Tibial nerve peripheral nerve sheath tumor in dog

 

 

  1. Loncar, DVM1

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    Dr Zoran Loncar

  2. Hadzic, DVM2

M.Dragomirov, DVM2

1,2 Department of Orthopedic Surgery and Neurology, Veterinary Clinic Novak, Belgrade, Serbia

 

INTRODUCTION

 

An 8,5 years old miniature schnauzer dog was presented at the clinic with finding of right hind limb monoparesis and grade 1 lameness. CT diagnostic study was done but it was suggested that there was no visible lesions. MRI study shoved a lesion consistent with PNST. The dog was treated surgically and the tumor was excised completely with large margins. The dog recovered completely. The purpose of the article is to suggest that a lesion consisted with PNST distal to the stifle an elbow can be treated with large margins and very good motility of the limb afterwards. This type of pathology can be often missed with orthopedic conditions.

CASE HISTORY

 

A 10 kg BW, 8,5 years old miniature schnauzer was presented at the clinic with owners complain of lameness on right hind limb for last five months.

At previous vet the dog was submitted to complete orthopedic, radiography and CT study with no diagnosis after the diagnostic workout. The dog was treated with 20 days of NSAID therapy (carprofen 2mg/kg BID 10 days and the dosage was reduced by half for the next 10 days). There was no improvement so the dog was treated with prednisolone for 20 days SID with again very little improvement.

The dog doesn’t have any important data in medical history.

At the presentation in our clinic:

During the walk dog showed grade one lameness.

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CT STUDY , Fig 1 and 2

At the clinical examination the dog showed normal proprioception but reduced withdraw reflex on right hind limb.  During palpation region of gastrocnemius muscle was markedly painful. The rest of nurology and orthopedic examination was in within normal limits.

CT Study

Figure 1. and 2.

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MRI SYUDY Fig 3

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MRY STUDY- Fig 4

There is a focal dilation of a vascular structure, presumably a vein, caudal to the medial aspect of the right stifle. The vascular dilation/aneurism has a maximal diameter of 7.7 mm and extends over a distance of approximately 4 cm. Contrast filling of the dilated area is heterogeneous with some areas lacking contrast filling. The affected vessel is an anastomosis/branch between the caudal branches of the saphenous vein and the caudal proximal femoral vein.

MRI study:

Figure 3. T1+contrast: On the right limb at the level of tibial nerve there is a lesion with heterogeneous contrast intake in long contact with blood vessel. The lesion is 3 cm long in diameter.

Figure 4. T1+contrast: Lesion at the level of tibial nerve in close contact with saphenous vein and the caudal proximal femoral vein. Heterogeneous contrast intake.

 

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Figure 5. Surgical field

The surgical approach was made from medial side at the level of proximal part of gastrocnemius muscle. The careful identification of blood supplies and nerve structure was needed. The healthy proximal and distal part of the nerve was identified and the excision with 3 cm margins has been done.

The dog was treated post operatively with antibiotics for 7 days (cephalexin 15mg/kg BID), fentanyl patch for 3 days, carprofen 2 mg/kg BID for 7 days, gabapentin since 3th day 20 days 10mg/kg TID.

Neurological exam has been done after 1,3,6 and 12 months. The only abnormal finding 6 and 12 months post op was longer ground phase during walk and reduced withdraw reflex.

 

DISCUSSION:

 

Tibial nerve is in charged for the motor function of caudal aspect of tibia and fibula. Deficit in function shows clinical signs that look similar to orthopedic conditions. Ground phase is longer, calcaneus drops distally more than in contralateral limb. Sometimes we can see plantigrade stance. Orthopedic conditions similar to these in term of signs are pathology of Achill’s tendon and tarsus and metatarsus.

PNST if at the distal part of peripheral nerves can be treated with good outcome. The reasons are fewer functions that lead in less of dysfunction of the limb, and good surgical margins.  If PNST is localized at plexus or nerve root, 78% of dogs are going to be euthanized. The prognosis depends on localization and histopathology grading.

 

CONCLUSION

 

This article shows how close sometimes can be neurology and orthopedic clinical findings. Even if advanced imaging is available the cruciate information is localization of the lesion during the clinical examination. Further a right interpretation of images is necessary to define the lesion. PNST is an important differential diagnosis in investigation of distal extremities dysfunctions.

 

VOG? WHO ARE VOG? Meeting with 4 real orthopedic vets from The Balkans

 

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https://www.vog-vet.org/

Dr Mario Kreszinger, Croatia

Dr Vladislav Zlatinov, Bulgaria

Dr Marko Novak, Slovenia

Dr Zoran Loncar, Serbia

 

  1. Who are you?

 

 Dr Zoran Loncar:

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Dr Zoran Loncar

My name is Zoran Loncar I am a vet who dedicated his professional life to improve the knowledge and to push the borders of veterinary science.

 

 

Dr Vladislav Zlatinov:

I graduated from University of Forestry- Sofia, in 2005. I started externship attendance in a private small animal practice quite early-since my second year. Right now I am one of the chief surgeons in the Central Veterinary Clinic, Sofia- one of the busiest 24/7 practices in the region. Working already 6 years in this sophisticated facility, I had the chance to master skills and advance in the field of small animal surgery, and particularly orthopedics. I am happy to be involved in BAVOT (Bulgarian Association Veterinary Orthopedics and Traumatology)- the very first specialized guild vet organization in BG. We feel proud to be quite active and have organized some really great seminars, already.

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Dr Vladislav Zlatinov

At present, my focused interest is regional implementation of advanced care standards in the veterinary orthopedics- popularizing the routine use of minimally invasive technique (arthroscopy), Canine Total Hip Replacement and one special pioneering project- “Feline amputee prosthesis”.

 

Dr Marko Novak:

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Dr Marko Novak

I am a vet working in a private small animal clinic Klinika Loka in the city Škofja Loka in Slovenia. I graduated in 2006 on School of Veterinary medicine in University of Ljubljana. Since than I finished multiple courses in Orthopedics and Neurology including four years of an ESAVS program, AOVet courses, ESVOT etc. Most of my today’s work are referring patients from other clinics. Concurrently I am a board member of VOG and a treasurer of VOG and active speaker and table instructor on Orthopedic courses.

Dr Mario Kreszinger:

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Dr Mario Kreszinger

Prof. Mario Kreszinger, DMV, MS, PhD
Veterinary Faculty, University of Zagreb

 

 

 

 

 

 

  1. What is VOG? What VOG means to you?

    vog

    VOG

 Dr Zoran Loncar:

VOG is a newborn that was created out of the frustration of the vets that are dealing in every day practice with neurology and orthopedic cases.

The idea was born after continuing education that we organized all around the world.

What we realized is that probably majority of orthopedics surgeries are done by general practitioners. The problem is that they don’t have guiding and possibility always to improve the skills.

This is what we found as a major frustration not only in east countries but also in developed ones. VOG role is to connect the knowledge, mentorship and to come close to the people who do orthopedics and neurosurgery in the practicesDr Zoran Loncar, Serbia.

Dr Vladislav Zlatinov:

When I joined the Veterinary Orthopedic and Neurology Group (VOG), I felt very thrilled. This newborn professional organization will face a bright future. It could not be different with so great open-minded co-founders, sharing the same sincere intentions.

The cradle of VOG may be Eastern Europe, but it is not confined geographically. It is open for all colleagues, interested in never ending process of learning and sharing. Standing for the evidence based approach, the group will encourage members to involve in clinical researches, too.

Nevertheless, the organization is focused just on veterinary orthopedics and neurology, the topics are still greatly diverse and laborious to explore. Unifying and sharing experience is the “enzyme” that fastens the growth of any vet community knowledge. Initiative like VOG may only make us better professionals and is a great chance for many new friendships to be started.

Dr Marko Novak:

A group of enthusiastic veterinarians who want to broaden the “knowhow” to other enthusiastic veterinarians in the region. By learning we evolve, by learning from those farther ahead and following “lege artis” we prosper as veterinary society.

Dr Mario Kreszinger:

VOG is regional orthopaedic Association established to promote and  organize orthopaedic, neurological and traumatological education with objective to connect the members and provide cooperation among each others. Establishing close contact and thrue friendship is one of main goal.15179126_666002020248637_6675110090243320994_nvog-1

 

  1. What means to be an orthopedic vet nowadays?

 Dr Zoran Loncar:

To be and orthopedic surgeon nowdays means that you learn and improve your knowledge and skills on a daily bases. The orthopedics is a mixture of knowledge and manual skills. That needs every day practice. On the other hand there is always a need to follow the new evidence based data in order to be updated.

Dr Vladislav Zlatinov:

The veterinary orthopedics was and still is tough field to work in, sometimes with quite ungratefully unforgiving obastcles. I have seen these: the vet staff staring at a radiograph with broken plate and shaking their heads meaningfully. Rarely you can see this with soft tissue surgeons’ work J

Indeed, the veterinary orthopedic surgeon is a person with serious proffesional responsibilties. Often, his work is not a matter of death or life. But almost always it affects the animal’s quality of life for many years. The job conatains a lot of not so obvious ethical issues behind many clinical decisions taken.

Speaking about “Nowadays”, there is a burst of companies that produce orthopedic implants and tools. Fortunately most of the products are faboulosly good and gives us a chance to help aniamls with “untreatable” conditions in the past. But for me I this also may raise a danger. Just because of a commercial emphasis, we can start easily implement new products without any evidence based justification. For me, there should be a carefull and responsible approach to the “ Fancies” in the sea of products offered to us.13245311_10206690540562329_7499136046518137278_n11986412_10153245936142960_4086193550529382361_n

Dr Marko Novak:

Well for one thing I am absolutly sure it takes a whole person ready to work, ready to work even more and finally uncompromisingly ready to work some more. :) And after you are finished working there comes a night shift… It takes a very, very loving and understanding wife. 😉
There comes a day when you want to quit but it always comes the next day when you want to get back and help some more. But I assume it is the same in any profession.

Dr Mario Kreszinger:

Being an Orthopaedist is one of the highest step in Veterinary speciality.

 

  1. What do you think about the level of veterinary orthopedic on The Balkans?

 

 Dr Zoran Loncar:

Unfortunately the level of knowledge at Balkan countries is low. The reason is old fashioned veterinary schools, the lack of continuing education at the field.

Dr Vladislav Zlatinov:

Our present status has a lot to do with the historical development of the region. I guess it is right to say that I am part of the “new generation” vets. At least in Bulgaria, this generation inherited the experience of very few small animal practitioners, working in the 90-ies. Unfortunately we cannot say that we have a long medical tradition in small animal care, as most Western Europe countries. But.. one way or another a new era has started. For me in the last ten years, the Balkan veterinarians put a hard work and did a huge development in every aspect of their work. The market was opened for Eastern Europe, the pet owners just demand and receive much better care. This includes also us- the orthopedic fellows in the region. I think that we already do quite a good job, with a real potential to shine for excellence

Dr Marko Novak:

I believe it has tremendously spiked in the last few years. There are still reserves, which is good. But what is most important is that people are more than willing to learn. Big thanks to many “good guys” who started teaching especially great orthopedic specialists like Allesandro Piras and Bruno Pierone, Massimo Petazoni etc.

Dr Mario Kreszinger:

The level is right now in extremely high learning curve, coresponds with highly developed western Countries.

 

  1. Your ” golden rules “to be professional orthoped ?

 

 Dr Zoran Loncar:

Learn, practice, learn, control your ego, learn, think out of the box and at the end, learn.
Dr Vladislav Zlatinov:

To be a good orthopedic, demands a lot. Vast stock of knowedge, skilled hands,  attention to the small details. Usually it takes so many years to develop qualities, a great determination is needed to bare the road. And the learning never stops. But this is the common knowledge. I am a believer that to become an especial orthopedic, you should be able to think “out of the box”. We should follow the great minds’ work, but there is always a place for personal contribution.  We should dare to fight paradigms; this is an essential “fuel” for medical science evolution.

Fianlly, our profession never works “good” without a sincere empathy to animals and fare etthical attitude to them and their owners15181147_10154094081597960_611406697039840077_n15181178_10154094095972960_9093230231692850684_n

Dr Marko Novak:

Be precise, train, learn, ask, always try to find mistakes and be better the next time, be objectively sharp to your work, take time for your family and for yourself. Charge your batteries regularly.

Dr Mario Kreszinger:

Be competely dedicated to your job with all efforts and breit knowledge.15181250_10154094080692960_1411178589932869639_n

 

 

  1. What do you think about  the online journal Vets on The Balkans?

Dr Zoran Loncar:

Vets on the Balkan is refreshment and result of people with good energy and wish to improve our region. We live in small countries and if we cooperate together we have better chance to improve ourselves.

 

Dr Vladislav Zlatinov:

It is so great to have such a professional forum, connecting Balkans (and not only) vets! I literally see people from different countries in the region, getting to know each other because of your journal.  The “Vets on The Balkans” deserve all the compliments for your great positive initiative and work!

Dr Marko Novak:

I came across VTB when I was scrolling down the facebook and I saw these interesting articles from guys doing great job. I think it is one of those starters that help people to become better at what they do.

Dr Mario Kreszinger:

It very usefull easy approachable source of infos we need in everyday Jobs routine.12072565_1159080807469853_2466737431594238709_n