The patient presented with per acute onset paraparesis, with no known history of trauma. Due to the patient's breed predisposition and previous history of an intervertebral disc (IVD) extrusion at T13–L1 which required surgical intervention, she was referred to the hospital as an emergency out of hours patient.
Signalment
- Species: Canine
- Breed: Miniature Dachshund
- Age: 3 years old
- Sex: Female (Neutered) Weight: 5.4 kg
Patient assessment
Neurological examination revealed paraparesis with very weak lower motor neuron function demonstrated by delayed proprioception in the hindlimbs. The patient was deep pain (DP) positive and spinal reflexes were normal. The veterinary surgeon (VS) localised T3–L3 to be the most likely area of compression. General examination revealed no other concerns.
Veterinary investigations and pre-surgical preparations
The patient was admitted and a blood sample was obtained for manual packed cell volume (PCV), total solids (TS) and in-house biochemistry. Intravenous access was gained in the right forelimb cephalic vein.
The patient was pre-medicated with 0.02 mg/kg of acepromazine (Calmivet 5 mg/ml, Vetoquinol) and methadone 0.3 mg/kg (Comfortan 10 mg/ml, Dechra) prior to receiving the blood results, which later revealed no abnormalities. The patient was anaesthetised using 4 mg/kg propofol (PropoFlo Plus 10 mg/ml, Zoetis) and maintained on isoflurane (Zoetis) inhalation agent once intubated for diagnostic imaging and possible surgery. Magnetic resonance imaging (MRI) is the ideal imaging technique for investigating spinal cord problems (Whitfield, 2010). However, due to the patient presenting out of hours the VS decided to use computed tomography (CT) which shows good detail when imaging thoracolumbar vertebrae (Olby and Thrall, 2004). The CT imaging revealed Hansen type I (disc extrusion) at the disc space L1–L2 which was lateralised to the left hand side. The patient was moved through to the radiography room where clipping and surgical preparation for a marker took place (Box 1). A marker was placed in L1 spinal vertebra and a lateral thoracolumbar spinal radiograph was taken to confirm this (Figure 1).
Box 1.Patient preparationThe patient was prepared for surgery in sternal recumbency in the radiography room. The thoracolumbar vertebrae were palpated and then fur was clipped from the patient's dorsum extending approximately 10 cm cranially and 10 cm caudally from this point. Approximately 5 cm either side/laterally of the junction was clipped also. The fur was removed with a vacuum, the patient's bladder was fully expressed and then a pre-operative surgical scrub was performed.NB: Check the clipper blades are clean and in good condition prior to clipping to minimise damage to skin and possible infection. If in doubt use a new blade.The surgical skin preparation
- Surgical scrub solution = chlorhexidine (50/50 solution in warm water) and 70% alcohol solution.
- Non sterile surgical gloves should be worn to prevent contamination of the patient's skin with potential bacteria from the veterinary nurse's hands.
- Using sterile lint-free swabs wash the site with the chlorhexidine solution, beginning at the proposed site for incision and working outwards. Once the edge of the clipped area is reached, discard the swab and take a new one.
- Continue this procedure until the swab comes off clear.
- Spray the site with a 70% alcohol solution (not on open wounds or mucous membranes).
- Once the patient is in theatre and positioned for surgery, the above procedure is repeated taking care not to disturb the marker.
- The surgical site is then sprayed with the 70% alcohol solution every 5 minutes until surgery commences.
The patient was moved to theatre where a nonsteroidal anti-infalmmatory drug (NSAID), meloxicam 0.2 mg/kg (Metacam, Boehringer Ingelheim), was given subcutaneously as an additional analgesic and anti-inflammatory. A cephalosporin antibiotic, cefuroxime 20 mg/kg (Zinacef, GlaxoSmithKline) was given slowly intravenously prior to the first incision. The patient was positioned in sternal recumbency towards the left hand side of the operating table on top of a warm air blanket and bubble wrap. A vital signs monitor was attached to the patient to allow electrocardiogram, capnography, pulse oximetry, non-invasive blood pressure and temperature monitoring. The patient's body was tilted away from the left hand side of the table and secured in this position to allow visualisation of the spine as advised by the VS. A final prep of the patient's skin was carried out taking care not to disturb the marker.
Surgical procedure
A left hand side hemilaminectomy was performed at L1–L2 by the VS. This involved a dorso-lateral approach to remove a portion of the lamina on the vertebral column in order to decompress the spinal cord (McKee, 2000). A large amount of extruded disc material (nucleus pulposus) was removed, the surgical site was lavaged with sodium chloride (0.9% saline, Aquapharm no.1, Animal Care LTD) and routinely closed with suture and skin glue (Dermabond, Ethicon) (Figure 2).
Discussion
IVD disease is one of the most common causes of spinal cord dysfunction in dogs (Kazakos et al, 2005). Chondrodystrophoid breeds, particularly Dachshunds, are predisposed to IVD disease however, non-chondrodystrophoid breeds can also be affected (Coates, 2004). The prognosis of patients' recovery to normal function has been discussed in veterinary literature and is dependent on the duration and the severity of the clinical signs and whether DP perception is present (Kazakos et al, 2005; Park et al, 2012). The prognosis is poorer if DP is absent (McKee, 2000). The patient was DP positive on admission and surgical intervention to decompress the spinal cord was carried out that day. This contributed to an improved prognosis as suggested by Young and Tivers (2008), however, recovery to normal function can take weeks to months (McKee, 2000).
Nursing considerations
Each spinal patient can present with different clinical signs. This is due to the localisation of the spinal cord problem. Therefore, spinal patients require a tailored nursing care plan (NCP) (Table 1). In addition to monitoring the patient in recovery from general anaesthesia (GA) and surgery the areas that are also important to consider are rehabilitation — returning to normal motor function and bladder management. Nursing these patients can be very rewarding.
Table 1. Nursing care plan
| Main nursing considerations 1. Recovery post GA and L1/L2 hemilaminectomy 01/02/142. Bladder management3. Physiotherapy4. Nutrition5. Pain management | Name: PoppyAge: 3 Years oldSex: Female (Neutered)Breed: Miniature DachshundDate: 01/02/14VN: | |||
| Date | Actual problem (AP) Potential problem (PP) | Goal | Nursing action | Review time |
|---|---|---|---|---|
| 01/02 | Eating Inappentant (AP)Non-ambulatory (AP) | Consume 1/3 RER today minimum | Encourage to consume RERBW X 70 = KCAL/dayHand feed or tempt to eat with 50 g warmed chicken if not eatingRemove food if not eaten withing ½ hour | Q4 hours |
| 01/02 | DrinkingNon-ambulatory (AP)Overinfusion (PP)Thrombophlebitis (PP) | Maintain hydration status | Hydration monitoring, through skin tenting and mucous membranes Offer water Q2 hours Keep on IVFT @2 ml/kg/hour until eating RER Undress and recheck IV site Q24 hours Feel above IV site Q4 to ensure fluid not going SC | Q4 hours |
| 01/02 | UrinatingBladder expression (AP)Urinary UTI (PP)Bladder distention, atony (PP) | Prevent urine scolding and soiling from urinary overflow | Manually check bladder size and express when necessary/largeCheck bladder empty post urination/expressionCheck bed to ensure dryCheck skin if urine passed on bedWalk outside 4x per day with sling support to encourage normal urinationLiaise with VS if bladder intervention needed (catheterisation) | Bed/Bladder/skin check Q4 hoursWalk Q6 hours |
| 01/02 | Defecating Inappetence (AP)General anaesthetic reduced gut motility (AP)Constipation (PP) | Normal faeces passed/prevent faecal soiling | Walk outside 4x per day with sling support to encourage normal defecation | Walk Q6 hours |
| 01/02 | BreathingRespiratory depression(PP) Respiratory arrest in recovery(PP) Hypostatic pneumonia (PP) | Normal breathing rate and effort | Pain managementHave front end in sternal recumbencyMonitor analgesia not causing respiratory depression | Q hour |
| 01/02 | Maintaining temperatureNon-ambulatory (AP)Hypothermia post GA (AP) | Maintain normothermia | If hypothermic (<37.0°C) place in incubator and monitor temperature every 15 minutes until normalRegularly monitor temperature Q8 hours/TID once normal Prevent hyperthermia | Qhr reduce when necessary |
| 01/02 | GroomingNon-ambulatory (AP)Stress/depression (PP) | Maintain clean dry coat | Check coat for urinary soilingGroom when necessary at least Q48 hours | Q4hr |
| 01/02 | MobilisingNon ambulatory paraparesis (AP)Muscle atrophy (PP)Muscle contracture (PP) | Maintain mobility and reduce muscle problems | Supported walking with a sling outside 4x daily to encourage ambulation and prevent depression by offering environmental enrichmentPhysiotherapy-cryo, PROM, massage, assisted standing Q6 hours | Walk Q6hrPhysio Q6 hours |
| 01/02 | Sleep/restHospital environment (AP)Stress (PP) | Allow adequate sleep | Quiet hospital environmentTurn off lights at 12amStop physio overnightMonitor if sleeps — move noisy dogs away | Q4 hours |
| 01/02 | AnalgesiaSpinal surgery (AP)Bladder expression (AP)Inadequate analgesia (PP) | Provide adequate level of analgesia | Administer methadone 0.3 mg/kg Q4s; pain score 30 mins pre and post admin using hospital pain score sheetCryo Q4–6 hoursProvide padded beddingLiaise with VS if concerned painful | Q4 hours |
| 01/02 | Maintain normal behaviour In hospital (AP)Aggression/stress/anxiety/Depression (PP)Boredorm(PP) | Provide TLC/interaction throughout the dayPhysioProvide toys from homeAllow owner visit if will not worsen behaviour | Constant assesment | |
Post-operative care
Consideration should be given to both the short and long-term recovery of patients. Immediate post-operative considerations are hypothermia, appropriate analgesia, respiratory and cardiovascular function, nutrition and patient positioning (Crompton and Hill, 2011). Hypothermia can cause a multitude of problems including delayed recovery times, decreased ventilation and impaired oxygen delivery to the tissues (Davies, 2012) therefore it was essential that the patient was placed in an incubator and had temperature, pulse and respiration checks every 15 minutes until normothermia was reached. However, there are many other methods of warming patients that can be utilised for those practices that do not have access to an incubator; forced warm air blankets or a blanket can reduce heat loss via radiation (Crompton and Hill, 2011). A fluid warmer can be utilised, however, it can be ineffective on its own (Crompton and Hill, 2011) so must be used alongside other warming devices. The patient's temperature increased, the heart rate, respiration rate and effort remained stable. Once the temperature reached 380C the patient was moved to a kennel with a padded waterproof mattress. An incontinence pad and a comfortable bed (Vetbed, Petlife International Ltd) were placed over this to allow the veterinary nurse (VN) to monitor if the patient had urinated. Recumbency care was instigated, which involved turning the patient every 2–4 hours until ambulatory. This was highlighted on the NCP to be carried out to reduce the risk of hypostatic pneumonia and pressure sores as advised by Campbell and Parish (2010). Intravenous fluid therapy was continued post operatively at 2 ml/kg/hour until the patient was eating and drinking. Intramuscular administration of methadone at 0.3 mg/kg was given every 4 hours with recommendation to pain score half an hour prior to and post analgesia. This was also highlighted on the patient's NCP. The patient ate well the next day after tempting with chicken. However, if this had not been the case the patient would have needed to tempt the patient to eat, or the VN may have needed to instigate assisted feeding techniques under direction of the VS (Lumbis, 2012), to ensure that the patient was receiving their required calorific intake each day.
Rehabilitation
There are many different types of physiotherapy that are indicated in the post-operative patient. Rehabilitation following neurological surgery incorporating a physiotherapy plan can help to improve the speed of the patient's recovery and return to normal function (Drum, 2010; Thomas, 2012). In addition, it can help improve patient wellbeing (Thomas, 2012). Physiotherapy techniques include cryotherapy, massage and passive range of motion (PROM) (Figure 3). Cryotherapy utilises an ice pack wrapped in a damp towel and placed over the surgical incision site and is repeated in the author's practice every 4 hours over a 72 hour period post operatively in the acute phase of inflammation until heat, swelling and redness has subsided. Cryotherapy has been shown to provide analgesic benefits and can be used as part of a multimodal regimen and reduces inflammation (Iveson, 2011). Massage, PROM and extension and flexion stretches help to prevent muscle atrophy and joint stiffness (McKee, 2000), muscle contracture and pain (Connell and Monk, 2010). The author believes cryotherapy and gentle massage to be easy and cheap techniques to implement and the patient tolerated these well. However, some patients may not tolerate the above due to their temperament and some should only be implemented by an animal physiotherapist (Connell and Monk, 2010). The patient was observed when walking outside by a VN using a support sling and any movement in the patient's hindlimbs post operatively was recorded on the hospital sheet and the VS informed.
In future cases it may be beneficial to utilise transcutaneous electrical nerve stimulation (TENS) which is a physiotherapy method that provides additional analgesia and helps to relax the patient (Sherman and Olby, 2004). In addition, McKee (2000) suggests that hydrotherapy should be utilised. However, with staff shortages and time constraints in some practices, and some patients' difficult temperaments, physiotherapy techniques may not be utilised to their full potential.
Bladder management
Bladder management is important in neurological patients post operatively because of the possibility of compromised nerve supply to the bladder (Daniels, 2010) causing abnormal micturition (Coates, 2004). Loss of or abnormal micturition facilitates the need for nursing intervention to minimise complications including: bladder distension; urine scalding; bladder atony and urinary tract infection (UTI) (Park et al, 2012). There are several methods of bladder management that may be employed, each with advantages and disadvantages that are discussed extensively in veterinary literature — manual expression (Figure 4), intermittent catheterisation and indwelling urinary catheterisation (IDUC).
Coates (2004) suggests that bladder expression can be an effective means of bladder control and is considered advantageous over other methods due to being non-invasive and inexpensive. This is supported by McKee (2000) who suggests that post-operative care for hemilaminectomy patients should include bladder management at least three times daily, with manual expression being the preferred method. If utilising manual bladder expression the bladder should be fully emptied as residual urine predisposes the patient to UTI (Coates, 2004). However, VNs need to be aware that this method may cause stress and pain to the patient post operatively which would not be appropriate (Bubenik and Hosgood, 2008). The patient's bladder was expressed fully post operatively while still under GA. Once the patient was recovering from her GA the ward's team were provided instructions to palpate the bladder every 4 hours and express if necessary when large (Figure 4). However, emphasis must be placed on the importance of vigilant bladder management because if the bladder is left distended for a long period of time it can become flaccid. Therefore, if the patient is perceived to have passed urine then the bladder needs to be palpated to ensure that this is not overflow from the bladder (Thomas, 2012). In contrast, constant expressing of the bladder will cause it to become resistant to stimulus resulting in an inability to empty itself (Park et al, 2012). The VN should be aware that urine and faeces on the patient's skin can lead to scalding and ulceration so bathing may be necessary post expression.
If the patient presented DP negative, non ambulatory or there are concerns that post operatively the patient may have worsening in clinical signs or abilities, then intermittent catheterisation or IDUC methods may be utilised using aseptic techniques. These methods allow for easier bladder management, reduce the risk of urinary scalding and allow measurement of urine output and observation of urine colour (Oosthuizen, 2011).
As with all bladder management options discussed there is potential for UTI in addition to bladder trauma (Dodd, 2011; Oosthuizen, 2011; Bloor, 2013). If using an IDUC it is advised to attach it to a closed collection system to prevent catheter-associated UTI (Bloor, 2013). A study by Bubenik and Hosgood (2008) has shown that the longer an IDU catheter is left in situ the more likely it is that a UTI will develop. Additionally, other factors discussed in veterinary literature that can contribute towards UTI are: non ambulatory patients; those that have not received antibiotics peri-operatively; and those patients who become hypothermic while undergoing surgery (Stiffler et al, 2006). The VN can ensure correct placement of urinary catheters and their management to minimise all aforementioned risks by following practice standard operating procedures (SOP).
The patient began voluntarily urinating and when checked post urination the bladder was found to be appropriately empty. The patient progressed well and was ambulatory within 24 hours with weak lower motor neuron function.
In future cases, patient assessment is advised to decide on the most appropriate management method for the bladder considering the advantages and disadvantages of each; this can be incorporated into a NCP. Compulsory urinalysis could be introduced into the author's practice in case of probable UTI allowing treatment to be instigated as soon as possible as suggested by Stiffler et al (2006).
Due to cost being an issue for the owners, the patient was discharged to continue physiotherapy at home (cryotherapy, massage and PROM). The patient had had surgery previously so the owners were confident with these techniques. A discharge sheet with post-operative written instructions were given to the owners to provide details regarding medications, exercise regimen and when re-examination appointments were necessary.
Conclusion
Spinal patients can require multiple nursing interventions which in the opinion of the author can be very rewarding. Important nursing interventions include improving the short-term recovery of the patient through bladder management, analgesia, recumbency care, nutrition and monitoring post GA and surgery. Long-term care focuses on rehabilitation and physiotherapy techniques. VNs can work alongside animal physiotherapists to guide them on implementing physiotherapy techniques, which help improve patients' recovery time and also assist when VNs are unavailable. The use of a NCP can assist nursing care and highlight the importance of bladder management, and can help to prevent possible complications that may occur such as UTI. Communication between VNs, VS and the owners is vital to provide appropriate care according to the patient's progress.
Key Points
- Intervertebral disk (IVD) disease is one of the most common causes of spinal cord dysfunction in dogs.
- Nursing care is vital to improve the speed of the patient's recovery both in the short and long term. Careful patient assessment is required to provide tailored nursing care and determine the nursing interventions required.
- Rehabilitation assists in the patient returning to normal function and improves overall patient wellbeing.
- Multimodal analgesia is provided by administering opioids, non-steroidal antiinflammatories (NSAIDs) and implementing physiotherapy.
- Cryotherapy is a cheap and easy physiotherapy technique to implement in practice.
Conflict of interest: none.