Pain Case of the Month: Lucy—Lameness and Incontinence in an American Bulldog

Treating lameness and incontinence in an American bulldog with spine issues.

Pain medications, adjunct therapies, and the use of her cart have been helpful in making Lucy comfortable and keeping her active.

Lucy presented for persistent pelvic limb lameness and fecal incontinence over the past six months.

by Stephanie Kube, DVM, and Jodi Croce, CVT

Signalment and History

Lucy is a seven-and-a-half-year-old spayed female American bulldog. She weighed 40 kg with a normal body condition at the time of initial presentation.

Lucy presented for persistent pelvic limb lameness and fecal incontinence over the past six months. Lucy had been treated by the previous veterinarian with carprofen at a dose of 75 mg twice daily, gabapentin 400 mg twice daily, polysulfated glycosaminoglycan injections every four weeks, and probiotics for several months with no resolution of either issue. Lucy previously had a lateral suture stabilization of her right stifle in 2016 to repair a cranial cruciate ligament rupture.

Physical Exam and Diagnostics

Lucy was ambulatory but with a paresis of the right pelvic limb. She had atrophy of the right gluteal muscles and changes to the right stifle consistent with the prior repair. She had decreased gastrocnemius and withdrawal reflexes and absent conscious proprioception in the right pelvic limb. She had apparent lumbosacral pain with a pain score of 2/10.

Bloodwork was within normal limits, but urinalysis revealed a urinary tract infection, so a urine culture was done. An MRI showed severe disc-associated lumbosacral stenosis, mild-chronic active diskospondylitis at the lumbosacral joint, severe bilateral lumbosacral foraminal stenosis with evidence of L7 neuropathy, and heterogeneous degenerative intervertebral disc disease of the lumbosacral spine. Spinal fluid showed an albuminocytologic dissociation with a normal number of cells, but an abnormal distribution (an abnormal percentage of neutrophils). Infectious testing on the spinal fluid was negative.

Treatments

Lucy was kept on her original doses of carprofen and gabapentin. A course of enrofloxacin 10 mg/kg once daily for the urinary tract infection was prescribed. Once the infectious testing was finalized, Lucy was switched to a continuous course of Augmentin 875 mg every 12 hours. Amantadine 100 mg twice a day was added for pain control (KuKanich 2013). The option of surgical decompression +/− biopsy and culture was discussed but declined because of financial constraints. Cold laser therapy to Lucy’s spine and stifle, hyperbaric oxygen therapy, and rehabilitation to help with Lucy’s pain management were also recommended but not pursued.

Lucy’s MRI revealed multiple
issues with her spine.

Outcome

Lucy initially didn’t have a great response to the medications. She seemed to have more energy but was still showing signs of discomfort, yelping and not getting in the car. Additionally, she was developing abrasions on her right hind paw from scuffing. Lucy was started in a rehabilitation program that included cold laser therapy once a week for five consecutive weeks. She also had a single hyperbaric oxygen treatment. Lucy’s gabapentin dose was increased to 400 mg three times a day.

Several months after starting rehabilitation, Lucy presented for a recheck exam. Lucy had more atrophy to her right pelvic limb and was now lame on her left pelvic limb. Radiographs were taken and showed effusion in the left stifle consistent with a cruciate tear. Radiographs of her lumbar spine showed that the LS region was (subjectively) stable. Her gabapentin dose was increased to 600 mg three times a day, and amitriptyline 50 mg once daily (Norkus, Rankin, and KuKanich 2015) was added in. All other medications were continued as previously prescribed. Lucy was fitted for a cart. Acupuncture was recommended but not pursued. Lucy responded to the amitriptyline and higher dose of gabapentin. Although the owners felt Lucy was not always completely pain-free, she was back playing with their other dog and seemed happier in general. There were days when Lucy was in more discomfort than others. On those days, it was recommended that Lucy receive an additional dose of gabapentin
(600 mg every six hours).

Conclusions and Comments

Lucy’s chronic pain is compounded by her comorbidities. Typically, for patients with intervertebral disc disease, surgical decompression and corticosteroids can be helpful. However, in Lucy’s case, her underlying diskospondylitis made corticosteroids contraindicated, and the history of prior expenses made a surgical option off-putting for the owner. Had diagnostics not been done, there would have been no knowledge of an underlying infection. Treatment of the underlying infection is challenging because the exact type of infection is still unclear. Even if a biopsy and culture had been done, cultures often come back negative or inconclusive.

Therefore, Lucy was treated with an antibiotic that is known to treat deep-seated bone infections. Knowing that Lucy’s owners did not want to move forward with surgery and a biopsy, other modalities that are known to be beneficial for pain, inflammation, and infections were recommended.

Lucy walking with friend Brady, and doing exercises on a balance ball.

Lucy was fortunate enough to have access to hyperbaric oxygen treatments, which are known to treat infections (Hochman and Shmalberg 2017), especially those that don’t respond or don’t have a great response to antibiotics. Lucy only received one of these treatments because of financial concerns, and there was no follow-up MRI, so it is unclear whether the treatment made a significant difference for Lucy. She also received cold laser therapy (Shaw and Brown 2017) to her stifles and lumbar spine during her sessions to treat pain and inflammation.

Her rehabilitation sessions focused on controlling her pain, building her core strength to support her spine, and treating her orthopedic issues. Often, patients exhibiting pain will shift their weight or change the way they move to guard the painful area. In doing so, this creates tight muscles and potentially further discomfort in other areas. In Lucy’s case, her rehabilitation plan also focused on her front legs and neck because she was now carrying most of her weight in those areas.

It was suggested that Lucy’s owners reach out to an acupuncturist to help with her pain. It was discussed with Lucy’s owners that there have been several studies showing that patients with chronic pain, both human and canine, benefit from an antidepressant (Lynch 2001). Amitriptyline was chosen for its usefulness as an adjunct for chronic neuropathic pain.

Pain medications and adjunct therapies have been helpful in making Lucy comfortable on most days. Lucy’s owners feel Lucy is happy and her good days exceed her bad days. Lucy has been using her cart more often, which gives her the freedom to continue to do activities she enjoys.

References

Hochman, L., and J. Shmalberg. 2017. “Veterinary Hyperbaric Oxygen Therapy: A Critical Appraisal.” Plumb’s Therapeutics Brief, June 2017, 37–40.

KuKanich, B. 2013. “Outpatient Oral Analgesics in Dogs and Cats Beyond Nonsteroidal Antiinflammatory Drugs: An Evidence-Based Approach.” Veterinary Clinics of North America: Small Animal Practice 43:1109–1125.

Lynch, M. E. 2001. “Antidepressants as Analgesics: A Review of Randomized Controlled Trials.” Journal of Psychiatry and Neuroscience 26, no. 1: 30–36.

Norkus, C., D. Rankin, and B. KuKanich. 2015. “Pharmacokinetics of Intravenous and Oral Amitriptyline and Its Active Metabolite Nortriptyline in Greyhound Dogs.” Veterinary Anaesthesia and Analgesia 42, no. 6: 580–589.

Shaw, Kristin Kirkby, and Liz Brown. 2017. “Modalities Part 2: Laser Therapy.” In Physical Rehabilitation for Veterinary Technicians and Nurses, ed. Mary Ellen Goldberg and Julia E. Tomlinson, 231–240. Ames, IA: Wiley Blackwell.

Discussion by Mike Petty, DVM, CCRT, CVPP, DAAPM

There are studies out there that show that veterinarians are often terrible at assessing how their patients are doing, and with good reason: We want to believe in our skills, we want our patients to get better, and we want our clients to believe that they are getting a good return on the money they spend at our clinics. As a result, we often see improvements where they either are minimal or don’t exist. In this case, the original veterinarian did not veer from the single diagnosis and therapy of a diagnosis of degenerative joint disease.

Not all clients are willing to invest time and money into additional diagnostics and second opinions in the form of referrals, but when we have a case that is not responding as expected, we should at least offer those options in a reasonable amount of time. In this case, the neurologist discovered not one but two additional issues affecting the patient.

Mike 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.

 

Stephanie Kube, DVM, CVPP, CCRT, DACVIM (Neurology), graduated from Colorado State University with her DVM in 2000. She went on to complete her neurology/neurosurgery residency at the University of California, Davis, and became a Diplomate of ACVIM (Neurology) in 2005. Kube is also a certified veterinary pain practitioner and a certified canine rehabilitation therapist. She incorporates pain management into her daily practice as a neurologist/neurosurgeon. She has worked as a neurologist/neurosurgeon/rehabilitation and pain practitioner in Massachusetts since 2005. In 2014, she opened the Veterinary Neurology and Pain Management Center of New England in Walpole, Massachusetts, the first private specialty neurology and pain center in the area.
Jodi Croce, CVT, CCRVN, graduated from Becker College in 2012 with an associate’s in veterinary technology and a bachelor’s of veterinary science and became a certified veterinary technician shortly thereafter. She became a neurology technician at the Veterinary Neurology and Pain Management Center of New England in 2014. She is also a certified canine rehabilitation veterinary nurse.

 

Photo credits: All photos courtesy of Veterinary Neurology and Pain Management

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