bromide)

• Compounded by pharmacist dissolved in H2O at
  250mg/ml
• Dose at 22 mg/kg q12h
• Blood level in 2 months between 1500-4000 µg/ml
• Use alone or in conjunction with Phenobarbital
• Bypass liver
• Good for cluster seizures

17
Other Anticonvulsants

• With Efficacy
• Diazepam
• 1 mg/kg q12h
• Primidone
• 15-22 mg/kg q12h
• Felbamate
• 15-45 mg/kg q8h
• Phenytoin
• 3-5 mg/kg q8h
• Gabapentin
• 30-60 mg/kg q8-12h
• Topiramate
• 15-25 mg/kg q8-12h

• No Efficacy
• Valproic acid
• Nimodapine
• Chorazepate
• Lamotrigine

Note TOXIC to Dogs
18
Seizures- -TCM

• Represent various aspects of the Liver (Wood)
  system
• Excess (3 types)
• Deficiency (3 types)

19
Seizures- -TCM

• Excess
• Wind-Phlegm
• Tongue pale greasy
• Pulse wiry slippery
• Phlegm-Fire
• Tongue red greasy
• Pulse rapid, wiry slippery
• Blood Stagnation
• Tongue Pulse like Wind-Phlegm
• History of head trauma

• Deficiency
• Liver Blood Def.
• Tongue pale dry
• Pulse weak thready
• Liver Kidney Yin Def.
• Tongue red dry
• Pulse weak thready
• Kidney Jing Def.
• Tongue pale or red dry
• Pulse weak thready
• lt 1 year of age

20
Seizures- -TCM

• Excess
• Wind-Phlegm
• expel phlegm, extinguish the wind, open the
  orifice and stabilize the seizures
• Ding Xian Wan
• Phlegm-Fire
• clear the liver, drain the heat, transform phlegm
  and open the orifices
• Di Tan Tang and Long Dan Xie Gan Tang
• Blood Stagnation
• expel phlegm, extinguish the wind, open the
  orifice, stabilize the seizures and invigorate
  blood
• Ding Xian Wan and Tao Hong Si Wu San

• Deficiency
• Liver Blood Def.
• tonify Qi and Blood and quiet the wind
• Bu Xue Xi Feng San or Di Tan Tang plus Rehmannia
  8
• Liver Kidney Yin Def.
• nourish Yin and extinguish wind
• Yang Yin Xi Feng San or Di Tan Tang and Left Side
  Replenished (Zuo Gui Wan) or Tian Ma Gou Teng
  plus
• Kidney Jing Def.
• extinguish the wind and astringe or nourish the
  kidney jing
• Di Tan Tang and Epimedium Powder

21
Epilepsy -- TCM

• Internal heat leading to generation of wind
• Clear wind heat and calm the Shen
• Points
• Constitutional points
• Clear wind heat
• GB20, LI4, LI11, GV14, LIV3
• Calm the shen
• PC6, HT7
• Local points
• GV17, GV20, GV21, Long hui, GB9, GB13, BL5, GV1,
  ST40
• TCM Herbals
• Di Tan Tang (TCM phenobarbital)
• Specific herbs for excesses or deficiencies
  present

22
Basic Antioxidants
Dogs
Cats

• Vitamin E 10 IU/lb daily
• Vitamin C 5-10 mg/lb twice a day
• Selenium 2 µg/lb daily
• Beta carotene 250 IU/lb daily
• B Complex 2mg/kg twice a day

• Vitamin E 100-400 IU daily
• Vitamin C 100-250 mg twice a day
• Selenium 50 µg daily
• Vitamin A 1000-5000 IU daily
• B Complex 10 mg twice a day

23
Additional Considerations

• Probably safe parasite control
• Interceptor
• Frontline Top Spot
• Revolution

• Should avoid
• Heartgard
• Proheart 6
• Program
• Sentinel
• Frontline Spray
• Advantage
• Advantix

24
Additional Considerations

• Diet
• Low-carbohydrate food

• Supplements
• Ginkgo biloba
• 2-4 mg/kg q8-12h
• Ginkoba or Publix brand
• Tofu or Lecithin
• 20 mg/kg daily
• Acetylcysteine
• 25 mg/kg q8h qod

25
Meningoencephalomyelitis

• Infectious Diseases
• Species Specific
• Steroid Response ME (SRME)
• Necrotizing Vasculitis (SRMA)
• Necrotizing ME (NME)
• Granulomatous ME (GME)

26
Meningoencephalomyelitis

• Pain to paresis to plegia
• Dx with CSF tap
• Spinal radiographs normal
• Myelography normal (might be contraindicated)

27
Meningoencephalomyelitis
28
CSF Tap

• Collection site for seizures is at the cisterna
  magnum.
• Allows analysis for cells, protein and pressure.
• Cytology and titers for infectious organisms can
  be obtained.

29
Meningoencephalomyelitis

• CSF Analysis
• may be normal or show increased pressure, protein
  and/or cells.
• CSF Titers
• species specific tests
• many must be paired with serum titers.

CSF cytology form a dog exhibiting a mixed
reaction with neutrophils, lymphocytes and
macrophages.
30
Meningoencephalomyelitis

• Infection
• virus
• rickettsia
• protozoa
• fungus
• bacteria
• Inflammation
• GME
• NME
• SRME
• SRMA

31
GME

• Can be
• peracute
• acute progressive
• chronic
• In brainstem, tends to be a multifocal
  inflammatory disorder
• Responds temporarily to steroids.

Patient with GME presenting with vertical
nystagmus, long tract signs, and circling with
incoordination.
32
GME
GME histologically causes multifocal
meningoencephalitis due to proliferation of
reticulohistiocytic cells. Lesions also show
multinucleated giant cells.
33
Treatment of ME

• Depends upon whether infectious or inflammatory
• Prednisolone
• Find minimum daily dose and then used 2 times MDD
  QOD

• Primor (activated sulfadimethoxine)
• 15 mg/kg BID
• Doxycycline
• 5-10 mg/kg QD
• Herbal Support
• Bromelain/Curcumin
• 2.5/5 mg/kg TID

34
Menigoencephalomyelitis

• Wind-Phlegm
• expel phlegm, extinguish the wind, open the
  orifice and stabilize the seizures
• Ding Xian Wan
• Phlegm-Fire
• clear the liver, drain the heat, transform phlegm
  and open the orifices
• Di Tan Tang and Long Dan Xie Gan Tan

35
Brain Abscess in a Foal
36
Brain Abscess in a Foal
37
Vestibular Disease

• Cardinal Signs
• Head Tilt
• Nystagmus
• Horizontal
• Rotatory
• Vertical
• Positional
• Circling (tight)
• Imbalance Incoordination

38
Vestibular Disease
Vestibular Disease
8th Nerve, 7th Nerve Horners Syndrome
8th Nerve only
Anything Else
Idiopathic V.D.
Inner Ear Disease
Central V.D.
39
Idiopathic Vestibular Disease

• Acute Onset of Vestibular Signs
• Head tilt
• Horizontal or Rotatory nystagmus with fast-phase
  away from head tilt
• Nothing else
• Can Be Very Severe
• Acute, regressive disease

40
Idiopathic Vestibular Disease -- TCM

• Wind (heat) invasion
• Clear wind heat and calm the Shen
• Points
• Constitutional points
• Clear wind heat
• GB20, LI4, LI11, GV14
• Calm Shen
• PC6, HT7, GV17, GV20, GV21
• Local points
• TH17, TH18, TH21, SI19, GB2, Er jian, An shen

41
Inner Ear Disease

• 8th Nerve Signs
• 7th Nerve Signs
• ear lip droop
• lack of palpebral reflex
• nose turn
• nostril flaring
• Horners Syndrome

42
Horners Syndrome

• Small Animals
• Ptosis
• Myosis
• Enophthalmos
• Large Animals
• Facial sweating (horse)
• Lack of muzzle sweating (cow)

43
Inner Ear Disease

• Most cases are secondary to bacterial infection
  (otitis media interna)
• extension from otitis externa
• pharyngitis with extension up the Eustachian tube
• hematogenous spread

44
Ear Polyps in Cats

• Benign growth in the external ear canal which
  causes signs by extension.
• Can also be pharyngeal mass which grows into
  middle ear via the Eustachian tube.

45
Ear Polyps in Cats

• Treatment is surgical removal.
• Damage can be permanent, if pressure necrosis has
  destroyed the inner ear structure.

46
Inner Ear Disease -- TCM

• Invasion of external pathogen leading to wind,
  heat, damp.
• Heat boils the fluids leading to the accumulation
  of phlegm.
• Quiet the wind, reduce heat, disperse damp and
  activate the blood to dissolve stagnation.

47
Inner Ear Disease -- TCM

• Points
• Constitutional points
• Clear wind heat
• GB20, LI4, LI11, GV14
• Calm the shen
• PC6, HT7, GV17, GV20, GV21
• Eliminate damp
• SP9
• Activate Qi blood
• ST36, ST40, Xin shu
• Local points
• TH17, TH18, TH21, SI19, GB2, Er jian, An shen

48
Central Vestibular Disease

• Postural Changes
• CP Deficit
• Dysmetria
• Reflex Changes
• hyperactive reflexes
• crossed-extensor reflexes
• Babinskis sign

Conscious proprioceptive deficit may be on the
same or opposite side of the lesion.
49
Central Vestibular Disease

• CSF Analysis
• may be normal or show increased pressure, protein
  and/or cells.
• CSF Titers
• species specific tests
• many must be paired with serum titers.

CSF cytology form a dog exhibiting a mixed
reaction with neutrophils, lymphocytes and
macrophages.
50
Central Vestibular Disease

• Inflammatory or Infectious Diseases
• canine distemper
• toxoplasmosis and neosporiosis
• fungal
• rickettsial
• GME
• SRME

51
Central Vestibular Disease

• Trauma or Vascular
• remember dogs dont get atherosclerosis !
• Neoplasia
• meningiomas
• choroid plexus papillomas
• oligodendrogliomas
• astrocytomas
• metastatic neoplasia

52
Central Vestibular Disease
MRI of Cerebellar Meningioma
53
Central Vestibular Disease

• Infectious Diseases
• FIP
• FeLV
• toxoplasmosis
• cryptococcosis
• Trauma
• Metabolic
• thiamine deficiency
• Toxicity
• organophosphates

• Neoplasia
• meningiomas

54
Central Vestibular Disease -- TCM

• Can be wind, heat-damp or wind cold based upon
  the causative factor involved.
• Points
• Constitutional
• 8 Principle
• Zang-Fu

55
IVD- -TCM Diagnosis

• Represents a bi syndrome often accompanied by
  wei syndrome
• Under domain of KID (bones) LIV (joints free
  flow of qi blood)

56
IVD- - TCM Patterns

• Excess types
• Wind-Cold-Damp
• Blood stagnation

• Deficient types
• Yang deficiency
• Yin deficiency
• Yin Yyang deficiency

57
Fibrocartilagenous Emboli

• Vascular occlusion from IVD material
• IVD herniates into the venous sinus or the
  vertebral body
• the venous sinuses have no valves
• increased pressure forces material into spinal
  cord

58
FCE

• Generally affects a radicular penetrating branch
  which leads to a quadrant (wedge) of infarction
• Many will improve with time

59
Schatzie
60
IVD- -Wind-Cold-Damp

• Acute invasion of external pathogen leading to
  stagnation (cold slows blood flow which is
  worsened by accumulation of damp)
• Tongue
• Greasy
• Pulse
• Slow soft

• Rx principle
• Dispel W-C-D, activate blood relieve stagnation
• TCM herbal
• Xiao Huo Luo Dan
• Acupuncture
• Hua-tuo-jia-ji, BL23, BL67, GB39, GV1, GV14

61
Acute Spinal Cord Injury

• Damage affects the vascular supply leading to
  ischemia
• The ischemia leads to lactic acidosis and lipid
  peroxidation which furthers the injury

62
Pathology of Spinal Injury

• Within 5 minutes there are petechiations in the
  grey matter
• Progresses to complete hemorrhagic necrosis of
  the grey matter by 4 hours

63
Pathology of Spinal Injury

• From 4-24 hours there is progressive local
  extension to involve the white matter.
• If force is great enough, then progresses up
  down spinal cord

64
Treatment of Acute SPI

• Antioxidant steroids (Solu Medral or Solu Delta
  Cortef)
• 30mg/kg
• 15mg/kg every 8 hours for 24-48 hours
• Surgical correction

Acupuncture needle in wei jian (tip of tail)
65
Intervertebral Disc Diseasechondrodystrophic
dogs

• Collagen fibers of the nucleus pulposus
  metamorphs into hyalin cartilage
• IVD looses elasticity and leads to damage of
  annulus fibrosus

66
IVD- -chondrodystrophy

• Annulus ruptures extruding degenerate nuclear
  material into the neural canal
• This leads to pain, paresis or paralysis

67
IVD- -Pain Only

• Cage Rest for 30 days or 3 weeks after patient
  becomes clinically normal.
• Acupuncture
• Oral steroids and diazepam only under supervision

68
IVD- -Paresis

• Hospitalize
• Prednisolone (2 mg/kg divided 2-3 times a day)
• Misoprostol 3-4 µg/kg twice a day
• Diazepam 0.25-0.5 mg/kg TID
• Should improve in first 5-7 days

69
IVD- -Paralysis with Deep Pain

• Emergency
• Give Solu Medral or Solu Delta Cortef 30 mg/kg
• Refer
• May observe for 24 hours to see if dramatic
  improvement
• If none, Emergency

70
IVD- -Paralysis No Deep Pain

• Emergency
• Give 30 mg/kg Solu Medral or Solu Delta Cortef
• Refer
• 75 respond in first 24 hours
• 50 in first 72 hours
• 25 after that

71
Integrative Therapy of IVD Disease

• Acute IVD Disease is a surgical emergency
• Even with no deep pain there is a 75 chance of
  success within the 1st 24 hours 50 chance in
  the 1st 72 hours

• After 72 hours with no deep pain, the chances are
  no different
• Chronic IVD Disease may respond poorly to surgery

72
Hemilaminectomy

• The thinned lamina is further removed and the
  laminectomy expanded with rongeurs exposing the
  spinal cord
• The area is probed for the problem

IVD material
73
IVD

• After surgery, healing is needed
• Physical therapy
• Passive movements
• Massage
• Standing exercises
• Hydrotherapy
• Walking

• Acupuncture
• Control pain
• Stimulate nerves
• Magnet therapy
• North pole magnet stimulates nerve regeneration
• Healing touch

74
IVD- -Diet

• Basic antioxidants
• Vitamin E, vitamin C, vitamin B complex,
  selenium, beta carotene
• Anti-inflammatory membrane stabilizers
• Omega-3-fatty acids, gamma linolenic acid,
  coenzyme Q-10

• Lecithin to help support myelination
• Herbal medications to help immune system
• Astragalus, cordyceps mushroom, garlic
• Dietary cartilage

75
IVD- -Prevention

• Diet weight control
• Low carbohydrate diet
• Basic antioxidants
• Chiropractic care
• Massage
• Exercise

76
Hans
77
Hans

• Routine radiographs showed a narrowed IVD space
  at T11-12 with a cloudy IV foramen
• Incidentally there was calcification of T13-L1

78
Hans
79
IVD- -Blood Stagnation

• Most common type in chondrodystrophic dogs
• KID Jing deficiency leads to failure to nourish
  LIV leads to joint problems stagnation
• Tongue
• Purple
• Pulse
• Wiry or Fast

• Rx Principle
• Activate blood, dissipate stagnation and resolve
  stasis
• TCM herbal
• Da huo luo dan (Double P formula 2)
• Acupuncture
• Hua-tuo-jia-ji, BL23, BL11, GB39, GV14, Wei jian,
  GV6, GV1, LIV3

80
Cervical Spondylomyelopathy

• Young Great Danes and older Doberman Pinchers
• Young dogs is due to misarticulation and
  spondylolithesis
• Older dogs is due to IVD disease and ligamentous
  hypertrophy

81
Diagnosis of CSM

• Plain Radiographs
• mild changes which suggest problem
• CSF tap
• normal
• EMG
• Myelography
• dynamic views

82
Myelograpgy- -dynamic views
Ventral Flexion Dorsal Flexion
83
CSM- -Treatment

• Surgery is designed to remove IVD protrusion and
  to lessen ligamentous compression
• Best accomplished with distraction techniques
• Screw and Washer
• methylmethacrylate

84
LS Stenosis

• A Pain in the Butt!

DVM
85
LS Stenosis- -Cardinal Signs

• LS Back Pain
• pain on palpation at LS junction
• pain on raising the tail head
• Diminished tail movement
• Urinary and Fecal continency problems

86
LS Stenosis
87
LS Stenosis- -Diagnosis

• EMG
• fibrillation potentials and positive sharp waves
  caudal to LS junction, distal limb and tail
• Imaging techniques
• CT Scan
• MRI Scan

88
LS Stenosis- -Treatment

• Medical management
• corticosteroids diazepam
• carprofen diazepam
• acupuncture TCM herbs
• Surgery
• dorsal laminectomy stabilization

89
IVD- -Yang Deficient

• Old age leads to KID deficiency
• General weakness cold back
• Tongue
• Pale wet (swollen with teeth marks)
• Pulse
• Deep weak

• Rx principle
• Nourish Yang warm KID
• TCM herbal
• Sang ji sheng san (lorathus powder)
• Chronic IVD

90
IVD- -Yin Deficiency

• Chronic illness or old age consumes KID Yin
• Weakness in back worse at night
• Tongue
• Red dry
• Pulse
• Deep, thready weak

• Rx principle
• Nourish Yin tonify KID
• TCM herbal
• Di gu pi san
• Chronic IVD

91
Discospondylitis

• Infection of the intervertebral space
• Common causes
• Staph. aureus
• Strep. sp.
• Corynebactrium
• Signs
• Pain (can be extreme)
• Ataxia to plegia

92
Discospondylitis

• Diagnosis can be made on plain radiographs
• May initially be normal, until 2-3 weeks of
  incubation
• Find organism via
• Blood culture
• Urine culture

93
Discospondylitis

• Also consider
• Nocardia or other fungal cause (aspergillosis)
• Brucella canis
• Spirocerca lupi
• Treatment (6-8 wk)
• Cephalosporins
• Sulfa drugs

94
Moose

• 9 year old M/C Labrador
• HBC 4 months ago
• Recovered
• Chronic, progressive paresis over 2 weeks

95
Moose- -Myelogram
96
Moose- -Surgical Observation
Abnormal articular process at T12
Epidural mass
97
Moose- -Cytology

• Impression smears from both the articular process
  and the epidural mass revealed PMN with
  intracellular bacteria

98
Moose- -CT scan
99
Moose- -Post OP

• Antibiotics
• Sulfadimethoxine (Primor) 15 mg/kg q12h
• Cephalexin 22 mg/kg every 8 hours
• Use for 6-8 weeks

100
IVD- -Yin Yang Def.

• Aging leads to KID Yang Yin deficiency
• decreases resistance allows low grade infection
  to start
• Tongue
• Pink or pale
• Pulse
• Deep weak

• Rx Principle
• Nourish Yin tonify KID
• TCM herbal
• Double P 1 (hindquarter formula)
• Very chronic

101
CNS Neoplasia

• Todays Frontier

102
CNS Neoplasia- -Dogs

• Common Types
• Meningioma
• Astocytoma
• Oligodendroglioma
• Choroid plexus papilloma
• Lymphoma
• Neuroectodermal tumors
• Metastatic tumor

103
CNS Neoplasia- -Dogs

• Dog has 1-18 months average survival time
• 1-3 with nothing
• 6-9 with surgery
• 12-18 with radiation treatment
• All tumors are invasive (malignant)

104
CNS Neoplasia- -Cats

• Most common is meningioma
• Usually extra-axial and benign
• Seen in aged cats
• Present with depression and dementia

105
Elvis
106
Elvis

• MRI revealed mass in the cerebral cortex

107
Elvis
108
Treatment

• Prednisolone (0.25-0.5 mg/kg q12h)
• Treats secondary effects
• Cover with gastroprotectants
• Chemotherapy
• Radiation therapy

109
Chemotherapy

• Lomustine
• 60 mg/M2 given
• Monitor CBC weekly
• If WBC and platelets okay in 5 weeks, then give
  80 mg/M2
• Repeat every 5-8 weeks

• Procarbazine
• 2-4 mg/kg/day for 1 week, then 4-6 mg/kg/day
• Monitor CBC
• Continue as long as WBC levels are gt 4000/µl
  platelet count is gt 100,000/µl

110
Chemotherapy

• 5-hydroxyurea
• Meningiomas
• 50 mg/M2 given
• Monitor CBC weekly
• Repeat every 3-4 weeks

• Melatonin
• Gliomas
• 0.1-0.2 mg/kg once a day in the evening
• Reduces growth of many tumors by 50

111
Treatment

• Diet
• Low carbohydrate
• Supplements
• Antioxidants membrane stabilizers
• Herbal medications
• Western- -Canine Cancer formula
• Traditional Chinese medicine- -Stasis in the
  Mansion of the Mind

112
Radiosurgery (3D radiation therapy)

• McKnight Brain Institute at UF
• High, single dose radiotherapy
• 5 arcs of radiation provide sphere of death
• Based upon the focal size and tissue treated

113
Radiosurgery- -MRI

• Tumors are identified with MRI
• Fusion studies are performed

114
Radiosurgery- -Bite plate

• A molded bite plate is made for the patient and
  secured in position
• Can be taken off and re-applied for later
  treatment

115
Radiosurgery- -3D alignment

• Special orientation system is applied to bite
  plate before CT scan
• Infrared cameras are used to align device for
  radiosurgery

116
Radiosurgery- -CT scan

• Fusion CT scan is obtained is bite-plate and
  alignment guide in place
• CT guided biopsy is obtained for tissue type

117
Image fusion snapshots
118
Radiosurgery- -Treatment plan

• Fused MRI and CT images provide target
• Provides anatomic detail of MRI with precision of
  CT
• Tumor margins outlined with combined spheres of
  radiation

119
Treatment plan

• Treatment plan generated evaluated in
  transverse, dorsal and sagittal planes

120
Radiosurgery- -Treatment

• Treatment is applied with LINAC unit at UFBI
• Cost of radiosurgery
• procedure is around 3000.00
• plus workup conventional surgery

121
Radiosurgery Success

• Overall ED50 is around 13 months
• Some patients survive much longer
• Prognosis for meningiomas is better than others

122
Cervical Neoplasia

• Acute or chronic progressive quadriparesis
• Usually has neck pain
• Often in older animals

123
Cervical Neoplasia
124
Cervical Neoplasia
125
Spinal Deformities

• Hemivertebra
• Typical butterfly vertebra
• May be incidental or cause progressive neurologic
  disease

126
Hemivertebra

• CT reconstruction can help determine nature of
  defects

127
Louis

• 9 month old GSD
• Progressive posterior paresis
• Also, poor foreleg conformation

128
Hemivertebra

• May correct by altering the vertebral body (floor
  of the vertebral canal) using CT-guided surgery

129
Hemivertebra

• Surgery is performed to stabilize condition and
  prevent progression
• Best by dropping the floor of the spinal canal
• Limitation is angle of deformity

130
Louis
131
German Shepherd Degenerative Myelopathy (GSDM)

• A chronic, progressive neurodegenerative disease
• Initial signs are due to TL spinal cord disease
• Represents an autoimmune disorder

132
Signalment

• Breeds
• German Shepherd dogs
• Belgium Shepherds
• Old English Sheepdogs
• Rhodesian Ridgebacks
• Weimaraner
• Probably Great Pyrenes
• Age
• gt 5 years old (usually 8-9)

• Sex
• Equal
• Onset
• 1 month to 1 year
• Clinical Course
• Paralysis within 3 to 6 month without treatment

133
Early Clinical Signs

• Mild Spinal Ataxia
• Diminished Proprioception
• Slight Hyper-reflexia in Rear Legs
• Rear Leg Weakness
• Slight Muscle Atrophy
• Occasionally, Atypical LMN Dysfunction

134
Late Clinical Signs

• Severe Spinal Ataxia
• Conscious Proprioceptive Deficits
• Unconscious Proprioceptive Deficits
• Crossed-extensor Reflex
• Babinskis Sign

135
Late Clinical Signs

• Severe Motor Weakness
• Loss of Weight Bearing
• Moderate Rear Leg Muscle Atrophy

136
Signs of GSDM
137
Histopathology

• Axon and myelin loss
• Swollen axons
• Patchy demyelination
• Astrocyte proliferation
• Increase in vasculature

138
Diagnosis

• Physical and Neurologic Examination
• History of chronic progressive posterior paresis
  in susceptible breed
• TL (non-localized) dysfunction

139
Diagnosis

• EMG
• Needle EMG- -normal
• NCV- -normal
• Repetitive Nerve Stimulation- -non-decremental
• Spinal Evoked Potential- -abnormal

140
Spinal Cord Evoked Potential
Normal
Early DM
Late DM
141
Diagnosis

• CSF tap (lumbar)
• ? protein with normal cells
• Elevated inflammatory proteins
• ? acetylcholinesterase levels (2 X normal)
• Negative titers for infectious disease

142
Diagnosis

• Spinal Radiographs
• Plain radiographs- -spondylosis spinal
  arthritis
• Myelography- -no significant lesions
• Immune Studies

143
Humeral Immunity

• ? Circulating Immune-complexes
• 59.3 2.5 µg/ml (normal 18.7 2.5 µg/ml)
• Contain ? non- specific inflammatory proteins on
  electrophoresis

144
Cell-Mediated Immunity

• Attenuated Response to Mytogens
• ConA
• Polkweed Mitogen
• PHA
• Circulating Suppressor Cells

145
2-D Electrophoresis of CSF

• Normal

• DM

146
CSF Cholinesterase


normal
DM
inflam
147
CSF Inflammatory Markers
148
Current Hypothesis

• An Auto-Immune CNS Disease
• Immune-complexes damage endothelium
• Leads to perivascular fibrin deposition
• Fibrin degradation leads to leukocyte
  infiltration
• Leukocytes produce prostaglandins and
  leukotreines
• Leads to Free-Radical production and damage
• Treatment must take these steps into account

149
Treatment

• Exercise
• 20-30 minutes twice a week
• 1 hour once a week
• sustained aerobic exercise is needed
• ? CNS O2 delivery

150
Treatment

• Dietary Considerations
• Tofu
• Fresh vegetables
• carrots
• greens
• peppers
• broccoli
• Ginger, garlic mustard

151
Treatment

• Supplements
• Antioxidants
• Membrane stabilizers
• Tonics
• Anti-inflammatory

152
Treatment

• Medication
• Aminocaproic acid (500 mg TID)
• n-Acetylcysteine (25 mg/kg TID QD for 2 weeks,
  then TID QOD)

153
Conclusion

• Degenerative Myelopathy appears to be an
  Autoimmune Disease and Treatment must be directed
  at this Process.
• Exercise
• Diet
• Supplements
• Medication

Things that ? CNS O2 Availability
154
Conclusions

• Acupuncture can help treat or control a number of
  neurologic diseases
• Point selection depends upon the constitution of
  the animal and the nature and location of the
  disease
• Patience is still a virtue with neurologic
  conditions