22 James M. Fingeroth and William B. Thomas Veterinarians confronted with a patient exhibiting signs of discomfort and/or neurologic deficits, and in whom spinal cord disease is suspected as the cause, properly include intervertebral disc disease (IVDD) in their differential diagnoses. Elsewhere in this book, the difference between IVDD and intervertebral disc herniation (IVDH) has been addressed, as has the concept of “discogenic” pain not associated with actual disc displacement. When speaking with clients the attending clinician should bear these distinctions in mind since having the correct concept of what is really transpiring in the patient can influence what information we convey to clients, and the sense of urgency we need to express. The focus of this chapter is not so much about what actions the attending veterinarian should take (that is covered in Chapter 19), but on the key concepts to pass along to clients so that they, the clients, can make informed decisions as we counsel them regarding treatment options, referral recommendations, or prognosis. As has been addressed elsewhere in this book, it is important not to provide a diagnosis of IVDD/IVDH to the clients as an established fact prematurely. Though IVDH may be far and away the most likely etiology for many of the patients we see with signs of neck or back pain or paresis, we should advise clients that there are other possible causes. It can be embarrassing or worse to subsequently find that the patient’s signs were due to non-disc-related disease and to not have informed the client of this possibility (see Chapters 9, 20, and 21). As outlined in the chapter on “when should dogs be referred for surgery” (Chapter 19), as well as the chapter on “history, neurologic examination, and neurolocalization” (Chapter 10), we at the outset have to formulate a recommended plan of action for the client based on our assessment of the patient. Concomitant with this formulated plan is the need to convey to the client what our reasoning is (e.g., conservative treatment initially or emergency referral?), as well as our expected results or alternative plans should we not achieve those expected results. The issue of taking plain radiographs on patients with suspected IVDD/IVDH is addressed elsewhere (Chapter 19). When the clinician elects to take survey radiographs, he or she should be clear in communicating to the client that the main objective in taking such images is to help rule out or reduce concern for other possible causes for the patient’s signs (such as fracture, obvious infiltrative disease in the bone, obvious changes that might suggest discospondylitis, etc.) rather than to “prove” that the patient has IVDD or IVDH. It can be misleading to conclude that normal radiographs rule out IVDD, or that lesions that support a diagnosis of IVDD (such as narrowed disc spaces, calcified discs, spondylosis, etc.) somehow confirm the diagnosis of IVDH as the cause for the current signs. It can also undermine the clinician’s relationship of trust with the client to point out a particular lesion on a plain radiograph, explain to the client that “the x-ray shows that the dog has a ruptured disc at T12–T13,” only to later find out that the lesion was elsewhere or of some other pathology. Cage rest or similar confinement is the bedrock of conservative care for dogs with suspected IVDH where surgery is deemed not immediately necessary. It is imperative that the clinician explicitly describes the conditions and duration of such confinement. Many clients may be under the misapprehension that “cage rest” means keeping the dog crated—except when it’s not and may not appreciate just how restrictive this limitation should be. This is especially true if the patient has minimal signs or signs that seem to be rapidly improving after only a few days. The veterinarian should describe in detail exactly what activity outside the crate is permissible, how the pet should be handled when outside the crate or cage, and the minimum time of such confinement regardless of perceived improvement. The crate should be large enough for the pet to stand up and lay down comfortably. Most important is a top that is low enough to prevent the patient from attempting to stand up on the pelvic limbs. The crate is placed in a quiet room where there is minimal activity. Having the crate in a busy room, such as the kitchen or family room, often leads to the pet becoming more anxious and barking in an attempt to get out of the crate to be with the family members the pet can see and hear. This behavior is also stressful for the client and may even persuade the client to stop confinement prematurely. The patient is kept confined except to go outside to urinate and defecate. For that, the pet is carried outside and placed on the ground with a leash and harness to eliminate and then carried back to the crate. Even 30 min of unrestricted activity can negate several days of confinement. Clients should also be educated as to what signs to look for that might suggest deterioration in patient status, and which should prompt an immediate call to the veterinarian. Any progression in neurologic deficits such as worsening ataxia, paresis, or pain is an indication for reevaluation. The veterinarian or veterinary staff should periodically contact the client to ensure the patient is not getting worse and find out if the client is having any trouble complying with recommendations. In addition to explaining how to provide restricted activity, it is critical to explain why
Client Communications When Confronted with a Patient with Suspected Intervertebral Disc Herniation
Imaging
Crate/cage rest
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