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CANINE-Postoperative Management of the Canine Spinal Surgery Patient-Part 1

CANINE-Postoperative Management of the Canine Spinal Surgery Patient-Part 1

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Vol. 19, No. 2February 1997Continuing Education Article
FOCAL POINTKEY FACTS
s
Untreated pain can lead tounfavorable physiologic andpsychologic responses that candelay normal healing.
s
Failure to maintain adequatevoiding of urine can lead tocystitis, bladder atony, andpyelonephritis.
s
Pharmacologic agents canassist in overall bladdermanagement but do not restorenormal bladder function.
s
Physical therapy should beginas soon after surgery as thepatient’s clinical conditionallows.
5
Careful attention to postoperativemanagement techniques in dogsthat have undergone spinalsurgery will improve surgicalsuccess rates and clientsatisfaction.
PostoperativeManagement of theCanine Spinal Surgery Patient—Part I
Texas A&M University 
Richard M. Jerram, BVSc, MRCVSRobert C. Hart, DVMKurt S. Schulz, DVM, MS
T
he two broad areas of vertebral surgery are (1) spinal cord decompres-sion (or exploratory surgery) for treatment of intervertebral disk dis-ease, neoplasia, and lumbosacral disease and (2) vertebral stabilizationfor treatment of atlantoaxial subluxation, cervical vertebral instability (wobblersyndrome), lumbosacral disease, and spinal fracture/luxation.
1
 Althoughsurgery is only one component in a comprehensive management plan for dogs with spinal neurologic disease, the scientific literature has focused on the surgi-cal procedure—leaving postsurgical management in need of further attention.Postsurgical management is a critical determinant of the success rate of spinal surgery. It is often difficult to accurately predict the outcome of animalsafter spinal surgery. Some completely recover, whereas others remain perma-nently paralyzed.Because each animal that will go undergo spinal surgery presents with a dif-ferent level of neurologic compromise, it is essential to develop a plan that istailored to meet the specific surgical, therapeutic, and nursing care needs of that animal. Client education must begin immediately after the decision toproceed with surgery because clients need to be aware of the time and effort re-quired in the postsurgical period.This two-part article focuses on helping veterinarians better understand thekey issues, required treatments, and some of the potential complications associ-ated with the postoperative management of dogs that have undergone spinalsurgery. Six primary areas of concern will be reviewed. Part I discusses painmanagement, bladder management, and physical therapy. Part II will addressgastrointestinal complications, such as fecal incontinence and steroid-inducedcolitis; wound complications, such as discharge, seroma and infection; and re-
 
cumbency management, with special attention tobedding, bathing, nutrition,and walking aids for pa-tients whose recovery periodis prolonged.The postsurgical needs of animals with spinal corddisease can be time-consum-ing and frustrating. The re- wards, however, of im-proved neurologic functionand client satisfaction canbe significant.
PAIN MANAGEMENT
Pain is an unpleasant sen-sory and emotional experi-ence associated with actualor potential tissue damage.
2
Surgical events, such aspain, hemorrhage, tissue damage, hypothermia, andhypoxia, initiate stress responses. These responses canbe metabolic, inflammatory, neural, or endocrine andresult in physiologic changes in the body.
3,4
Pain canlead to hypoxia, hypercalcemia, lung atelectasis, andpneumonia.Compensatory responses to the demands of damagedtissue include an increase in the release of cortisol, cate-cholamines, renin, and inflammatory mediators.
5
If these unfavorable physiologic changes become extreme,a delay in normal healing may occur. These changes areof particular importance in animals that have under-gone neurosurgery. Recovery is often prolonged as a re-sult of neurologic dysfunction, and unnecessary imped-iments to healing should be avoided.
5
In addition, thepsychologic impact of pain is to create a cycle of anxi-ety, fear, and sleep deprivation, all of which further ex-acerbate the delay in tissue healing.
5
The key steps to managing pain successfully are to(1) recognize the presence of pain and identify itssource and (2) provide the most appropriate form of analgesia. Good-quality nursing care must also beprovided. After surgery, animals should be placed ina quiet environment with warm, dry, and well-paddedcages.
Recognizing Pain
Veterinarians must be able to determine whether ananimal is in pain. If behavioral changes or clinical signsthat are abnormal for the individual or for the speciesare observed, pain should be suspected. A stoic animalmay need to be assessed subjectively. For instance, if astimulus applied to a human is considered painful, thesame stimulus applied to ananimal should also be con-sidered painful. Treatmentbased on this anthropomor-phic view of pain shouldnot be considered inappro-priate
6,7
(Figure 1).The clinical signs andphysiologic effects of painseen in dogs after spinalsurgery are given in the box. All of these signs are notpresent in every patient, buta subjective diagnosis of pain can be made if severalof these signs occur concur-rently.
6
12
Because animals may notvocalize until pain is severe,vocalization is not a sensitive indicator of pain.
6
12
 Also,many animals vocalize in the dysphoric phase of nor-mal anesthetic recovery, thus making vocalization evenmore difficult to interpret.
12
Analgesic Agents
 Analgesics should be a stan-dard component (unless con-traindicated because of under-lying cardiovascular or respira-tory disease)of the anestheticpremedications given to dogsundergoing spinal surgery.Opioids, nonsteroidal antiin-flammatory drugs (NSAIDs),and local analgesics are thepredominant types of drugsused for postoperative pain re-lief.
6,8,10,12,14
 Although pain is mostcommonly reduced by phar-macologic methods, alterna-tive pain relief methods may be explored. Acupuncturehas long been recognized asan effective treatment forpain and has been used suc-cessfully in the conservativemanagement of interverte-bral disk disease in dogs.
10,13
Other available methods in-clude transcutaneous electri-cal stimulation (TENS) andacupressure.
10
Small Animal
The Compendium 
February 1997
PHYSIOLOGIC CHANGES
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CLINICAL SIGNS
s
PHARMACOLOGIC MANAGEMENT
Figure 1—
 A dachshund in its cage after spinal surgery. It isoften difficult to determine whether a dog is experiencingpain after surgery because signs of pain are varied and non-specific.
Clinical andPhysiologic Signsof Pain
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Depression
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Reluctance to move
s
Timidity
s
Inappetence
s
Restlessness
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Anxiety
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Guarding of surgicalarea
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Vocalization?
s
Tachypnea
s
Tachycardia
s
Mydriasis
s
Salivation
s
Hyperglycemia
s
Premature atrialor ventricularcontractions
Each animal responds dif-ferently to pain. The signs ofpain may be difficult to in-terpret.
 
Opioids 
Narcotic agonists have traditionally been the main-stay of postoperative analgesia in dogs (Table I). Opi-oids act both peripherally, by inhibiting transmissionfrom primary afferent nociceptors to the dorsal rootganglia, and centrally, by inhibiting nociceptive condi-tions locally in the spinal cord.Morphine has profound analgesic and sedative ef-fects.
8,10,14
The onset of action of morphine can be up to45 minutes, and it has an intermediate duration of ac-tion of 3 to 5 hours.
15
The side effects of morphine in-clude emesis and defecation, respiratory depression,and increases in intracranial pressure.
8,10,14
Meperidine has milder narcotic and gastrointestinaleffects than morphine but only provides effective anal-gesia for 1 to 2 hours.
8,10,14,15
Intravenous injection of morphine or meperidine has been associated with his-tamine release; therefore, these drugs should be adminis-tered by intramuscular and subcutaneous routes only.
15
Oxymorphone is commonly used and provides goodanalgesia with mild sedative effects. It has 10 times thepotency of morphine, with less respiratory depressionand less gastrointestinal stimulation.
8,10,14
Buprenorphine is a partial opioid agonist that is 30times more potent than morphine. It provides excellentanalgesia for 6 to 8 hours and has minimal respiratory and gastrointestinal effects.
15,16
Butorphanol is a mixed agonist
antagonist that isfive times more potent than morphine. It is an excellentanalgesic for moderate levels of pain. The respiratory depression associated with butorphanol is dose relatedup to a point beyond which higher doses do not furtherdepress respiratory effort.
8,10,14,15
Fentanyl, which has a short duration of action whengiven parenterally, is now available in a transdermaltherapeutic system patch.
17,18
Effective pain relief hasbeen attained using the transdermal patch in our clinic. Advantages of using the patch are that therapeutic lev-els of fentanyl are achieved and that injections of otheropioids are required less frequently or not at all.
17,18
Nonsteroidal Antiinflammatory Drugs 
Nonsteroidal antiinflammatory drugs exert theiranalgesic effect by acting peripherally, with the inhibi-
The Compendium 
February 1997Small Animal
DURATION OF ACTION
s
RESPIRATORY EFFECTS
s
GASTROINTESTINAL EFFECTS
TABLE IDrugs Used for Postoperative Pain Relief in Canine Spinal Surgery Patients
DosageDuratioDrug (mg/kg)(hr)Side Effect
Opioids
Morphine0.25
1.25 IM, SQ3
5Emesis; respiratory depression; increasedintracranial pressureOxymorphone0.05
0.2 IV, IM2
5Respiratory depression; auditorhypersensitivity; altered thermoregulationMeperidine2.0
5.0 IM, SQ1
2Mild gastrointestinal effectsButorphanol0.1
0.8 IV, IM, SQ2
4Some nausea and vomitingBuprenorphine0.005
0.01 IV, IM, SQ6
8Mild respiratory depression; sedation
Nonsteroidal Antiinflammatory Drugs
 Aspirin10 PO12
14Gastrointestinal hemorrhage; plateletdysfunctionPhenylbutazone20 IV, PO12
24Gastrointestinal hemorrhage; renal toxicitPiroxicam0.2
0.4 PO12
24Gastrointestinal hemorrhage; renal toxicitCarprofen4.0 IV, SQ, PO12
24NoneKetoprofen1.0 IV, IM, PO12
24Gastrointestinal hemorrhage; renal toxicit
IM 
= intramuscularly,
IV 
= intravenously,
PO 
= orally,
SQ 
= subcutaneously.

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