Presentation is loading. Please wait.

Presentation is loading. Please wait.

Ariel Kravitz Senior Seminar March 5, 2014 Basic Science Advisor: Dr. Marnie FitzMaurice Clinical Advisor: Dr. Chelsie Estey.

Similar presentations


Presentation on theme: "Ariel Kravitz Senior Seminar March 5, 2014 Basic Science Advisor: Dr. Marnie FitzMaurice Clinical Advisor: Dr. Chelsie Estey."— Presentation transcript:

1 Ariel Kravitz Senior Seminar March 5, 2014 Basic Science Advisor: Dr. Marnie FitzMaurice Clinical Advisor: Dr. Chelsie Estey

2  Signalment  13 wo FI CKCS  Not vaccinated  Previously diagnosed with Bordetella  Day 2 of Amoxicillin/Clavulanic acid

3  Unsupervised outside  Good Samaritan witnessed the vehicular trauma and brought her to an ER/CC center  Treated for shock and cerebral edema  Kept overnight - no improvement

4  Initial assessment  Vocalizing in pain when moved → methadone  Mild hypoxemia (SpO 2 : 21%: 92-93%)  Hypotensive (96/58) (MAP 72) → fluid bolus  T FAST → negative  A FAST → negative  Parvovirus SNAP test → negative

5  Neurologic examination  Mental Status: Bright, Alert, Responsive  Attitude/Posture: Slightly hunched posture  Conformation/Muscularity: Normal  Gait: Non ambulatory paraparesis (with minimal motor)  Cranial Nerves: Normal  Proprioception: Absent in pelvic limbs  Spinal Reflexes: normal thoracic limb reflexes; decreased withdrawal reflexes bilaterally in the pelvic limbs; decreased patellar reflexes on the right and absent on left; normal cutaneous trunci reflex on the right but cutoff at L3 on the left  Nociception: lumbar discomfort

6  Neurologic examination  Mental Status: Bright, Alert, Responsive  Attitude/Posture: Slightly hunched posture  Conformation/Muscularity: Normal  Gait: Non ambulatory paraparesis (with minimal motor)  Cranial Nerves: Normal  Proprioception: Absent in pelvic limbs  Spinal Reflexes: normal thoracic limb reflexes; decreased withdrawal reflexes bilaterally in the pelvic limbs; decreased patellar reflexes on the right but absent on left; normal cutaneous trunci reflex on the right but cutoff at L3 on the left  Nociception: lumbar discomfort

7  Neurologic examination  Mental Status: Bright, Alert, Responsive  Attitude/Posture: Slightly hunched posture  Conformation/Muscularity: Normal  Gait: Non ambulatory paraparesis (with minimal motor)  Cranial Nerves: Normal  Proprioception: Absent in pelvic limbs  Spinal Reflexes: normal thoracic limb reflexes; decreased withdrawal reflexes bilaterally in the pelvic limbs; decreased patellar reflexes on the right but absent on left; normal cutaneous trunci reflex on the right but cutoff at L3 on the left  Nociception: lumbar discomfort Neurolocalization: T3-L3 and L4-S3 myelopathy

8  Plan  Full body CT  Restrained on a backboard in O2 cage  Supportive care in ICU  Transfer to the Neurology Service in the AM

9 Transverse soft tissue window post-contrast Coronal bone window post-contrast

10 Transverse soft tissue window post-contrast Coronal bone window post-contrast

11 Transverse soft tissue window post-contrast Coronal bone window post-contrast

12 Sagittal bone window

13

14 Transverse soft tissue window

15

16 Transverse bone window through L4 Sagittal bone window throughL3-L5

17 Transverse bone window through L4 Sagittal bone window throughL3-L5 Transverse bone window through L3

18  Comminuted fracture of L4 vertebra  Fissure fracture of C3 vertebra  Bilateral pulmonary contusions  Fractures of the right orbit  Fractures of the frontal sinus with pneumocephalus and intracranial hemorrhage  Hypoxemia  Bordetella positive

19  High energy blunt injury  Trauma - 2 nd most common cause of death  Most common cause of vertebral fractures  2 nd spinal fracture/luxation - ~20%  Additional injuries – 40-50%  PE findings more sensitive than radiographs Figure 2 from Evaluation of vehicular trauma in dogs: 239 cases (January-December 2001)

20  Pathophysiology  1 o injury  Immediate result of the trauma  Mechanical damage to the spinal cord → physical disruption of neuronal and glial cell membranes  2 o injury  Hours to days following trauma  Biomechanical processes triggered by the primary injury → worsening spinal cord damage

21  Pathophysiology  1 o injury  immediate result of the trauma  Mechanical damage to the spinal cord → physical disruption of neuronal and glial cell membranes  2 o injury  Hours to days following trauma  Biomechanical processes triggered by the primary injury → propagated spinal cord damage

22  3 compartment model  Boney and soft tissue structures  Dorsal  Middle  Ventral  If 2 of the 3 compartments are affected → unstable injury Figure 12.1 from A Practical Guide to Canine and Feline Neurology

23  Prevent ongoing primary injury and allay perpetuation to secondary injury  Stabilization of a fracture is based on:  The damaged structures  The forces acting on them

24  Goals  Realign and stabilize the spinal column  Decompress the spinal cord  Surgical techniques  Pins + PMMA*  Locking plates *  External fixators*  Vertebral body plates  Modified segmental fixation  Tension band stabilization  Spinous process plating

25  Goals  Realign and stabilize the spinal column  Decompress the spinal cord  Surgical techniques  Pins + PMMA*  Locking plates *  External fixators*  Vertebral body plates  Modified segmental fixation  Tension band stabilization  Spinous process plating

26  Dorsal laminectomy  Dorsal decompression  Visualize L4 vertebral fracture  Cortical screw placed transarticularly through the R articular facet joint of L4  4 screws placed bicortically through L3 and L5  Screws placed through the base of L and R transverse processes of L3  Screw placed through the base of the L transverse process of L5  Screw placed through the R transverse process and pedicle of L5  PMMA with cefazolin molded around the screws Fig. 35-6 from Small Animal Surgery

27 Transverse bone window through L5 Sagittal bone window through L2-L5

28

29  Treatment  40% O2  Plasmalyte + 1.5% dextrose  Fentanyl CRI  Ampicillin/Sulbactam  Ceftazidime  Ondansetron, Pantoprazole and Sucralfate

30  Neurologic examination – Day 1 post-op  Ambulatory paraparesis with voluntary motor function in all limbs  Absent placement in the hindlimbs bilaterally  Intact withdrawal, patellar and perineal reflexes  Cutaneous trunci reflex cutoff at the level of L3 on the left; normal on the right  Continue to improve in hospital  Oxygen independent day 3 post-op  Fluids tapered and switched to all oral medication

31  TGH  Medications  Cefpodoxime  Amoxicillin/Clavulanic acid  Pregabalin  Tramadol  Metronidazole  Exercise restriction  At home rehabilitation

32  Fair to good  Comminuted fracture - L4 Vertebra  Failure of perfect anatomical alignment - potential for the spinal cord to be compressed if the fragments dislodge from their current locations  60-70% chance to return to normal function  Fissure fracture - C3 Vertebra  Not at issue at this time  Potential for neurologic deficits in the future  Growing  Trauma

33  Bilateral pulmonary contusions – improving  Fractures of the right orbit  Not at issue at this time  Unknown in future  Fractures of the frontal sinus with pneumocephalus and intracranial hemorrhage  Not at issue at this time  Unknown in future  Predisposed to seizures

34  4 weeks post-op  Neurolocalization: Thoracolumbar spine (T3-L3)  Mild hindlimb spinal ataxia  Absent postural thrust on the right, delayed on the left, normal placing in all four limbs  Pain elicited on head palpation, cranial cervical and thoracolumbar spine  Spinal radiographs

35

36  Prognosis  Still fair to good  Recommendation:  Medications  Pregabalin  Tramadol  Exercise restriction  At home rehabilitation

37  10 weeks post-op  Neurolocalization: Thoracolumbar spine (T3-L3)  Mild hindlimb spinal ataxia  Delayed hopping on the right pelvic limb, normal hopping in other limbs, normal placing in all four limbs  No pain elicited on palpation  Spinal radiographs

38

39  Prognosis  Good!  Recommendation:  Medications  Pregabalin (tapered dose for 1 week)  Tramadol  Exercise restriction

40 Initial Stay ECC exam$113.00 Full body CT$733.00 Surgery + Anesthesia$2078.26 Supportive therapy +maintenance in ICU x 9 days$4254.34 Total$7178.60 4 Week Recheck Exam + Radiographs$220.40 10 Week Recheck Exam + Radiographs$200.00 Total Cost$7599.00

41  Dewey, C. A Practical Guide to Canine & Feline Neurology. 2 nd ed. pp 405-414. Wiley-Blackwell, 2008. Ames, Iowa.  Fleming J.M. et al. Mortality in north american dogs from 1984 to 2004: an investigation into age-, size-, and breed-related causes of death. Journal of Veterinary Internal Medicine. 2011 Mar. 25(2), pp 187- 98.  Fossum, T. Small Animal Surgery. 1 st ed. pp 1118-1127. Mosby and Co., 1997. St. Louis, Missouri.  Olby, N. The pathogenesis and treatment of acute spinal cord injuries in dogs. 2010 Sep. 40(5), pp791-80.  Rockar, R.A et al. Development a Scoring System for the Veterinary Patient. Journal of Veterinary Emergency and Critical Care. 2007 Jul. 4 (2), pp 77-83.  Streeter, E. et al. Evaluation of vehicular trauma in dogs: 239 cases (January–December 2001). JAVMA. 2009 Aug. 235 (4), pp 405-408.  Tobias K, Johnston S: Veterinary Surgery: Small Animal. 1 st ed. pp 487- 496. Elsevier/Sauders, 2012. St. Louis, Missouri.

42  Dr. Chelsie Estey  Dr. Marnie FitzMaurice  Dr. Sofia Cerda-Gonzalez  My family  Class of 2014

43


Download ppt "Ariel Kravitz Senior Seminar March 5, 2014 Basic Science Advisor: Dr. Marnie FitzMaurice Clinical Advisor: Dr. Chelsie Estey."

Similar presentations


Ads by Google