Pain Case of the Month: Hershey—The Importance of Radiographs

by Michael C. Petty, DVM, CCRT, CVPP, DAAPM

Introduction

As a pain practitioner, about 50% of my caseload involves pain cases. They are referrals from other veterinarians, self-referrals from people who have found out about me from the internet or other happy clients, and pain patients from my own practice.

The secret to success is a step-wise progression in the management of each pain case. I am going to tell the story of one patient who was brought to me for a chronic pain issue (two years) that had not been satisfactorily addressed by the dog’s original veterinarian. This is not a complicated case, or at least it should not have been had things been handled correctly from the beginning.

The Patient

The clients brought their dog Hershey, a two-year-old female spayed chocolate Labrador retriever, to me for a second opinion. Hershey had been seeing the same veterinarian since she was a puppy for routine visits and to be spayed. Early in Hershey’s life, at about six months of age, the owners could tell that there was some kind of gait abnormality, and that it affected Hershey’s ability to run and play and go on lengthy walks. They told me that the therapies that the dog had received over time for her issue were just not working.

History

When there was an initial complaint at six months of age, the owners had been told that Hershey had some “growing pains” and that they should ignore it and she would “grow out of them.” After several months, and no resolution, they returned to the veterinarian. This time, the diagnosis was “muscle pain” and it was suggested they wait it out. Another six months went by and this time the veterinarian told the clients that Hershey had hip dysplasia. She was put on turmeric, glucosamine, and chondroitin sulfate, along with a commercial joint supplement for dogs. By the time she was two years old, it was obvious that the therapy was not helping and she was brought to me for a second opinion.

In my discussion with the clients, I asked whether we could call the original veterinarian and get a copy of the radiographs sent over, but they told me no radiographs were ever taken. I asked about other diagnostics and they said that he had barely touched Hershey and had made the diagnosis by observation and conversation with them.

Physical Exam

I did a full pain exam of all of the limbs, joints, and spine, but started with the hips. To my surprise, Hershey had a full range of motion of both hips, with no apparent pain. I did discover a luxating patella on the left leg that easily went in and out of joint with an audible clicking sound. My next discovery was pain at the lumbosacral junction. My final discovery was effusion, pain, and crepitus in both elbows.

I moved on to a neurologic exam. Because of the pain at the lumbosacral junction, I was concerned about the possibility of lumbosacral disease. A check for conscious proprioception in the hind feet showed that it was significantly delayed, confirming my suspicion. I also did a cross extensor reflex on both hind legs, which was normal.

Diagnostics

Based on my findings, I told the owners that I did not feel Hershey had any significant hip disease and requested that we take the radiographs—a study that should have been done early on. They agreed and the radiographs confirmed my findings.

As you can see, there is mild sclerosing at the capsular attachment, but as of yet there is no significant osteoarthritis.

The lumbosacral radiographs have some bridging spondylosis at L7-S1. In addition, there may be a shortening of the length of L7. A short L7 could be a transitional vertebra, pathognomonic for cauda equina syndrome.

The elbows also show a significant degree of osteoarthritis, possibly obscuring the originating cause of the elbow dysplasia.

Needless to say, the owners were quite upset that their dog had suffered needlessly for most of her life. They were also upset that they missed an early opportunity to intervene with the elbow dysplasia; early surgical intervention for the removal of something like a fractured coronoid can greatly improve the long-term function of the elbow joint. Therapy now has to be directed at preventing neurologic decline, and treatment of the osteoarthritis using laser, acupuncture, nonsteroidal anti-inflammatory drugs, and other ancillary therapies as needed.

Discussion

Every pain case deserves a complete and thorough pain evaluation, especially when it is the owners who are bringing that pain to their veterinarian’s attention. It only takes about three minutes to palpate, flex, and extend most of the major joints, check paraspinal muscles for heat and fasciculations, and look for gait abnormalities as you walk the dog up and down your hallway. It also takes less than two minutes to do the two neurologic tests I performed in this case. It is especially sad in this case that the attending veterinarian made vague diagnoses like “growing pains” and “muscle pain.”

I don’t always recommend radiographs; sometimes they are just not indicated. But when a dog is not responsive to therapy, or the pain is chronic or going from acute to chronic, radiographs should always be suggested, and in some cases insisted on. Even if the owner declines, it takes the burden off of us for an incomplete workup and we can send the patient out the door with pain medications and the warning that the etiology may be a serious matter that will need further investigation.

Michael C. Petty, DVM, CCRT, CVPP, DAAPM, is in private practice in Canton, Michigan. He is a frequent national and international lecturer on topics related to pain management. Petty offers commentary on each Pain Case of the Month (and occasionally writes one himself). He was also a member of the task force for the 2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats.

Photo credits: Photos courtesy of Michael Petty