Fibrocartilagenous embolic myelopathy

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Dr. Ionuţ Alexandru Ciupercă, CCRP, CVA (IVAS)

Dr. Ionuţ Alexandru Ciupercă, CCRP, CVA (IVAS)

VetPhysioCenter Bucureşti

Email: ionut@vetcenter.ro

Fibrocartilagenous embolism it is a spinal cord infarction caused by a vascular emboli, presumed to be fibrocartilage. It may produce bilateral or unilateral signs and can happen anywhere in the spinal cord, the thoraco-lumbar region being the most common. Usually it has a sudden onset and a full development in 12 hours. There are 50% chance of spontaneous recovery if it shows signs of improvement within the first week.

It is a nonpainful acute disease, seen only in nonchondrodystrophic breeds. It is very important to differentiate from the intervertebral disk disease, either protrusion or extrusion. This condition is less common in small dogs or cats. Any region of the spinal cord may be affected, and the spinal cord segments dictate the specific neurologic deficits. Very common are also asymmetric or unilateral signs. Also, ataxia, paresis or paralysis may affect all limbs or only pelvic limbs. There can be a loss of deep pain sensation caudal to the lesion.

Diagnosis is based on the clinical picture and by exclusion of other possible causes. The most important clues are the signalment, the acute onset, the stationary course of the disease and the absence of pain. The differential diagnosis include intervertebral disk disease, trauma, neoplasia and inflammatory disease. The best imaging modality is the MRI showing usually signal changes suggestive of focal spinal cord infraction.

There isn’t any specific treatment for this condition even though corticosteroids are used, but there is a lack of scientific evidence that they might work. Physical therapy and nursing care are the most beneficial treatment modalities to use; about 85% of the patients recover, depending of the severity of the lesions (De Risio and others, 2007).

Sara - assisted walking

Sara-assiced walking

Sara it is a 2 years old intact female Labrador retriever with a sudden onset of paraplegia; the disease started with a lameness of the left hind leg, then with a proprioceptive ataxia and in 2 hours she was already paraplegic.

Sara X-ray

Sara X-Ray

Sara MRI

Sara MRI

Sara did an MRI immediately which revealed a unique hyper signal medullary lesion of about 3 centimeters localized at the level of L2-L3 intervertebral disk. The lesion was consistent with a vascular disorder caused by a fibrocartilagenous emboli.

Sara started a therapy with corticosteroids for a week and also vitamins and antioxidants. The second day after the incident she started also rehabilitation.

At the first visit the patient was paraplegic with no deep pain sensation and also incontinent. The spinal reflexes were present and normal and the cutaneous trunci reflex was lost at the level of L3 – L4.

Sara on ground treadmill

Sara on ground treadmill

For the first sessions she did transcutaneous electrical nerve stimulation for 30 minutes followed by   class IV laser therapy, 8 – 10 joules per square centimeter. After that modalities we started static balance exercises on the peanut shaped physio roll and reflex exercises on the proprioceptive plate. We introduced also the underwater treadmill but she was not able to move the hind legs.

For the home exercises we recommended to the owners to perform passive range of motion exercises and assisted standing followed by weight shifting exercises, 2-3 times a day; also, we instructed them to try the flexor – reflex exercise.

Sara - therabands on ground treadmill

Sara – therabands on ground treadmill

The sessions were performed twice a week and after 10 days she was already able to maintain the standing position on her own, and also started to show some motion in the hind legs. After 5 sessions she started to perform walking in the underwater treadmill; for the home exercise we instructed the owners to start with assisted walking exercise and more weight shifting and balance exercises.

After 6 sessions she became ambulatory but with severe proprioceptive and motor deficits, so we introduced also ground treadmill with incline and then with resistive elastic bands. We increased the time spend in the underwater treadmill up to 25 minutes and also, gradually, we introduced cavaletti rails and weave polls exercise.

For the home program she had to walk assisted on inclines, on stairs, on sand and grass, and also to start sit-to-stand exercises.

Sara - underwater treadmill

Sara – underwater treadmill

After 12 sessions, Sara is now ambulatory with mild proprioceptive deficit on the left hind leg at walking, and a little bit more uncoordinated at trotting and turning. The strengthening exercises were increased with more resistive elastic bands on the ground treadmill and with more speed on the inclines, and of course with higher speed and lower water in the underwater treadmill.

She is still doing rehabilitation because we need to correct all the proprioceptive deficit, as much as possible, and also to increase the muscle mass in the hind legs. We are also very happy because during the rehabilitation we were able to reduce her weight with 6 kilograms, from a body condition score of 8 out of 10 to a 6 / 10.

References:

  1. Bockstahler, Barbara; Levine, D.; Millis, D. “Essential Facts of Physiotherapy in Dogs and Cats. Rehabilitation and Pain Management”  –  2004
  2. Millis D.L.; Levine D. “Canine Rehabilitation and Physical Therapy” 2nd; Elsevier, 2014

Luba Gancheva