1. Vehicular Polytrauma in a Cavalier King Charles Spaniel Puppy
Ariel Kravitz
Senior Seminar
March 5, 2014
Basic Science Advisor: Dr. Marnie FitzMaurice
Clinical Advisor: Dr. Chelsie Estey

2. OUR PATIENT Signalment Not vaccinated
13 wo FI CKCS
Not vaccinated
Previously diagnosed with Bordetella
Day 2 of Amoxicillin/Clavulanic acid

3. 1 DAY PRIOR TO PRESENTATION TO CUHA
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. PRESENTATION TO CUHA EMERGENCY
Initial assessment
Vocalizing in pain when moved → methadone
Mild hypoxemia (SpO2: 21%: 92-93%)
Hypotensive (96/58) (MAP 72) → fluid bolus
T FAST → negative
A FAST → negative
Parvovirus SNAP test → negative

5. PRESENTATION TO CUHA EMERGENCY
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. PRESENTATION TO CUHA EMERGENCY
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. PRESENTATION TO CUHA EMERGENCY
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. PRESENTATION TO CUHA EMERGENCY
Plan
Full body CT
Restrained on a backboard in O2 cage
Supportive care in ICU
Transfer to the Neurology Service in the AM

9. FULL BODY CT- HEAD Transverse soft tissue window post-contrast
Coronal bone window post-contrast

10. FULL BODY CT- HEAD Transverse soft tissue window post-contrast
Coronal bone window post-contrast

11. FULL BODY CT- HEAD Transverse soft tissue window post-contrast
Coronal bone window post-contrast

12. FULL BODY CT- CERVICAL VERTEBRAE
Sagittal bone window

13. FULL BODY CT- CERVICAL VERTEBRAE
Sagittal bone window

14. Transverse soft tissue window
FULL BODY CT- THORAX
Transverse soft tissue window

15. Transverse soft tissue window
FULL BODY CT- THORAX
Transverse soft tissue window

16. FULL BODY CT- LUMBAR VERTEBRAE
Transverse bone window through L4
Sagittal bone window throughL3-L5

17. FULL BODY CT- LUMBAR VERTEBRAE
Transverse bone window through L4
Sagittal bone window throughL3-L5
Transverse bone window through L3

18. PROBLEM LIST 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. VEHICULAR POLYTRAUMA High energy blunt injury
Trauma - 2nd most common cause of death
Most common cause of vertebral fractures
2nd 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. SPINAL TRAUMA Pathophysiology 1o injury 2o injury
Immediate result of the trauma
Mechanical damage to the spinal cord → physical disruption of neuronal and glial cell membranes
2o injury
Hours to days following trauma
Biomechanical processes triggered by the primary injury → worsening spinal cord damage

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

22. PRIMARY SPINAL CORD INJURY
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. GOALS OF SPINAL MANAGEMENT
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. VERTEBRAL FRACTURE REPAIR
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. VERTEBRAL FRACTURE REPAIR
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. L4 VERTEBRAL FRACTURE REPAIR
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 from Small Animal Surgery

27. POST-OP CT Sagittal bone window through L2-L5
Transverse bone window through L5
Sagittal bone window through L2-L5

28. POST-OP CT

29. POST-OP TREATMENT Treatment 40% O2 Plasmalyte + 1.5% dextrose
Fentanyl CRI
Ampicillin/Sulbactam
Ceftazidime
Ondansetron, Pantoprazole and Sucralfate

30. DAY 1 POST-OP PROGRESS 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. DAY 5 POST-OP TGH Medications Exercise restriction
Cefpodoxime
Amoxicillin/Clavulanic acid
Pregabalin
Tramadol
Metronidazole
Exercise restriction
At home rehabilitation

32. PROGNOSIS 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. PROGNOSIS 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
Predisposed to seizures

34. RECHECK 1
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. RECHECK 1- SPINAL RADIOGRAPHS

36. RECHECK 1 Prognosis Recommendation: Still fair to good Medications
Pregabalin
Tramadol
Exercise restriction
At home rehabilitation

37. RECHECK 2
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. RECHECK 2 - SPINAL RADIOGRAPH

39. RECHECK 2 Prognosis Recommendation: Good! Medications
Pregabalin (tapered dose for 1 week)
Tramadol
Exercise restriction

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

41. SELECTED REFERENCES
Dewey, C. A Practical Guide to Canine & Feline Neurology. 2nd ed. pp Wiley-Blackwell, 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 Mar. 25(2), pp
Fossum , T. Small Animal Surgery.   1st ed. pp Mosby and Co., 1997. St. Louis, Missouri.
Olby, N. The pathogenesis and treatment of acute spinal cord injuries in dogs Sep. 40(5), pp
Rockar, R.A et al. Development a Scoring System for the Veterinary Patient. Journal of Veterinary Emergency and Critical Care Jul. 4 (2), pp
Streeter, E. et al. Evaluation of vehicular trauma in dogs: 239 cases (January–December 2001). JAVMA Aug. 235 (4), pp
Tobias K, Johnston S: Veterinary Surgery: Small Animal. 1st ed. pp Elsevier/Sauders, St. Louis, Missouri.

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

43. QUESTIONS?